What are the recommended transfer protocols for a patient with severe injuries being transferred from an Emergency Room (ER) to a trauma center?

Transfer Protocols for Severely Injured Trauma Patients

Patients with severe injuries should be transported directly to the highest-level trauma center available (Level I preferred) rather than to the nearest hospital, as this approach reduces mortality and improves outcomes. 1

Step-by-Step Transfer Decision Algorithm

Step 1: Assess Physiologic Criteria (Highest Priority)

Transport immediately to a Level I trauma center if ANY of the following are present:

• Glasgow Coma Scale (GCS) <14 1
• Systolic blood pressure (SBP) <90 mmHg 1
• Respiratory rate <10 or >29 breaths per minute (>29 in infants) 1

Patients meeting these physiologic criteria have the greatest mortality reduction when treated at Level I centers, with odds ratios for survival of 0.7 for GCS <14 and 0.6 for abnormal respiratory rate compared to Level II or non-trauma centers 1.

Step 2: Evaluate Anatomic Criteria

If Step 1 criteria are not met, transport to a trauma center if ANY of these injuries are identified:

• All penetrating injuries to head, neck, torso, and extremities proximal to elbow/knee 1
• Flail chest 1, 2
• Two or more proximal long-bone fractures 1, 2
• Crushed, degloved, or mangled extremity 1, 2
• Amputation proximal to wrist/ankle 1, 2
• Pelvic fractures 1, 2
• Open or depressed skull fracture 1, 2
• Paralysis 1, 2

Step 3: Consider Mechanism of Injury

Transport to a trauma center for high-risk mechanisms including:

• Motor vehicle crash with intrusion or significant deformation 1
• Pedestrian/bicyclist struck with impact >20 mph 1
• Falls from significant height 1

Step 4: Special Patient Populations

Mandatory trauma center transport for:

• Pregnancy >20 weeks with any trauma 1, 2
• Patients on anticoagulation therapy 2
• Age >55 years with trauma 1
• Age <15 years 1

Critical Time Considerations

Minimize elapsed time between injury and definitive care—every minute counts. 1

• Each additional minute of pre-hospital scene time correlates with 1% increased mortality 1
• Each additional minute of pre-hospital response time correlates with 2% increased mortality in penetrating trauma 1
• Direct transport from scene to trauma center is superior to transfer through intermediate hospitals 3, 4

Ground vs. Air Transport Decision

For moderate distances (15-45 minutes ground transport time), rapid ground transport reduces mortality compared to waiting for helicopter arrival. 5

• Ground transport mortality: 5.6-10.1% 5
• Helicopter transport mortality: 15.4-18.4% when response time is prolonged 5
• Use ground transport when scene-to-ED time can be minimized and helicopter response would be delayed 5

Avoid Interhospital Transfer When Possible

Patients with Injury Severity Score >15 who undergo interhospital transfer have:

• 2.4 times higher odds of death compared to direct transport (after adjusting for survival bias) 4
• Significantly longer ICU stays (14 vs 10 days) 3
• Significantly longer hospital stays (21 vs 16 days) 3
• Higher overall mortality rates 3, 4

Common Pitfalls to Avoid

Do not delay at referring hospitals for stabilization procedures that can be performed at the trauma center. The time lost during interhospital transfer increases mortality, particularly when "potential transfers" (patients who die before transfer can occur) are considered 4.

Do not rely solely on physiologic criteria. Combining physiologic and anatomic criteria increases sensitivity to 80% for identifying severely injured patients, compared to 70% for physiologic criteria alone 1.

Do not undertriage based on initial stable vital signs. Up to 34.5% of early hemorrhagic trauma deaths are potentially preventable with early intervention, and patients may decompensate rapidly 1.

Pre-Hospital Management During Transfer

• Apply external pelvic compression immediately for suspected pelvic trauma 6
• Limit aggressive fluid resuscitation in penetrating truncal injury with uncontrollable hemorrhage 7
• Minimize positive pressure ventilation volume in severe hemorrhage (reduces venous return) 7
• Use tourniquets for extremity hemorrhage control 7

When in Doubt

Transport to a trauma center. 1 The target undertriage rate (patients needing trauma center care who don't receive it) should be 0-5%, even if this means accepting overtriage rates of 25-50% 1.