Research shows benefits to critically ill make up for risk of moving patients
By Joe Rojas-Burke
The Oregonian
Copyright 2007 The Oregonian
PORTLAND, Ore. — Seriously injured patients in Oregon are more likely to survive when transferred from small-town hospitals to high-level trauma centers, a new study shows.
While transporting critically ill patients long distances by ambulance or aircraft adds risk, the study provides evidence that the benefits of specialized trauma centers more than make up for that risk.
“That’s been the assumption, but this is statistical proof that the system does work,” said Dr. Seth Izenberg, a trauma surgeon at Legacy Emanuel Hospital & Health Center in Portland who was not involved in the study.
In Oregon’s statewide trauma system, small community hospitals serve as the first providers of care for people injured in rural areas. Emergency room doctors at such hospitals must decide whether to treat the patient locally or arrange a transfer to a more advanced trauma center.
Izenberg said it’s often a tough decision complicated by the patient’s changing condition, which can deteriorate unexpectedly, and the limits imposed by weather and the availability of aircraft, surgeons and hospital beds at trauma centers.
“It’s a fluid and dynamic problem,” Izenberg said.
Previous studies have shown that poorly handled transfers can delay urgent care to patients. A Rhode Island study documented delays averaging more than two hours and found that many patients arrived at the major center in dire need of critical interventions. More than half of those patients died.
To measure the effectiveness of transfers, researchers at Oregon Health & Science University compared the survival rates of more than 10,000 patients with serious injuries taken to emergency rooms at 42 small hospitals from 1998 to 2003.
About 3,800 patients transferred to one of the six high-level trauma centers in Portland, Bend and Eugene. Absolute death rates were higher among transfer patients, but only because they had injuries more severe than the overall group.
After adjusting for the severity of injuries and other differences, researchers showed that death rates for transfer patients were about 33 percent lower than for patients who remained at smaller hospitals.
“We were able to demonstrate there was in fact a survival benefit to transferring,” said Dr. Craig Newgard, an associate professor of emergency medicine at OHSU and one of the study authors.
But Newgard said the findings aren’t much use in helping doctors decide under pressure when to transfer an individual patient.
“What we’d really like to have is some way to rapidly identify which patients are likely to benefit from transfer,” he said. As it stands, some patients are transported at great expense, but their injuries later prove to be less than critical. Others die because they weren’t transferred.
Oregon emergency medicine experts have adopted criteria to identify appropriate transfer cases. But Newgard said the criteria depend on having a diagnosis that can take several hours of testing.
“When you are in real time, trying to figure out the best plan for that patient, and you wait long enough to have all that information, it may be too late,” he said.