Every trauma network is laid out on the assumption that the right hospital is worth the extra miles. Since 2012, ambulance crews in England have driven seriously injured patients past their local emergency departments to newly designated major trauma centres (MTCs) [1]. The premise is simple - definitive care beats proximate care. Last week, a study in The Lancet Global Health suggested that, in some health systems at least, the wager does not always pay off [2,3].
The Equi-Injury Group followed 8,858 patients admitted with moderate to severe injuries to 19 hospitals in Ghana, Pakistan, Rwanda and South Africa [2]. Patients who arrived by ambulance did worse. Patients who had already been seen elsewhere in the health system did better. Getting to hospital faster did not predict survival. The lead author described the failure of ambulance transport and rapid transfer to predict better outcomes as one of the study’s “most surprising findings” [3].
The question the study raises - is the nearest hospital a hazard to be bypassed, or a resource to be used? - is a question foundational to ATLS, and very much the motivation for its very creation.
What the Equi-Injury study found
Injury kills around 4.4 million people a year, nearly 8% of all deaths worldwide, and roughly nine in ten of those deaths occur in low- and middle-income countries [3,4]. The Equi-Injury cohort reflected that burden: median age 31, 76.8% male, road traffic collisions accounting for half of all injuries, and orthopaedic injuries the commonest type at 39.2% [2,3].
The outcomes were sobering. In-hospital mortality was 6.1% and three-month mortality 9.7%, while 40.6% of those assessed were living with moderate to severe disability three months after discharge, measured with the WHO Disability Assessment Schedule. Of the patients for whom the composite outcome could be determined, 47.6% had died or were moderately to severely disabled at three months [2].
The provocative results came from multivariable models adjusted for age, sex, education, wealth, and injury type and severity [2]:
Ambulance arrival was associated with higher odds of death or disability (odds ratio 1.86; 95% CI 1.51–2.29) and, according to the university’s summary, more than double the odds of death within three months [2,3].
A prior healthcare encounter - contact with the health system before reaching the study hospital - was associated with lower odds of the composite outcome (OR 0.61; 95% CI 0.52–0.71) [2].
- Neither hospital level nor delay made a statistically significant difference: the level of the receiving hospital (OR 1.14; 95% CI 0.96–1.35) and delay in reaching it (OR 0.86; 95% CI 0.74–1.00) were not associated with the primary outcome [2].
The paper’s own conclusion is cautious: post-injury mortality and disability are bound up with health-system factors that need to be understood before countries commit to “potentially expensive” plans [2]. The accompanying press release goes further, reporting that stopping first at a nearby hospital for stabilisation may sometimes help, particularly when the specialist hospital is far away, whereas going straight there may be better when it is close [3]. Medical news coverage framed the message as a case for locally tailored, coordinated trauma care rather than investment in emergency transport alone [5].
Why this is uncomfortable
To see why this matters, recall what the case for regionalised trauma care rests on. The US National Study on the Costs and Outcomes of Trauma compared 18 level I trauma centres with 51 non-trauma centres and, after propensity-score weighting, found lower in-hospital mortality (7.6% vs 9.5%; relative risk 0.80) and lower one-year mortality (10.4% vs 13.8%; RR 0.75) in trauma centres, with the benefit largely confined to the more severely injured [6]. A 2021 meta-analysis of 52 studies and more than a million patients found higher odds of death outside a trauma system (OR 1.17; 95% CI 1.10–1.24), with further gains as systems mature [7]. A review of individual system components found inclusive design and system maturity associated with lower mortality, while rating the certainty of that evidence as low [8].
England’s 2012 reorganisation was associated with a 19% increase in the case-mix-adjusted odds of survival across a nine-year study period (95% CI 3%–36%), although unadjusted mortality did not change [1]. Most ambulance services initially bypassed trauma units only when the MTC was within 45 minutes; after national guidance in 2016, many extended the threshold to 60 minutes [9]. NICE advises that the optimal destination for major trauma is usually an MTC, while acknowledging that intermediate care in a trauma unit is sometimes needed [10].
