Question: In the BLS Standards I found in Section 1, General Standard of Care, Directive H. Patient Transport, the following statement in subsection 1 "in the absence of direction, transport to the closest or most appropriate hospital emergency unit capable of providing the medical care apparently required by the patient." So one question I have is the trauma patient, if they needed care above the capabilities of the closest hospital emergency unit, do we transport the patient to the closest hospital emergency unit that has these capabilities?
Great question! The real issue is how you define the trauma patient. The BLS Patient Care Standards in Section 1- General Standards of Care have described a set of criteria which are known as the Field Trauma Triage Guidelines. The closest most appropriate hospital for on-scene call patients assessed as meeting the Field Trauma Triage Guidelines is the closest Lead Trauma Hospital. The page reference is Section 1-25.
On-scene call patients assessed as meeting the Field Trauma Triage Guidelines (FTTG) will bypass other hospitals to go to the closest Lead Trauma Hospital if the closest Lead Trauma Hospital is less than thirty minutes away by land ambulance. It is essential to note however that the FTTG does not include every patient that has been injured by a traumatic mechanism: there are specific criteria that need to be met and these are described in the BLS PCS.
Note that paramedics will divert to the closest hospital with an emergency department when, in their judgment, the patient could not survive transport to the nearest Lead Trauma Hospital (complete airway obstruction, no spontaneous respirations, no palpable carotid pulse). The 30 minutes in an approximation and includes extrication time, traffic and road/weather conditions, and those factors which affect response/transport time but cannot be predetermined.
One of the confusing components of the BLS PCS is the definition of the Lead Trauma Hospital. Officially at the moment, London Health Sciences Centre (LHSC) Victoria Hospital is considered a Level I LTH and Hotel Dieu in Windsor is considered a Level II. For the majority of paramedics in the Southwest however, the closest ED becomes the destination since these two LTH's fall outside the 30min transport window. Therefore, in practicality, all hospitals play a role in the management of the trauma patient. It is also essential for paramedics to follow their local destination protocols which may have addressed these scenarios in collaboration with the Base Hospital.
The Trauma Association of Canada, has gone through a two year process where, Accreditation Canada will now accredit the trauma programs through a trauma distinction program. Windsor will be going through the pilot process in November. Interestingly they will be looking at three local hospitals, and the level of trauma care provided.
In the future, it is possible that all of the hospitals will have a level, and paramedics could possibly be bypassing lower level centers for those with a surgeon and scanner in rural areas. This is where destination policies and local trauma networks come into play: stay tuned!
The Ontario Base Hospital Group (OBHG) along with Ornge and the Ontario Trauma Advisory Committee (OTAC) have revised the Field Trauma Triage Guidelines within the last few years. The revised versions of these guidelines are anticipated to be released shortly from the MOHLTC.