[Analysis of a differentiated resuscitation room activation at a national trauma center]

BACKGROUND

In order to continue to efficiently provide both personnel-intensive and resource-intensive care to severely injured patients, some hospitals have introduced individually differentiated systems for resuscitation room treatment. The aim of this study was to evaluate the concept of the A and B classifications in terms of practicability, indications, and potential complications at a national trauma center in Bavaria.

METHODS

In a retrospective study, data from resuscitation room trauma patients in the year 2020 were collected. The assignment to A and B was made by the prehospital emergency physician. Parameters such as the injury severity score (ISS), Glasgow outcome scale (GOS), upgrade rate, and the indication criteria according to the S3 guidelines were recorded. Statistical data comparisons were made using t‑tests, χ2-tests, or Mann-Whitney U‑tests.

RESULTS

A total of 879 resuscitation room treatments (A 473, B 406) met the inclusion criteria. It was found that 94.5% of resuscitation room A cases had physician accompaniment, compared to 48% in resuscitation room B assignments. In addition to significantly lower ISS scores (4.1 vs. 13.9), 29.8% of B patients did not meet the treatment criteria defined in the S3 guidelines. With a low upgrade rate of 4.9%, 98% of B patients had a GOS score of 4 or 5.

CONCLUSION

The presented categorization is an effective and safe way to manage the increasing number of resuscitation room alerts in a resource-optimized manner.

Identifying the severely injured benefitting from a specific level of trauma care in an inclusive network: A multicentre retrospective study

INTRODUCTION

Defining major trauma (MT) with an Injury Severity Score (ISS) > 15 has limitations. This threshold is used for concentrating MT care in networks with multiple levels of trauma care.

OBJECTIVE

This study aims to identify subgroups of severely injured patients benefiting on in-hospital mortality and non-fatal clinical outcome measures in an optimal level of trauma care.

METHODS

A multicentre retrospective cohort study on data of the Dutch National Trauma Registry, region South West, from January 1, 2015 until December 31, 2019 was conducted. Patients ≥ 16 years admitted within 48 h after trauma transported with (H)EMS to a level I trauma centre (TC) or a non-level I trauma facility with a Maximum Abbreviated Injury Scale (MAIS) ≥ 3 were included. Patients with burns or patients of ≥ 65 years with an isolated hip fracture were excluded. Logistic regression models were used for comparing level I with non-level I. Subgroup analysis were done for MT patients (ISS > 15) and non-MT patients (ISS 9-14).

RESULTS

A total of 7,493 records were included. In-hospital mortality of patients admitted to a non-level I trauma facility did not differ significantly from patients admitted to the level I TC (adjusted Odds Ratio (OR): 0.94; 95% confidence interval (CI) 0.68-1.30). This was also applicable for MT patients (OR: 1.06; 95% CI 0.73-1.53) and non-MT patients (OR: 1.30; 95% CI (0.56-3.03). Hospital and ICU LOS were significantly shorter for patients admitted to a non-level I trauma facilities, and patients admitted to a non-level I trauma facility were more likely to be discharged home. Findings were confirmed for MT and non-MT patients, per injured body region.

CONCLUSION

All levels of trauma care performed equally on in-hospital mortality among severely injured patients (MAIS ≥ 3), although patients admitted to the level I TC were more severely injured. Subgroups of patients by body region or ISS, with a survival benefit or more favorable clinical outcome measures were not identified. Subgroups analysis on clinical outcome measures across different levels of trauma care in an inclusive trauma network is too simplistic if subgroups are based on injuries in specific body region or ISS only.

[Requirements for trauma rehabilitation centers : Post-acute rehabilitation (phase C) after severe trauma injury]

Severely injured patients need a qualified and seamless rehabilitation after the end of the acute treatment. This post-acute rehabilitation (phase C) places high demands on the rehabilitation facility in terms of personnel, material, organizational and spatial requirements.The working group on trauma rehabilitation of the German Society for Orthopedics and Traumatology e. V. (DGOU) and other experts have agreed on requirements for post-acute phase C rehabilitation for seriously injured people. These concern both the personnel and material requirements for a highly specialized orthopedic trauma surgery trauma rehabilitation as well as the demands on processes, organization and quality assurance.A seamless transition to the follow-up and further treatment of seriously injured people in the TraumaNetzwerk DGU® is ensured through a high level of qualification and the corresponding infrastructure of supraregional trauma rehabilitation centers. This also places new demands on the TraumaZentren DGU®. Only if these are met can the treatment and rehabilitation of seriously injured people be optimized.

