A population-based study of the association of medical manpower with county trauma death rates in the United States

Impact of a New Helicopter Base on Transport Time and Survival in a Rural Adult Trauma Population

BACKGROUND

Significant disparities in access to prompt helicopter transport exist among rural trauma populations. We evaluated the impact of an additional helicopter base on transport time and mortality in a rural adult trauma population.

MATERIALS AND METHODS

We performed a retrospective cohort study of adult patients with trauma transported by helicopter from scene to a level one trauma center between 2014 and 2018. A new rural helicopter base added to the trauma center's catchment area in 2016 served as the transition time for an interrupted time series analysis. Patients injured in this base's county and adjoining counties were analyzed. Baseline characteristics were compared with a Student's t-test and Pearson's chi-squared test. Cox and linear regression models evaluated the new base's effect on mortality and transport time, respectively.

RESULTS

A total of 332 patients were analyzed: 120 (36.1%) transported before the addition of the new helicopter base and 212 (63.9%) transported after. Patients transported after the addition of the base had higher injury severity score (13.7 versus 10.1, P < 0.001) and were more likely to receive blood en route (19.3% versus 6.7%, P = 0.005). After the addition of the base, there was a decreased hazard ratio for mortality (hazard ratio 0.26, 95% confidence interval: 0.11-0.65, P = 0.004) with no significant change in transport time (-36.7 min, P = 0.071) for the area.

CONCLUSIONS

Local helicopter transport units may confer improved survival for the injured patient. This study demonstrates the important role of helicopter transport within a regional trauma system and the impact that expanded access to rapid air transport can have on mortality.

Delivering trauma mastery with an international trauma masters

INTRODUCTION

Trauma is a global problem. The goal of optimising multidisciplinary trauma care through speciality education is a challenge. No single pathway exists to educate care providers in trauma knowledge, management and skills. Queen Mary University of London (QMUL) devised an online electronic learning (e-learning) Master's degree (MSc) in Trauma Sciences in 2011. E-learning is increasingly popular however low progression rates question effectiveness. The further post-graduate impact is unknown. Our goal was to establish whether this program is a successful method of delivering multidisciplinary trauma education to an international community. We hypothesized that graduating students make a global impact in trauma care, education and research.

METHODS

The Trauma Sciences MSc programs launched in 2011. Electronic surveys were distributed worldwide to students who successfully completed the program between 2013-2016. Graduation rates, degree/qualification awarded, clinical involvement in trauma management, presentation of MSc work, academic progression and roles in trauma education were explored. Supporting demographics were extracted from the QMUL student database.

RESULTS

A total of 176 students, of 29 nationalities, enrolled in the two year course between 2011 and 2014. Clinical backgrounds included multi-speciality physicians (83.5%), nurses (9.6%) and paramedics (6.8%). 119 (67.6%) graduated within the study period, 108 (60.8%) with the full masters award. Completion was independent of clinical background (p = 0.20) and age (p = 0.99). Highest completion rates were seen in students from Australia and New Zealand, Asia and Europe (p = 0.03). All survey responders were currently providing regular clinical care to trauma patients. 73% (n = 36) were delivering trauma education, many at national or international level. 49% (n = 24) had presented work from the MSc and 23% (n = 11) published their dissertation.12% (n = 6) subsequently enrolled in a PhD program.

CONCLUSION

Compared with other e-learning courses this Masters program has an enviable completion rate. Graduates go on to make an international multidisciplinary impact with diverse roles in clinical management, research and trauma education. This programme provides a robust trauma education curriculum. The QMUL Trauma Sciences MSc program is an excellent resource for clinicians participating in any form of trauma care or who wish to augment sub-speciality training in trauma.

Individual, programmatic and systemic indicators of the quality of mental health care using a large health administrative database: an avenue for preventing suicide mortality

Suicide is a major public health issue in Canada. The quality of health care services, in addition to other individual and population factors, has been shown to affect suicide rates. In publicly managed care systems, such as systems in Canada and the United Kingdom, the quality of health care is manifested at the individual, program and system levels. Suicide audits are used to assess health care services in relation to the deaths by suicide at individual level and when aggregated at the program and system levels. Large health administrative databases comprise another data source used to inform population-based decisions at the system, program and individual levels regarding mental health services that may affect the risk of suicide. This status report paper describes a project we are conducting at the Institut national de santé publique du Québec (INSPQ) with the Quebec Integrated Chronic Disease Surveillance System (QICDSS) in collaboration with colleagues from Wales (United Kingdom) and the Norwegian Institute of Public Health. This study describes the development of quality of care indicators at three levels and the corresponding statistical analysis strategies designed. We propose 13 quality of care indicators, including system-level and several population-level determinants, primary care treatment, specialist care, the balance between care sectors, emergency room utilization, and mental health and addiction budgets, that may be drawn from a chronic disease surveillance system.

