Effect of referral on mortality in trauma victims admitted in trauma centre of Chattrapati Shahuji Maharaj Medical University: A one year follow up study

Introduction The objectives of this study were to outline the effect of referral from peripheral hospitals on mortality in patients admitted to the trauma centre of Chattrapati Shahuji Maharaj Medical University and to describe inter-hospital transfer. Methods Patients admitted on all Mondays of a year and eight randomly selected Mondays and Wednesdays were enrolled and compared. Demographic and clinical profiles of patients presenting directly to the Trauma Centre of CSMMU and those referred from peripheral hospitals were compared. Transfer vehicle was evaluated and accompanying personnel were interviewed to ascertain the clinical status of the patients during transfer, details of the transfer process, training of the transfer personnel, adequacy of the transfer vehicle and its outfitted monitoring equipment. Results Five hundred seventy two patients were enrolled in the study including 327 referred and 245 directly admitted patients. There was 27 % mortality in the referred group and 22% mortality in the directly admitted group (p value 0.20). Despite similar ISS patients referred from peripheral hospitals had lower GCS ( p value 0.029), and higher TRISS (p value 0.01) Referred group had greater delay in presentation (p value 0.0001) to the trauma centre and longer duration of hospital stay (p value 0.013). The date and time of injury, GCS score, pupil size and reaction was not documented in transfer record in any of the 327 referred patients. Referral time, pulse rate and blood pressure were recorded in transfer records in 13.71%, 34.38% and 34.25% cases respectively. On arrival 71 patients had a GCS score of less than 8. Of these, none had been intubated in the referral hospital or on way. Ambulances were used for transfer in 15.12% cases. Equipment to measure blood pressure, intravenous access and fluids, and suctioning were present in 95.91%, 61.22%, and 44.89% of ambulances respectively. Conclusion Referral from a peripheral hospital results in significant delay in presentation to the trauma centre but does not affect mortality adversely. There is a need to devise a national referral policy. Introduction The trauma centre of Chattrapati Shahuji Maharaj Medical University (CSMMU) is the only trauma centre in Uttar Pradesh and serves the needs of rural areas of Uttar Pradesh up to a radius of 100 miles. Many trauma victims are first admitted to inadequately equipped primary or secondary care hospitals due to geographical and economic considerations. India has no trauma care referral algorithm, or an established system of pre-hospital care or transfer. This raises the possibility that the patients being referred from peripheral hospital may be adversely affected due to attendant delays with such transfers, lack of well-defined transfer protocols and poor treatment at peripheral hospitals. The objective of this study was to describe the process of inter-hospital transfer and the effect of referral on mortality. Materials and methods Patients that were simply picked up from the site of injury and transported by police, relatives or passerby to our institution without any medical treatment being administered were considered as ‘direct admissions’. Patients which stopped and received treatment at peripheral hospitals prior to referral to our institution were considered as ‘referred patients’. Similar treatment protocols were followed in both the groups after arrival at the emergency room of the trauma centre. Approval for the study was obtained from the Institutional Review Board. A questionnaire was prepared in which item analysis was done for inter-observer and intra-observer variability. The inclusion criteria for the study were all patients admitted on all Mondays of a year (1st March 2010 to 28th February 2011) consecutively recruited subject to written informed consent. For critically ill patients consent was obtained from a relative. Additionally data was collected on patients admitted on Wednesdays and Saturdays of 8 randomly selected weeks (using opaque chits to ensure simple random sampling). Patients admitted on Wednesday and Saturdays were compared among themselves and with those admitted on Mondays to determine whether day of admission made any difference on patient characteristics. Patients admitted on Wednesdays and Saturdays were to *Corresponding author Email: [email protected] 1 Department of Orthopaedics, C S M Medical university, Lucknow 2 Department of General Surgery, AIIMS, Patna