[Safety aspects, emergency preparedness and hazard prevention in hospitals concerning mass casualty incidents (MCI)/terror-related MCI : Prospects on future challenges based on survey results from the 3rd emergency conference of the DGU]

Hintergrund

Weltweite terroristische Aktivitäten seit „9/11“ und folgend auch im europäischen Raum haben im Rahmen der Bewertung von kritischer Infrastruktur in Deutschland zu einem Umdenken auch hinsichtlich der Sicherheit an und in Kliniken geführt.

Ziel der Arbeit

Die vorliegende Publikation befasst sich mit der Bewertung vorliegender Konzepte zu Themen wie „Alarmierung“, „Sicherheit“, „Kommunikation“ und „Vorbereitung“ im vorgenannten Kontext.

Material und Methoden

Anhand einer Literatursichtung sowie einer Umfrage unter den Teilnehmern*innen der 3. Notfallkonferenz der DGU (Deutsche Gesellschaft für Unfallchirurgie) werden diese Thematik und die aktuell vorliegende Situation weiter analysiert und vorgestellt.

Ergebnisse

Die gewonnenen Daten verdeutlichen, dass ein Großteil der Kliniken zwar über eine Krankenhausalarm- und Einsatzplanung verfügt, jedoch die Frequenz der Aktualisierungen und die innerklinische Kommunikation zur Steigerung der Wahrnehmung eine deutliche Streuung zeigen.

Weiterhin verdeutlichen die Ergebnisse eine Heterogenität der vorliegenden innerklinischen Alarmierungskonzepte sowie einen Mangel an Sicherheitskonzepten und Kooperationen mit Sicherheits- und Wachdiensten. Zudem zeigt sich, dass die Thematik einer möglichen CBRN(chemical, biological, radiological, nuclear)-Bedrohung in der Risikoanalyse noch nicht adäquat wahrgenommen wird bzw. umgesetzt ist.

Diskussion

Zusammenfassend scheint die latente Bedrohung durch terroristische Aktivitäten dazu geführt zu haben, dass sich deutsche Kliniken in der Bewertung als kritische Infrastruktur mit der Thematik „Krankenhausalarm- und Einsatzplanung“ auseinandergesetzt und diese überwiegend auch umgesetzt haben. Allerdings zeigt sich für die nachgeordneten Bereiche und die aus der Alarmplanung ableitbaren Konsequenzen noch nicht die nötige Stringenz, um letztendlich adäquate Reaktionen in diesen besonderen Szenarien im Hinblick auf die Sicherheit in und an deutschen Kliniken zu gewährleisten.

[Competence, creativity and communication: basics for quality improvement in traumatology : Reality and future challenges]

Interdisciplinary collaboration is one of the key factors for successful treatment of patients with complex injuries and diseases. Hence, several innovative concepts have been initiated to improve the treatment quality within the field of trauma surgery. The implementation of a ward pharmacist with the daily discussion of prescribed medications shows a reduction of side effects, costs for medicaments and the use of antibiotics. An interdisciplinary and multimodal delirium team was introduced and every patient over the age of 65 years was screened for the risk of perioperative and postoperative delirium, the medication was adjusted and expert advice was available in the case of acute delirium. Corresponding to the well-established tumor boards, an interdisciplinary musculoskeletal conference to decide on the treatment of complex interdisciplinary injuries of the musculoskeletal system should be established. The future challenges will include the digital connection of hospitals within the already existing trauma networks in order to provide rapid access to this interdisciplinary expertise also outside maximum care hospitals.

Validity of the Best Practice Tariff in paediatric major trauma: A retrospective cohort study from a level 1 children's major trauma centre

INTRODUCTION

The Best Practice Tariff (BPT) in major trauma awards Major Trauma Centres (MTCs) a financial incentive when predefined standards of care are met. However, no tailored criteria exist with regards to the reimbursement policy in paediatric major trauma. In this study, we aim to examine the utility of the paediatric Major Trauma BPT and identify predictors of additional resource utilisation.

