Patients with severe traumatic brain injury transferred to a Level I or II trauma center: United States, 2007 to 2009

Temporal Delays in the Management of Traumatic Brain Injury: A Comparative Meta-Analysis of Global Literature

OBJECTIVE

A meta-analysis was conducted to compare: 1) time from traumatic brain injury (TBI) to the hospital, and 2) time within the hospital to intervention or surgery, by country-level income, World Health Organization region, and healthcare payment system.

METHODS

A comprehensive literature search was conducted and followed by a meta-analysis comparing duration of delays (prehospital and intrahospital) in TBI management. Means and standard deviations were pooled using a random effects model and subgroup analysis was performed using R software.

RESULTS

Our analysis comprised 95,554 TBI patients from 45 countries.

BY COUNTRY-LEVEL INCOME

From 23 low- and middle-income countries, a longer mean time from injury to surgery (862.53 minutes, confidence interval [CI]: 107.42-1617.63), prehospital (217.46 minutes, CI: -27.34-462.25), and intrahospital (166.36 minutes, 95% CI: 96.12-236.60) durations were found compared to 22 high-income countries.

BY WHO REGION

African Region had the greatest total (1062.3 minutes, CI: -1072.23-3196.62), prehospital (256.57 minutes [CI: -202.36-715.51]), and intrahospital durations (593.22 minutes, CI: -3546.45-4732.89).

BY HEALTHCARE PAYMENT SYSTEM

Multiple-Payer Health Systems had a greater prehospital duration (132.62 minutes, CI: 54.55-210.68) but greater intrahospital delays were found in Single-Payer Health Systems (309.37 minutes, CI: -21.95-640.69).

CONCLUSION

Our study concludes that TBI patients in low- and middle-income countries within African Region countries face prolonged delays in both prehospital and intrahospital management compared to high-income countries. Additionally, patients within Single-Payer Health System experienced prolonged intrahospital delays. An urgent need to address global disparities in neurotrauma care has been highlighted.

Approaches and reporting of alcohol and other drug testing for injured patients in hospital-based studies: A systematic review

ISSUE

Hospital alcohol and/or other drug (AOD) testing is important for identifying AOD-related injuries; however, testing methods vary. This systematic review aimed to examine biological AOD testing methods from hospital-based studies of injured patients and quantify what proportion reported key information on those testing methods.

APPROACH

Observational studies published in English from 2010 onwards involving biological AOD testing for injured patients presenting to hospital were included. Studies examining single injury causes were excluded. Extracted data included concentration thresholds for AOD detection (e.g., lower limits of detection, author-defined cut-offs), test type (e.g., immunoassay, breathalyser) and approach (e.g., routine, clinical discretion), timing of testing, sample type and the proportion of injured cases tested for AODs.

KEY FINDINGS

Of 83 included studies, 76 measured alcohol and 37 other drugs. Forty-nine studies defined blood alcohol concentration thresholds (ranging from 0 to 0.1 g/100 mL). Seven studies defined concentration thresholds for other drugs. Testing approach was reported in 39/76 alcohol and 18/37 other drug studies. Sample type was commonly reported (alcohol: n = 69/76; other drugs: n = 28/37); alcohol was typically measured using blood (n = 60) and other drugs using urine (n = 20). Studies that reported the proportion of cases tested (alcohol: n = 53/76; other drugs: n = 28/37), reported that between 0% and 89% of cases were not tested for alcohol and 0% and 91% for other drugs. Timing of testing was often unreported (alcohol: n = 61; other drugs: n = 30).

IMPLICATIONS AND CONCLUSION

Variation in AOD testing methods alongside incomplete reporting of those methods limits data comparability and interpretation. Standardised reporting of testing methods will assist AOD-related injury surveillance and prevention.

Review article: Emergency medical services transfer of severe traumatic brain injured patients to a neuroscience centre: A systematic review

Patients with severe traumatic brain injuries require urgent medical attention at a hospital. We evaluated whether transporting adult patients with a severe traumatic brain injury (TBI) to a Neuroscience Centre is associated with reduced mortality. We reviewed studies published between 2010 and 2023 on severe TBI in adults (>18 years) using Medline, CINAHL, Google Scholar and Cochrane databases. We focused on mortality rates and the impact of transferring patients to a Neuroscience Centre, delays to neurosurgery and EMS triage accuracy. This review analysed seven studies consisting of 53 365 patients. When patients were directly transported to a Neuroscience Centre, no improvement in survivability was demonstrated. Subsequently, transferring patients from a local hospital to a Neuroscience Centre was significantly associated with reduced mortality in one study (adjusted odds ratio: 0.79, 95% confidence interval: 0.64-0.96), and 24-h (relative risk [RR]: 0.31, 0.11-0.83) and 30-day (RR: 0.66, 0.46-0.96) mortality in another. Patients directly transported to a Neuroscience Centre were more unwell than those taken to a local hospital. Subsequent transfers increased time to CT scanning and neurosurgery in several studies, although these were not statistically significant. Additionally, EMS could accurately triage. None of the included studies demonstrated statistically significant findings indicating that direct transportation to a Neuroscience Centre increased survivability for patients with severe traumatic brain injuries. Subsequent transfers from a non-Neuroscience Centre to a Neuroscience Centre reduced mortality rates at 24 h and 30 days. Further research is required to understand the differences between direct transport and subsequent transfers to Neuroscience Centres.

Firearm-Related Traumatic Brain Injury Homicides in the United States, 2000-2019

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of homicide-related death in the United States. Penetrating TBI associated with firearms is a unique injury with an exceptionally high mortality rate that requires specialized neurocritical trauma care.

OBJECTIVE

To report incidence patterns of firearm-related and nonfirearm-related TBI homicides in the United States between 2000 and 2019 by demographic characteristics to provide foundational data for prevention and treatment strategies.

METHODS

Data were obtained from multiple cause of death records from the National Vital Statistics System using Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database for the years 2000 to 2019. Number, age-adjusted rates, and percent of firearm and nonfirearm-related TBI homicides by demographic characteristics were calculated. Temporal trends were also evaluated.

RESULTS

During the study period, there were 77 602 firearm-related TBI homicides. Firearms were involved in the majority (68%) of all TBI homicides. Overall, men, people living in metro areas, and non-Hispanic Black persons had higher rates of firearm-related TBI homicides. The rate of nonfirearm-related TBI homicides declined by 40%, whereas the rate of firearm-related TBI homicides only declined by 3% during the study period. There was a notable increase in the rate of firearm-related TBI homicides from 2012/2013 through 2019 for women (20%) and nonmetro residents (39%).

CONCLUSION

Firearm-related violence is an important public health problem and is associated with the majority of TBI homicide deaths in the United States. The findings from this study may be used to inform prevention and guide further research to improve treatment strategies directed at reducing TBI homicides involving firearms.

The significance of direct transportation to a trauma center on survival for severe traumatic brain injury

INTRODUCTION

While timely specialized care can contribute to improved outcomes following traumatic brain injury (TBI), this condition remains the most common cause of post-injury death worldwide. The purpose of this study was to investigate the difference in mortality between regional trauma centers in Sweden (which provide neurosurgical services round the clock) and non-trauma centers, hypothesizing that 1-day and 30-day mortality will be lower at regional trauma centers.

PATIENTS AND METHODS

This retrospective cohort study used data extracted from the Swedish national trauma registry and included adults admitted with severe TBI between January 2014 and December 2018. The cohort was divided into two subgroups based on whether they were treated at a trauma center or non-trauma center. Severe TBI was defined as a head injury with an AIS score of 3 or higher. Poisson regression analyses with both univariate and multivariate models were performed to determine the difference in mortality risk [Incidence Rate Ratio (IRR)] between the subgroups. As a sensitivity analysis, the inverse probability of treatment weighting (IPTW) method was used to adjust for the effects of confounding.

RESULTS

A total of 3039 patients were included. Patients admitted to a trauma center had a lower crude 30-day mortality rate (21.7 vs. 26.4% days, p = 0.006). After adjusting for confounding variables, patients treated at regional trauma center had a 28% [adj. IRR (95% CI): 0.72 (0.55-0.94), p = 0.015] decreased risk of 1-day mortality and an 18% [adj. IRR (95% CI): 0.82 (0.69-0.98)] reduction in 30-day mortality, compared to patients treated at a non-trauma center. After adjusting for covariates in the Poisson regression analysis performed after IPTW, admission and treatment at a trauma center were associated with a 27% and 17% reduction in 1-day and 30-day mortality, respectively.

CONCLUSION

For patients suffering a severe TBI, treatment at a regional trauma center confers a statistically significant 1-day and 30-day survival advantage over treatment at a non-trauma center.

Predictors for Withdrawal of Life-Sustaining Therapies in Patients With Traumatic Brain Injury: A Retrospective Trauma Quality Improvement Program Database Study

Many patients with severe traumatic brain injuries (TBIs) undergo withdrawal of life-sustaining therapies (WLSTs) or transition to comfort measures, but noninjury factors that influence this decision have not been well characterized. We hypothesized that WLST would be associated with institutional and geographic noninjury factors. All patients with a head Abbreviated Injury Scale score ≥3 were identified from 2016 Trauma Quality Improvement Program data. We analyzed factors that might be associated with WLST, including procedure type, age, sex, race, insurance, Glasgow Coma Scale score, mechanism of injury, geographic region, and institutional size and teaching status. Adjusted logistic regression was performed to examine factors associated with WLST. Sixty-nine thousand fifty-three patients were identified: 66% male, 77% with isolated TBI, and 7.8% had WLST. The median age was 56 years (34-73). A positive correlation was found between increasing age and WLST. Women were less likely to undergo WLST than men (odds ratio 0.91 [0.84-0.98]) and took more time to for WLST (3 vs 2 days, P < .001). African Americans underwent WLST at a significantly lower rate (odds ratio 0.66 [0.58-0.75]). Variations were also discovered based on US region, hospital characteristics, and neurosurgical procedures. WLST in severe TBI is independently associated with noninjury factors such as sex, age, race, hospital characteristics, and geographic region. The effect of noninjury factors on these decisions is poorly understood; further study of WLST patterns can aid health care providers in decision making for patients with severe TBI.

