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A new study has identified several predictors of clinical deterioration and ICU admission in patients transferred from the Nunavik region of northern Quebec to a level 1 trauma center.

The retrospective cohort study examined data from patients transported from Nunavik, the home of approximately 11,000 Inuit people, to Montreal General Hospital between 2010 and 2019. The investigators found that longer transport time and the presence of certain injuries predicted clinical deterioration during the transfer. They also identified this deterioration as one of several predictors of ICU admission upon arrival.

"Trauma care in Nunavik involves unique challenges related to the vast and isolated geographic location, in addition to unpredictable meteorologic conditions that create substantial difficulty in transferring injured patients in a safe and timely manner," study author Evan G. Wong, MD, MPH, an assistant professor of surgery at McGill University in Montreal, Quebec, Canada, told Medscape Medical News.

The study was published on February 21 in the Canadian Journal of Surgery.

The 'Golden Hour'

While two regional hospitals serve the Inuit population of northern Quebec, patients requiring tertiary care are transferred by plane to the region's level 1 trauma center: Montreal General Hospital. For the best outcomes, patients should arrive at a trauma center within an hour of the injury. This is the so-called "golden hour" principle. But for patients whose transport time was recorded, it took a median of 9.3 hours to arrive at Montreal General Hospital.

To improve patient transport and triage in the future, the study aimed to identify key predictors of clinical deterioration during transport, specifically changes from normal cardiovascular and neurologic function. The investigators collected data from Montreal General Hospital's trauma registry, which included 704 patients. The median age of transferred patients was 33 years, and the median Injury Severity Score was 10.

The study identified several predictors of clinical deterioration, including longer transport time from the site of injury to the trauma center (odds ratio [OR], 1.04), thoracic injuries (OR, 1.75), and head and neck injuries (OR, 3.76). It also identified independent predictors of ICU admission, including deterioration during transfer (OR, 4.22). Scores for injury severity (OR, 1.04) and consciousness (OR, 2.57), traumatic brain injury (OR, 2.44), and the need for transfusion (OR, 4.63) also predicted ICU admission.

Refining Triage

"These predictors can first and foremost be used to refine the current triage criteria and provide guidance to determine the need for a higher level of care during transport," said Wong. All patients must be accompanied by at least one health professional, and that professional may be a first responder, nurse, or physician.

Until shorter transport times are achieved, the results suggest that in-flight resources such as blood products and thoracostomy tubes are likely beneficial, Wong added. Transfusions and thoracostomy were important for patients upon arrival at Montreal General Hospital, which may indicate a need for these interventions during or before transport, the authors wrote.

Wong noted that the study is limited by its retrospective design. In addition, data on local trauma mortality and on transferred patients who were not admitted to the trauma center are missing. The registry also lacked data for some patients on transport times and vital signs on the scene. "Nevertheless, it highlights the substantial barriers faced by trauma patients originating from Nunavik in reaching definitive care," said Wong.

'Tyranny of Distance'

Commenting on the study for Medscape Medical News, Andrew Beckett, MD, a trauma surgeon and associate professor of surgery at the University of Toronto, Toronto, Ontario, Canada, said that it highlights the disparity in trauma care for remote and indigenous communities across Canada.

"We live in this situation called the 'tyranny of distance'," said Beckett, who also serves as the president of the Trauma Association of Canada. Because most of the larger hospitals are in the southern part of the country, many remote communities lack access to specialized care and diagnostic imaging, which puts patients at higher risk.

Establishing a more clearly defined referral pattern and a more formal triage system could help, according to Beckett. In addition, he believes that the federal government should invest more funding in better infrastructure and resources, such as blood product or telemedicine setups.

Because of the lengthy transport time, it's important for patients to receive blood product to "fill up the tank" until they undergo surgical intervention, Beckett added. "When you're bleeding, the best resuscitation fluid is blood." However, remote communities don't have much blood product pre-positioned. Beckett is currently working on a project to expand the use of freeze-dried plasma.

Funding for the study was not reported. Wong and Beckett reported no relevant financial relationships.

Gwendolyn Rak is a health reporter for Medscape Medical News based in Brooklyn, New York.