Telemedicine Use Decreases Rural Emergency Department Length of Stay for Transferred North Dakota Trauma Patients

BACKGROUND

Telemedicine has been proposed as one strategy to improve local trauma care and decrease disparities between rural and urban trauma outcomes.

OBJECTIVES

This study was conducted to describe the effect of telemedicine on management and clinical outcomes for trauma patients in North Dakota.

METHODS

Cohort study of adult (age ≥18 years) trauma patients treated in North Dakota Critical Access Hospital (CAH) Emergency Departments (EDs) from 2008 to 2014. Records were linked to a telemedicine network's call records, indicating whether telemedicine was available and/or used at the institution at the time of the care. Multivariable generalized estimating equations were developed to identify associations between telemedicine consultation and availability and outcomes such as transfer, timeliness of care, trauma imaging, and mortality.

RESULTS

Of the 7,500 North Dakota trauma patients seen in CAH, telemedicine was consulted for 11% of patients in telemedicine-capable EDs and 4% of total trauma patients. Telemedicine utilization was independently associated with decreased initial ED length of stay (LOS) (30 min, 95% confidence interval [CI] 14-45 min) for transferred patients. Telemedicine availability was associated with an increase in the probability of interhospital transfer (adjusted odds ratio [aOR] 1.2, 95% CI 1.1-1.4). Telemedicine availability was associated with increased total ED LOS (15 min, 95% CI 10-21 min), and computed tomography scans (aOR 1.6, 95% CI 1.3-1.9).

CONCLUSIONS

ED-based telemedicine consultation is requested for the most severely injured rural trauma patients. Telemedicine consultation was associated with more rapid interhospital transfer, and telemedicine availability is associated with increased radiography use and transfer. Future work should evaluate how telemedicine could target patients likely to benefit from telemedicine consultation.

How do the definitions of urban and rural matter for transportation safety? Re-interpreting transportation fatalities as an outcome of regional development processes

Urban and rural places are integrated through economic ties and population flows. Despite their integration, most studies of road safety dichotomize urban and rural places, and studies have consistently demonstrated that rural places are more dangerous for motorists than urban places. Our study investigates whether these findings are sensitive to the definition of urban and rural. We use three different definitions of urban-rural continua to quantify and compare motor vehicle occupant fatality rates per person-trip and person-mile for the state of Wisconsin. The three urban-rural continua are defined by: (1) popular impressions of urban, suburban, and rural places using a system from regional economics; (2) population density; and (3) the intensity of commute flows to core urbanized areas. In this analysis, the three definitions captured different people and places within each continuum level, highlighting rural heterogeneity. Despite this heterogeneity, the three definitions resulted in similar fatality rate gradients, suggesting a potentially latent "rural" characteristic. We then used field observations of urban-rural transects to refine the definitions. When accounting for the presence of higher-density towns and villages in rural places, we found that low-density urban places such as suburbs and exurbs have fatality rates more similar to those in rural places. These findings support the need to understand road safety within the context of regional development processes instead of urban-rural categories.

Controversies in advanced trauma life support

Since its introduction to the UK in 1988, the Advanced Trauma Life Support (ATLS) course has become the accepted standard for the care of victims of trauma during the ‘golden hour’. Yet despite this success, ATLS has been criticized over the years for its philosophy, the course contents, the rigid regulations, cost to participants and lack of validation. The aim of this article is to explore these and other frequently voiced concerns in the light of evidence gathered over the 20 years since ATLS was first introduced in the USA.

Census-based socioeconomic indicators for monitoring injury causes in the USA: a review

BACKGROUND

Unlike the UK or New Zealand, there is no standard set of census variables in the USA for characterising socioeconomic (SES, socioeconomic status) inequalities in health outcomes, including injury. We systematically reviewed existing US studies to identify conceptual and methodological strengths and limitations of current approaches to determine those most suitable for research and surveillance.

