The majority of trauma patients are seen initially at non-trauma centers. And the majority of those patients can be treated just fine at that local hospital. However, a few (some say about 15%) do need to be transferred. The question frequently arises, “what studies do I need to do before transferring?”
The danger is that doing things that slow down the transfer can result in bad outcomes. For example, a patient may have a spleen injury that is actively bleeding. Every minute that this patient is not receiving “definitive treatment”, she loses more blood. And every cc of blood lost causes her to inch closer to shock, other complications, or death.
The key is to get people who need a higher level of trauma care on their way to a higher level trauma center as soon as the need is recognized. There is a natural tendency to do diagnostic studies, such as CT scan, in these patients. Sometimes they are needed to actually figure out what is going on. But more often they are obtained to “do a complete workup” or because “the trauma center expects me to.”
Unfortunately, these are incorrect assumptions. The complete workup cannot be used by the referral center if they are shipping the patient, and for a variety of reasons they may not be useful to the trauma center. This is one of the major reasons that referral patients receive extra radiation exposure. About half of the studies performed at the referral hospitals need to be repeated!
The Referral Hospital Trauma Rule: Do any simple study needed to ensure the patient will stay alive until the helicopter/ambulance arrives (typically chest or pelvic xray). If at any point, you see something obviously not treatable at your hospital (i.e. open fracture, GCS 8, partial amputation), DO NO FURTHER STUDIES AND PREPARE TO TRANSFER. If the patient does not have such an obvious problem, do only the tests you need to determine if you can keep the patient. But as soon as you find anything that you cannot treat, stop further studies and prepare to send the patient onward. And don’t forget to send working copies of the few studies that you did get.
CT scan is essential in diagnosing injury, although concerns for unnecessary radiation exposure are growing. These concerns are even greater in children, who may be more likely to have long-term effects from it. This makes avoiding duplication of CT scanning extremely important.
Unfortunately, there are only about 50 pediatric trauma centers in the US, so the majority of seriously injured children are seen at another hospital before transfer. Does CT evaluation at the first hospital increase the likelihood that a repeat scan will be needed at the trauma center, increasing radiation exposure and risk?
Rainbow Babies and Children’s Hospital in Cincinnati looked at 3 years of transfers of injured children from community hospitals. They then looked at how many of those children had an initial head and/or abdomen scan at the outside hospital, and whether a repeat scan of those areas was performed within 4 hours or arrival at Rainbow.
Numbers were small, but here are the results:
- 33 had an outside CT scan, 28 (90%) were repeated
- 6 had an outside abdominal scan, 2 (33%) were repeated
- 55 did not have outside scans, none were repeated at Rainbow. (This is a weird thing to look at. I would hope that the trauma center didn’t have to repeat any of their own scans within 4 hours!)
Bottom line: It is critically important for referring hospitals to use radiation wisely! First, if the patient has obvious injuries that require transfer, don’t scan, just send. If you need to scan to decide whether you can keep the patient, use the best ALARA* technique you can. And trauma centers, please send a copy of your CT protocols to your referring hospitals so they can get the best images possible.
*ALARA = As low as reasonably achievable (applied to radiation exposure). Also known as ALARP outside of North America (as low as reasonably practicable). Click here for more info.
Reference: Computed tomography before transfer to a level I pediatric trauma center risks duplication with associated radiation exposure. J Pediatric Surg 43(12): 2268-2272, 2008.
Smaller trauma hospitals, both designated and undesignated, are the front line for the initial care of the majority of trauma patients. Many patients can be evaluated and sent home or admitted to the initial hospital. More severely injured patients are commonly transferred to the nearest Level I or Level II trauma center for care of injuries requiring specialists.
Imaging studies such as conventional xray and CT scan are a necessary part of the initial trauma evaluation. But is it necessary to do a full radiographic evaluation, even when it is known that the patient will have to be transferred?
Researchers at Dartmouth Hitchcock Medical Center examined the issue of repeat imaging at their Level I center. They looked at 138 patients that were transferred to them from other rural hospitals. They found that 75% underwent CT scanning prior to transfer, and 58% underwent repeat scanning upon arriving at Dartmouth.
The authors discovered the following:
- Head CTs were repeated 52% of the time, primarily due to clinical indications
- Spine reconstructions were repeated 33-50% of the time due to inadequate reconstruction technique
- Chest (31%) and abdomen (20%) were repeated due to inappropriate use of IV contrast
- 13% of image disks used incompatible software
- 7% of images were not sent with the patient
Here are my recommendations for imaging by hospitals that refer patients to Level I or II trauma center:
- Obtain the essential plain films recommended by ATLS (chest, pelvis)
- If an obvious injury requiring transfer is found on exam (e.g. open fracture) do no further studies
- Obtain any imaging studies needed to decide if you can admit the patient to your own hospital (example: abdominal CT for abdominal pain and negative FAST. Keep if no injury, transfer if solid organ injury)
- As soon as an injury is identified that mandates transfer, do no further studies
- Always send image disks with the patient
- Work with your referral trauma center to obtain a copy of their CT imaging protocols so if you do need to perform a study you can duplicate their technique
Reference: Gupta et al. Inefficiencies in a Rural Trauma System: The Burden of Repeat Imaging in Interfacility Transfers. J Trauma 69(2):253-255, 2010.