NSW Major Trauma Retrieval & Transfers Guidelines · NSW Major Trauma Retrieval & Transfers ... Code Crimson pathway Yes No ... HIGH-RISK MECHANISM OF INJURY BLUNT TRANSPORT INCIDENT

1

NSW Institute of Trauma and Injury Management

NSW Major Trauma Retrieval

& Transfers

Consensus guidelines

NSW ITIM NSW Major Trauma Retrieval and Transfers: Consensus Guidelines ii

1

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NSW ITIM NSW Major Trauma Retrieval and Transfers: Consensus Guidelines iii

Prelude 1

The NSW Major Trauma Retrieval and Transfers consensus guidelines have been developed to 2

assist clinicians in providing a more selective, evidence-based approach to the management of 3

major trauma patients. 4

These consensus guidelines aim to provide all hospitals with a standardised set of criteria to 5

support transfer agreements within their networks for the identification and transfer of trauma 6

patients as necessary. This document sets out suggested criteria for early consultation and 7

transfer; however, these may vary with the level of clinical services available at individual hospitals 8

These guidelines are intended for use by staff involved in the care and/or coordination of adult and 9

paediatric major trauma patients requiring inter-hospital retrieval or transfer during the acute phase 10

of trauma management. 11

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NSW ITIM NSW Major Trauma Retrieval and Transfers: Consensus Guidelines iv

Algorithm 1

Any time urgent

critical trauma transfer

criteria?

Contact ACC/NETS within 30mins of arrival for time urgent medical consult or retrieval to the

nearest appropriate Trauma Service

Any non-time urgent

critical trauma transfer criteria?

Complete initial trauma assessment

Any high risk

mechanism of injury or comorbities?

No

Provide required care at local hospital. Reassess need for transfer.

Early consult as required

Conduct primary survey

Consult with networked Trauma Service / Patient Flow Units or the ACC/NETS for non-time

urgent medical retrieval to the nearest appropriate Trauma Service

Medical Retrieval team to consider activation of Code Crimson pathway

Yes

No

Perform complete trauma assessment and observe. If any clinical deterioration, early consult with

networked Trauma Service / Patient Flow Units for potential transfer to nearest appropriate Trauma

Service

Interhospital Transfer of Major Trauma Patients

Yes

No

ACC*: 1800 650 004

NETS#: 1300 36 2500


networked Trauma Service / Patient Flow Units for potential time urgent transfer to nearest

appropriate Trauma Service

Currently at a Regional Trauma Service?

Yes

No

Any time urgent

critical trauma transfer

criteria?

Contact networked Trauma Service, and ACC/NETS for time urgent consultation or medical retrieval to

the nearest appropriate Trauma Service within 30mins of arrival.

Medical Retrieval team to consider activation of Code Crimson pathway

Yes

No

Currently at a Major Trauma Service?

Provide required care. Consider need for transfer for specialty care

including burns, spinal and paediatrics. Early consult as required

Yes

No

Any non-time urgent

critical trauma transfer Criteria or high risk

mechanism of injury or comorbities?

Yes


networked Trauma Service / Patient Flow Units for potential transfer to nearest appropriate Trauma

Service

No

Provide required care. Consider need for transfer for specialty care

including burns, spinal and paediatrics. Early consult as required

Yes

Aeromedical Control Centre*

Newborn and paediatric Emergency Transport Service#

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NSW ITIM NSW Major Trauma Retrieval and Transfers: Consensus Guidelines v

Time Urgent Critical trauma consult and/or transfer criteria 1

SIGNS AND SYMPTOMS (AFTER INITIAL ASSESSMENT, TREATMENT, CLINICAL DETERIORATION OR SYMPTOMS NOT IMPROVING)

AIRWAY:

Requiring Intubation At risk airway,

hoarseness, stridor

BREATHING:

Respiratory compromise

Hypoxia, cyanosis Pa02 <60 or PaC02

>60 or pH < 7.2 or BE <-5

CIRCULATION:

Severe haemorrhage Haemodynamic

instability Requiring blood

transfusion for resuscitation

Ongoing significant bleeding

DISABILITY:

Lateralising signs Falling GCS Paralysis/sensory

deficit

AGE TERM – 3M 4 – 12 MTHS 1 – 4 YRS 5 – 12 YRS 12+ YRS ADULT

HR <100 or >180 <100 or >180 <90 or >160 <80 or >140 <60 or >130 <40 or >140

RR >60 >50 >40 >30 >30 <10 or >30

BP SYS <50 <60 <70 <80 <90 <90

SPO2 <90% <90%

GCS <15 <13

INJURIES (SUSPECTED OR ACTUAL)

PENETRATING INJURIES

Serious Penetrating injuries to the head, neck, torso or abdomen

HEAD (REQUIRING URGENT NEUROSURGICAL CONSULTATION)

Intracranial FB / Open Fracture Depressed or complex skull fracture Lateralising signs Traumatic intracranial haemorrhage

NECK / SPINAL CORD / VERTEBRAL COLUMN

Unstable vertebral column injury Spinal cord injury (to spinal cord injury unit as per SSCIS)

Peripheral neurological deficit in suspected spinal cord or vertebral column injury Aerodigestive injury (larynx, trachea, oesophagus) Major vascular injury (carotid artery, vertebral artery, internal jugular vein)

CHEST

Any injury involving mediastinum or great vessels Major thoracic cage injury e.g. flail chest Massive haemothorax (>1,000ml)

ABDOMEN / PELVIS

Complex or open pelvic fracture Severe or complex solid organ or hollow viscous injury suspected Haemoperitoneum on FAST Urogenital injury

LIMBS / EXTREMITIES

Major limb amputation Major crush injury Fracture/dislocation with neurovascular compromise Penetrating limb injury with neurovascular compromise

BURNS

Severe Burns (refer to State-wide burns transfer guidelines)

SECONDARY DETERIORATION

Deteriorating condition requiring prolonged ICU e.g. sepsis with multiple injury Organ failure: single or multiple Major tissue necrosis

NSW ITIM NSW Major Trauma Retrieval and Transfers: Consensus Guidelines vi

Non-Time Urgent critical trauma consult and/or transfer criteria 1



Penetrating injuries to the limbs (excluding isolated minor injury to hands or feet)

HEAD (REQUIRING URGENT CT SCAN)

Loss of consciousness or persistent amnesia (failed A-WPTAS after 4 hours) Signs or suspicion of signs of base of skull fracture or skull fracture