METHODS

We searched seven electronic databases to identify census variables proposed in the peer-reviewed literature to monitor injury risk. Inclusion criteria were that numerator data were derived from hospital, trauma or vital statistics registries and that exposure variables included census SES constructs.

RESULTS

From 33 eligible studies, we identified 70 different census constructs for monitoring injury risk. Of these, fewer than half were replicated by other studies or against other causes, making the majority of studies non-comparable. When evaluated for a statistically significant relationship with a cause of injury, 74% of all constructs were predictive of injury risk when assessed in pairwise comparisons, whereas 98% of all constructs were significant when aggregated into composite indices. Fewer than 30% of studies selected SES constructs based on known associations with injury risk.

CONCLUSIONS

There is heterogeneity in the conceptual and methodological approaches for using census data for monitoring injury risk as well as in the recommendations as to how these constructs can be used for injury prevention. We recommend four priority areas for research to facilitate a more unified approach towards use of the census for monitoring socioeconomic inequalities in injury risk.

Educational and clinical impact of Advanced Trauma Life Support (ATLS) courses: a systematic review

BACKGROUND

We aimed to systematically review the literature on the educational impact of Advanced Trauma Life Support (ATLS) courses and their effects on death rates of multiple trauma patients.

METHODS

All Medline, Pubmed, and the Cochrane Library English articles on the educational impact of ATLS courses and their effects on trauma mortality for the period 1966-2012 were studied. All original articles written in English were included. Surveys, reviews, editorials/letters, and other trauma courses or models different from the ATLS course were excluded. Articles were critically evaluated regarding study research design, statistical analysis, outcome, and quality and level of evidence.

RESULTS

A total of 384 articles were found in the search. Of these, 104 relevant articles were read; 23 met the selection criteria and were critically analyzed. Ten original articles reported studies on the impact of ATLS on cognitive and clinical skills, six articles addressed the attrition of skills gained through ATLS training, and seven articles addressed the effects of ATLS on trauma mortality. There is level I evidence that ATLS significantly improves the knowledge of participants managing multiple trauma patients, their clinical skills, and their organization and priority approaches. There is level II-1 evidence that knowledge and skills gained through ATLS participation decline after 6 months, with a maximum decline after 2 years. Organization and priority skills, however, are kept for up to 8 years following ATLS. Strong evidence showing that ATLS training reduces morbidity and mortality in trauma patients is still lacking.

CONCLUSIONS

It is highly recommended that ATLS courses should be taught for all doctors who are involved in the management of multiple trauma patients. Future studies are required to properly evaluate the impact of ATLS training on trauma death rates and disability.

Safety in numbers: are major cities the safest places in the United States?

STUDY OBJECTIVES

Many US cities have experienced population reductions, often blamed on crime and interpersonal injury. Yet the overall injury risk in urban areas compared with suburban and rural areas has not been fully described. We begin to investigate this evidence gap by looking specifically at injury-related mortality risk, determining the risk of all injury death across the rural-urban continuum.

METHODS

A cross-sectional time-series analysis of US injury deaths from 1999 to 2006 in counties classified according to the rural-urban continuum was conducted. Negative binomial generalized estimating equations and tests for trend were completed. Total injury deaths were the primary comparator, whereas differences by mechanism and age were also explored.

RESULTS

A total of 1,295,919 injury deaths in 3,141 US counties were analyzed. Injury mortality increased with increasing rurality. Urban counties demonstrated the lowest death rates, significantly less than rural counties (mean difference=24.0 per 100,000; 95% confidence interval 16.4 to 31.6 per 100,000). After adjustment, the risk of injury death was 1.22 times higher in the most rural counties compared with the most urban (95% confidence interval 1.07 to 1.39).

CONCLUSION

Using total injury death rate as an overall safety metric, US urban counties were safer than their rural counterparts, and injury death risk increased steadily as counties became more rural. Greater emphasis on elevated injury-related mortality risk outside of large cities, attention to locality-specific injury prevention priorities, and an increased focus on matching emergency care needs to emergency care resources are in order.

