Referring A Patient – for Providers

The majority of trauma patients can, and should, receive definitive care at the nearest regional hospital. A small percentage, 5-8 percent, will require transfer to the Trauma Center. The triage decision is the responsibility of the emergency department attending at each facility. It is incumbent upon that physician to be familiar with the degree of definitive care capability at his/her facility. If the patient’s need exceeds that capability, then prompt movement through the trauma system is in the best interest of the patient. This may involve air medical directly to the scene, ground EMS bypass of the nearest facility directly to the Trauma Center, air medical or ground transport from the regional facility to the Trauma Center.

Consider Immediate Trauma Center Diversion/Transfer

CDC 2011 Field Triage Guidelines for Injured Patients

Vitals Signs and Level of Consciousness

• Gloscow <= 13
• Systolic BP < 90 mmHg in an adult or signs of shock in a pediatric patient. HR > 90 or SBP < 110 mmHg should be considered in the geriatric blunt trauma patients.
• Respiratory rate < 10 or > 29 bpm or need for ventilator support (< 20 in infant < 1 yr).

Assess Anatomy for Injury

• All penetrating injury to head, neck, torso and extremities proximal to elbow or knee
• Chest wall instability or deformity (e.g., flail chest)
• Two or more proximal long-bone fractures
• Crushed, degloved, mangled or pulseless extremity
• Amputation proximal to wrist or ankle
• Pelvic fractures
• Open or depressed skull fractures
• Paralysis

Assess Mechanism of Injury for High-Energy Impact
Falls

• Falls
  • Adults > 20 feet
  • Children > 10 feet or two to three times the height of the child
• High-risk auto crash
  • Intrusion including roof > 12 inches occupant side or 18 inches any side
  • Ejection (partial/complete) from automobile
  • Death in the same passenger compartment
  • Vehicle telemetry consistent with high-risk injury
• Auto vs. pedestrian/bicyclist thrown, run over or with significant (> 20 mph) impact\
  • Motorcycle crash > 20 mph

Assess special patient or system considerations

• Older Adults
  • Risk of injury/death increases after age 55
  • SBP < 110 or HR > 90 may represent shock after age 65
  • Low impact (falls level surface) may result in severe injury
• Children
  • Should preferably be triaged to a trauma center with pediatric capabilities?
• Anticoagulants and bleeding disorders
  • Patient with head injury are at high risk for rapid deterioration
• Burns
  • Without other trauma mechanism: triage to Burn Center
  • With trauma mechanism: triage to Trauma Center
• Pregnancy > 20 weeks
• EMS provider judgement
• Other patients at the discretion of the regional emergency department attending

NOTE: All such decisions rest with the emergency medicine physician in regional hospitals. It is vital to remember and understand that major trauma victims must move through the trauma system quickly to realize maximum benefit from the system. Complete, definitive, time-consuming radiologic evaluation is neither necessary nor desirable prior to Trauma Center transfer. This is the standard of care established by MATRAC in 2000 and has not changed. The emergency medicine physician at Mission is authorized to accept any trauma patient in transfer from the region. This decision will be supported by the on-call trauma surgeon. It is necessary for the referring MD to speak only with the EM MD at Mission to initiate the transfer.

The Mission Health System Regional Referral Call Center is responsible for the coordination of all regional and direct admission patient placements through Mission Direct. Clinical judgement will be utilized to coordinate and expedite the transfer of patients within the region while simultaneously working with the receiving and sending physicians to resolve any issues that may arise.

The Transfer Center RN (TCRN) works collaboratively with the house supervisor to determine bed availability within the Mission Health system. The TCRN is responsible for the coordination of all EMTALA forms from the organization ensuring all patients are transferred in and out of the Mission Health system with appropriate documentation.