Equi-Injury therefore runs against the grain of decades of trauma-system thinking. Either the result is an artefact of its setting, or the orthodoxy is less universal than we assume. The honest answer is a little of both.
The strongest case against the headline
Start with the reasons not to take the headline at face value, because they are strong.
Confounding by indication. Ambulances are called for the sickest patients. The unconscious motorcyclist travels by ambulance; the patient with a fractured wrist arrives by taxi. Adjustment for injury severity narrows this gap but rarely closes it, because severity scores capture anatomy far better than physiology. The authors are explicit that their data do not show that ambulances cause worse outcomes [3].
Survivorship. Patients were recruited at hospitals able to provide definitive care. Anyone who died at a first facility, or between facilities, never entered the cohort. If a stop-first pathway loses its sickest patients before they reach the definitive hospital, those who do arrive will look healthier than their directly transported counterparts, and a prior healthcare encounter will appear protective. The same logic applies to delay: a patient who survives a long journey has already passed a test that others failed. A near-null association between delay and outcome is exactly what survivorship would produce.
Missing outcomes. The composite primary outcome was available for 5,199 of the 8,858 patients [2]. When around four in ten patients lack the main outcome, modest differences in who is followed up can tilt the result.
Context. In some settings an ambulance is little more than transport, without trained crews or equipment, and a referral hospital may be overwhelmed. The study tests the systems that exist, not the concept of prehospital care. Read this way, it does not refute regionalisation; it shows what happens when the parts of a trauma system are bought without the connections between them, which is precisely the authors’ point [3].
High-income data contain an echo. In a US study of penetrating trauma in urban trauma systems, patients brought by private vehicle had markedly lower adjusted odds of death than those brought by ground ambulance (OR 0.38; 95% CI 0.31–0.47) [11]. The authors did not argue for abolishing ambulances; they concluded that prehospital care may have a limited role for that subset of patients [11]. For a stab wound to the heart, the decisive intervention happens in an operating theatre, not in the back of a vehicle.
Where the uncomfortable finding still bites
Even after those caveats, a residue remains that the bypass orthodoxy should take seriously, and some of it comes from the UK.
When English investigators tried to test bypass for suspected severe head injury in a cluster-randomised feasibility trial, HITS-NS, 56 ambulance-station clusters recruited 293 patients in a year [12]. Bypass to a neuroscience centre produced overtriage ratios of 4:1 for traumatic brain injury and 13:1 for neurosurgery; crews at the roadside could not reliably identify who had a surgical brain injury. The investigators concluded that a definitive trial of early neurosurgery through bypass was not plausible with that design [12]. Bypass for head injury, in other words, rests largely on observational evidence, and the one English attempt at a trial could not settle the question.
Secondary transfer, by contrast, unquestionably costs time. National audit data from England show that patients who went first to a trauma unit waited longer for urgent surgery (median 7.2 vs 4.4 hours) and had higher crude mortality than those taken directly to an MTC [9]. Yet in a six-year study of injured children in the East of England, those who underwent secondary transfer reached the MTC about five hours later than those who bypassed, and 30-day mortality did not differ (4.0% vs 5.2%) [13]. The bypass group had more polytrauma, more chest injury and more high-energy mechanisms, so this comparison is confounded too; the authors still concluded that bypass decisions are necessary [13].
Taken together, the data suggest that time to definitive care is a powerful but not universal determinant of outcome. It matters enormously for the patient bleeding into a body cavity or developing an expanding intracranial haematoma. It matters far less for the patient whose immediate threats can be controlled by a competent team in the first hospital. The difficulty is that these two patients can look identical at the roadside.
ATLS was created by this dilemma
This is where ATLS candidates should sit up. In 1976 the light aircraft that orthopaedic surgeon James Styner was piloting crashed in a Nebraska cornfield. His wife was killed, and he and three of his four children were severely injured [14]. Styner was deeply dissatisfied with the quality and timeliness of the care his family then received, which he judged inferior to what he had managed to provide at the scene [14,15]. With Ronald Craig, a family physician in Lincoln, he set out to give doctors who rarely see major trauma the skills to manage it [14].
