Purpose, definitions and principles

To describe in detail the South East Scotland regional Major Trauma Network transfer policy from Trauma Units (TUs) and Local Emergency Hospitals (LEH) to the Edinburgh Major Trauma Centre (MTC) at the Royal Infirmary of Edinburgh (RIE).

Triage is the process of sorting patients by urgency and priority. It is a dynamic process and should be reassessed at multiple points.  There is a nationally agreed SASTTT in the pre-hospital arena to decide the initial destination of the patient.  This can, and should initially be applied by SAS to determine suspected major trauma patients.  The majority of suspected major trauma patients will undertake primary transfer including bypassing nearby hospitals, to the MTC.

Major trauma patients are often only defined days after their injury, when their injury severity score (ISS) has been calculated as >15.  This document uses the term major trauma patients to encompass any patient taken to a TU or MTC who is suspected to have suffered major trauma based upon a triage tool or clinical judgement, regardless of their eventual ISS score.

Please also refer to SAS guidance on booking transfers.

The majority of major trauma patients will be brought to the MTC by SAS using the TTT.  Major trauma patients may be in other Emergency Departments (ED) if the patient:

• Was under triaged or mis-triaged by the TTT.
• Deteriorates following triage.
• Has a compromised airway and SAS need immediate assistance.
• Self presents.

The following units may be involved in secondary transfers to the MTC at RIE:

• St John’s Hospital (LEH)
• Borders General Hospital (TU)
• Victoria Hospital, Kirkcaldy (TU)
• Forth Valley Royal Hospital (TU)

Automatic patient acceptance is a fundamental principle of the network.  In essence, if a phone call is made about a critically injured patient the patient is accepted.  Critical Care bed availability in the MTC is not a pre-requisite for automatic acceptance. The MTC trauma team leader (TTL) should be called by the TU consultant to notify them of the patient and allow the MTC to make preparation for their arrival.  Such patients are not for discussion about whether or not to be transferred.  The SAS will still place a 15 minute pre alert call stating trauma unit transfer with the standardised ATMIST handover.  The following patents may be transferred under automatic acceptance criteria though these are by no means mandatory criteria:

• See separate TBI transfer guideline.
• Major vessel injuries.
• Flail chest.
• Crushed, de-gloved, mangled or pulseless extremity.
• Amputation proximal to wrist or ankle.
• Pelvic fracture with haemodynamic instability.
• Paralysis.
• Multisystem injuries and a suspected ISS>15.
• Grade III or above solid organ that may require Interventional Radiology.
• High energy open long bone fracture (as decided by senior Orthopod).
• Post Damage Control Surgery performed at TU.
• TU TTL believes the patient would benefit from MTC care.

Even if a patient fits the above criteria it is still  permissible for the patient to remain in TU care if this is deemed appropriate by the TU TTL.  Similarly, the TU TTL consultant may wish to discuss with the MTC TTL at consultant level the suitability of transfer of certain major trauma patients where remaining at the TU may be more appropriate.  Examples may include:

• Patients with a DNACPR, advance directive with major injuries where interventions may not be appropriate.

The process for undertaking TU to MTC transfers is detailed in the transfer algorithm.

Paediatric trauma transfers are detailed in the Paediatric transfer protocol.

Once the decision to transfer the patient and contact has been made with MTC, it remains the responsibility of the TU TTL consultant to determine the appropriate person and equipment to undertake the transfer (using the transfer checklist).  The  escorts should have appropriate training and skills to manage the patient during the transfer, be familiar with equipment and process surrounding the  transfer of critically ill or injured patients.

For intubated patients the following specialties include transfer training in their curricula:

• Anaesthesia
• Intensive Care Medicine
• Pre-Hospital Emergency Medicine

For non-intubated patients the TU consultant must decide if an escort is necessary or the patient can be transported with SAS and no escort.  If an escort is necessary the TU TTL should decide on the most appropriate person.  Escort not routinely required, only consider if specific complication expected.  These decisions should take into account the severity of injuries, ongoing treatment and staffing levels in the TU/LEH.

In some circumstances liaise the trauma desk as the availability of an Enhanced Care Team to facilitate transfer.  SAS will not routinely return the team to their base hospital.

• A send and call policy exists, so patient  transfers can occur without delay.
• The TU Consultant should call the MTC TTL as soon as possible but this should not delay transfer.
• All TU to MTC referrals must have been discussed with the TU consultant prior to referral.
• The MTC at RIE cannot refuse a patient whom the TU consultant is concerned requires MTC care.
• All time critical transfers will be arranged through the trauma triage desk.
• Patient stability is not a prerequisite for  transfer.  The TU is responsible for ensuring the patient is as safe as possible for transfer but it is recognised that stability may be impossible to achieve, particularly when this may be the reason for MTC transfer.