2 or more vomits or a seizure

NECK / SPINE

Stable vertebral injury (single column injury) Swelling, bruising, haematoma, hoarseness or stridor

CHEST

Seatbelt abrasions / contusions Pneumothorax/haemothorax 3 or more rib fractures or flail segment ECG changes

ABDOMEN / PELVIS

Seatbelt abrasions / contusions Severe pain, rigidity, swelling, Pelvic fracture Solid organ injury (AAST Grade I, II or III liver, spleen, pancreas or kidneys)

LIMBS / EXTREMITIES

2 or more proximal long bone fractures Open fracture of long bone

MULTIPLE SYSTEM

Injury to >2 body systems (minor)

OTHER TRAUMA TRANSFER CRITERIA

Head or torso and pelvic injuries without evidence of time critical or complex features (above)

High-risk mechanism of injury or comorbidities 2

HIGH-RISK MECHANISM OF INJURY

BLUNT TRANSPORT INCIDENT

Death in same vehicle Steering wheel deformity Vehicle vs. pedestrian/cyclist/motor bike Ejection from vehicle Entrapment with compression

BLUNT OTHER INCIDENTS

Focal blunt trauma to head or torso Falls > 3m or paediatrics twice the child’s height High voltage injury Crush injury Drowning

COMORBIDITY FACTORS ASSOCIATED WITH ANY INJURY

Patients <16 years of age Patients >65 years of age Obstetric patients >20 weeks gestation Patients on anticoagulants Immunosuppression Cardio, respiratory or chronic disease Morbid obesity

Alcohol or Illicit Drug use

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NSW ITIM NSW Major Trauma Retrieval and Transfers: Consensus Guidelines vii

Acknowledgements 1

NSW Institute of Trauma and Injury Management (ITIM) 2

Assoc. Prof. Michael Dinh, Clinical Director 3 Ms Christine Lassen, Manager 4 Mr Glenn Sisson, Project Officer 5 Ms Kelly Dee, Clinical Review Officer 6 Dr Pooria Sarrami, Research Officer 7 Mr Hardeep Singh, Data Manager 8 Mr Benjamin Hall, Project Officer 9 10

NSW Trauma Innovation Committee 11

Dr Yashvi Wimalasena - Co-chair 12 Mr Dwight Robinson - Co-chair 13 Mr Adam Parker 14 Dr Alan Garner 15 Mr Alex Peters 16 Mr Christopher Ennis 17 Ms Gayle Van Zyl 18 Mr Giles Buchanan 19 Dr Jason Bendall 20 Ms Jessica Keady 21 Ms Julie Friendship 22 Dr Matthew Oliver 23 Dr Negin Sedaghat 24 Mr Nick Cockrell 25 Dr Torgrim (Tom) Soeyland 26 27

Supporting documents 28

Selected Speciality and Statewide Service Plans, NSW Trauma Services Number Six, 2009 29 Critical Care Tertiary Referral Networks & Transfer of Care (Adults) 2017 – PD2017_XXX 30 Critical Care Tertiary Referral Networks (Paediatrics) 2010 – PD2010_030 31 Care Coordination: Planning from Admission to Transfer of Care in NSW Public Hospitals 2011 – 32 PD2011_015 33 Inter-facility Transfer Process for Adults Requiring Specialist Care 2011 – PD2011_031 34 Recognition and Management of Patients who are Clinically Deteriorating 2013 – PD2013_049 35 CEC Patient Safety report – Retrieval and Inter-hospital transfer 2013 36 NSW Ambulance Protocols and Pharmacology 2014 37 38

Trauma Services 39

The development and contents for these guidelines were adapted from NSW, Australian and 40

International Trauma Services transfer guidelines. 41

NSW ITIM NSW Major Trauma Retrieval and Transfers: Consensus Guidelines viii

Glossary 1

Aeromedical Control Centre The Aeromedical Control Centre (ACC) coordinates all Medical 2

Retrievals throughout NSW, excluding those in far-west NSW (west 3

of the Darling River) which are managed by the Royal Flying Doctor 4

Service). The ACC is the central control facility of the Aeromedical 5

Services and manages all requests for air rescue, aeromedical 6

transport and adult medical retrieval. 7

Conference call “One phone call” referral where possible to connect the referring 8

clinician, medical retrieval consultant and receiving clinician. 9

Critically injured A patient whose injuries or physiologic instability constitutes a 10

significant and imminent threat to their life without appropriate 11

resuscitation and support. Patients may be classified as Time 12

Urgent or Non-Time Urgent 13

Definitive treatment Definitive treatment is defined as the hospital providing the highest 14

level of care to meet all the clinical needs of the patient. Many 15

patients receive definitive care at Regional Trauma Services, but a 16

small number of patients are transferred to a Major Trauma Service 17

(higher level) for specialised care. 18

Designated Trauma Service A facility that has been designated as a trauma service by NSW 19

Health. A designated trauma service comprises a multidisciplinary 20

structure including staff and resources necessary to ensure the 21

appropriate and efficient provision of trauma care to injured patients. 22

This includes access to relevant sub specialties and coordinated 23

multidisciplinary care. Designated Trauma Services comprise Major 24

Trauma Services, Regional Trauma Services and Paediatric 25

Trauma Services. 26

Inter-hospital retrieval Movement of critically injured and/or unwell patients from one 27

hospital to another hospital by a medical retrieval team. 28

Inter-hospital transfer Movement of patients from one hospital to another requiring access 29

to specialised care. 30

Local Hospital Local hospitals play a part in the trauma system but are not 31

designated trauma services. These may be tertiary hospitals, while 32

others are hospitals serving predominantly local communities in 33

metropolitan or rural areas. As part of the NSW Ambulance Protocol 34

T1, local hospitals will be bypassed for major trauma where possible. 35

Local hospitals will, however, continue to receive minor to moderate 36

trauma cases. 37

Major Trauma A major trauma is defined as any patient who meets the trauma 38

triage tool in the pre hospital setting or any patient who has 39

sustained serious injuries to two or more body regions and/or meets 40

the transfer criteria as outlined in this document. 41

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NSW ITIM NSW Major Trauma Retrieval and Transfers: Consensus Guidelines ix