Influence of race and neighborhood on the risk for and outcomes of burns in the elderly in North Carolina

Risk factors for mortality and length of hospital stay in elderly burn patients are well established, but the influence of race and socioeconomic status has not been evaluated. This study evaluates the effect of neighborhood level socioeconomic indicators on burns risk, and determines whether race and neighborhood influence burn injury outcomes in the elderly. Data from the North Carolina Jaycee Burn Center was linked to United States Census Bureau block group socioeconomic data. The odds of death and increased length of hospital stay for European-Americans and Minorities were determined using logistic regression. Rates of burn were determined using Poisson regression, and multilevel modeling was used to evaluate the influence of neighborhood on outcomes. No significant differences in mortality were observed between European-American and Minority patients in individual (Minority OR 0.71; p=0.3200) and multilevel (0.72; p=0.4020) models. Minorities had significantly higher odds of increased length of hospital stay in individual (2.05; p=0.0020) and multilevel (2.55; 0.037) models. High proportions of rural households (RR=1.39; p=0.0010) and poverty (1.26; p<0.0001) were significantly associated with increased risk of burn. Additional investigation using larger databases will allow further elucidation of the contextual effects of socioeconomic status on burn in the elderly.

Traumatic brain injury research priorities: the Conemaugh International Brain Injury Symposium

In 2005, an international symposium was convened with over 100 neuroscientists from 13 countries and major research centers to review current research in traumatic brain injury (TBI) and develop a consensus document on research issues and priorities. Four levels of TBI research were the focus of the discussion: basic science, acute care, post-acute neurorehabilitation, and improving quality of life (QOL). Each working group or committee was charged with reviewing current research, discussion and prioritizing future research directions, identifying critical issues that impede research in brain injury, and establishing a research agenda that will drive research over the next five years, leading to significantly improved outcomes and QOL for individuals suffering brain injuries. This symposium was organized at the request of the Congressional Brain Injury Task Force, to follow up on the National Institutes of Health Consensus Conference on TBI as mandated by the TBI ACT of 1996. The goal was to review what progress had been made since the National Institutes of Health (NIH) Consensus Conference, and also to follow up on the 1990's Decade of the Brain Project. The major purpose of the symposium was to provide recommendations to the U.S. Congress on a priority basis for research, treatment, and training in TBI over the next five years.

Rural-urban differences in injury hospitalizations in the U.S., 2004

BACKGROUND

Despite prior research demonstrating higher injury-mortality rates among rural populations, few studies have examined the differences in nonfatal injury risk between rural and urban populations. The objective of this study was to compare injury-hospitalization rates between rural and urban populations using population-based national estimates derived from patient-encounter data.

METHODS

A cross-sectional analysis of the 2004 Nationwide Inpatient Sample was conducted in 2007. Rural-urban classifications were determined based on residence. SUDAAN software and U.S. Census population estimates were used to calculate nationally representative injury-hospitalization rates. Injury rates between rural and urban categories were compared with rate ratios and 95% CIs.

RESULTS

An estimated 1.9 million (95% CI=1,800,250-1,997,801) injury-related hospitalizations were identified. Overall, injury-hospitalization rates generally increased with increasing rurality; rates were 27% higher in large rural counties (95% CI=10%, 44%) and 35% higher in small rural counties (95% CI=16%, 55%). While hospitalization rates for assaults were highest in large urban counties, the rates for unintentional injuries from motor vehicle traffic, falls, and poisonings were higher in rural populations. Rates for self-inflicted injuries from poisonings, cuttings, and firearms were higher in rural counties. The total estimated hospital charges for injuries were more than $50 billion. On a per-capita basis, hospital charges were highest for rural populations.

CONCLUSIONS

These findings highlight the substantial burden imposed by injury on the U.S. population and the significantly increased risk for those residing in rural locations. Prevention and intervention efforts in rural areas should be expanded and should focus on risk factors unique to these populations.

What is the future of advanced trauma life support training?

Within the past 20 years, advanced trauma life support has developed from a regional to an international educational programme, with 31 participating countries. Notwithstanding the general acknowledgement of the effectiveness of advanced trauma life support procedures for improving early hospital trauma management and the specific knowledge and skills of participants, some criticism has come from the community of British anaesthetists, regarding course contents, the possibility of participating, the significance of skills for trained anaesthetists, team-related concerns and, of course, costs. Now that we have 10 years' experience from European advanced trauma life support courses, we want to take the opportunity to assess the advantages and possible deficiencies of this programme.

Threats to rural surgery

BACKGROUND

Rural surgery is a subject that often is discussed but little has been done to address the problems of rural surgery. With a decreased interest in broad-based general surgery, an aging population (especially in rural America), an aging population of general surgeons who are retiring early, surgical care in rural North America is approaching a crisis.