Traumatic Brain Injury-Related Hospitalizations and Deaths in Urban and Rural Counties-2017

STUDY OBJECTIVE

A better understanding of differences in traumatic brain injury incidence by geography may help inform resource needs for local communities. This paper presents estimates on traumatic brain injury-related hospitalizations and deaths by urban and rural county of residence.

METHODS

To estimate the incidence of traumatic brain injury-related hospitalizations, data from the 2017 Healthcare Cost and Utilization Project's National Inpatient Sample were analyzed (n=295,760). To estimate the incidence of traumatic brain injury-related deaths, the Centers for Disease Control and Prevention's National Vital Statistics System multiple-cause-of-death files were analyzed (n=61,134). Datasets were stratified by residence, sex, principal mechanism of injury, and age group. Traumatic brain injury-related hospitalizations were also stratified by insurance status and hospital location.

RESULTS

The rate of traumatic brain injury-related hospitalizations was significantly higher among urban (70.1 per 100,000 population) than rural residents (61.0), whereas the rate of traumatic brain injury-related deaths was significantly higher among rural (27.5) than urban residents (17.4). These patterns held for both sexes, individuals age 55 and older, and within the leading mechanisms of injury (ie, suicide, unintentional falls). Among patients with Medicare or Medicaid, the rate of traumatic brain injury-related hospitalizations was higher among urban residents; there was no urban/rural difference with other types of insurance. Nearly all (99.6%) urban residents who were hospitalized for a traumatic brain injury received care in an urban hospital. Additionally, approximately 80.3% of rural residents were hospitalized in an urban hospital.

CONCLUSION

Urban residents had a higher rate of traumatic brain injury-related hospitalizations, whereas rural residents had a higher rate of traumatic brain injury-related deaths. This disparity deserves further study using additional databases that assess differences in mechanisms of injury and strategies to improve access to emergency care among rural residents.

Hospital Volume-Outcome Relationship in Severe Traumatic Brain Injury: A Nationwide Observational Study in Japan

OBJECTIVE

The hospital volume-outcome relationship in patients with severe traumatic brain injury (TBI) remains unclear. This study investigated the association between the volume of patients with severe TBI and in-hospital mortality.

METHODS

This observational study identified patients with severe TBI (Glasgow Coma Scale score <9 and Abbreviated Injury Scale head score ≥3) from the Japan Trauma Databank (2010-2018). Hospitals were grouped on the basis of annual patient volume as follows: low-volume (4-19 patients/year); middle-volume (20-35 patients/year); and high-volume (36-51 patients/year) groups. The association between hospital volume categories and in-hospital mortality was examined using a multivariate mixed-effect logistic regression analysis. A subgroup analysis was performed based on the presence of severe extracranial injuries.

RESULTS

A total of 11,344 patients from 64 hospitals were included. The median age of the patients was 57 years (interquartile range, 40-77), and 7933 (70.0%) patients were men. A total of 4879 (43.1%) patients died in the hospital. The medium-volume (adjusted odds ratio [OR], 0.76; 95% confidence interval [CI], 0.62-0.93) and high-volume (adjusted OR, 0.69; 95% CI, 0.52-0.94) groups were significantly associated with lower in-hospital mortality. The subgroup analysis revealed that the medium-volume (adjusted OR, 0.70; 95% CI, 0.54-0.92) and high-volume (adjusted OR, 0.64; 95% CI, 0.42-0.96) groups were significantly associated with lower in-hospital mortality for isolated TBI patients.

CONCLUSIONS

Higher hospital volumes were significantly associated with lower in-hospital mortality after severe TBI. Regionalization and referral to higher-volume hospitals are beneficial for severe TBI patients.

A single dose of valproic acid improves neurologic recovery and decreases brain lesion size in swine subjected to an isolated traumatic brain injury

BACKGROUND

We lack specific treatments for traumatic brain injury (TBI), which remains the leading cause of trauma-related morbidity and mortality. Treatment with valproic acid (VPA) improves outcomes in models of severe TBI with concurrent hemorrhage. However, it is unknown if VPA will have similar benefits after isolated nonlethal TBI, which is the more common clinical scenario. The goal of this study was to evaluate the effect of VPA treatment in a preclinical isolated TBI swine model on neurologic outcomes and brain lesion size and to perform detailed pharmacokinetic analyses for a future clinical trial.

METHODS

Yorkshire swine (n = 10; 5/cohort) were subjected to TBI (8-mm controlled cortical impact). An hour later, we randomized them to receive VPA (150 mg/kg) or saline placebo (control). Neuroseverity scores were assessed daily (0 [normal] to 36 [comatose]), brain lesion size was measured on postinjury 3, and serial blood samples were collected for pharmacokinetic studies.

RESULTS

Physiologic parameters and laboratory values were similar in both groups. Valproic acid-treated animals demonstrated significantly better neuroseverity scores on postinjury 1 (control, 9.2 ± 4.4; VPA, 0 ± 0; p = 0.001). Valproic acid-treated animals had significantly smaller brain lesion sizes (mean volume in microliter: control, 3,130 ± 2,166; VPA, 764 ± 208; p = 0.02). Pharmacokinetic data confirmed adequate plasma and tissue levels of VPA.

CONCLUSION

In this clinically relevant model of isolated TBI, a single dose of VPA attenuates neurological impairment and decreases brain lesion size.

The value of simplicity: externally validating the Baylor cranial gunshot wound prognosis score

OBJECTIVE

Gunshot wounds to the head (GSWH) are devastating injuries with a grim prognosis. Several prognostic scores have been created to estimate mortality and functional outcome, including the so-called Baylor score, an uncomplicated scoring method based on bullet trajectory, patient age, and neurological status on admission. This study aimed to validate the Baylor score within a temporally, institutionally, and geographically distinct patient population.

METHODS

Data were obtained from the trauma registry at a level I trauma center in the southeastern US. Patients with a GSWH in which dural penetration occurred were identified from data collected between January 1, 2009, and June 30, 2019. Patient demographics, medical history, bullet trajectory, intent of GSWH (e.g., suicide), admission vital signs, Glasgow Coma Scale score, pupillary response, laboratory studies, and imaging reports were collected. The Baylor score was calculated directly by using its clinical components. The ability of the Baylor score to predict mortality and good functional outcome (Glasgow Outcome Scale score 4 or 5) was assessed using the receiver operating characteristic curve and the area under the curve (AUC) as a measure of performance.

RESULTS

A total of 297 patients met inclusion criteria (mean age 38.0 [SD 15.7] years, 73.4% White, 85.2% male). A total of 205 (69.0%) patients died, whereas 69 (23.2%) patients had good functional outcome. Overall, the Baylor score showed excellent discrimination of mortality (AUC = 0.88) and good functional outcome (AUC = 0.90). Baylor scores of 3-5 underestimated mortality. Baylor scores of 0, 1, and 2 underestimated good functional outcome.

CONCLUSIONS

The Baylor score is an accurate and easy-to-use prognostic scoring tool that demonstrated relatively stable performance in a distinct cohort between 2009 and 2019. In the current era of trauma management, providers may continue to use the score at the point of admission to guide family counseling and to direct investment of healthcare resources.

Predictors of traumatic brain injury morbidity and mortality: Examination of data from the national trauma data bank: Predictors of TBI morbidity & mortality

BACKGROUND

There is evidence to suggest that traumatic brain injuries (TBI) are increasing in the United States. It is important to examine predictors of TBI outcomes to formulate better prevention and care strategies.

RESEARCH DESIGN

National Trauma Data Bank (NTDB) data from 2016 were used to report the percentage of TBI by age, sex, race/ethnicity, health insurance status, intent/mechanism of injury, Glasgow Coma Scale (GCS), disposition at emergency department, and trauma center level. Logistic regression models were run to estimate the adjusted odds ratios of patient and facility characteristics on length of hospital stay and in-hospital mortality (analyzed in 2020).

RESULTS

There were 236,873 patients with TBI in the NTDB in 2016. Most patients with a TBI were male, non-Hispanic white, and had sustained a TBI due to an unintentional injury. After adjusting for other factors, individuals age 0-17, those who self-pay, and those with intentional injuries had increased odds of a shorter hospital stay. Older individuals, non-Hispanic black or Hispanic patients, those who had sustained an intentional injury, and those who were not seen in a Level I trauma center had higher odds of mortality following their TBI.

CONCLUSIONS

Public health professionals' promotion of fall and other TBI prevention efforts and the development of strategies to improve access to Level I trauma centers, may decrease adverse TBI health outcomes. This may be especially important for older adults and other vulnerable populations.