Major Trauma Service A Major Trauma Service can provide the full spectrum of care for 1

major and moderately injured patients, across the trauma care 2

continuum from initial resuscitation through to rehabilitation and 3

discharge. These hospitals provide a full range of specialist services. 4

This includes Adult Major Trauma Services (MTS) and Paediatric 5

Major Trauma Services (PTS) 6

NETS Newborn and paediatric Emergency Transport Service. A medical 7

retrieval service for babies and children who require intensive care. 8

Non-Time Urgent Patient that is stabilised requiring transfer for a higher level of 9

definitive critical care or clinical specialty, but whose transfer is not 10

time- urgent requiring transfer within 24-72 hoursThis is facilitated 11

by the LHD Patient Flow Unit or Critical Care Advisory Service in 12

consultation with the patient’s clinical management team. 13

Paediatric Trauma Service A Paediatric Trauma Service can provide the full spectrum of care 14

for major and moderately injured paediatric patients, across the 15

trauma care continuum from initial resuscitation through to 16

rehabilitation and discharge. These hospitals provide a full range of 17

specialist paediatric services. 18

Patient Flow Unit Responsible for managing patient flow within a given facility 19

Risk of critical deterioration A patient who has suffered a significant injury or illness who may 20

appear to be stable but whose condition may quickly deteriorate 21

requiring constant monitoring and early transfer for definitive care. 22

Primary cases In the prehospital setting these cases are taken to a designated 23

trauma or specialty services from the scene of injury by road 24

ambulance or medical retrieval team 25

Protocol T1 / T1 Protocol NSW Ambulance Trauma Protocol: Pre-Hospital Management of 26

Major Trauma (commonly referred to as Protocol T1). Protocol T1 27

states any major trauma patient meeting the set criteria for (or 28

potential) major trauma must be transferred from scene to the 29

highest level trauma service with one hour travel time. This ensures 30

that critically injured patients are brought as quickly as possible to 31

the highest level of trauma care for the greatest chance of early 32

survival and recovery. 33

Regional Trauma Service A Regional Trauma Service can provide a high level of care to the 34

injured patient. Definitive trauma care can be provided to a limited 35

number of major trauma patients in collaboration with the major 36

trauma service and can provide all aspects of care to people with 37

moderate and minor trauma. 38

Serious Penetrating Injury Penetrating injury to the head, neck, torso or abdomen involving or 39

likely to involve injury to deep or underlying structures. 40

Specialist Burn Injury Unit Three units in NSW located at Concord Repatriation General 41

Hospital, Royal North Shore Hospital and The Children’s Hospital at 42

Westmead and are part of the Statewide Burn Injury Service (SBIS). 43

Spinal Cord Injury Unit Four units in NSW located at Royal North Shore Hospital, Prince of 44

Wales Hospital, Sydney Children’s Hospital and The Children’s 45

NSW ITIM NSW Major Trauma Retrieval and Transfers: Consensus Guidelines x

Hospital at Westmead part of the NSW State Spinal Cord Injury 1

Service (SSCIS). 2

T1 preferred hospital T1 preferred destinations (hospitals) are NSW Ambulance 3

nominated hospitals and whilst these generally have more 4

resources than a local hospital, they are limited in their capacity to 5

manage a major trauma patient. 6

Time Urgent A patient whose injuries requires emergency care at the closest 7

appropriate hospital in the shortest time possible to achieve early 8

intervention and stabilisation and definitive care. This includes 9

physiologic signs or symptoms that constitutes a significant and 10

imminent threat to the patient’s life without appropriate resuscitation 11

and support. 12

Unstable vertebral injury Disruption of two or more columns through fracture, dislocation or 13

ligamentous injuries. 14

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NSW ITIM NSW Major Trauma Retrieval and Transfers: Consensus Guidelines xi

Acronyms 1

AAST American Association for the Surgery of Trauma 2

ACC Aeromedical Control Centre 3

ACI Agency for Clinical Innovation 4

A-WPTAS Abbreviated Westmead post traumatic Amnesia Scale 5

BE Base Excess 6

BP Blood Pressure 7

CEC Clinical Excellence Commission 8

ETA Estimated Time of Arrival 9

GCS Glasgow Coma Scale 10

HR Heart rate 11

ISBAR Identification, Situation, Background, Assessment, Reccomendation 12

ITIM Institute of Trauma and Injury Management 13

LHD Local Health District/s 14

M Months 15

mmHg Millimetre of mercury 16

MTS Major Trauma Service 17

NETS Newborn and Paediatric Emergency Transport Service 18

NSW New South Wales 19

PaCO2 Partial pressure of carbon dioxide 20

PaO2 Partial pressure of oxygen 21

pH Potential of hydrogen 22

PFU Patient Flow Unit 23

PTS Paediatric Trauma Service 24

RR Respiratory Rate 25

RTS Regional Trauma Service 26

SBIS Statewide Burn Injury Service 27

SBIU Specialist Burn Injury Unit 28

SCIU Spinal Cord Injury Unit 29

SpO2 Saturation of Peripheral Oxygen 30

SSCIS State Spinal Cord Injury Service 31

SYS Systolic 32

T1 Trauma protocol 1 33

TBSA Total Body Surface Area 34

< Less than 35

> Greater than 36

% Percentage 37

NSW ITIM NSW Major Trauma Retrieval and Transfers: Consensus Guidelines xii

Prelude ......................................................................................................................................... iii 1

Algorithm ...................................................................................................................................... iv 2

Time Urgent Critical trauma consult and/or transfer criteria ..................................................... v 3

Non-Time Urgent critical trauma consult and/or transfer criteria ............................................. vi 4

High-risk mechanism of injury or comorbidities ....................................................................... vi 5

Acknowledgements .................................................................................................................... vii 6

Glossary ..................................................................................................................................... viii 7

Acronyms ..................................................................................................................................... xi 8

Tables ......................................................................................................................................... xiii 9

1. Introduction .......................................................................................................................... 1 10

2. Scope of guidelines ............................................................................................................. 1 11

3. NSW Trauma Services ......................................................................................................... 2 12

4. NSW Trauma Networks ....................................................................................................... 3 13

5. Interstate referral locations ................................................................................................. 4 14

6. Inter-hospital trauma transfer guidelines ........................................................................... 5 15

7. Transfer of a burn injury.................................................................................................... 11 16

8. Transfer of an acute spinal cord injury ............................................................................ 13 17

9. Handover of patient information ....................................................................................... 14 18

10. Preparation for transfer ..................................................................................................... 15 19

