2.5 Protocol for Inter-Facility Transfer

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Description of Indicator

Relationship to Quality  Medical care should be timely, equitable, and efficient 
Type of Indicator Prehospital and Hospital structure, System level
Proposed Data Source Survey
Definition Trauma systems with a protocol to guide the transfer of injured patients from a lower-level facility to a highter-level facility
Numerator Truama systems with protocol for transfer of injured patients age 18 years and older from a lower-level facility to a higher-level facility
Denominator Not applicable
Benchmark Not applicable
Risk Adjustment Not applicable


This indicator is intended to identify trauma systems with protocols for guiding transfer of injured patients between healthcare facilities.

Panel Review
Panelists emphasized the importance of this indicator for rural regions where Level 1 centers are significant distances from the site of injury. It was noted that there is a need to evaluate both the application and effectiveness of the protocol in addition to simply having a protocol. Panelists reported that protocols may vary between centers and this could impact protocol effectiveness.

Trauma Center Review
The trauma centers emphasized the importance of protocols for both patient transfer and transfer agreements between centers. They noted that getting the patient to the most appropriate facility is important. The trauma centers highlighted that all centers, regardless of trauma center status, needed to be involved in documentation for this indicator.

Review of Literature & Evidence
Face Validity: In one study, 88% of Delphi panel participants ranked implementation of a protocol to ensure prompt transfer of trauma patients from a lower-level to a higher-level facility as very important13.
Construct Validity: No studies identified.
Reliability: No studies identified.
Risk Adjustment: Not applicable.
Utilization: Patient Transfer Protocol is used as an indicator by a moderate number of trauma centers: USA 38% (75/200), Canada 3% (1/35), Australasia 0% (0/12).
Protocols should specify the transfer of appropriate injured patients from rural areas to Level 1 trauma centers in a timely fashion in order to reduce mortality rates30. Two hours has been suggested as one possible time threshold for transfer31. There is some evidence to support the use of helicopter transfer to improve patient survival32. Pretransfer interventions such as CT scan and laparotomy have been shown to delay time of transportation and increase cost and not improve outcomes33. Protocols should include means to ensure the equitable transfer of patients and not be based on patients’ ability to pay34.


Rosengart et al. developed the indicator using a Delphi panel of trauma experts13.


13. Rosengart MR, Nathens AB, Schiff MA. The identification of criteria to evaluate prehospital trauma care using the Delphi technique. J Trauma. 2007;62(3):708-713.
30. Garwe T, Cowan LD, Neas BR, Sacra JC, Albrecht RM. Directness of transport of major trauma patients to a level i trauma center: A propensity-adjusted survival analysis of the impact on short-term mortality. J Trauma. 2011;70(5):1118-1127.
31. Crandall ML, Esposito TJ, Reed RL, Gamelli RL, Luchette FA. Analysis of compliance and outcomes in a trauma system with a 2-hour transfer rule. Arch Surg. 2010;145(12):1171-1175.
32. Brown JB, Stassen NA, Bankey PE, Sangosanya AT, Cheng JD, Gestring ML. Helicopters improve survival in seriously injured patients requiring interfacility transfer for definitive care. J Trauma. 2011;70(2):310-314.
33. Mohan D, Barnato AE, Angus DC, Rosengart MR. Determinants of compliance with transfer guidelines for trauma patients: a retrospective analysis of CT scans acquired prior to transfer to a Level I trauma center. Ann Surg. 2010;251(5):946-951.
34. Parks J, Gentilello LM, Shafi S. Financial triage in transfer of trauma patients: a myth or a reality? Am J Surg. 2009;198(3):e35-e38.