Blunt and Penetrating Severe Traumatic Brain Injury

Severe traumatic brain injury is a common problem. Current practices focus on the importance of early resuscitation, transfer to high-volume centers, and provider expertise across multiple specialties. In the emergency department, patients should receive urgent intracranial imaging and consideration for tranexamic acid. Close observation in the intensive care unit environment helps identify problems, such as seizure, intracranial pressure crisis, and injury progression. In addition to traditional neurologic examination, patients benefit from use of intracranial monitors. Monitors gather physiologic data on intracranial and cerebral perfusion pressures to help guide therapy. Brain tissue oxygenation monitoring and cerebromicrodialysis show promise in studies.

Brain proteomic changes by histone deacetylase inhibition after traumatic brain injury

Background

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality. There are currently no cytoprotective treatments for TBI. There is growing evidence that the histone deacetylase inhibitor valproic acid (VPA) may be beneficial in the treatment of TBI associated with hemorrhagic shock and in isolation. We sought to further evaluate the mechanistic underpinnings of this demonstrated efficacy via proteomic analysis of injured brain tissue.

Methods

Swine were subjected to TBI via controlled cortical impact, randomized to treatment with VPA or control and observed for 6 hours. The brains of the pigs were then sectioned, and tissue was prepared and analyzed for proteomic data, including gene ontology (GO), gene-set enrichment analysis and enrichment mapping, and network mapping.

Results

Proteomic analysis demonstrated differential expression of hundreds of proteins in injured brain tissue after treatment with VPA. GO analysis and network analyses revealed groups of proteins and processes that are known to modulate injury response after TBI and impact cell fate. Processes affected included protein targeting and transport, cation and G-protein signaling, metabolic response, neurotransmitter response and immune function.

Discussion

This proteomic analysis provides initial mechanistic insight into the observed rescue of injured brain tissue after VPA administration in isolated TBI.

Level of evidence

Not applicable (animal study).

Valproic acid treatment rescues injured tissues after traumatic brain injury

BACKGROUND

No agents that are specifically neuroprotective are currently approved to emergently treat patients with traumatic brain injury (TBI). The histone deacetylase inhibitor, high-dose valproic acid (VPA) has been shown to have cytoprotective potential in models of combined TBI and hemorrhagic shock, but it has not been tested in an isolated TBI model. We hypothesized that VPA, administered after isolated TBI, will penetrate the injured brain, attenuate the lesion size, and activate prosurvival pathways.

METHODS

Yorkshire swine were subjected to severe TBI by cortical impact. One hour later, animals were randomized to VPA treatment (150 mg/kg delivered intravenously for 1 hour; n = 4) or control (saline vehicle; n = 4) groups. Seven hours after injury, animals were sacrificed, and brain lesion size was measured. Mass spectrometry imaging was used to visualize and quantitate brain tissue distribution of VPA. Sequential serum samples were assayed for key biomarkers and subjected to proteomic and pathway analysis.

RESULTS

Brain lesion size was 50% smaller (p = 0.01) in the VPA-treated animals (3,837 ± 948 mm) compared with the controls (1,900 ± 614 mm). Endothelial regions had eightfold higher VPA concentrations than perivascular regions by mass spectrometry imaging, and it readily penetrated the injured brain tissues. Serum glial fibrillary acid protein was significantly lower in the VPA-treated compared with the control animals (p < 0.05). More than 500 proteins were differentially expressed in the brain, and pathway analysis revealed that VPA affected critical modulators of TBI response including calcium signaling pathways, mitochondria metabolism, and biosynthetic machinery.

CONCLUSION

Valproic acid penetrates injured brain tissues and exerts neuroprotective and prosurvival effects that resulted in a significant reduction in brain lesion size after isolated TBI. Levels of serum biomarkers reflect these changes, which could be useful for monitoring the response of TBI patients during clinical studies.

The Effect of Trauma Center Verification Level on Outcomes in Traumatic Brain Injury Patients Undergoing Interfacility Transfer

BACKGROUND

Previous literature demonstrates increased mortality for traumatic brain injury (TBI) with transfer to a Level II versus Level I trauma center. Our objective was to determine the effect of the most recent American College of Surgeons-Committee on Trauma (ACS-COT) "Resources for the Optimal Care of the Injured Patient" resources manual ("The Orange Book") on outcomes after severe TBI after interfacility transfer to Level I versus Level II center.

METHODS

Utilizing the Trauma Quality Program Participant Use File of the American College of Surgeons admission year 2017, we identified patients with isolated TBI undergoing interfacility transfer to either Level I or Level II trauma center. Logistic regression was performed to determine independent associations with mortality.

RESULTS

There were 10,268 (71.6%) transferred to a Level I center and 4,025 (28.4%) were transferred to a Level II center. They were mostly male (61.4%) with a mean ± SD age of 61 ± 20.8 years. Mean Injury Severity Score was 16.3 ± 6.3 and most were injured in a single-level fall (51.5%). Patients transferred to a Level I center were less likely to be White (82.3% vs. 84.7%, 0.002) and more likely to have sustained penetrating trauma (2.7% vs. 1.6%, <0.001). The incidence of severe TBI (Glasgow Coma Scale [GCS] = 3-8) was similar (9.3% vs. 8.3%, 0.068). On logistic regression, severity of TBI predicted death; however, there was no difference in adjusted mortality outcome with admission to a Level II versus a Level I center (0.998 [0.836-1.192], 0.985).

CONCLUSIONS

There is no mortality discrepancy in patients with isolated TBI transferred to a Level II versus Level I center despite previous contrary evidence and thus no reason to bypass a Level II in favor of a Level I. This relative improvement potentially relates to the new requirements as defined in the latest version of the ACS-COT's resources manual.

Pre- and in-hospital mortality for moderate-to-severe traumatic brain injuries: an analysis of the National Trauma Data Bank (2008-2014)

Objectives: This study aimed to: (1) evaluate pre- and in-hospital mortality for moderate-to-severe TBI in the U.S. by injury type (blunt vs. penetrating) and (2) estimate annual regression-adjusted mortality from 2008-2014.Methods: Data were analyzed from the National Trauma Data Bank (N=247,648). Multivariable logistic regression analyses were performed by injury type to assess changes in mortality between study periods (early period: 2008-2010; late period: 2011-2014) and to estimate annual regression-adjusted mortality. Mortality odds ratios and 95% confidence intervals were calculated.Results: Total observed mortality was 18.8%. After covariate adjustment, patients in the late period had an increased odds of prehospital mortality compared to patients in the early period for blunt (OR: 4.69; 95%CI: 4.41-4.98) and penetrating trauma (OR: 4.71; 95%CI: 4.39-5.06). In contrast, patients in the late period had a decreased odds of in-hospital mortality compared to patients in the early period for blunt (OR: 0.95; 95%CI: 0.91-0.98) and penetrating trauma (OR: 0.92; 95%CI: 0.85-0.98).Conclusions: The decreasing in-hospital mortality trend is consistent with previous literature. Additional research is warranted to validate the observed increase in prehospital mortality and to identify best practices that can improve prehospital outcomes for patients with moderate-to-severe TBI.

Delayed Neurosurgical Intervention in Traumatic Brain Injury Patients Referred From Primary Hospitals Is Not Associated With an Unfavorable Outcome

Background: Secondary transports of patients suffering from traumatic brain injury (TBI) may result in a delayed management and neurosurgical intervention, which is potentially detrimental. The aim of this study was to study the effect of triaging and delayed transfers on outcome, specifically studying time to diagnostics and neurosurgical management.

Methods: This was a retrospective observational cohort study of TBI patients in need of neurosurgical care, 15 years and older, in the Stockholm Region, Sweden, from 2008 throughout 2014. Data were collected from pre-hospital and in-hospital charts. Known TBI outcome predictors, including the protein biomarker of brain injury S100B, were used to assess injury severity. Characteristics and outcomes of direct trauma center (TC) and those of secondary transfers were evaluated and compared. Functional outcome, using the Glasgow Outcome Scale, was assessed in survivors at 6–12 months after trauma. Regression models, including propensity score balanced models, were used for endpoint assessment.

Results: A total of n = 457 TBI patients were included; n = 320 (70%) patients were direct TC transfers, whereas n = 137 (30%) were secondary referrals. In all, n = 295 required neurosurgery for the first 24 h after trauma (about 75% of each subgroup). Direct TC transfers were more severely injured (median Glasgow Coma Scale 8 vs. 13) and more often suffered a high energy trauma (31 vs. 2.9%) than secondary referrals. Admission S100B was higher in the TC transfer group, though S100B levels 12–36 h after trauma were similar between cohorts. Direct or indirect TC transfer could be predicted using propensity scoring. The secondary referrals had a shorter distance to the primary hospital, but had later radiology and surgery than the TC group (all p < 0.001). In adjusted multivariable analyses with and without propensity matching, direct or secondary transfers were not found to be significantly related to outcome. Time from trauma to surgery did not affect outcome.

Conclusions: TBI patients secondary transported to a TC had surgical intervention performed hours later, though this did not affect outcome, presumably demonstrating that accurate pre-hospital triaging was performed. This indicates that for selected patients, a wait-and-see approach with delayed neurosurgical intervention is not necessarily detrimental, but warrants further research.

Transport Time and Mortality in Critically Ill Patients with Severe Traumatic Brain Injury

PURPOSE

Severe traumatic brain injury (TBI) is a major cause of morbidity and mortality in critically ill patients. Pre-hospital care and transportation time may impact their outcomes.

METHODS

Using the British Columbia Trauma Registry, we included 2,860 adult (≥18 years) patients with severe TBI (abbreviated injury scale head score ≥4), who were admitted to an intensive care unit (ICU) in a centre with neurosurgical services from January 1, 2000 to March 31, 2013. We evaluated the impact of transportation time (time of injury to time of arrival at a neurosurgical trauma centre) on in-hospital mortality and discharge disposition, adjusting for age, sex, year of injury, injury severity score (ISS), revised trauma score at the scene, location of injury, socio-economic status and direct versus indirect transfer.