11. Inter-hospital transport providers .................................................................................... 15 20

12. Roles and Responsibilities ............................................................................................... 16 21

13. Endorsement ...................................................................................................................... 17 22

14. Appendices ........................................................................................................................ 18 23

24

25

Contents

NSW ITIM NSW Major Trauma Retrieval and Transfers: Consensus Guidelines xiii

Tables 1

Table 1: NSW Trauma Services .................................................................................................... 2 2

Table 2: NSW T1 preferred hospitals ........................................................................................... 2 3

Table 3: NSW Trauma networks ................................................................................................... 3 4

Table 4: Interstate trauma referral patterns ................................................................................ 4 5

Table 5: Signs and symptoms of Time Urgent Critical major trauma ....................................... 7 6

Table 6: Time Urgent Critical Injury criteria for inter-hospital trauma transfer ........................ 7 7

Table 7: Non-Time Urgent Critical Injury criteria for inter-hospital trauma transfer ................ 9 8

Table 8: High-risk mechanism of injury and comorbidities factors ........................................ 10 9

Table 9: Criteria for transfer and/or referral of a burns patient from any hospital to a 10

specialist burn injury unit. .......................................................................................... 12 11

Table 10: Criteria for transfer and/or referral of an acute spinal cord injury patient from any 12

hospital to a State Spinal Cord Injury Unit ................................................................. 13 13

Table 11: ISBAR handover guide ............................................................................................... 14 14

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NSW ITIM NSW Major Trauma Retrieval and Transfers: Consensus Guidelines 1

1. Introduction 1

The NSW trauma system currently operates as a series of networks, mostly driven by local 2

decisions and requirements. Currently, although the NSW Trauma model of care is followed at the 3

highest level, there is high variability with how each network functions. 4

Across NSW Health over 900 major trauma patients require referral and transfer to a designated 5

trauma service each year1. Whilst vital, transfers prolong the time before the definitive care can be 6

provided, such as specialised surgery, interventional radiology or paediatric services. The overall 7

median time to definitive care in NSW in 2015 was 660 minutes1. This median time is considered 8

excessive and is thought to be having a direct impact on patient outcomes. 9

Recently there has been an emerging trend of unwarranted clinical variation in the identification, 10

referral and transfer of major trauma patients. Overall, these variations in referral and transfer of 11

patients were apparent across all Major Trauma Service (MTS), Regional Trauma Service (RTS) 12

and Paediatric Trauma Service (PTS) during the NSW Trauma Patient Outcome Evaluation2 and 13

Clinical Excellence Commission (CEC) Patient Safety Report titled Retrieval and Inter-hospital 14

Transfer Patient Safety Report3. 15

These consensus guidelines aim to provide all hospitals with a standardised set of criteria to 16

support transfer agreements within their networks for the identification and transfer of trauma 17

patients as necessary. This document sets out suggested criteria for early consultation and 18

transfer; however, these may vary with the level of clinical services available at individual hospitals. 19

2. Scope of guidelines 20

The NSW Major Trauma Retrieval and Transfers consensus guidelines have been developed to 21

assist clinicians in providing a more selective, evidence-based approach to the management of 22

major trauma patients. They are not intended to replace senior clinical decision-making. The 23

authors appreciate the heterogeneity of the patient population and their signs and symptoms and 24

the need to often modify management in light of a patient’s co-morbidities. The guidelines rely on 25

individual clinicians to interpret the needs of individual patients. 26

These guidelines are intended for use by staff involved in the care and/or coordination of adult and 27

paediatric major trauma patients requiring inter-hospital retrieval or transfer during the acute phase 28

of trauma management. 29

The information provided is based on the best available information at the time of writing, which is 30

January 2017. These guidelines will, therefore, be updated every 3 years and consider new 31

evidence as it becomes available. 32

33

1 NSW Institute of Trauma and Injury Management. Major Trauma in NSW 2015. Sydney: NSW Agency for Clinical Innovation, 2016.

2 NSW Institute of Trauma and Injury Management. Trauma Patient Outcome Evaluation: Qualitative Report. Sydney: NSW Agency for Clinical Innovation, 2016.

3 Clinical Excellence Commission Patient Safety report – Retrieval and Inter-hospital transfer 2013


3. NSW Trauma Services 1

The trauma services of NSW provide expert care for injured patients, coordinating the 2

multidisciplinary teams and advocating for patients, both within the acute and rehabilitative phases. 3

A major trauma service (MTS/PTS) can provide the full spectrum of care for major and moderately 4

injured patients, from initial resuscitation through to rehabilitation and discharge. There are 5

currently seven adult and three paediatric designated MTSs in NSW. 6

A RTS can provide all aspects of care to patients with moderate to minor trauma and definitive 7

care to a limited number of major trauma patients in collaboration with the MTS. A RTS provides 8

initial assessment, stabilisation, definitive care and initiate transfer to an MTS when a patient 9

requires services not available at the RTS. There are currently 10 designated RTSs in NSW. 10

Table 1: NSW Trauma Services 11

Adult Major Trauma

Services

Paediatric Major Trauma

Services Regional Trauma Services

John Hunter Hospital John Hunter Children’s Hospital Coffs Harbour Health Campus

Liverpool Hospital Sydney Children’s Hospital Gosford Base Hospital

Royal North Shore Hospital Children’s Hospital at Westmead Lismore Base Hospital

Royal Prince Alfred Hospital

Nepean Hospital

St George Hospital Orange Health Service

St Vincent's Hospital Port Macquarie Base Hospital

Westmead Hospital Tamworth Rural Referral Hospital

The Tweed Hospital

Wagga Wagga Rural Referral

Hospital

Wollongong Base Hospital

12

T1 preferred hospitals (destinations) are NSW Ambulance nominated hospitals and whilst these 13

generally have more resources than a local hospital, they are limited in their capacity to manage a 14

major trauma patient. 15

Table 2: NSW T1 preferred hospitals 16

NSW T1 PREFERRED HOSPITALS

Armidale Rural Referral Hospital Bathurst Base Hospital South East Regional Hospital (Bega)

Broken Hill Base Hospital Dubbo Base Hospital Griffith Base Hospital

Goulburn Base Hospital Manning Rural Referral Hospital (Taree)

Shoalhaven District Memorial Hospital (Nowra)

