DIRECT TRANSPORT TO TERTIARY TRAUMA CENTERS VERSUS TRANSFER FROM LOWER LEVEL FACILITIES - IMPACT ON MORTALITY AND MORBIDITY AMONG PATIENTS WITH MAJOR TRAUMA

Background: The purpose of the study was to compare the outcome of sev erely injured patients who were transported directly to a Level I, ter tiary trauma center with those who were transferred after being first transported to less specialized hospitals. Methods: The data were base d on all patients treated at three tertiary trauma centers in Quebec b etween April 1, 1993, and December 31, 1995. There were 1,608 patients (37%) transferred and 2,756 patients (63%) transported directly. Resu lts: The mean age of the patients was approximately 45 years, and more than 60% were males. The predominant mechanisms of injury were falls and motor vehicle crashes. The transfer and direct transport groups we re similar with respect to age, gender, and mechanism of injury. Body regions injured were also similar with the exception of head or neck i njuries (transfer, 56%; direct, 28%; p < 0.0001). The mean Injury Seve rity Score was 14, the mean Pre-Hospital Index score was 5.5, and the mean Revised Trauma Score was 7.5. The two groups were similar with re spect to these injury severity measures. The primary outcome of intere st was mortality described as overall death rate, death rate in the em ergency room, and death rate after admission. Other outcomes studied w ere hospital length of stay and duration of treatment in an intensive care unit. When compared with the direct transport group, transferred patients were at increased risk for overall mortality (transfer, 8.9%; direct, 4.8%; odds ratio, 1.96; 95% confidence interval (CI) = 1.53-2 .50), emergency room mortality (transfer, 3.4%; direct, 1.2%; odds rat io, 2.96; 95% CI = 1.90-4.6), and mortality after admission (transfer, 5.5%; direct, 3.6%; odds ratio, 1.57; 95% CI = 1.17-2.11). All of the se differences were statistically significant (p < 0.003). Stratified and multiple logistic regression analysis did not alter these results and failed to identify a patient subgroup for which transfer was assoc iated with a reduced risk of mortality. After adjusting for patient ag e, Injury Severity Score, and presence of injuries to the head or neck and extremities, transferred patients stayed significantly longer in the hospital and the intensive care unit as indicated by the mean leng th of stay (transfer, 16.0 days; direct, 13.2 days; p = 0.02) and the mean intensive care unit stay(transfer, 2.0 days; direct, 0.95 days; p = 0.001). Conclusion: The results of this study have shown that trans portation of severely injured patients from the scene directly to Leve l I trauma centers is associated with a reduction in mortality and mor bidity. Further studies are required for the evaluation of transport p rotocols for rural trauma. Economic and cost-effectiveness considerati ons of patient triage are also essential.