RESULTS

Patients had a median age of 43 years (interquartile range [IQR] 26-59) and 676 (23.6%) were female. They had a median ISS of 33 (IQR 26-43). Median transportation time was 80 minutes (IQR 40-315). ICU and hospital length of stay were 6 days (IQR 2-12) and 20 days (IQR 7-42), respectively. Six hundred and ninety-six (24.3%) patients died in hospital. After adjustment, there was no significant impact of transportation time on in-hospital mortality (odds ratio 0.98, 95% confidence interval 0.95-1.01). There was also no significant effect on discharge disposition.

CONCLUSIONS

No association was found between pre-hospital transportation time and in-hospital mortality in critically ill patients with severe TBI.

Interhospital Transfer and Outcomes in Patients with AKI: A Population-Based Cohort Study

BACKGROUND

Patients with AKI may require interhospital transfer to receive RRT. Interhospital transfer may lead to delays in therapy, resulting in poor patient outcomes. There is minimal data comparing outcomes among patients undergoing transfer for RRT versus those who receive RRT at the hospital to which they first present.

METHODS

We conducted a population-based cohort study of all adult patients (≥19 years) who received acute dialysis within 14 days of admission to an acute-care hospital between April 1, 2004 and March 31, 2015. The transferred group included all patients who presented to a hospital without a dialysis program and underwent interhospital transfer (with the start of dialysis ≤3 days of transfer and within 14 days of initial admission). All other patients were considered nontransferred. The primary outcome was time to 90-day all-cause mortality, adjusting for demographics, comorbidities, and measures of acute illness severity. We also assessed chronic dialysis dependence as a secondary outcome, using the Fine and Gray proportional hazards model to account for the competing risks of death. In a secondary post hoc analysis, we assessed these outcomes in a propensity score-matched cohort, matching on age, sex, and prior CKD status.

RESULTS

We identified 27,270 individuals initiating acute RRT within 14 days of a hospital admission, of whom 2113 underwent interhospital transfer. Interhospital transfer was associated with lower rate of mortality (adjusted hazard ratio [aHR], 0.90; 95% CI, 0.84 to 0.97). Chronic dialysis dependence was not significantly different between groups (aHR, 0.98; 95% CI, 0.91 to 1.06). In the propensity score-matched analysis, interhospital transfer remained associated with a lower risk of death (HR, 0.88; 95% CI, 0.80 to 0.96).

CONCLUSIONS

Interhospital transfer for receipt of RRT does not confer higher mortality or worse kidney outcomes.

Timeliness of Care for Injured Patients Initially Seen at Freestanding Emergency Departments: A Pilot Quality Improvement Project

BACKGROUND

The impact of freestanding emergency departments (FSEDs) on timeliness of care for trauma patients is not well understood. This quality improvement project had 2 objectives: (1) to determine whether significant delays in definitive care existed among trauma patients initially seen at FSEDs compared with those initially seen at other outlying sites prior to transfer to a level I trauma center; and (2) to determine the feasibility of identifying differences in time-to-definitive care and emergency department length of stay (ED LOS) based on initial treatment location.

METHODS

Trauma registry data from January 1, 2017, through December 31, 2017, from a verified level I trauma center were analyzed by location of initial presentation. Appropriate statistical tests are used to make comparisons across transport groups.

RESULTS

Patients initially seen at non-FSEDs experienced ED LOS that were, on average, 24.5 minutes greater than patients seen initially at FSEDs, although the difference was not statistically significant (P = .3112). Several challenges were identified in the feasibility analysis that will inform the design for a larger study including large quantities of missing time stamp data and potential selection bias. Prospective solutions were identified.

CONCLUSION

This project found that there were not significant differences in ED LOS for injured patients presenting initially to FSEDs or other non-FSED facilities, suggesting that timeliness of care was similar across location types.

The Association of Trauma Center Transport and Long-term Functional Outcomes in Head-injured Older Adults Transported by Emergency Medical Services

OBJECTIVE

It is unclear whether trauma center care is associated with improved outcomes in older adults with traumatic brain injury (TBI) compared to management at nontrauma centers. Our primary objectives were to describe the long-term outcomes of older adults with TBI and to evaluate the association of trauma center transport with long-term functional outcome.

METHODS

This was a prospective, observational study at five emergency medical services (EMS) agencies and 11 hospitals representing all 9-1-1 transfers within a county. Older adults (≥55 years) with TBI (defined as closed head injury associated with loss of consciousness and/or amnesia, abnormal Glasgow Coma Scale [GCS] score, or traumatic intracranial hemorrhage) and transported by EMS from August 2015 to September 2016 were eligible. EMS providers completed standardized data forms and emergency department (ED) and hospital data were abstracted. Functional outcomes were measured using the Extended Glasgow Outcome Scale (GOS-E) at 3- and 6-month intervals by telephone follow-up. Reasons for disabilities were coded as due to head injury, due to illness or injury to other part of body, or due to a mixture of both. To evaluate the association of trauma center transport and functional outcomes, we conducted multivariate ordinal logistic regression analyses on multiple imputed data for 1) all patients with TBI and 2) patients with traumatic intracranial hemorrhage.

RESULTS

We enrolled 350 patients with TBI; the median (Q1, Q3) age was 70 (61, 84) years, 187 (53%) were male, and 91 patients (26%) had traumatic intracranial hemorrhage on initial ED cranial computed tomography (CT) imaging. A total of 257 patients (73%) were transported by EMS to a Level I or II trauma center. Sixty-nine patients (20%) did not complete follow-up at 3 or 6 months. Of the patients with follow-up, 119 of 260 patients (46%) had moderate disability or worse at 6 months, including 55 of 260 patients (21%) who were dead at 6-month follow-up. Death or severe disabilities were more commonly attributed to non-TBI causes while moderate disabilities or better were more commonly due to TBI. On adjusted analysis, an abnormal GCS score, higher Charlson Comorbidity Index scores, and the presence of traumatic intracranial hemorrhage on initial ED cranial imaging were associated with worse GOS-E scores at 6 months. Trauma center transport was not associated with GOS-E scores at 6 months for TBI patients and in patients with traumatic intracranial hemorrhage on initial ED CT imaging.

CONCLUSIONS

In older adults with TBI, moderate disability or worse is common 6 months after injury. Over one in five of older adults with TBI died by 6 months, usually due to nonhead causes. Patients with TBI or traumatic intracranial hemorrhage did not have improved functional outcomes with initial triage to a trauma center.

Diagnostic and predictive value of white blood cell count, erythrocyte sedimentation rate, and coagulation tests in patients with blunt head trauma

Introduction: Head trauma is the third leading cause of death and one of the most common causes of referral to the emergency department. Prognosis in these patients identifies individuals at higher risk and provides them with faster and more complete treatment, so it is of particular importance. The aim of this study is to evaluate the diagnostic and predictive value of white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and coagulation tests in the outcome of patients with blunt head trauma. Methods: In this retrospective study, 91 patients referred to the emergency department of Imam Reza hospital of Tabriz, with a complaint of DAI type of blunt head trauma, were enrolled in a complete and sequential study during the first six months of the year 2017. The patientswere divided into two groups according to good or poor prognosis and their association with leukocytosis status and other paraclinical factors at the baseline. Results: The final outcome in high consciousness group was 13.3% need for intubation,26.7% need for surgery, 50% improvement without complications, and 10% mortality. In the low consciousness group, 16.7% required intubation, 20.0% required surgery, 10% had no complications, and 53.3% experienced mortality. The significance level of the chi-squaretest was 0.001. Independent t test results showed that the WBC and ESR values in the lowconsciousness group were significantly higher than the high consciousness group. But the international normalized ratio (INR) in the high consciousness group was significantly higher than the low consciousness group (P<0.05). Conclusion: There is a significant relationship between severity of injury and leukocytosis, ESRelevation, and related coagulopathy after major trauma.

Mild traumatic brain injuries with minor intracranial hemorrhage: Can they Be safely managed in the community? - A cohort study

BACKGROUND

Patients with mild traumatic brain injury (mTBI) are frequently transferred to level 1 trauma centers (L1TC) if they have minor findings on a computerized tomographic scan of the head due to the absence of continuous neurosurgical coverage in community hospitals (CH). We hypothesized that such patients can be safely managed at community hospitals with a qualified Trauma team.

METHODS

This is a multicentered Retrospective Cohort Study. Patients with mild Traumatic Brain Injury (defined as Glasgow Coma Scale [GCS] 13-15 at presentation) and with minor findings on head Computerized Tomography (CT) presenting at a L1TC or 4 Community Hospitals between March 1st, 2012 and February 28th, 2014 were included. All these community hospitals are Level III Trauma center with a well-organized trauma team. Minor CT findings were defined as 1) epidural hematoma<2 mm; 2) subarachnoid hemorrhage<2 mm; 3) subdural hematoma<4 mm; 4) intraparenchymal hemorrhage<5 mm; 5) minor pneumocephalus; or 6) linear or minimally depressed skull fracture. Our primary end point was the need for TBI specific interventions in 3 groups of patients: 1) direct admission to the L1TC (L1TC group), 2) those admitted at one of the 4 CH (CH group), and 3) those transferred from CH to L1TC (TRANSFER group). TBI-specific interventions were defined as intracranial pressure monitor (ICP) placement, hyperosmolar therapy, or neurosurgical operation. Our secondary aim was to demonstrate that these patients can be safely managed in Community Hospitals with qualified Trauma teams. We also sought to identify the clinical outcomes in these three groups of patients - in terms of mortality and complications.