17


4. NSW Trauma Networks 1

Trauma networks are closely aligned with the NSW Critical Care Tertiary Referral Networks, define 2

the links between Local Health Districts (LHD) and tertiary referral hospitals, and are largely 3

determined by the location of the MTS and the imperative to achieve early clinical intervention for 4

seriously injured patients. The networks take into account established clinical referral relationships 5

which may include referral patterns across LHD boundaries and cross jurisdictional border 6

arrangements. Details of the MTS, PTS, RTS and their networked LHD are outlined in Table 3. 7

Table 3: NSW Trauma networks 8

NSW TRAUMA SERVICE NETWORKS

MTS PTS RTS REFERRING LHD

John Hunter Hospital John Hunter Children’s Hospital

Coffs Harbour Health Service Lismore* Port Macquarie Tamworth Tweed Heads*

Northern NSW*

Mid North Coast Hunter New England

Liverpool Hospital Children’s Hospital at Westmead

N/A South West Sydney

Royal North Shore Hospital Sydney Children’s Hospital Gosford Central Coast Northern Sydney

Royal Prince Alfred Hospital Sydney Children’s Hospital N/A Sydney

St George Hospital Sydney Children’s Hospital Wollongong Wagga Wagga

Illawarra and Shoalhaven

Murrumbidgee*

South East Sydney*

Southern NSW

St Vincent's Hospital Sydney Children’s Hospital N/A N/A

Westmead Hospital Children’s Hospital at Westmead

Nepean Orange

Nepean Blue Mountains

Far West*

Western Sydney Western NSW

9

*Due to proximity the following LHD/ hospitals maintain referral networks to Interstate referral locations 10

11


5. Interstate referral locations 1

Owing to proximity, some facilities may refer major trauma patients to an interstate trauma service 2

or specialty service. 3

Table 4: Interstate trauma referral patterns 4

INTERSTATE TRAUMA REFERRAL PATTERNS

MTS PTS REFERRING FACILITIES/LHD

Gold Coast University Hospital Lady Cilento Children’s Hospital Northern NSW

The Canberra Hospital Sydney Children’s Hospital Southern NSW Batlow/Adelong Multi Purpose Service Boroowa Multi Purpose Service Murrumburrah-Harden Hospital Tumut Hospital Young Hospital

The Alfred Hospital Royal Melbourne Hospital

Royal Children’s Hospital Barham Health Service Deniliquin Health Service Finley Hospital Tocumwal Multi Purpose Service Berrigan Health Service Corowa Health Service Holbrook Health Service Culcairn Multi Purpose Service

Royal Adelaide Hospital Women’s and Children’s Hospital Far West

5


6. Inter-hospital trauma transfer guidelines 1

GUIDELINES

T1 Preferred or Local Hospital

Where a patient has any of the Time Urgent Critical criteria of potential major trauma, the senior treating

clinician should consult with ACC/NETS as per local procedure in order to arrange a time critical medical

retrieval to the nearest appropriate Trauma Service. This should occur as soon as possible, but no later

than 30 minutes of the patient’s arrival or identification of criteria being met.

Where a patient meets any of the Non-Time Urgent Critical criteria, the senior treating clinician should

consult with their local networked trauma service and/or Patient Flow Units (PFU) as per local procedure in

order to arrange transfer to the nearest appropriate Trauma Service (Regional or Major). This should

occur as soon as possible, but no later than 30 minutes of the patient’s arrival.

Where a patient does not meet any of the inter-hospital trauma consult and or transfer criteria but does meet

any of the High-risk mechanism of injury or comorbidities criteria, a complete trauma assessment and

observation is required due to the high risk of deterioration. If any clinical deterioration is observed, the

senior treating clinician should consult with their networked trauma service and/or Patient Flow Units as per

local procedure in order to arrange potential transfer to the nearest appropriate Trauma Service (Regional

or Major).

Regional Trauma Service

Where a patient is being assessed at a Regional Trauma Service and has injuries meeting Time Urgent

Critical criteria, the senior treating clinician should consult with their networked Major Trauma Service

and/or Patient Flow Units and the ACC/NETS as per local policy in order to arrange a time critical medical

retrieval to the nearest appropriate Major Trauma Service. This should occur as soon as possible, but

no later than 30 minutes of the patient’s arrival or identification of criteria being met.

Where a patient is being assessed at a Regional Trauma Service and does not meet any of time urgent

critical criteria but does meet any of the Non-Time Urgent Critical criteria or High-risk mechanism of

injury or comorbidities criteria, a complete trauma assessment and observation is required due to the high

risk of deterioration. If any clinical deterioration is observed, the senior treating clinician should consult

with their networked trauma service and/or Patient Flow Unit as per local procedure in order to arrange

consultation and potential transfer to the nearest appropriate Major Trauma Service.

Other

Where a direct transfer to a Major Trauma Service is indicated but not achievable, patients should be

transported to the nearest Trauma Service for initial assessment and resuscitation with a view to further

transfer onto a Major Trauma Service as required.

In certain circumstances, trauma patients who do not meet the outlined trauma transfer criteria may still be

transferred to the local networked trauma service to ensure an adequate standard of care, including when

the resources at a metropolitan or rural hospital are overwhelmed.

Where a patient meets specialist burn or spinal cord injury criteria, where clinically indicated, patients may be

transported directly to the networked Specialist Burn Injury Unit (SBIU) or Spinal Cord Injury Unit (SCIU)

after consultation with the service and ACC/NETS.

2

3


Inter-hospital Trauma Transfers 1

The aim of the NSW Trauma Plan is to concentrate trauma care in major and regional trauma 2

centres, transporting the right patient to the right hospital as soon as possible. Criteria for inter-3

hospital trauma transfer are reflective of signs and symptoms, specific injury patterns and the 4

resources available at the local hospital. The decision to transfer trauma patients to a higher level 5

of care should be made on clinical grounds by senior clinicians in consultation with networked 6

Trauma Service, PFU or the ACC/NETS. Availability of an intensive care unit (ICU) bed or other 7

resources at the receiving facility is not to delay the acceptance of time critical patients for 8

emergency care. 9

Once the need for transfer has been recognised, arrangements for transfer should be expedited. 10

They should not be delayed for diagnostic procedures that have no impact on resuscitation or the 11

transfer process and do not change the immediate plan of care. Once contacted, the ACC or NETS 12

will coordinate the retrieval of the patient. 13

The destination of the secondary transport cases, which are cases requiring transfer to a higher 14

level trauma service, will be the responsibility of the networked trauma service. These are outlined 15

in: 16

NSW Policy Directive PD20xx_xxx Critical Care Tertiary Referral Networks & Transfer of 17