The first course ran in Auburn, Nebraska, on 11–12 February 1978, and its intended audience was the small-town doctor [14]. By 1980, when the American College of Surgeons began taking it across the United States, the course taught doctors to judge whether their own institution had the resources a patient needed and, if not, how to arrange interhospital transfer safely [14].
ATLS, in other words, was never primarily a course for the trauma centre. It was a course for the first hospital — the one modern networks are designed to bypass. Its implicit theory of trauma systems is that the nearest hospital is not a hazard if it does three things well: treats immediate threats to life, recognises early that the patient needs more than it can offer, and moves them without avoidable delay. ATLS 11, launched in 2025, added an entirely new chapter on trauma systems, making that system-level thinking explicit [16].
Read in that light, Equi-Injury is not an argument against ambulances or trauma centres. It is an argument that the value of each link in the chain depends on the competence of the link before it and the connection to the link after it. A prior healthcare encounter is protective if it delivered a secured airway, a decompressed tension pneumothorax, controlled external haemorrhage and an early phone call. It is harmful if it delivered a long wait for a scanner and a transfer that nobody owned.
The NHS has codified the second half of that lesson. NICE expects patients who need critical interventions at an MTC to leave the sending emergency department within 30 minutes of the decision to transfer [10]. That standard works only if the decision is made early, by someone trained to think about transfer from the moment the patient arrives.
So: bypass or stop?
The defensible position is neither “always bypass” nor “always stop”. Bypass when the specialist centre is close enough that the journey costs less than the stop would. Stop when it is not, or when the patient has an immediate threat that a capable local team can fix. In either case, design the system so that the first hospital works as a stabilise-and-transfer unit rather than a holding area.
For low- and middle-income countries, the message of Equi-Injury is to build competence and connections before buying ambulances and centralised centres. For the UK and other high-income systems the message is subtler: bypass rules are only as good as the trauma units they bypass, and trauma units are only as good as the clinicians in them who have been trained to make the transfer decision early.
What this means for your ATLS exam
ATLS treats transfer to definitive care as a core clinical competence, not an administrative afterthought [17]. Questions in this area tend to be “best next step” items, and the distractors are predictable.
Decide early. The need for transfer is set by the patient’s needs relative to your hospital’s capabilities, and it can be recognised during the primary survey. Completing the secondary survey should not delay the decision.
Do not delay for diagnostics. If the patient needs a capability you lack, the correct answer is rarely “obtain a CT first”. Investigations that will not change what you do before transfer belong at the receiving hospital.
Stabilise within your capabilities. Before departure, secure an airway at risk of deterioration, decompress the chest when indicated, control external haemorrhage, and apply a pelvic binder or splints as needed. Problems that arise in the back of an ambulance are much harder to fix.
Communicate doctor to doctor. The referring doctor initiates the transfer and determines the mode of transport and level of care needed en route, working with the receiving doctor. Use a structured handover (ATLS has recommended the ABC-SBAR template) and send records and images with the patient [17].
Choose the right escort. The accompanying team must be able to manage the complications the patient might develop on the journey.
- Think in systems. With a dedicated trauma-systems chapter in ATLS 11, expect the course to frame your hospital as one node in a network, and to test whether you know when it is the right place for the patient - and when it is not [16].
The most useful habit, in the examination and in practice, is the same: at the end of every primary survey, ask “Does this patient need to be somewhere else, and what must I do before they go?” That question is where ATLS began.