RESULTS

A total of 191 patients were included - 39 CH, 64 L1TC and 88 TRANSFER. There was no difference among the groups in terms of TBI-specific interventions: one TRANSFER, four L1TC, and no CH patients required hyperosmolar therapy (p = 0.277). None of the patients required placement of an intracranial pressure monitoring device (ICP) or a neurosurgical operation and complications and mortality rates were similar among the groups.

CONCLUSIONS

Patients with mild TBI and minor findings on head CT can be safely managed at CH with qualified Trauma Teams.

LEVEL OF EVIDENCE

Therapeutic/Care Management Study, Level IVhbv.

Long-term functional outcome following minimally invasive endoscopic intracerebral hemorrhage evacuation

Background and purpose

Preclinical studies suggest that clot removal may mitigate primary and secondary brain injury following intracerebral hemorrhage (ICH). Although the MISTIE trial did not demonstrate an overall outcome benefit, it did demonstrate outcome benefit from effective reduction of clot burden. Minimally invasive endoscopic ICH evacuation may provide an alternative option for clot evacuation.

Methods

Patients presenting to a single healthcare system from December 2015 to October 2018 with supratentorial spontaneous ICH were evaluated for minimally invasive endoscopic evacuation. Inclusion and exclusion criteria were prospectively established by a multidisciplinary group in the healthcare system. The prespecified primary analysis was the proportion of patients with modified Rankin Score (mRS) 0–3 at 6 months.

Results

One hundred patients met the inclusion and exclusion criteria and underwent minimally invasive endoscopic ICH evacuation. The mean (SD) hematoma size was 49.7 (30.6) mL, the mean (SD) evacuation percentage was 88.2 (20.3)%, and 86% of patients had postoperative residual hematoma ≤15 mL. At 6 months the proportion of patients with an mRS of 0–3 was 46%.

Conclusions

This study suggests that minimally invasive endoscopic ICH evacuation may produce favorable long-term functional outcomes. Further evaluation of this technique in a randomized clinical trial is necessary.

Direct transport vs secondary transfer to level I trauma centers in a French exclusive trauma system: Impact on mortality and determinants of triage on road-traffic victims

Background

Transporting a severely injured patient directly to a trauma center (TC) is consensually considered optimal. Nevertheless, disagreement persists regarding the association between secondary transfer status and outcome. The aim of the study was to compare adjusted mortality between road traffic trauma patients directly or secondarily transported to a level 1 trauma center (TC) in an exclusive French trauma system with a physician staffed prehospital emergency medical system (EMS).

Methods

A retrospective cohort study was performed using 2015–2017 data from a regional trauma registry (Traumabase®), an administrative database on road-traffic accidents and prehospital-EMS records.

Multivariate logistic regression models were computed to determine the role of the modality of admission on mortality and to identify factors associated with secondary transfer. The primary outcome was day-30 mortality.

Results: During the study period, 121.955 victims of road-traffic accident were recorded among which 4412 trauma patients were admitted in the level 1 regional TCs, 4031 directly and 381 secondarily transferred from lower levels facilities. No significant association between all-cause 30-day mortality and the type of transport was observed (Odds ratio 0.80, 95% confidence interval (CI) [0.3–1.9]) when adjusted for potential confounders. Patients secondarily transferred were older, with low-energy mechanism and presented higher head and abdominal injury scores. Among all 947 death, 43 (4.5%) occurred in lower-level facilities. The population-based undertriage leading to death was 0.15%, 95%CI [0.12–0.19].

Conclusion

In an exclusive trauma system with physician staffed prehospital care, road-traffic victims secondarily transferred to a TC do not have an increased mortality when compared to directly transported patients.

Outcomes in patients with gunshot wounds to the brain

Introduction

Gunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR.

Methods

We performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation.

Results

825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation.

Conclusion

We found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition.

Level of evidence

Level II.

A clinical prediction model for raised intracranial pressure in patients with traumatic brain injuries

BACKGROUND

Intracranial hypertension is believed to contribute to secondary brain insult in traumatically brain injured patients. Currently, the diagnosis of intracranial hypertension requires intracranial monitoring or advanced imaging. Unfortunately, prehospital transport times can be prolonged, delaying time to the initial radiographic assessment. The aim of this study was to identify clinical variables associated with raised intracranial pressure (ICP) prior to the completion of neuroimaging.

METHODS

We performed a retrospective cohort study of head injured patients over a 3-year period. Patients were labeled as having increased ICP if they had a single reading of ICP greater than 20 mm Hg within 1 hour of ICP monitor insertion or computed tomography findings suggestive of raised ICP. Patient and clinical characteristics were analyzed using stepwise multivariable logistic regression with ICP as the dependent variable.

RESULTS

Of 701 head injured patients identified, 580 patients met inclusion criteria. Mean age was 48.65 ± 21 years, 73.3% were male. The mean Injury Severity Score was 22.71 ± 12.38, and the mean Abbreviated Injury Scale for body region head was 3.34 ± 1.06. Overall mortality was 14.7%. Only 46 (7.9%) patients had an ICP monitor inserted; however, a total of 107 (18%) patients met the definition of raised ICP. The mortality rate for patients with raised ICP was 50.4%. Independent predictors of raised ICP were as follows: age, older than 55 years (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.35-3.76), pupillary fixation (OR, 5.76; 95% CI, 3.16-10.50), signs of significant head trauma (OR, 2.431; 95% CI, 1.39-4.26), and need for intubation (OR, 3.589; 95% CI, 2.10-6.14).

CONCLUSION

This study identified four independent variables associated with raised ICP and incorporated these findings into a preliminary risk assessment scale that can be implemented at the bedside to identify patients at significant risk of raised ICP. Future work is needed to prospectively validate these findings prior to clinical implementation.

LEVEL OF EVIDENCE

Prognostic, Epidemiological, level III.

Trauma center need: the American College of Surgeons' definition in contrast to Swiss highly specialized medicine regulations-a Swiss trauma center perspective

PURPOSE

According to the American College of Surgeons (ACS) recommendations, the benchmark for trauma center need (TCN) is an Injury Severity Score (ISS) > 15. In contrast, Swiss highly specialized medicine (HSM) regulations set out TCN for all patients with an ISS > 19 or an Abbreviated Injury Severity (AIS) of the head ≥ 3. This investigation assessed to what extent the modification might be justified.

METHODS

Consecutive analysis of all significantly injured (new ISS, NISS ≥ 8) adults treated in a trauma center from 2010 to 2016 based on their ISS and AIS head and in respect to utilized resources and outcome.

RESULTS

Of 2171 patients (mean age 57.2 ± 21.6; ISS 15.0 ± 8.5) 40.1% fulfilled the ACS and 52.7% the HSM-definition of TCN. Comparative analysis of specified subgroups representing combinations of the ISS and the AIS head revealed that patients within the HSM but not within the ACS-definition of TCN achieved worse outcomes in mortality or on the Glasgow Outcome Score and had a higher inpatient rehabilitation rate than patients with an ISS < 15 and an AIS head < 3 compared to patients with an ISS > 15. Mortality for patients with an ISS 16-19 and AIS head < 3 (qualifying for the ACS but not the HSM-definition of TCN) was found to be twice as high for patients who were not in the ACS or the HSM group (ISS < 16 & AIS head < 3).

CONCLUSIONS

If confirmed by others, both the ACS and the Swiss-recommendations for TCN should be adapted accordingly, provided that the resultant increased workload is feasible for the trauma centers concerned.

Defining severe traumatic brain injury readmission rates and reasons in a rural state

Background

Readmissions after a traumatic brain injury (TBI) have significant impact on long-term patient outcomes through interruption of rehabilitation. This study examined readmissions in a rural population, hypothesizing that readmitted patients after TBI will be older and have more comorbidities than those not readmitted.

Methods

Discharge data on all patients 15 years and older who were admitted to an Arkansas-based hospital for TBI were obtained from the Arkansas Hospital Discharge Data System from 2010 to 2014. This data set includes diagnoses (principal discharge diagnosis, up to 3 external cause of injury codes, 18 diagnosis codes using the International Classification of Disease, 9th Edition, Clinical Modifications), age, gender, and inpatient costs. Hospital Cost and Utilization Project Clinical Classification and Chronic Condition Indicator were used to identify chronic disease and body systems affected in principal diagnosis.

Results

Of the 3114 cases of significant head trauma, more than two-thirds were attributed to fall injuries, with motor vehicle crashes accounting for 20% of the remainder. The mean length of stay was 6.5 days. 691 of these patients were admitted to an Arkansas hospital in the following year, totaling 1368 readmissions. Of the readmissions, 16.4% of patients were admitted for altered mental status, 12.9% with shortness of breath (SOB), and 9.4% with chest pain. Mental disorders (psychosis, dementia, and depression) and organic nervous symptoms (Alzheimer’s disease, encephalopathy, and epilepsy) were the primary source of readmissions. More than one-third of the patients were admitted in the following year for chronic diseases such as heart failure (8.6%), psychosis (5.2%), and cerebral artery occlusion (4.1%).

Discussion

This study showed that there is a significant rate of readmissions in the year after a diagnosis of TBI. Complications with existing chronic diseases are among the most reported reasons for admission in this time period, demonstrating the effect severe head trauma has on long-term treatment.