Care (Adults) 18

NSW Policy Directive PD2010_030 Critical Care Tertiary Referral Networks (Paediatrics) 19

NSW Policy Directive PD2011_031 Inter-facility Transfer Process for Adults Requiring 20

Specialist Care 21

Signs and symptoms of Time Urgent Critical major trauma 22

The first step in identifying patients with potential major trauma is to assess their vital signs and 23

symptoms. If the trauma patient meets any of the criteria in Table 5 below, they may have 24

sustained major trauma. The senior treating clinician should consult as soon as possible with the 25

ACC/NETS as per local procedure. For RTSs this includes consultation with the networked trauma 26

service and/or Patient Flow Unit. 27

28

http://www0.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_021.pdf






Table 5: Signs and symptoms of Time Urgent Critical major trauma 1

SIGNS AND SYMPTOMS (AFTER INITIAL ASSESSMENT, TREATMENT, CLINICAL DETERIORATION OR SYMPTOMS NOT IMPROVING)

AIRWAY:

Requiring Intubation At risk airway,

hoarseness, stridor

BREATHING:

Respiratory compromise

Hypoxia, cyanosis Pa02 <60mmHg or

PaC02 >60mmHg or pH < 7.2 or BE <-5

CIRCULATION:

Severe haemorrhage Haemodynamic

instability Requiring blood

transfusion for resuscitation

Ongoing significant bleeding

DISABILITY:

Lateralising signs Falling GCS Paralysis/sensory

deficit

AGE TERM – 3M 4 – 12 M 1 – 4 YEARS 5 – 12 YEARS 12+ YEARS ADULT

HR <100 or >180 <100 or >180 <90 or >160 <80 or >140 <60 or >130 <40 or >140

RR >60 >50 >40 >30 >30 <10 or >30

BP SYS <50 <60 <70 <80 <90 <90

SPO2 <90% <90%

GCS <15 <13

PaO2 = partial pressure of oxygen, < = Less than, mmHg = millimeter of mercury, > = greater than, PaCO2 = partial pressure of carbon 2 dioxide, pH = potential of hydrogen, BE = Base Excess, GCS = Glasgow Coma Scale, M = Months, HR = Heart rate, RR = Respiratory 3 Rate, BP = Blood Pressure, SYS = Systolic, SpO2 = Saturation of Peripheral Oxygen, % = Percentage 4

Specific injuries of Time Urgent Critical major trauma 5

The presence of any suspected or actual injuries as outlined in Table 6 indicates they may have 6

sustained major trauma should be transferred to the nearest appropriate Trauma Service. The 7

senior treating clinician should consult as soon as possible with the ACC/NETS as per local 8

procedure. For RTSs this includes consultation with the networked trauma service and/or Patient 9

Flow Unit. 10

Table 6: Time Urgent Critical Injury criteria for inter-hospital trauma transfer 11



Serious penetrating injuries to the head or torso

HEAD (REQUIRING URGENT NEUROSURGICAL CONSULTATION)

Penetrating injury / Intracranial Foreign Body / Open Fracture Depressed, complex skull fracture Lateralising signs Traumatic intracranial haemorrhage

NECK / SPINAL CORD / VERTEBRAL COLUMN

Unstable vertebral column injury Spinal cord injury (to spinal cord injury unit as per SSCIS) Peripheral neurological deficit in suspected spinal cord or vertebral column injury Aerodigestive injury (larynx, trachea, oesophagus) Major vascular injury (carotid artery, vertebral artery, internal jugular vein)

CHEST

Any injury involving mediastinum or great vessels Major thoracic cage injury e.g. flail chest Massive haemothorax (>1,000ml)

ABDOMEN / PELVIS

Complex or open pelvic fracture Severe or complex solid organ or hollow viscous injury suspected Haemoperitoneum on FAST Urogenital injury


LIMBS / EXTREMITIES

Major limb amputation Major crush injury Fracture/dislocation with neurovascular compromise Penetrating limb injury with neurovascular compromise

BURNS

Severe Burns (refer to State-wide burns transfer guidelines – Section 7)

SECONDARY DETERIORATION

Deteriorating condition requiring prolonged ICU e.g. sepsis with multiple injury Organ failure: single or multiple Major tissue necrosis

1

2


Specific injuries of Non-Time Urgent Critical major trauma 1

The presence of any suspected or actual injuries as outlined in Table 7 as moderate or major 2

trauma should be transferred to the nearest appropriate trauma service (Regional or Major). The 3

senior treating clinician should consult as soon as possible with the networked trauma service 4

and/or Patient Flow Unit or ACC/NETS as per local procedure. For RTSs this includes consultation 5

with the networked trauma service and/or Patient Flow Unit if any clinical deterioration or additional 6

time urgent critical criteria is identified. 7

Table 7: Non-Time Urgent Critical Injury criteria for inter-hospital trauma transfer 8



Penetrating injuries to the limbs (excluding isolated minor injury to hands or feet)

HEAD (REQUIRING URGENT CT SCAN)

Loss of consciousness or persistent amnesia (failed A-WPTAS# after 4 hours) Signs or suspicion of base of skull fracture or skull fracture

2 or more vomits or a seizure

NECK/SPINE

Stable vertebral injury (single column injury) Swelling, bruising, haematoma, hoarseness or stridor

CHEST

Seatbelt abrasions / contusions Pneumothorax/haemothorax 3 or more rib fractures or flail segment ECG changes

ABDOMEN / PELVIS

Seatbelt abrasions / contusions Severe pain, rigidity, swelling Pelvic fracture Solid organ injury (AAST* Grade I, II or III liver, spleen, pancreas or kidneys)

LIMBS / EXTREMITIES

2 or more proximal long bone fractures Open fracture of long bone

MULTIPLE SYSTEM

Injury to >2 body systems (minor)

OTHER TRAUMA TRANSFER CRITERIA

Head or torso and pelvic injuries without evidence of time critical or complex features (above)