MATERIALS AND METHODS

This cohort study encompassed all paediatric major trauma calls (N = 682) presenting to a designated combined adult and paediatric MTC between July 2014 and June 2017. Patient demographics, admission pattern, injury parameters, length of stay (LOS) and the need for operative management were collected. Patients approved for the BPT uplift payment (BPT group) were compared with the cohort of children not qualifying (non-BPT group).

RESULTS

Overall, less than a quarter (23.2%) of the trauma population qualified for the BPT. The proportion of patients requiring operative intervention and CT scanning in the BPT group was significantly higher (p<0.001). These children also attained a higher ISS (median, 13.5 vs. 0, p <0.001) and required longer hospitalisation. Following a Receiver Operator Characteristic (ROC) curve analysis, a cut off ISS score > 8 demonstrated an excellent predictive value in identifying children qualifying for BPT (true positive and false positive rates: 90% and 10.7%). However, a subgroup analysis including the more severely injured children (ISS >8) not qualifying for the uplift payment revealed that equally substantial resource went into their management - 42.9% needed surgical intervention and 57.1% a CT scan.

DISCUSSION

This study demonstrated that BPT in paediatric major trauma is a valuable reimbursement; however, our findings also unveiled a cohort deemed ineligible for BPT despite the high costs accrued. Re-evaluation of the remuneration criteria of paediatric major trauma networks with an alternative, more inclusive reimbursement policy is needed.

Quality of life after multiple trauma: results from a patient cohort treated in a certified trauma network

PURPOSE

Besides mortality, the patient-reported outcome (PRO) in survivors of multiple trauma is of increasing interest. So far, no data on patient-reported outcome measures (PROMs) after multiple trauma from an entire trauma network are available. Within this study, the course of the PRO over time and differences between level I and level II trauma centers within an entire trauma network was evaluated.

METHODS

Multiple injured patients, treated in a rural trauma network over 2 years, were prospectively included in this study. After 6, 12 and 24 months the results of the European Quality of Life (EuroQoL) EQ-5D outcome instrument were evaluated. To adjust for differences in trauma severity between level I and level II centers, the Revised Injury Severity Classification II (RISC II) and the Functional Capacity Index (FCI) were used to adjust the life-quality results of patients.

RESULTS

501 patients were included, 118 patients with an ISS < 16 points, 383 patients reached 16 points or more. Despite a steady increase of EQ-5D index over time (6 months: 0.71 ± 0.31; 12 months: 0.74 ± 0.28; 24 months: 0.76 ± 0.27; p < 0.001), the values of a reference population could not be reached even 2 years after trauma (EQ-5D reference population: 0.9). After adjustment for trauma severity, no significant differences in PROMs between level I and level II centers could be detected (p = 0.188).

CONCLUSION

The consistently low EQ-5D index relative the reference population and the lack of a difference between level I and II centers suggest that improved strategies for polytrauma aftercare are called for.

Early management of severe pelvic injury (first 24 hours)

OBJECTIVE

Pelvic fractures represent 5% of all traumatic fractures and 30% are isolated pelvic fractures. Pelvic fractures are found in 10 to 20% of severe trauma patients and their presence is highly correlated to increasing trauma severity scores. The high mortality of pelvic trauma, about 8 to 15%, is related to actively bleeding pelvic injuries and/or associated injuries to the head, abdomen or chest. Regardless of the severity of pelvic trauma, diagnosis and treatment must proceed according to a strategy that does not delay the management of the most severely injured patients. To date, in France, there are no guidelines issued by healthcare authorities or professional societies that address this subject.

DESIGN

A consensus committee of 22 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et de Réanimation; SFAR) and the French Society of Emergency Medicine (Société Française de Médecine d'Urgence; SFMU) in collaboration with the French Society of Radiology (Société Française de Radiologie; SFR), French Defence Health Service (Service de Santé des Armées; SSA), French Society of Urology (Association Française d'Urologie; AFU), the French Society of Orthopaedic and Trauma Surgery (Société Française de Chirurgie Orthopédique et Traumatologique; SOCFCOT), and the French Society of Digestive Surgery (Société Française de Chirurgie digestive; SFCD) was convened. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently from any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE^® methodology.