Level of evidence

Level IV, Retrospective epidemiological study.

Analysis of incidence of traumatic brain injury in blunt trauma patients with Glasgow Coma Scale of 12 or less

PURPOSE

Early diagnosis of traumatic brain injury (TBI) is important for improving survival and neurologic outcome in trauma victims. The purpose of this study was to assess whether Glasgow Coma Scale (GCS) of 12 or less can predict the presence of TBI and the severity of associated injuries in blunt trauma patients.

METHODS

A retrospective cohort study including 303,435 blunt trauma patients who were transferred from the scene to hospital from 1998 to 2013. The data was obtained from the records of the National Trauma Registry maintained by Israel's National Center for Trauma and Emergency Medicine Research, in the Gertner Institute for Epidemiology and Health Policy Research. All blunt trauma patients with GCS 12 or less were included in this study. Data collected in the registry include age, gender, mechanism of injury, GCS, initial blood pressure, presence of TBI and incidence of associated injuries. Patients younger than 14 years old and trauma victims with GCS 13-15 were excluded from the study. Statistical analysis was performed by using Statistical Analysis Software Version 9.2. Statistical tests performed included Chi-square tests. A p-value less than 0.05 was considered statistically significant.

RESULTS

There were 303,435 blunt trauma patients, 8731 (2.9%) of them with GCS of 3-12 that including 6351 (72%) patients with GCS of 3-8 and 2380 (28%) patient with GCS of 9-12. In these 8731 patients with GCS of 3-12, 5372 (61.5%) patients had TBI. There were total 1404 unstable patients in all the blunt trauma patients with GCS of 3-12, 1256 (89%) patients with GCS 3-8, 148 (11%) patients with GCS 9-12. In the 5095 stable blunt trauma patients with GCS 3-8, 32.4% of them had no TBI. The rate in the 2232 stable blunt trauma patients with GCS 9-12 was 50.1%. In the unstable patients with GCS 3-8, 60.5% of them had TBI, and in subgroup of patients with GCS 9-12, only 37.2% suffered from TBI.

CONCLUSION

The utility of a GCS 12 and less is limited in prediction of brain injury in multiple trauma patients. Significant proportion of trauma victims with low GCS had no TBI and their impaired neurological status is related to severe extra-cranial injuries. The findings of this study showed that using of GCS in initial triage and decision making processes in blunt trauma patients needs to be re-evaluated.

Pre-Trauma Center Management of Intracranial Pressure in Severe Pediatric Traumatic Brain Injury

OBJECTIVES

Pre-trauma center care is a critical component in severe pediatric traumatic brain injury (TBI). For geographically large trauma catchment areas, optimizing increased intracranial pressure (ICP) management may potentially improve outcomes. This retrospective study examined ICP management in nontrauma centers and during interfacility transport to the trauma center.

METHODS

Charts from a pediatric level I trauma center were reviewed for admissions between 2008 and 2013. Patients with a Glasgow Coma Scale score of 8 or less, head Abbreviated Injury Scale score of 3 or higher, and requiring intubation at a nontrauma center were included. Exclusion criteria included head injury secondary to drowning, stroke, obstetrical complications, asphyxia, and afflicted head trauma (younger than 5 years). Trauma center charts contained coalesced data from first responders, nontrauma centers, and transport.

RESULTS

Twenty-five patients (74%) had increased ICP upon admission at trauma center, 48% experienced ICPs greater than 20 cm H2O within 12 hours of admission, 12% required an urgent craniotomy, and 16% had herniation syndromes on neuroimaging. Pre-trauma center ICP management included osmotherapy and head-of-bed elevation. Sixty-four percent of patients with increased ICP at trauma center admission received pre-trauma center ICP management.

CONCLUSIONS

Early increased ICP is a common presentation of severe pediatric TBI during pre-trauma center management. However, what constitutes optimal care remains unknown. Given the difficulties of diagnosing early increased ICP in this setting, prophylactic raising ICP-lowering strategies may be considered.

Head CT before Transfer Does Not Decrease Time to Craniotomy for TBI Patients

Rural trauma education emphasizes that radiologic imaging should be discouraged if it delays transfer to definitive care. With increased capacity for image sharing, however, radiography obtained at referring hospitals (RH) could help providers at trauma centers (TC) prepare for patients with traumatic brain injury. We evaluated whether a head CT prior to transfer accelerated time to neurosurgical intervention at the TC. The study was conducted at a combined adult Level I and pediatric Level II TC with a catchment area that includes rural hospitals within a 150 mile radius. The trauma registry was used to identify patients with traumatic brain injury who went to surgery for a neurosurgical procedure immediately after arrival at the TC. All patients were transferred in from a RH. Differences between groups were assessed using analysis of variance and chi-square. Fifty-six patients met study criteria during the study period (2010-2015). The majority (86%) of patients received head CT imaging at the RH, including a significant percentage of patients (18%) who presented with GCS ≤8. There was no statistically significant decrease in time to surgery when patients received imaging at the RH. CTimaging was associated with a delay in transfer that exceeded 90 minutes. Findings demonstrate that imaging at the RH delayed transfer to definitive care and did not improve time to neurosurgical intervention at the TC. Transfer to the TC should not be obstructed by imaging, especially for patients with severe TBI.

Medical Management of the Severe Traumatic Brain Injury Patient

Severe traumatic brain injury (sTBI) is a major contributor to long-term disability and a leading cause of death worldwide. Medical management of the sTBI patient, beginning with prehospital triage, is aimed at preventing secondary brain injury. This review discusses prehospital and emergency department management of sTBI, as well as aspects of TBI management in the intensive care unit where advances have been made in the past decade. Areas of emphasis include intracranial pressure management, neuromonitoring, management of paroxysmal sympathetic hyperactivity, neuroprotective strategies, prognostication, and communication with families about goals of care. Where appropriate, differences between the third and fourth editions of the Brain Trauma Foundation guidelines for the management of severe traumatic brain injury are highlighted.

Prehospital Assessment of Trauma

The organization of prehospital care for trauma patients began in the military arena. At the urging of multiple stakeholders and providers, these lessons were applied to the civilian setting and emergency medical services were created across the nation. Advances have taken place in the triage, transport, and management of severely injured patients. Many issues remain in the care of trauma patients in the prehospital environment. Collaboration between stakeholders and providers, regionalization of trauma care, and protocol-driven care may be solutions to some of these issues. Further research is necessary to dictate standard of care in this early phase after injury.

The accuracy of acuity scoring tools to predict 24-h mortality in traumatic brain injury patients: A guide to triage criteria

BACKGROUND AND AIM

Prompt identification of traumatic brain injury (TBI) is vital for patients in critical condition; however, it is not clear which acuity scoring tools are associated with short-term mortality. The aim of this study was to determine the accuracy of acuity scoring tools and 24-h mortality among TBI patients in both prehospital and hospital settings.

METHODS

This study was an observational, prospective cohort, in which patients with TBI were followed from the accident scene to the hospital. Vital signs and acuity scoring tools, including the Revised Trauma Score (RTS), Injury Severity Score (ISS), National Early Warning Score (NEWS), Shock Index (SI), Modified Shock Index (MSI) and Trauma and Injury Severity Score (TRISS), were collected both on the scene as well as at the hospital. A logistic regression was performed to ascertain the effects of clinical parameters on the likelihood of survival of patients with TBI regarding 24-h mortality.

RESULTS

A total of 185 patients were included in this study. The mortality rate was 14% (25/185). The logistic regression model was statistically significant at χ²=60.8, p=0.001. A hierarchical forward stepwise logistic regression analysis showed that age, hospital RTS and prehospital NEWS significantly improved mortality predictions. The model explained the 51.2% variance in survival of patients with TBI.

CONCLUSIONS

The NEWS and the RTS may be used to triage TBI patients for prehospital and hospital emergency care, respectively. Therefore, because traditional vital signs criteria may be of limited use for the triage of TBI patients, it is recommended that acuity scoring tools be used in such cases.

Relationship between hospital volume and outcomes in patients with traumatic brain injury: A retrospective observational study using a national inpatient database in Japan

BACKGROUND

The relationship between hospital volume and outcome after traumatic brain injury (TBI) is not completely understood in a real clinical setting. We investigated whether patients admitted with TBI achieved better outcomes in high-volume hospitals than in low-volume hospitals using a national inpatient database in Japan.

METHODS

This retrospective cohort study used the Diagnosis Combination Procedure database in Japan. We included patients with TBI admitted to hospitals with a Japan Coma Scale (JCS) score ≥2 between April 1, 2013 and March 31, 2014. Hospital volume was defined as the annual number of all admissions with TBI in individual hospitals. The hospital volume was categorized into four volume groups: low (≤60 admissions per hospital), medium-low (61-120 admissions per hospital), medium-high (121-180 admissions per hospital) and high (≥181 admissions per hospital). The outcomes of interest included 28-day mortality and survival discharge with complete dependency defined as a Barthel Index score of 0 at discharge. We used multivariate logistic regression models fitted with generalized estimating equations to evaluate relationships between the hospital volume and the outcomes. The hospital volume was evaluated both as categorical variables defined above and as continuous variables.

RESULTS

The analysis dataset consisted of 20,146 eligible patients. Of these, 2,784 died within 28days (13.8%) and 3,409 were completely dependent among 16,996 patients discharged alive (20.1%). Multivariate analyses found that there was no significant difference between the high-volume and low-volume groups for 28-day mortality (adjusted odds ratio [OR] 0.79, 95% confidence interval [CI] 0.58-1.06 for the high-volume group) or complete dependency at discharge (adjusted OR 0.94, 95% CI 0.71-1.23 for the high-volume group). The results were the same when the hospital volume was evaluated as a continuous variable.