# Abbreviated Westmead Post Traumatic Amnesic Scale 9 * American Association for the Surgery of Trauma 10

11


High-risk mechanism of injury and comorbidities 1

The high-risk mechanisms of injury and comorbidity factors listed in Table 7 below should be 2

considered when assessing all trauma patients. Whilst patients meeting these criteria only (no 3

signs and symptoms or injuries requiring inter-hospital trauma consultation or transfer) are not 4

considered as major trauma requiring inter-hospital trauma transfer to a designated trauma service, 5

this cohort of patients are at high risk of deterioration. As such, they should receive a thorough 6

trauma assessment and be observed. 7

If any clinical deterioration is observed, the senior treating clinician should consult with their local 8

networked trauma service and/or Patient Flow Unit as per local procedure in order to arrange 9

potential transfer to the nearest appropriate Trauma Service (Regional or Major). 10

Table 8: High-risk mechanism of injury and comorbidities factors 11

HIGH-RISK MECHANISM OF INJURY

BLUNT TRANSPORT INCIDENT

Death in same vehicle Steering wheel deformity Vehicle vs. pedestrian/cyclist/motor bike Ejection from vehicle Entrapment with compression

BLUNT OTHER INCIDENTS

Focal blunt trauma to head or torso Falls > 3m or paediatrics twice the child’s height High voltage injury Crush injury Drowning

COMORBIDITY FACTORS

Patients <16 years of age Patients >65 years of age Obstetric patients >20 weeks gestation Patients on anticoagulants Immunosuppression Cardio, respiratory or chronic disease Morbid obesity Alcohol or Illicit Drug use

12

13


7. Transfer of a burn injury 1

GUIDELINES

Patients meeting the criteria for inter-hospital transfer of burns patients as outlined in Table 8 below must be

referred and/or transferred to a specialist burns injury unit (SBIU) as a trauma burns transfer as per the

SBIS.

In certain circumstances, patients who have suffered a burn injury but do not meet the criteria set out in

Table 8 may also be transferred to the networked SBIU to ensure an adequate standard of care, including

when the resources at a referring hospital are overwhelmed.

Adult cases of severe burn injury without combined trauma may be transported to Concord 2

Repatriation General Hospital or appropriate interstate facility. 3

All adult cases of combined severe trauma and burn injury should be transported to Royal North 4

Shore Hospital or appropriate interstate facility following discussion with their networked trauma 5

service. 6

All paediatric burns patients, including combination paediatric trauma patients, should be 7

transferred to the Children’s Hospital at Westmead or appropriate interstate facility. 8

If the referring practitioner is unsure or seeking advice they should contact the ACC for guidance 9

on best management of the patient. 10

Please refer to the ACI Statewide Burn Injury Service NSW Burn Transfer Guidelines for Criteria 11

for transfer and/or referral of a burns patient from any hospital to a Severe Burn Injury Service and 12

NSW Policy Directive PD20xx_xxx Critical Care Tertiary Referral Networks & Transfer of Care 13

(Adults) and NSW Policy Directive PD2010_030 Critical Care Tertiary Referral Networks 14

(Paediatrics). 15

Statewide specialist severe burn injury services and contact numbers are: 16

Royal North Shore Hospital – 02 9463 2111 17

Concord Repatriation General Hospital – 02 9767 7776 18

Children’s Hospital at Westmead – 02 9845 1114 19

20

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/162634/Burns_Transfer_Guidelines_2013-14_-_web.pdf






Table 9: Criteria for transfer and/or referral of a burns patient from any hospital to a 1

specialist burn injury unit. 2

ABSOLUTE INDICATORS FOR TRANSFER TO AN SPECIALIST BURN INJURY UNIT

Any intubated patient Inhalation injuries with cutaneous burns

Head and neck burns Mid-dermal, deep dermal or full thickness burns >10% in children Mid-dermal, deep dermal or full thickness burns >20% in adults Burns with significant co-morbidities Associated trauma Significant pre-existing medical disorder Circumferential burn to limbs or chest that compromises circulation or respiration Electrical conduction injury with cutaneous burns Chemical injury with cutaneous burns.

INDICATORS FOR THE REFERRAL TO A SPECIALIST BURNS INJURY UNIT

Mid to deep dermal burns in adults >10% TBSA (total body surface area) Full thickness burns in adults >5% TBSA Mid-dermal, deep dermal or full thickness burns in children >5% TBSA Burns to the face, hands, feet, genitalia, perineum and major joints Chemical burns Electrical burns including lightning injuries Burns with concomitant trauma Burns with associated inhalation injury Circumferential burns of the limbs or chest Burns in patients with pre-existing medical conditions that could adversely affect patient care and outcome Suspected non-accidental injury including children, assault or self-inflicted Pregnancy with cutaneous burns Burns at the extremes of age – infants and frail elderly

3

4


8. Transfer of an acute spinal cord injury 1

GUIDELINES

Patients meeting the criteria for inter-hospital transfer of spinal cord patients as outlined in Table 9

below must be referred and/or transferred to a spinal cord injury unit (SCIU).

In certain circumstances, patients who have suffered a spinal cord injury but do not meet the

criteria set out in Table 9 may also be transferred to the networked SCIU to ensure an adequate

standard of care, including when the resources at a referring hospital are overwhelmed.

In cases of an isolated acute spinal cord injury, where clinically indicated, patients may be referred 2

and transported directly to the relevant specialist spinal cord injury unit. Spinal cord and spinal 3

column imaging may not be required prior to referral or transfer; advice on this should be sought 4

from the referral SCIU. 5

In cases of combined severe trauma and acute spinal cord injury patients should be transported to 6

Royal North Shore Hospital, the Children’s Hospital at Westmead, the Sydney Children’s Hospital 7

or appropriate interstate facility following discussion with their networked trauma service. 8

If the referring practitioner is unsure or seeking advice they should contact the ACC for guidance 9

on best management of the patient. 10

Please refer to NSW Policy Directive PD20xx_xxx Critical Care Tertiary Referral Networks & 11

Transfer of Care (Adults) and NSW Policy Directive PD2010_030 Critical Care Tertiary Referral 12

Networks (Paediatrics). 13

State Spinal Cord Injury Units and contact numbers are: 14

Royal North Shore Hospital - 02 9926 7111 15

Prince of Wales Hospital - 02 9382 2222 16

Children’s Hospital at Westmead – 02 9845 0000 pg 82399 17

Sydney Children’s Hospital – 02 9382 1000 18

Table 10: Criteria for transfer and/or referral of an acute spinal cord injury patient from 19

any hospital to a State Spinal Cord Injury Unit 20

ABSOLUTE INDICATORS FOR REFERRAL/TRANSFER TO A SPECIALIST ACUTE SPINAL CORD INJURY SERVICE

Sudden onset of neurological deficit affecting spinal segments from C1 to S5 following trauma

Complete or Incomplete spinal cord injury

Cauda equina

Neurogenic shock

21

22






9. Handover of patient information 1

GUIDELINE

Referring clinicians are encouraged to provide handover to the receiving clinician for all patients using the

standardised mnemonic ISBAR (Identification, Situation, Background, Assessment, Recommendation) to

improve quality and safety in the transfer of critical information.

