Our study demonstrated that regular feedback on the inter-hospital transfer improved the quality of blood transfusion on initial resuscitation. Patients with major trauma were more likely to be transfused with packed RBC on arrival at the emergency department of regional hospital when the feedback on inter-hospital transfer was done on a monthly basis. Although the time span before transfer was not decreased, because of the increased percentage of blood transfusion before transfer, the mortality risk was reduced. (Fig. 1)
Undertriage of major trauma patients has been a common problem, and inter-hospital transfer remains a great challenge of trauma system.[8, 11–13] The published literature focused mainly on the causes and outcomes of under-triage. [11, 14, 15] Building up an organized regional trauma system required a lot of resources without guaranteeing rapid inter-hospital transfer. [8, 9, 16] The rural trauma team development course has been reported to decrease the time for patient transfer; the risk of death, however, was not reduced as expected.[10, 17, 18] To the best of our knowledge, our study firstly demonstrated that regular feedback on the inter-hospital transfer might contribute to the reduction of mortality risk.
Hemorrhage is the main cause of preventable death of trauma patients. [19–21] Early blood transfusion serves as a bridging measure to definitive hemostasis procedures so that the mortality risk could be decreased.  In fact, our feedback for regional hospital emphasizes not only the importance of early blood transfusion, but also the transportation of blood component. To solve these problems as a whole, we break down the issues into small steps and optimize each of them. We have set up the protocol as to early notification of blood bank for O + blood preparation, and the personnel for blood component transportation from the blood bank to the emergency department or the operating room. These experiences were shared with the regional hospital. This explain why the mortality risk was decreased in our study but not in other study. [10, 17]
The context of feedback was not only lecture or presentation on the outcomes of the transferred patients, but also communication and interaction of emergency department physicians and trauma surgeons on the transfer detail. The feedback is supposed to be innovative and problem-solving instead of fault-finding and anxiety-provoking. In the process of monthly feedback, we acknowledged that one-way feedback from the tertiary trauma center focusing on the backend processing more often becomes captious or hypercritical than constructive in terms of a rapidly responsive and effective trauma system. Breaking down the transfer issue into small steps highlighted the emerging problem and enhanced the will of cooperation especially when the triage took right measure to the initial resuscitation. Interaction from both sides helped emergency physicians and trauma surgeons comprehend the patient evaluation at the scene and the rationale of decision making on hemostasis, compensating the gap of judgement and enhancing the will of cooperation.
Some limitations do exist in our study. Selection bias was inevitable because of the retrospective nature of our study. The small number of study cohorts in a single tertiary center was another disadvantage, and the shortage of medical personnel at the emergency department in regional hospital might be overlooked. Since inter-hospital transfer occurred to severely injured yet salvageable patients, patients presenting with cardiopulmonary collapse and dismal outcome might be neglected. Further investigation on a larger population among different tertiary centers is mandatory to consolidate our conclusion.