METHODS

An internet search was performed to analyze the problems in rural surgery. Also, the experience of a 90-bed rural hospital in south central Kentucky was analyzed.

RESULTS

Approximately 17% to 25% of the population in America (55 million) live in a rural environment, depending on the way rural is defined. Rural general surgeons may become an endangered species because of multiple factors, including: lack of broad-based training, increased specialization, lifestyle issues, decreased interest in surgery, increased technology, aging rural surgeons, increased workload for the general surgeon, decreased reimbursement, increased expenses, increased expectations of the general public, and increased malpractice costs. Solutions include programs dedicated to training rural surgeons, networking with university tertiary care hospitals, equal pay for work performed regardless of the location, regionalization of rural surgery centers with multiple surgeons so the lifestyle issues can be addressed.

CONCLUSIONS

There is an increasing need for broad-based general surgeons in rural America. Training programs need to address the problem by offering dedicated training programs that should include primary training in general surgery and fellowships for special needs. A new specialty in rural general surgery needs to be created.

Acute traumatic injuries in rural populations

In the United States, injuries are the leading cause of death among individuals aged 1 to 45 years and the fourth leading cause of death overall. Rural populations exhibit disproportionately high injury mortality rates. Deaths resulting from motor vehicle crashes, traumatic occupational injuries, drowning, residential fires, and suicide all increase with increasing rurality. We describe differences in rates and patterns of injury among rural and urban populations and discuss factors that contribute to these differences.

Characteristics of twice-transferred, rural trauma patients

OBJECTIVE

Undertriage has seldom been evaluated in the trauma population. In rural states patients often go to the nearest hospital first, where they are evaluated and, if necessary, transferred to another hospital. If they are undertriaged when transferred to the second hospital, they will require a second transfer to a higher-level trauma center.

METHODS

The authors retrospectively reviewed the charts of all trauma patients at a level I trauma center from 1996 to 1999 who were seen at two acute care facilities because of a single acute traumatic event before reaching the trauma center. Ninety-three patient charts were analyzed.

RESULTS

Forty-six percent of the patients were victims of a motor vehicle crash. Patients were mostly transferred to the level I trauma center for non-spine orthopedic injuries (28%), followed by spine injuries (14%) and head injuries (13%). These patients were stable, as manifested by an average trauma score of 11.6. However, there was a significant positive interaction between injury severity score and time to definitive care.

CONCLUSIONS

The authors infer from the data analysis that more serious or complex injuries took longer to evaluate. Since these patients were physiologically stable, reducing the number of twice-transferred trauma patients will involve refining transfer protocols concerning the need for specialty care.

Trauma education

OBJECTIVE

Trauma is a diverse disease in which time critical decisions and skills affect patient outcome. This review article examines the methods and assessment of education for the management of the trauma patient.

METHOD

Literature review.

RESULTS

Education is a planned experience that leads to a change in behaviour. Adult education methods can be used to improve the knowledge, skills, attitudes and relationships of health care workers. Adult learners need careful consideration of lecture style, small group work, role play and skills stations in order to achieve these aims. These techniques are typically used in short intensive courses such as Advanced Trauma Life Support (ATLS) aimed at the initial care of the trauma patient. There is a relative lack of education directed at definitive care. It is important to assess the impact of trauma education in terms of clinical process, retention of skills/knowledge and the outcome of patients. A generic approach (the ABC approach) is applicable to the care of all critically ill or injured patients. This approach should be taught at junior level.

CONCLUSION

The care of trauma patients can be improved by educating health care workers using adult educational strategies.

Looking at trauma and deaths: Diyarbakir city in Turkey

There were 329 trauma related deaths in Diyarbakir in 1997. Of these 226 were male (69%) and 103 were female (31%). The median age was 20 years old (range 1-82 years). Of the deaths, 30.5% were under 10, 51% were under 20 and 67% were under 30 years old. Two hundred and eleven deaths occurred in the hospital while 118 deaths occurred prehospital. Seventy-seven percent of hospital deaths (191) occurred in the first day. The most common cause of death was multiple injuries (151, 46%). Head injuries were the main reason for 128 deaths (46%). The most common mechanism of death was motor vehicle accident (131, 40%). The second was falls from a residential building (117, 33.7%).

