Major Trauma Patients Transferred From Rural and Remote Western Australia by the Royal Flying Doctor Service

Background: The "golden hour" of trauma care is irrelevant in rural areas. We studied the effect of distance and remoteness on major trauma patients transferred by the Royal Flying Doctor Service from rural and remote Western Australia. Methods: The Royal Flying Doctor Service retrieval and Trauma Registry databases were linked for the period of July 1, 1997, to June 30, 2006. Major trauma was defined as Injury Severity Score (ISS) > 15. Remoteness was quantified using the Accessibility/Remoteness Index of Australia (ARIA) classes: inner regional, outer regional, remote, and very remote. The primary outcome was death. Results: Among 1328 major trauma transfers to Perth, mean age was 34.2 years +/- 18.3 years (range, 0-87 years) and 979 (73.7%) were male. Over half were motor vehicle crashes. Mean transfer time was 11.6 hours (95% confidence interval [CI], 11.2-12.1). The median ISS was 25 (interquartile range [IQR], 18-29), and there were no differences within the ARIA classes for cause and injury patterns. After adjusting for ISS, age, and time, the risk of death increases as remoteness increases: outer regional odds ratio (OR), 2.25 (95% CI, 0.58-8.79); remote, 4.03 (95% CI 1.04-15.62); and very remote, 4.69 (95% CI, 1.23-17.84). Risk increases by 87% for each 1,000 km (OR, 1.87; 95% CI, 1.007-3.48; p = 0.05) flown. Despite long retrieval times, there were no deaths in flight. Conclusion: There is an excess of a fourfold increase in the risk of major trauma death in patients transferred to Perth from remote and very remote Western Australia. Remoteness, as measured by the ARIA, is more important than distance, in the risk of death.