RESULTS

The SFAR Guideline panel provided 22 statements on prehospital and hospital management of the unstable patient with pelvic fracture. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, 11 have a high level of evidence (Grade 1 ± ), 11 have a low level of evidence (Grade 2 ± ).

CONCLUSIONS

Substantial agreement exists among experts regarding many strong recommendations for management of the unstable patient with pelvic fracture.

The effect of indirect admission via hospital transfer on hip fracture patients in Ireland

BACKGROUND AND AIMS

Current best practice states that hip fracture patients should undergo surgery within 48 hours to minimise perioperative complications. There are 10 emergency departments (EDs) in Ireland that receive hip fracture patients without a trauma and orthopaedic surgery unit on site. Idle periods and duplicated preoperative investigations can lead to a prolonged time to surgery. The aim of this study was to identify the effect of admission route on the time to surgery, length of stay and pressure ulcer development in patients who sustain a hip fracture in Ireland.

METHODS

A retrospective cohort study was performed, using 2013 and 2014 data from the Irish Hip Fracture Database. Age, gender and ASA grade were identified as confounders and adjusted for accordingly.

RESULTS

Of the 3893 hip fractures identified, indirect admissions via hospital transfer occurred in 8.6% of cases. Surgery was performed within 48 h in 72.0% of indirect admission and 73.7% of direct admission cases (p = 0.502). The length of stay was significantly prolonged for patients admitted via hospital transfer (25.6 compared to 19.6 days, p < 0.001).

CONCLUSION

Delayed discharges post hip fracture have been shown to expose patients to increased perioperative morbidity and mortality rates, as well as reduced rehabilitation potential and less chance of returning home on discharge. This has significant cost implications for the health service and justifies the introduction of hospital bypass protocols for patients with hip fractures.

Social capital in a regional inter-hospital network among trauma centers (trauma network): results of a qualitative study in Germany

Background

As inter-hospital alliances have become increasingly popular in the healthcare sector, it is important to understand the challenges and benefits that the interaction between representatives of different hospitals entail. A prominent example of inter-hospital alliances are certified ‘trauma networks’, which consist of 5-30 trauma departments in a given region. Trauma networks are designed to improve trauma care by providing a coordinated response to injury, and have developed across the USA and multiple European countries since the 1960s. Their members need to interact regularly, e.g. develop joint protocols for patient transfer, or discuss patient safety. Social capital is a concept focusing on the development and benefits of relations and interactions within a network. The aim of our study was to explore how social capital is generated and used in a regional German trauma network.

Methods

In this qualitative study, we performed semi-standardized face-to-face interviews with 23 senior trauma surgeons (2013-14). They were the official representatives of 23 out of 26 member hospitals of the Trauma Network Eastern Bavaria. The interviews covered the structure and functioning of the network, climate and reciprocity within the network, the development of social identity, and different resources and benefits derived from the network (e.g. facilitation of interactions, advocacy, work satisfaction). Transcripts were coded using thematic content analysis.

Results

According to the interviews, the studied trauma network became a group of surgeons with substantial bonding social capital. The surgeons perceived that the network’s culture of interaction was flat, and they identified with the network due to a climate of mutual respect. They felt that the inclusive leadership helped establish a norm of reciprocity. Among the interviewed surgeons, the gain of technical information was seen as less important than the exchange of information on political aspects. The perceived resources derived from this social capital were smoother interactions, a higher medical credibility, and joint advocacy securing certain privileges.

Conclusion

Apart from addressing quality of care, a trauma network may, by way of strengthening social capital among its members, serve as a valuable resource for the participating surgeons. Some member hospitals could exploit the social capital for strategic benefits.