References
Moran CG, Lecky F, Bouamra O, et al. Changing the system – major trauma patients and their outcomes in the NHS (England) 2008–17. EClinicalMedicine. 2018;2–3:13–21. doi:10.1016/j.eclinm.2018.07.001. https://doi.org/10.1016/j.eclinm.2018.07.001
The Equi-Injury Group (Davies J, Chu K, Tabiri S, et al.). Mortality and disability after hospitalisation for injuries in low-income and middle-income countries: a cohort study. Lancet Glob Health. Published online 7 October 2026. doi:10.1016/j.langlo.2026.104053. https://doi.org/10.1016/j.langlo.2026.104053 Abstract: https://research.birmingham.ac.uk/en/publications/mortality-and-disability-after-hospitalisation-for-injuries-in-lo/
University of Birmingham. Global injury crisis highlights urgent need for smarter trauma care [press release]. 8 October 2026. https://www.birmingham.ac.uk/news/2026/global-injury-crisis-highlights-urgent-need-for-smarter-trauma-care Also issued via EurekAlert!, 7 October 2026: https://www.eurekalert.org/news-releases/1146485
World Health Organization. Injuries and violence [fact sheet]. Geneva: WHO. Accessed 12 October 2026. https://www.who.int/news-room/fact-sheets/detail/injuries-and-violence
Medical Xpress. Global injury crisis highlights urgent need for smarter trauma care. 8 October 2026. https://medicalxpress.com/news/2026-10-global-injury-crisis-highlights-urgent.html
MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366–378. doi:10.1056/NEJMsa052049. https://doi.org/10.1056/NEJMsa052049
Alharbi RJ, Shrestha S, Lewis V, Miller C. The effectiveness of trauma care systems at different stages of development in reducing mortality: a systematic review and meta-analysis. World J Emerg Surg. 2021;16:38. doi:10.1186/s13017-021-00381-0. https://doi.org/10.1186/s13017-021-00381-0
Moore L, Champion H, Tardif PA, et al. Impact of trauma system structure on injury outcomes: a systematic review and meta-analysis. World J Surg. 2018;42(5):1327–1339. doi:10.1007/s00268-017-4292-0. https://doi.org/10.1007/s00268-017-4292-0
Haslam NR, Bouamra O, Lawrence T, Moran CG, Lockey DJ. Time to definitive care within major trauma networks in England. BJS Open. 2020;4(5):963–969. doi:10.1002/bjs5.50316. https://doi.org/10.1002/bjs5.50316
National Institute for Health and Care Excellence. Major trauma: service delivery. NICE guideline NG40. London: NICE; 2016. https://www.nice.org.uk/guidance/ng40
Wandling MW, Nathens AB, Shapiro MB, Haut ER. Association of prehospital mode of transport with mortality in penetrating trauma: a trauma system–level assessment of private vehicle transportation vs ground emergency medical services. JAMA Surg. 2018;153(2):107–113. doi:10.1001/jamasurg.2017.3601. https://doi.org/10.1001/jamasurg.2017.3601
Lecky F, Russell W, Fuller G, et al. The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study. Health Technol Assess. 2016;20(1):1–198. doi:10.3310/hta20010. https://doi.org/10.3310/hta20010
Hibberd O, Price J, Laurent A, Agrawal S, Barnard E. Paediatric major trauma: a retrospective observational comparison of mortality in prehospital bypass and secondary transfer in the East of England. Cureus. 2023;15(3):e36808. doi:10.7759/cureus.36808. https://doi.org/10.7759/cureus.36808
Hoyt DB. Looking forward – March 2018 [ATLS 40th anniversary]. Bulletin of the American College of Surgeons. 1 March 2018. https://facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2018/03/looking-forward-march-2018
Driscoll P, Wardrope J. ATLS: past, present, and future. Emerg Med J. 2005;22(1):2–3. doi:10.1136/emj.2004.021212. https://doi.org/10.1136/emj.2004.021212
American College of Surgeons. Trauma care gets major upgrade with launch of ATLS 11. ACS Brief. 16 September 2025. https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/acs-brief/september-16-2025-issue/trauma-care-gets-major-upgrade-with-launch-of-atls-11/
- American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Student Course Manual. 10th ed. Chicago: American College of Surgeons; 2018. Chapter 13, Transfer to definitive care. https://www.facs.org/quality-programs/trauma/education/advanced-trauma-life-support/