Impact of level III verification on trauma admissions and transfer: comparisons of two rural hospitals

PURPOSE

To study the impact of Level III verification and other changes in rural hospitals on trauma delivery and to examine factors affecting transfer to a Level I trauma center.

SETTING

Two rural Kentucky hospitals and a Level I trauma center.

METHOD OF REVIEW

Concurrent review of all trauma patients in 1988 and re-review of the same parameters in 1995.

FINDINGS

In 1988, both hospitals had similar management practices in trauma care. A significant number of patients were transferred for (a) patient choice, (b) serious and/or multiple trauma, (c) specialty care in non-life threatening situations, and (d) to exclude a potentially serious problem seen on radiologic evaluation (usually questionable cervical spine or widened mediastinum). Both hospitals had major changes in trauma delivery. One hospital received Level III verification, and the other had changes that lessened the general surgeon's involvement with initial evaluation and treatment. A re-review in 1995 disclosed major changes at both institutions. Transfers to exclude radiologic abnormalities had virtually disappeared. The Level III status had increased the surgical involvement in that hospital; there was actually an increase in patients transferred to the Level I hospital and an increase in patient acuity. More operations were performed locally, and the care was more efficiently delivered. The other hospital had a large increase in transfers and decreased admissions locally as general surgical involvement decreased.

CONCLUSIONS

The factors related to patient transfer for trauma care are complex and require careful elucidation to improve care. The development of a Level III trauma service appeared to increase the number of seriously injured patients treated in the rural hospital and the efficiency of the care delivered.

A model for an integrated emergency medicine/trauma service

OBJECTIVE

To describe a model for an integrated multidisciplinary trauma service and to compare survival outcomes for patients resuscitated by either emergency medicine (EM) or surgical housestaff assigned to the trauma service.

METHODS

A prospective observational study was performed using injured patients evaluated in the trauma room at Hartford Hospital from July 1 through December 31, 1995. Inclusion criteria included an ICD-9-CM code of 800 through 959.9 and any of the following: transfer from another hospital, admission to the intensive care unit, hospitalization for > or = 23 hours, survival probability of < or = 90%, or Abbreviated Injury Score of > or = 3. Patients were excluded for burns necessitating transfer to a burn unit for definitive care, and for missing data elements that prevented a patient from being analyzed by the TRISS method. Data elements included mechanism of injury, Injury Severity Score, Revised Trauma Score, probability of survival, age, gender, and whether an EM resident was team leader. Patients in the EM cohort (group 1) were compared with patients for whom a surgical resident was team leader (group 2) for all data elements and for hospital survival. TRISS analysis was performed to evaluate outcomes in comparison with national norms.

RESULTS

After exclusions, 609 patients were left for analysis. There were 141 (30%) resuscitated with an EM resident as team leader. No significant difference was found for matched variables between the groups. Both groups had good comparability with the Major Trauma Outcome Study (MTOS) database baseline, with M scores of 0.949 and 0.942, respectively. Outcomes for both groups also compared favorably with the MTOS norm for survival, with Z scores of 2.38 and 2.35 for groups 1 and 2.

CONCLUSIONS

These results suggest that in this model of integrated EM/trauma service, equivalent survival outcomes occur whether EM or surgery housestaff act as team leaders.

The early effects of implementing American College of Surgeons level II criteria on transfer and survival rates at a rurally based community hospital

We conducted a retrospective review to determine the early effects of implementing the American College of Surgeons (ACS) level II criteria on the number of transferrals and survival rates of trauma patients in a rurally based hospital. Data were collected from time period "B" (13 months before) and time period "A" (14 months after) implementing ACS criteria. Patient data parameters included age, sex, Revised Trauma Score, Glasgow Coma Scale score, Injury Severity Score, number of days hospitalized, diagnoses, place of injury (i.e., local county or transfer from another county), outcome, and probability of survival. There was a significant increase in the number of patients with Injury Severity Score > or = 15 from period B to period A (189 vs. 297, p = 0.002). A much higher percentage of these patients were transfers from out of county (period B = 33% vs. period A = 59.5%, p = 0.0001). Despite a higher percentage of transferred patients with probability of survival < or = 25% (period B = 25% vs. period A = 58%, p = 0.002), the survival rate in this group improved from 7.5% during time period B to 25.5% after implementing level II criteria (p = 0.0303). This data suggest that implementing level II ACS guidelines has the early beneficial effects of increasing transfers of seriously injured patients and improving survival in the most critically injured group.