The decline of elective operating at major trauma centres

INTRODUCTION Major trauma is a leading cause of death in those aged under 40 years. In order to improve the care for multiply injured patients, the major trauma network was activated in April 2012 in England. Its goal was to link all district hospitals to major trauma centres (MTCs) and allow for rapid transfer of patients. Anecdotally, this has affected elective orthopaedic operating at MTCs. The aim of this study was to compare the number of lower limb arthroplasty procedures performed before and after the establishment of the trauma network. METHODS Data on hip and knee arthroplasties in England during the two years prior to and the two years following the introduction of the trauma network were obtained from the National Joint Registry. These were broken down by type of unit (MTCs vs non-MTCs). Differences between the number of hip and knee arthroplasties undertaken in the two time periods were analysed. The chi-squared test was used to assess statistical significance. RESULTS The total number of lower limb arthroplasties increased after the activation of the trauma network by 5.5% (from 211,453 to 223,119). When stratifying the data by type of unit, this increasing trend was present for non-MTCs; however, in MTCs, a reduction occurred: the number reduced by 13.6% (from 13,492 to 11,657). This reversal of trend was seen in both hip and knee procedures independently (both p<0.01). CONCLUSIONS The introduction of the trauma network has led to a reduction in the total number of lower limb arthroplasty procedures performed in MTCs. Various reasons have been postulated for this but its impact on surgical training and hospital finances must be scrutinised in future research.

Mechanisms, patterns and outcomes of paediatric polytrauma in a UK major trauma centre

Introduction Paediatric trauma is a significant burden to healthcare worldwide and accounts for a large proportion of deaths in the UK. Methods This retrospective study examined the epidemiological data from a major trauma centre in the UK between January 2012 and December 2014, reviewing all cases of moderate to severe trauma in children. Patients were included if aged ≤16 years and if they had an abbreviated injury scale score of ≥2 in one or more body region. Results A total of 213 patients were included in the study, with a mean age of 7.8 years (standard deviation [SD]: 5.2 years). The most common cause of injury was vehicle related incidents (46%). The median length of hospital stay was 5 days (interquartile range [IQR]: 4-10 days). Approximately half (52%) of the patients had to stay in the intensive care unit, for a median of 1 day (IQR: 0-2 days). The mortality rate was 6.6%. The mean injury severity score was 19 (SD: 10). Pearson's correlation coefficient showed a positive correlation for injury severity score with length of stay in hospital (p<0.001). Conclusions There is significant variation in mechanism of injury, severity and pattern of paediatric trauma across age groups. A multidisciplinary team approach is imperative, and patients should be managed in specialist centres to optimise their care and eventual functional recovery. Head injury remained the most common, with significant mortality in all age groups. Rib fractures and pelvic fractures should be considered a marker for the severity of injury, and should alert doctors to look for other associated injuries.

Management of hip fractures pre- and post-Major Trauma Centre activation

INTRODUCTION

In April 2012, the activation of the regional trauma networks in England was carried out to improve the organisation of trauma care. NHS Trusts that could meet the highest standard of care to complex trauma were designated Major Trauma Centres (MTCs). MTCs receive patients fulfilling certain triage criteria, as well as secondary transfers from nearby trauma units. While complex trauma care is streamlined with this new organisation, the impact this would have on the rest of the trauma workload within MTCs as well as non-MTC hospitals is uncertain. We investigate whether the management of hip fracture cases had suffered as a result of a trauma unit becoming a MTC.

METHODS

Summary data was collated from the National Hip Fracture Database website for the periods of April 2011-April 2012 (the 'pre-MTC' activation period) and April 2012-April 2013 (the 'post-MTC' activation period). As our primary outcome, we compared the time to surgery within 36h between MTCs and non-MTCs for the periods detailed above. Other outcome measures were: reasons for delay to surgery, length of acute stay, proportion of cases meeting Best Practice Tariff criteria.

RESULTS

A total of 54,897 and 55,998 fNOF patients were included for all hospitals in England in the pre- and post-MTC periods respectively. For MTCs, a weighted mean average of 66.6% patients had surgery within 36h in the pre-MTC period versus 71.4% of patients in the post MTC period (p<0.0001). For non-MTCs, a weighted mean average of 70.0% of patients had surgery within 36h in the pre-MTC period versus 73.8% of patients in the post-MTC period (p<0.0001). Non-MTCs in both pre- and post-MTC activation periods were therefore better in percentage of patients receiving surgery within 36h.

DISCUSSION

The data presented suggests that the creation of MTCs has not had a deleterious effect on the management of hip fracture patients. This paper aims to stimulate the important discussion of maintaining a consistently improving standard throughout the spectrum of trauma care, in conjunction with the development of regional Major Trauma Networks.