CONCLUSIONS

Hospital volume did not appear to influence outcomes in patients with TBI. High-volume hospitals may not be necessarily beneficial for patients with TBI exhibiting impaired consciousness as a whole.

Mortality rates of severe traumatic brain injury patients: impact of direct versus nondirect transfers

BACKGROUND

Direct transport of patients with severe traumatic brain injury (sTBI) to trauma centers (TCs) that can provide definitive care results in lower mortality rates. This study investigated the impact of direct versus nondirect transfers on the mortality rates of patients with sTBI.

METHODS

Data on patients with TBI admitted between January 1, 2012, and December 31, 2013, to our Level I TC were obtained from the trauma registry. Data included patient age, sex, mechanism, and type of injury, comorbidities, Glasgow Coma Scale, Injury Severity scores, prehospital time, time to request and to transfer, time to initiation of multimodality monitoring and goal-directed therapy protocol, dwell time in the emergency department (EDT), and mortality. Data, reported in means ± standard deviation, were analyzed with the Student t-test and chi-square. Statistical significance was accepted at a P value < 0.05.

RESULTS

sTBI direct transfer to TC versus transfer from non-TCs (NTC): Of the 1187 patients with TBI admitted to our TC, 768 (64.7%) were admitted directly from the scene, whereas 419 (35.3%) were admitted after secondary transfer. One hundred seventy-one (22.2%) of the direct transfers had Glasgow Coma Scale < 8 (sTBI) and 92 (21.9%) of the secondary transfers had sTBI. The transfer time: Time from scene to arrival to the EDT was significantly shorter for TC versus NTCs 43 ± 14 versus 77 ± 26 min, respectively (P < 0.05). EDT dwell time before transfer and time from injury to arrival to TC were 4.2 ± 2.1 and 6.2 ± 8.3 h, respectively. Mortality: There was a statistically significant lower mortality for patients with sTBI transferred directly from the scene to TCs as opposed to patients secondarily transferred, 33/171 (19.3%) versus 33/92 (35.8%), respectively (P < 0.05).

CONCLUSIONS

To decrease TBI-related mortality, patients with suspected sTBI should be taken directly to a Level I or II TC unless they require life-saving stabilization at NTCs.

Civilian cerebral gunshot wounds in rural South African patients are associated with significantly higher mortality rates than in urban patients

INTRODUCTION

This study focuses on a specific and often dramatic injury, namely gunshot wounds (GSW) of the head in order to determine whether there is a discrepancy in outcome between patients who sustain their injury in a rural setting and those who sustain it in an urban setting.

MATERIALS AND METHODS

This study involves a retrospective review of our prospectively maintained regional electronic trauma registry. All patients who sustained a cerebral GSW from January 2010 to December 2014 were reviewed.

RESULTS

During the 5-year study period, a total of 102 patients sustained an isolated cerebral GSW. Ninety-two per cent (94/102) were male and the mean age was 29 years. Ninety-four per cent (94/102) of injuries were related to interpersonal violence. Of the 102 patients in the study, 54% (55/102) were urban and were transported directly to our trauma centre. The remaining 46% (47/102) were rural and were transported to a rural district hospital prior to being referred to our trauma centre. The time of injury was available in 60% (61/102) of patients. The mean time from injury to arrival for all patients was 11 h (SD 7). The mean time from injury to arrival was significantly shorter for urban versus rural, 6 h (SD 5) and 15 h (SD 5), respectively (p < 0.001). The median admission GCS score was significantly lower in rural compared to urban patients (p = 0.022). The need for neurosurgery, need for ICU admission or length of hospital stay was not significantly different between rural and urban patients. Rural patients have a fourfold higher mortality compared with urban patients (36 vs 9%, p = 0.001). Amongst survivors, there was no significant difference in median length of hospital stay or mean discharge GCS.

CONCLUSIONS

Cerebral GSWs are highly lethal injuries associated with significant mortality. Rural patients have a significantly longer transfer time, lower GCS on arrival and higher mortality than urban patients. Efforts should be directed at improving the pre-hospital EMS system in order to reduce delay to definitive care so that patient outcome can be optimised.

Therapeutic benefits of phosphodiesterase 4B inhibition after traumatic brain injury

Traumatic brain injury (TBI) initiates a deleterious inflammatory response that exacerbates pathology and worsens outcome. This inflammatory response is partially mediated by a reduction in cAMP and a concomitant upregulation of cAMP-hydrolyzing phosphodiesterases (PDEs) acutely after TBI. The PDE4B subfamily, specifically PDE4B2, has been found to regulate cAMP in inflammatory cells, such as neutrophils, macrophages and microglia. To determine if PDE4B regulates inflammation and subsequent pathology after TBI, adult male Sprague Dawley rats received sham surgery or moderate parasagittal fluid-percussion brain injury (2 ± 0.2 atm) and were then treated with a PDE4B - selective inhibitor, A33, or vehicle for up to 3 days post-surgery. Treatment with A33 reduced markers of microglial activation and neutrophil infiltration at 3 and 24 hrs after TBI, respectively. A33 treatment also reduced cortical contusion volume at 3 days post-injury. To determine whether this treatment paradigm attenuated TBI-induced behavioral deficits, animals were evaluated over a period of 6 weeks after surgery for forelimb placement asymmetry, contextual fear conditioning, water maze performance and spatial working memory. A33 treatment significantly improved contextual fear conditioning and water maze retention at 24 hrs post-training. However, this treatment did not rescue sensorimotor or working memory deficits. At 2 months after surgery, atrophy and neuronal loss were measured. A33 treatment significantly reduced neuronal loss in the pericontusional cortex and hippocampal CA3 region. This treatment paradigm also reduced cortical, but not hippocampal, atrophy. Overall, these results suggest that acute PDE4B inhibition may be a viable treatment to reduce inflammation, pathology and memory deficits after TBI.

The Effect of Sporting Events on Medical Transport Time at a Level 1 Trauma Center: a Retrospective Cohort Study

OBJECTIVE

We investigate how West Virginia University football games affect transport to Ruby Memorial Hospital, which shares a parking lot with Milan Puskar Football Stadium.

METHODS

A retrospective chart review of a trauma registry from a level 1-trauma center was conducted from 2007 to 2011 for all home and away football games. Home games served as time period of interest and away games served as a control time period. Patient charts were collected for a 36-hour time window surrounding the game. 250 patient charts were complete for home games and 185 patient charts for away games. Data analyzed were time from scene to arrival at hospital, use of air transport, transport time in relation to kick-off, and comparison between demographic and emergency department disposition of patients arriving during home games vs. patients arriving during away games.

RESULTS

No statistically significant differences were found for demographic data or emergency department disposition between groups. For ground transport directly from scene, the average time to arrival at the hospital was 44.9 minutes for home games and 45.1 minutes for away games. For air transport directly from the scene, the average time to arrival at the hospital was 44.9 minutes for home games and 44.0 minutes for away games. For ground transfer from another facility, the average time to arrival at the hospital was 76.4 minutes for home games and 52.9 minutes for away games. For air transport from another facility, the average time to arrival at the hospital was 37.4 minutes for home games and 24.0 minutes for away games. Air transportation utilization was increased in inter-facility transfers during home games (5/16, 31.3% vs. 4/20, 22.2%), and helicopters traveled a further distance (avg. 66.6 vs. 50.25 air miles). For patients coming from the scene during a home game, if the start of the game occurred after the trauma but before arrival to the trauma center, the average time of ground transport increased from 44.9 minutes to 120 minutes (p<0.0001).

CONCLUSION

A mass gathering in close proximity to a rural trauma center does affect transport patterns and transport times for trauma patients. Further investigation is warranted in order to improve patient care during mass gathering events.

Geriatric assault victims treated at U.S. trauma centers: Five-year analysis of the national trauma data bank

INTRODUCTION

While geriatric trauma patients have begun to receive increased attention, little research has investigated assault-related injuries among older adults. Our goal was to describe characteristics, treatment, and outcomes of geriatric assault victims and compare them both to geriatric victims of accidental injury and younger assault victims.

PATIENTS AND METHODS

We conducted a retrospective analysis of the 2008-2012 National Trauma Data Bank. We identified cases of assault-related injury admitted to trauma centers in patients aged ≥60 using the variable "intent of injury."

RESULTS

3564 victims of assault-related injury in patients aged ≥60 were identified and compared to 200,194 geriatric accident victims and 94,511 assault victims aged 18-59. Geriatric assault victims were more likely than geriatric accidental injury victims to be male (81% vs. 47%) and were younger than accidental injury victims (67±7 vs. 74±9 years). More geriatric assault victims tested positive for alcohol or drugs than geriatric accident victims (30% vs. 9%). Injuries for geriatric assault victims were more commonly on the face (30%) and head (27%) than for either comparison group. Traumatic brain injury (34%) and penetrating injury (32%) occurred commonly. The median injury severity score (ISS) for geriatric assault victims was 9, with 34% having severe trauma (ISS≥16). Median length of stay was 3 days, 39% required ICU care, and in-hospital mortality was 8%. Injury severity was greater in geriatric than younger adult assault victims, and, even when controlling for injury severity, in-hospital mortality, length of hospitalization, and need for ICU-level care were significantly higher in older adults.

