Diagnostic studies delay transfer to definitive care

In emergency medicine, time is life, and most emergency departments meet or exceed the time-to-treatment benchmarks for ST-segment elevation myocardial infarction and acute stroke. But much less attention is given to the rapid triage and transfer of trauma patients, for whom time is just as critical.

Part of the problem is the lack of national benchmarking for trauma performance. So in 2014, the Southern Minnesota Regional Trauma Advisory Committee (SMRTAC) issued regional trauma team activation criteria aimed at decreasing time to definitive care. Under this system, Red criteria patients have compromised airways or circulation, and the decision to transfer them should be made within 20 minutes. Yet patients who meet these criteria may spend two or more hours undergoing imaging tests in Level IV trauma centers.

"Providers feel compelled to perform imaging tests because they want to do something for the patient and provide the surgical team with a diagnosis. But the focus should be on identifying critically injured patients and transferring them from the smaller hospital to the receiving center as quickly as possible," explains Christopher S. Russi, D.O., an emergency medicine physician at Mayo Clinic's campus in Rochester, Minnesota.

He points out that it doesn't make sense to image patients in centers that don't have the capacity to treat them. "We all believe the needs of the patient come first, and imaging is part of that. But if the issues raised by the imaging can't be resolved, then it's better to do the tests at the receiving end and minimize the time patients spend outside the operating room," Dr. Russi says.

This doesn't apply to every patient — only those with hemorrhagic shock, decreasing Glasgow Coma Scale scores or other signs of significant traumatic injury requiring immediate surgical intervention. And it doesn't mean providers in Level III and IV centers should never image these patients.

"Imaging tests can sometimes be performed when there are multiple processes in parallel," Dr. Russi explains. "If a badly injured patient is being resuscitated in Lake City, then getting that patient to Rochester is of the greatest importance. But there is a window of opportunity for imaging while waiting for transport. The process can work if providers make an early call to Rochester to mobilize resources, and then, because it can take a while for transport to arrive, there may be time for imaging to help their surgical colleagues. But if providers perform imaging tests first and then make the phone call, a lot of time is lost."

He stresses that all trauma providers are part of the same team. "If providers have concerns about a patient or are unsure how to manage a case, we are more than happy to talk to them about it. Call the Admission & Transfer Center, and we will do our best to answer all questions and, if necessary, mobilize a team from Rochester and get Mayo One headed in their direction or send a flight team by ground if Mayo One is unavailable. In trauma, time is life," Dr. Russi says.