The use of secure anonymised data linkage to determine changes in healthcare utilisation following severe open tibial fractures

Severe open fractures of the lower limbs are complex injuries requiring expert multidisciplinary management in appropriate orthoplastic centres. This study aimed to assess the impact of open fractures on healthcare utilisation and test the null hypotheses that there is no difference in healthcare utilisation between the year before and year after injury, and that there is no difference in healthcare utilisation in the year post-injury between patients admitted directly to an orthoplastic centre in keeping with the joint BOA/BAPRAS standards and those having initial surgery elsewhere. This retrospective cohort study utilising secure anonymised information linkage (SAIL), a novel databank of anonymised nationally pooled health records, recruited patients over 18 years of age sustaining severe open lower limb fractures managed primarily or secondarily at our centre and who had data available in the SAIL databank. 101 patients met inclusion criteria and 90 of these had records in the SAIL databank. The number of days in hospital, number of primary care attendances, number of outpatient attendances and number of emergency department attendances in the years prior and subsequent to injury were recorded. Patients sustaining open fractures had significantly different healthcare utilisation in the year after injury when compared with the year before, in terms of days spent in hospital (23.42 vs. 1.70, p=0.000), outpatient attendances (11.98 vs. 1.05, p=0.000), primary care attendances (29.48 vs. 11.99, p=0.000) and emergency department presentations (0.2 vs. 0.01, p=0.025). Patients admitted directly to orthoplastic centres had significantly fewer operations (1.78 vs. 3.31) and GP attendances (23.6 vs. 33.52) than those transferred in subsequent to initial management in other units. There is a significant increase in healthcare utilisation after open tibial fracture. Adherence to national standards minimises the impact of this on both patients and health services.

TraumaNetzwerk DGU(®): optimizing patient flow and management

PURPOSE

Caring for severely injured trauma patients is challenging for all medical professionals involved both in the preclinical and in the clinical course of treatment. While the overall quality of care in Germany is high there still are significant regional differences remaining. Reasons are geographical and infrastructural differences as well as variations in personnel and equipment of the hospitals.

METHODS

To improve state-wide trauma care the German Trauma Society (DGU) initiated the TraumaNetzwerk DGU(®) (TNW) project. The TNW is based on five major components: (a) Whitebook for the treatment of severely injured patients; (b) evidence-based guidelines for the medical care of severe injury; (c) local auditing of participating hospitals; (d) contract of interhospital cooperation; (d) TraumaRegister DGU(®) documentation.

RESULTS

By the end of 2013, 644 German Trauma Centres (TC) had successfully passed the audit. To that date 44 regional TNWs with a mean of 13.5 TCs had been established and certified. The TNWs cover approximately 90% of the country's surface. Of those hospitals, 2.3 were acknowledged as Supraregional TC, 5.4 as Regional TC and 6.7 as Lokal TC. Moreover, cross border TNW in cooperation with hospitals in The Netherlands, Luxembourg, Switzerland and Austria have been established. Preparing for the audit 66% of the hospitals implemented organizational changes (e.g. TraumaRegister DGU(®) documentation and interdisciplinary guidelines), while 60% introduced personnel and 21% structural (e.g. X-ray in the ER) changes.

CONCLUSIONS

The TraumaNetzwerk DGU(®) project combines the control of common defined standards of care for all participating hospitals (top down) and the possibility of integrating regional cooperation by forming a regional TNW (bottom up). Based on the joint approach of healthcare professionals, it is possible to structure and influence the care of severely injured patients within a nationwide trauma system.

Trauma network for severely injured patients

Survival after severe trauma may depend on a structured chain of care from the management at the scene of trauma to hospital care and rehabilitation. In the USA, the trauma system is organized according to a pre-hospital triage by paramedics to facilitate the admission of patients to tertiary trauma centres. In France, trauma patients are transported to the most suitable facility, according to the on-scene triage by an emergency physician. Because French hospital's resources become scarce and expensive, the access to all techniques of resuscitation after severe trauma is restricted to tertiary trauma centres, at the expense of prolonged duration of transfer to these centres with a possible impact on mortality. The Northern French Alps Emergency Network created a regional trauma network system in 2008. This organization was based upon the interplay between the resources of each hospital participating to the network and the categorization of trauma severity at the scene. A regional registry allows the assessment of trauma system, which has included 3,690 severe trauma patients within the past 3 years. Bystanders, medical call dispatch centres, and interdisciplinary trauma team should form a structured and continuous chain of care to allocate each severe trauma patient to the best place of treatment.