The information in Table 10 below will be required by the receiving hospital and the ACC. It is 2

encouraged to have as much information at hand before calling. 3

Table 11: ISBAR handover guide 4

ISBAR INFORMATION

IDENTIFICATION Clinician’s name Clinician’s role/position Clinician’s ward/unit/hospital Identify the patient including name, age, sex and MRN

SITUATION Injuries sustained / Preliminary diagnosis

BACKGROUND Mechanism of injury / Presenting problem Include time of event

ASSESSMENT Signs and Symptoms o Include pre-hospital and current vital signs and trends

Primary Survey assessment o Airway & c-spine (e.g. neck pain) o Breathing & ventilation (e.g. pneumothorax) o Circulation & haemorrhage control (e.g. arterial laceration) o Disability (GCS) (e.g. closed head injury) o Environment (temperature) (e.g. hypothermia)

Treatment given and effect Diagnostic tests and results Other (Secondary survey assessment and interventions if time has permitted)

RECOMMENDATION Care plan Level of specialist care required Level of urgency Confirmation of handover and transfer

5

6

7


10. Preparation for transfer 1

GUIDELINES

The patient’s airway, breathing and circulation should be stabilised prior to transfer. All efforts should be

made to control significant haemorrhage prior to transfer. If such control cannot be achieved, advice should

be sought from the senior trauma clinician at the networked MTS or ACC Consultant.

A senior trauma clinician from the networked MTS, ACC Consultant or Retrieval Specialist should advise the

referring hospital regarding patient management and preparation for transfer using the established

processes.

Wherever practicable, all patients identified as requiring inter-hospital trauma transfer should be seen by the

most senior clinician prior to leaving the referring hospital whilst not delaying the transfer process.

Where available, telemedicine should be utilised during this process to connect the patient and clinicians with

the remote specialists and improve accuracy of advice regarding patient management, stabilisation,

treatment, critical decisions

The use of a transfer checklist may assist in streamlining the preparation of the trauma patient for safe

transfer (see Appendix 1).

11. Inter-hospital transport providers 2

NSW Aeromedical Control Centre (ACC) 3

The need for physician-assisted transfer is determined by the ACC in consultation with the 4

receiving facility. Transfer will generally require medically supervised transport which may be via 5

ACC. 6

Cases requiring complex decision making may warrant a teleconference involving the referring 7

(treating) service, ACC and the receiving facility trauma and/or specialty services. 8

For non-time urgent transfers ACC should be contacted on 1800 650 004 by the referring hospital, 9

once the patient has been accepted by the referral trauma service, to facilitate timely medical 10

retrieval. 11

http://www.ambulance.nsw.gov.au/about-us/aeromedical.html 12

Paediatric trauma 13

Children, less than 16 years of age should be transferred to a paediatric MTS. For clinical guidance, 14

transport and patient acceptance at a paediatric MTS please contact NETS retrieval: 1300 36 2500. 15

For further information refer to NSW Policy Directive PD2010_030 Critical Care Tertiary Referral 16

Networks (Paediatrics) and NSW Policy Directive PD2005_157 Emergency Paediatric Referrals – 17

Policy 18

19

http://www.ambulance.nsw.gov.au/about-us/aeromedical.html

http://www.ambulance.nsw.gov.au/about-us/aeromedical.html

http://www0.health.nsw.gov.au/policies/pd/2010/PD2010_030.html





12. Roles and Responsibilities 1

Referring facility clinicians 2

Referring clinicians are encouraged to: 3

Refer trauma cases to their networked trauma service or ACC/NETS without delay. It is not 4

necessary to have made a diagnosis nor have stabilised the injured patient prior to 5

contacting the referring trauma service. 6

Call the ACC as soon as the treating physician ascertains that the patient has severe 7

trauma related injuries that meet criteria or exceed the local institutional capabilities. This 8

should occur within 30 minutes of arrival or identification of meeting criteria. 9

Seek advice via the ACC if uncertain of the appropriateness of referral or are seeking 10

guidance regarding the medical treatment of the patient. 11

Both referring and receiving clinicians should be encouraged to discuss over telemedicine if 12

the technology is available. 13

Receiving facility clinicians 14

Receiving clinicians are encouraged to: 15

Accept call and handover from referring clinicians. 16

Request details of the Primary Survey to provide appropriate medical advice. 17

Provide advice for management and stabilisation of patient regardless of if accepting the 18

transfer of the patient. 19

Inform referring clinician to contact ACC to arrange transfer. 20

Inform the Emergency Department, Surgeon on call, Bed Manager, ICU (if required) and 21

other specialties of incoming trauma transfer and the patient’s estimated time of arrival 22

(ETA) as required. 23

Where necessary, facilitate direct transfer of the patient to the operating theatre if required 24

(see Trauma ‘Code Crimson’ pathway). 25

Retrieval Services 26

Aeromedical Control Centre (ACC): 27

Upon being contacted by referring hospital ACC will arrange appropriate transportation of 28

the patient/s to the receiving trauma service. 29

Provide advice for interim management or confirmation of management plan via 30

teleconference if required. 31

Newborn and paediatric Emergency Transport Service (NETS): 32

Upon being contacted by either ACC or referring hospital NETS will arrange appropriate 33

transportation of the patient/s to the accepting trauma service. 34

Provide advice for interim management or confirmation of management plan via 35

teleconference if required. 36

https://www.aci.health.nsw.gov.au/get-involved/institute-of-trauma-and-injury-management/clinical/trauma-guidelines/Guidelines/trauma-code-crimson-pathway


13. Endorsement 1

These guidelines have been reviewed and endorsed by XXX committee/s and approved by the 2

NSW ITIM Executive Committee. 3

4


14. Appendices 1

Appendix 1: ECI Inter-hospital Adult Retrieval Checklist 2

3

4


1 2

3


1 2

3

Collaboration. Innovation. Better Healthcare.

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Documents

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