CONCLUSIONS

Geriatric assault victims have characteristics and injury patterns that differ significantly from geriatric accidental injury victims. These victims also have more severe injuries, higher mortality, and poorer outcomes than younger victims. Additional research is necessary to improve identification of these victims and inform treatment strategies for this unique population.

Through the looking glass: early non-invasive imaging in TBI predicts the need for interventions

Background

Early diagnosis and treatment of traumatic brain injury (TBI) lead to better outcomes. It is difficult to predict which patients benefit from specialised centres, leading to over triage or delay in definitive care. We propose that a non-invasive test comprising optic nerve sheath ultrasound, transcranial Doppler and quantitative papillary reactivity is feasible, correlates with CT findings and may allow for accurate early identification of TBI.

Methods

A 1-year, prospective observation study evaluated a low-risk, non-invasive method of assessing brain injury. Patients underwent a non-invasive neurological examination for trauma, including the above assessments. Data from the three examinations were collected within 6 hours of injury and at 24 hours, and were analysed. Demographics, haemodynamic data, imaging results and short-term outcomes/interventions were recorded.

Results

Trauma patients over the age of 18 years, with a Glascow coma scale (GCS) of <12 or CT evidence of TBI, and intubated were included (N=100). These were divided into +CT (n=49) and −CT groups (n=51) according to the Marshall CT classification of TBI. The +CT group was older, with worse GCS and higher lactate (p=0.008, p=0.001 and p=0.01) but were otherwise well matched. The +CT group included all TBI types, with 96% of the patients having more than one type of TBI. Pulsatility index and neurologic pupillary index were predictive of a +CT (p=0.04, p=0.02). Area under the receiver-operating curve for the logistic regression model for the prediction of positive radiographic findings was r=0.718. Finally, we suggest a preliminary scoring heuristic for predicting a positive radiological finding in a patient with TBI.

Conclusions

The proposed examination is a feasible, non-invasive tool that may have clinical utility in the early prediction of TBI. If validated, it may improve trauma triage for the brain-injured patient. Further studies are warranted to validate this model.

Factors Associated with the Use of Helicopter Inter-facility Transport of Trauma Patients to Tertiary Trauma Centers within an Organized Rural Trauma System

OBJECTIVE

A review of the literature yielded little information regarding factors associated with the decision to use ground (GEMS) or helicopter (HEMS) emergency medical services for trauma patients transferred inter-facility. Furthermore, studies evaluating the impact of inter-facility transport mode on mortality have reported mixed findings. Since HEMS transport is generally reserved for more severely injured patients, this introduces indication bias, which may explain the mixed findings. Our objective was to identify factors at referring non-tertiary trauma centers (NTC) influencing transport mode decision.

METHODS

This was a case-control study of trauma patients transferred from a Level III or IV NTC to a tertiary trauma center (TTC) within 24-hours reported to the Oklahoma State Trauma Registry between 2005 and 2012. Multivariable logistic regression was used to determine clinical and non-clinical factors associated with the decision to use HEMS.

RESULTS

A total of 7380 patients met the study eligibility. Of these, 2803(38%) were transported inter-facility by HEMS. Penetrating injury, prehospital EMS transport, severe torso injury, hypovolemic shock, and TBI were significant predictors (p<0.05) of HEMS use regardless of distance to a TTC. Association between HEMS use and male gender, Level IV NTC, and local ground EMS resources varied by distance from the TTC. Many HEMS transported patients had minor injuries and normal vital signs.

CONCLUSIONS

Our results suggest that while distance remains the most influential factor associated with HEMS use, significant differences exist in clinical and non-clinical factors between patients transported by HEMS versus GEMS. To ensure comparability of study groups, studies evaluating outcome differences between HEMS and GEMS should take factors determining transport mode into account. The findings will be used to develop propensity scores to balance baseline risk between GEMS and HEMS patients for use in subsequent studies of outcomes.

Urban/Rural disparities in Oregon pediatric traumatic brain injury

Background

Traumatic brain injury (TBI) greatly contributes to morbidity and mortality in the pediatric population. We examined potential urban/rural disparities in mortality amongst Oregon pediatric patients with TBI treated in trauma hospitals.

Methods

We conducted a retrospective study of children ages 0–19 using the Oregon Trauma Registry for years 2009–2012. Geographic location of injury was classified using the National Center for Health Statistics Urban/Rural Classification Scheme. Incidence rates were calculated using Census data for denominators. Associations between urban/rural injury location and mortality were assessed using multivariable logistic regression, controlling for potential confounders. Generalized estimating equations were used to help account for clustering of data within hospitals.

Results

Of 2794 pediatric patients with TBI, 46.6 % were injured in large metropolitan locations, 24.8 % in medium/small metropolitan locations, and 28.6 % in non-metropolitan (rural) locations. Children with rural locations of injury had a greater annualized TBI incidence rate, at 107/100,000 children per year, than those from large metropolitan areas (71/100,000 per year). Compared to children injured in urban locations, those in rural locations had more than twice the crude odds of mortality (odds ratio [OR], 2.5; 95 % CI, 1.6–4.0). This association remained significant (OR, 1.8; 95 % CI, 1.04–3.3) while adjusting for age, gender, race, insurance status, injury severity, and type of TBI (blunt vs. penetrating).

Conclusion

We observed higher rates of TBI and greater proportions of severe injury in rural compared to urban areas in Oregon. Rural children treated in the trauma system for TBI were more likely to die than urban children after controlling for demographic and injury factors associated with urban/rural residence. Further research is needed to examine treatment disparities by urban/rural location. Future work should also identify interventions that can reduce risk of TBI and TBI-related mortality among children, particularly those who live in rural areas.

Electronic supplementary material

The online version of this article (doi:10.1186/s40621-015-0063-2) contains supplementary material, which is available to authorized users.

Functional and long-term outcomes in severe traumatic brain injury following regionalization of a trauma system

BACKGROUND

We previously demonstrated that regionalization of trauma (RT) significantly reduced in-hospital mortality from 19% to 14% in patients with severe traumatic brain injury (sTBI). However, functional and long-term outcomes had not been assessed. We hypothesized that RT would be associated with improved functional and long-term outcomes in sTBI patients.

METHODS

All TBI patients older than 14 years with a head Abbreviated Injury Scale (AIS) score of 3 or greater were identified from the RT database and matched to the state death index and the regional TBI rehabilitation (TBIr) database. Data from 2008 through 2012 were analyzed before and after RT in 2010. For patients discharged to the TBIr unit, overall Functional Independence Measure (FIM) scores and FIM score gains were compared before and after RT.

RESULTS

A total of 3,496 patients with sTBI were identified in the RT database, 1,359 in the pre-RT and 2,137 in the post-RT period. The mortality rate after discharge decreased significantly after RT from 21% to 16% (p < 0.0001) at 30 days and from 24% to 20% (p = 0.004) at 6 months. Multivariable logistic regression demonstrated RT to be an independent predictor against mortality at 30 days (odds ratio, 0.74; 95% confidence interval, 0.60-0.91; C statistic, 0.84) and 6 months (odds ratio, 0.82; 95% confidence interval, 0.67-0.99; C statistic, 0.82). Discharges to the TBIr unit increased from 117 (9%) in the pre-RT to 297 (14%) in the post-RT period (p < 0.0001), while discharges to home and non-TBIr units remained similar. Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) score for all discharged patients remained similar. FIM admission scores were similar in the pre-RT (median, 54; interquartile range [IQR], 30-65) and post-RT period (median, 48; IQR, 31-61) (p = 0.2) and remained similar at discharge in the pre-RT (median, 92; IQR, 75-102) and post-RT period (median, 89; IQR, 73-100) (p = 0.1). TBIr patients showed similar FIM score gains in the pre-RT (median, 37; IQR, 26-46) and post-RT period (median, 36; IQR, 24-49) (p = 0.6).

CONCLUSION

RT was associated with reduced long-term mortality, increased TBIr admissions, and similar FIM score improvements for patients with sTBI.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

Emergent and Urgent Transfers to Neurosurgical Centers in Ontario

Critically ill neurosurgical patients require expedient access to neurosurgical centers (NC) to improve outcome. In regionalized health systems patients are often initially evaluated at a non-neurosurgical center (NNC) and are subsequently transferred to a NC using air or ground vehicles. We sought to identify barriers to accessing a NC for critically ill patients by analyzing interfacility transfer times and referral patterns in the province of Ontario. A retrospective observational analysis was undertaken. The cohort included patients in Ontario with emergent and urgent neurologic pathologies who underwent transfer from a NNC to NC between January 1, 2011 and December 31, 2013. Timing, clinical, and geographic data were collected for each transfer. We identified 1103 emergent/urgent transfers. The median transfer time to a NC was 3.4 h (IQR -2.2, 3.8) and varied by the geographic region of origin. A total of 17% of the patients bypassed a closer NC during transfer to their destination NC. Transfers that bypassed a closer NC travelled further (101 miles vs. 296 miles, p < 0.001), took longer (3.1 h vs. 3.9 h, p < 0.001), and in some regions were associated with a higher risk of in-transit clinical decline (3.0% vs. 8.3%, p < 0.05) when compared with transfers that ended at the closest NC. Regionalization of neurosurgical services in Ontario has led to heavy reliance upon patient transfers to maintain continuity of care. Access to a NC varied across the province, which may represent regional differences in neurosurgical bed availability, resource limitations at smaller NCs, or environmental factors. Our descriptions of referral patterns and transport times can guide health system planning in Ontario and similar jurisdictions in the United States and Canada.