ED to ED transfer does not prolong emergency department stays in a rural trauma system



      In many rural trauma systems injured patients are initially evaluated at a local hospital, and once stabilized transferred to a trauma center for definitive care. In the U.S. most trauma transfers occur as emergency department (ED) to ED transfers, however there is little evidence to guide systems in whether this is beneficial. We implemented a practice change in August 2018, changing from commonly admitting trauma transfers directly to the floor, to a protocol for ED to ED transfer for all trauma patients. We aimed to evaluate this practice change and its effects on outcomes and ED length of stay.


      We retrospectively reviewed all trauma transfers to our Level 1 trauma center between 8/1/2017–8/30/2020. Study groups were created based on the presence of a transfer protocol: a control group with no protocol, a selective ED pitstop protocol group and a systemwide ED pitstop protocol group. We compared patient and injury factors between groups, and evaluated each group's hospital mortality, unplanned ICU admission within 24 h, need for return to radiology for imaging, and ED length of stay.


      1,987 patients were transferred during the study period. In our control group 37% of transfers were directly admitted. Implementing a selective ED pitstop decreased direct admissions to 17% and a systemwide ED pitstop decreased direct admissions to 10%. There was no difference in mortality between groups. Protocol implementation decreased unplanned ICU admissions from 2% to 1% in the selective protocol and 0.8% in the systemwide protocol, as well as decreasing the need for further diagnostic imaging (5% to 2.5% and 2%; in each group respectively). ED length of stay was not different between time periods.


      Implementing an ED pitstop protocol for trauma transfers led to decreased direct admissions, without increasing the ED length of stay, and less need for delayed imaging.


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        • Adzemovic T.
        • Murray T.
        • Jenkins P.
        • Ottosen J.
        • Iyegha U.
        • Raghavendran K.
        • Napolitano L.
        • Hemmila M.
        • Gipson J.
        • Park P.
        • et al.
        Should they stay or should they go? Who benefits from interfacility transfer to a higher-level trauma center following initial presentation at a lower-level trauma center.
        J Trauma Acute Care Surg. 2019; 86 (Jun): 952-960
        • Newgard C.D.
        • McConnell K.J.
        • Hedges J.R.
        • Mullins R.J.
        The benefit of higher level of care transfer of injured patients from nontertiary hospital emergency departments.
        J Trauma Acute Care Surg. 2007; 63 (Nov): 965-971
        • Safavi K.C.
        • Gaitanidis A.
        • Breen K.
        • Seelen M.
        • Raja A.
        • Velmahos G.C.
        • Dunn P.F.
        Direct admission to improve timely access to care for patients requiring transfer to a level 1 trauma center.
        Trauma Surg Acute Care Open. 2020; 5 (Dec)e000607
        • American College of Surgeons
        Committee on trauma.
        National Trauma Data Standard Data Dictionary, 2021 (Admissions [Internet]. Available from)
        • Taylor M.D.
        • Tracy J.K.
        • Meyer W.
        • Pasquale M.
        • Napolitano L.M.
        Trauma in the elderly: intensive care unit resource use and outcome.
        J Trauma. 2002; 53 (Sep): 407-414
        • Jarman
        Rural risk: geographic disparities in trauma mortality.
        Surgery. 2016; 160 (Dec 1): 1551-1559
        • Røislien J.
        • Lossius H.M.
        • Kristiansen T.
        Does transport time help explain the high trauma mortality rates in rural areas? New and traditional predictors assessed by new and traditional statistical methods.
        Inj Prev. 2015; 21 (Dec): 367-373
        • Gomez D.
        • Berube M.
        • Xiong W.
        • Ahmed N.
        • Haas B.
        • Schuurman N.
        • Nathens A.
        Identifying targets for potential interventions to reduce rural trauma deaths: a population-based analysis.
        J Trauma Acute Care Surg. 2010; 69 (Sep): 633-639
        • Bauman Z.M.
        • Loftus J.
        • Hodson A.
        • Farrens A.
        • Shostrom V.
        • Summers J.
        • Phillips P.
        • Evans C.
        • Schlitzkus L.
        Rural trauma team development course instills confidence in critical access hospitals.
        World J Surg. 2020; 44 (May 1): 1478-1484
        • Kappel D.A.
        • Rossi D.C.
        • Polack E.P.
        • Avtgis T.A.
        • Martin M.M.
        Does the rural trauma team development course shorten the interval from trauma patient arrival to decision to transfer?.
        J Trauma. 2011; 70 (Feb): 315-319
        • Malekpour M.
        • Neuhaus N.
        • Martin D.
        • Widom K.
        • Rapp M.
        • Leonard D.
        • Baro S.
        • Dove J.
        • Hunsinger M.
        • Blansfield J.
        • et al.
        Changes in rural trauma prehospital times following the rural trauma team development course training.
        Am J Surg. 2017; 213 (Feb 1): 399-404