Continuity of Care for Major Trauma Victims in an Integrated and Regionalized System

Key Implications for Decision Makers

Several Canadian provinces have created integrated networks based on the principle of referring clients from general facilities to a few designated centres for trauma, oncology, cerebrovascular science, cardiology, etc. This concentration of expertise in a limited number of facilities is designed to increase the efficiency of healthcare services.

What are the implications, however, for major trauma victims who require a very extensive range of care? No single healthcare facility is able to meet all these needs and typically, major trauma victims must be transferred from centre to centre as required. This situation raises questions about the accessibility and continuity of care.

The study shows that:

  • Transfer of trauma victims from one hospital to another is based on ad hoc decisions by emergency physicians and there is no recognized criterion to guide these decisions.
  • Healthcare network planners have few indicators to assess network performance.
  • There are major discrepancies between decisions made locally and the needs of trauma victims generally acknowledged by experts. These discrepancies are probably due in part to the lack of specific criteria to guide clinicians, that could be monitored by administrators.
  • The study identified a number of criteria for transfer, through consultation with expert clinicians involved in traumatology. These transfer criteria can be used to guide attending physicians while contributing to the standardization of quality of care.
  • There are two practical applications for these transfer criteria for major trauma patients: issue guidelines for the physicians in charge of these patients, and provide a reliable tool for assessing the trauma care system.

Executive Summary

Quebec's trauma system currently consists of 58 hospitals designated by intervention level into primary, secondary or tertiary (the most specialized level of care) centres. "Service corridors" allow a primary centre to transfer any trauma patient it considers too serious to one of the four tertiary centres. Once the acute phase has passed, the patient returns to his region. However, the decision to transfer a trauma patient to a tertiary centre ultimately depends on the emergency physician and there currently are no official criteria for transfer.

The lack of transfer criteria prevents some trauma victims from obtaining the care they need. More than 80 percent of the 77 experts consulted consider transfer to a tertiary trauma centre "essential" for 12 types of victims, ranging from severe burns to cranial trauma. At present, however, data for primary and secondary centres show that for comparable conditions, barely 40 percent of patients are transferred. Yet these trauma victims require much more specialized care since, even in tertiary centres, they have a very high mortality, require intensive care more often and suffer complications more often than other victims.

Needs

Based on the experts consulted, patients who must be transferred suffer general injuries or specific cranial traumas. General injuries include amputation with potential for reimplantation, embolization to control hemorrhage, medulla injuries, suspected damage to the large mediastinum or cardiac vessels, and severe burns. The cranial traumas involve a score of less than 9 on the Glasgow scale - which is used to assess the level of consciousness in patients with traumatic brain injuries - or a deteriorating score, anomalies from neurological examination, open cranial fractures or crushing, certain fractures at the base of the cranium and, if a tomogram is available and the examination is abnormal, those involving altered consciousness or an examination showing subdural or epidural hematoma, or intracerebral hemorrhage.

Data from Quebec's trauma register, from 1998 to 2001, identified many injuries similar to these types of trauma. The data show that by no means all of these patients are transferred. While 88 percent of cranial traumas with a deteriorating Glasgow score are transferred, by contrast, barely 32 percent of patients with an injury to the medulla area of the brain are transferred, 41 percent of cases involving unstable hip fracture and 45 percent of patients with anomalies revealed by a neurological examination.

Yet the risks incurred by this population are real. Even among patients admitted directly into tertiary centres, excluding deaths occurring within two hours of arrival in emergency (probably too dangerous for transfer), one in seven (14 percent) of these patients died, almost two thirds (63 percent) stayed in intensive care and one third (33 percent) suffered complications during hospitalization. These proportions are much higher for some subgroups. Thus, close to 40 percent of patients with an injury to the mediastinum area of the brain die, as do more than one third of patients with a Glasgow score of less than 9 or 26 percent of trauma victims with an open cranial fracture or crushing. Among trauma victims, each of these conditions leads to at least 50 percent of admissions into intensive care, and this proportion actually climbs to more than 90 percent for mediastinum injuries, including those with a Glasgow score of less than 9. Similarly, more than half of those with a mediastinum injury and those with an unstable hip fracture experience complications during hospitalization.

Outcomes

Twelve criteria were selected as essential to determine transfer to a tertiary centre.

General criteria

  • Amputation with potential for reimplantation
  • Patient requiring embolization to control hemorrhage
  • Medulla injury (with or without neurogenic shock), after stabilization
  • Suspected injury of the large mediastinum vessels or cardiac injury
  • Severe burns (with or without systemic injuries)

Criteria for cranial trauma patients (without a cerebral tomogram)

  • Cranial trauma with a Glasgow score < 9
  • Cranial trauma with a deteriorating Glasgow score
  • Anomaly from neurological examination (not caused by limb fracture)
  • Cranial fracture with crushing, or open cranial fracture
  • Fracture of the base of the cranium with fistula of cerebrospinal fluid,
  • hemotympanum or bleeding from the ears or nose

Criteria for cranial trauma patients (with cerebral tomogram)

  • Altered state of consciousness with abnormal cerebral tomogram
  • Subdural or epidural hematoma, intracerebral hemorrhage

Although the experts agree on these criteria (80 percent of respondents to the third questionnaire - see approach), differences in opinion persist between experts in various specialties or practising in trauma centres of various levels.

Approach

The study is divided into two main sections. The first develops criteria for transfer by seeking consensus among experts involved in institutions in the system, while the second statistically validates the indicators resulting from the criteria selected.

A total of 58 hospitals at various levels identified one of their emergency physicians and the more specialized centres also identified a surgeon, a neurosurgeon and an intensive care specialist to form part of a group of experts consulted through three questionnaires. A total of 83 experts were designated: 65, 82 et 69 percent of them respectively responded to the three questionnaires. Only six of the 83 designated experts failed to respond to any of the three questionnaires.