The accident and emergency department as a single portal of entry for the reassessment of all trauma patients transferred to specialist units

The evolution of trauma services at Beaumont Hospital

OBJECTIVE

To review and examine the epidemiology, severity and management of trauma admissions at the national neurosurgical teaching hospital.

METHODS

An extensive audit of volume, type and severity of injury and the management requirements of the trauma population admitted to the hospital.

RESULTS

The vast majority of severely injured patients were referred from outside the catchment area of the hospital with only 26% being admitted directly through the Emergency Department. As a consequence, 73% of patients arrived out of normal working hours, which posed problems in providing skilled trauma specialists.

CONCLUSIONS

The management of patients with serious injury is complex. The large proportion of patients with critical injuries, some of whom were paediatric, highlighted the need for 24 h cover by senior trauma personnel and the provision of radiology and operating facilities to meet their needs. The inclusion of indicators of alterations in innate or adaptive immune responses may improve the predictive power of severity of injury scores.

Emergency department organisation of critical care transfers in the UK

OBJECTIVES

Transport of the critically ill patient to or from the emergency department (ED) is a frequent occurrence. This study was designed to determine whether UK EDs currently have appropriate equipment, monitoring, staff training systems, and processes of care for transportation of the critically ill patient.

METHODS

A postal questionnaire regarding ED transfer patients was sent to 247 UK EDs, followed by repeat mailing and telephone follow up of non-responders.

RESULTS

In total, 139 EDs (56%) responded. An estimated 20-30 critically ill patients are transferred from and <20 are received by each ED annually. Processes of care are poorly developed; only 79 EDs (56%) have transfer guidelines available. Audit of transfers is ongoing in 59 EDs (42%), and critical incident reporting is ongoing in 122 (88%). There is a lack of immediately available transport equipment; for example, 17 EDs (12%) have no transport ventilator, 9 (6%) have no transport monitor, and 9 (6%) have no syringe pump. Transport equipment is invariably not standardised. Anaesthetic staff of specialist registrar (74 doctors; 53%) or senior house officer (36 doctors; 26%) grades carry out the majority of ED transfers accompanied by a D or E grade nurse. Both invariably have no formal transfer training.

CONCLUSIONS

This study highlights inadequacies in provision of equipment and monitoring during interhospital transfer from the ED. Training and processes of care for transport of the critically ill are also suboptimum. Many departments are currently reviewing these processes to formalize and improve transfer training procedures and protocols.

Secondary transport of the critically ill and injured adult

There is significant interest in the secondary transport of the critically ill and injured. High profile cases entailing the long distance transfer of patients have highlighted the lack of availability of critical care beds and appropriate systems for transferring this patient group. These and other issues have culminated in the release of Comprehensive Critical Care by the Department of Health in 2000. It has been shown that a large number of critical care transfers originate in the emergency department. The transportation of patients has not traditionally been part of the core curriculum of emergency medicine specialists in the UK. It is imperative that clinicians have an understanding of the issues surrounding transportation of the critically ill and injured. This should include appreciation of the local and regional organisational frameworks implemented for this patient group. This review describes the core issues relevant to emergency medicine relating to the transportation of the critically ill and injured.

Addressing the growing burden of trauma and injury in low- and middle-income countries

Low- and middle-income countries suffer disproportionately from reduced life expectancy and quality of life. Injuries are overlooked as contributors to global inequities in health, yet the long-term disabilities they frequently produce represent a significant burden. The Fogarty International Center of the National Institutes of Health convened a panel of experts in trauma and injury from the United States and low- and middle-income nations to identify research gaps in this area and opportunities to create new knowledge. Panel members identified sustainable programs of research established through stable linkages between institutions in high-income nations and those in low- and middle-income nations as a priority. The resulting benefits of addressing the growing burden of trauma and injury to communities in resource-constrained settings around the world would be substantial.

Descriptive epidemiology of adult critical care transfers from the emergency department

AIMS

To describe the nature, frequency, and characteristics of adult critical care transfers originating from the emergency department (ED).

METHODS

A one year prospective regional descriptive study using multiple data sources of all critically ill adults transferred from an ED or a minor injuries unit (MIU) within the former Yorkshire Regional Health Authority Area or into a regional critical care facility if originating from an ED or MIU elsewhere.

RESULTS

29 EDs transferred 349 adults into the regional critical care facilities. The median number of transfers per department within the region was 18 (range 1 to 42). Seventeen were transferred from outside the region. A total of 263 (75%) patients were transferred for specialist care and 76 (22%) for non-clinical reasons. Altogether 294 (84%) were admitted to intensive care or a high dependency unit at the receiving hospital. The in-hospital documented mortality rate was 26%. A total of 170 patients (49%) had traumatic pathology of which 101 were principally transferred for management of a head injury. Median time in the ED was 3 hours 5 minutes (range 11 minutes to 17 hours 47 minutes). In 146 (42%) patients the decision to transfer was primarily made by the emergency medicine clinician. A total of 251 (72%) patients were intubated. The documented critical incident rate was 15%.

CONCLUSION

Trauma is the most common reason for transfer of the critically ill adult from the ED. A significant number of patients are transferred, however, with medical and surgical conditions and for non-clinical reasons. There continues to be problems with the quality of care that these patients receive. Emergency medicine clinicians must be actively involved in the development of regional critical care systems as a significant proportion of all critically ill adults transferred originate from the ED.