E. Turner1, K. A. Hollenbach1, W. D’Angelo1, B. Chung1, J. Rappold1 1Maine Medical Center,Acute Care Surgery/Surgery/Tufts University School Of Medicine,Portland, MAINE, USA
Introduction: Traumatic brain injury (TBI) affects patients of all ages and genders and often results in significant morbidity and mortality. This is particularly true for patients with moderate to severe TBI (GCS 3-12) who often require emergent neurosurgical (NS) interventions (ICP monitoring, EVD, craniotomy and/or craniectomy). In rural states, this access is often limited or requires transfer to higher level of care facilities, resulting in a significant delay to intervention. To address this issue, our rural ACS verified Level I trauma center (TC) instituted a program whereby a single, dedicated neurosurgeon was available Monday through Friday for emergent NS consultations and operative procedures as indicated.
Methods: A retrospective cohort study was conducted at a rural Level I trauma center utilizing the institution’s trauma registry. Information on all trauma admissions from 1 October 2012 through 30 September 2016 with TBI were included. Standard demographics and injury related variables were abstracted. Survival by period of care (pre-hospitalist NS; 1 October 2012-30 September 2014 to post-hospitalist NS: 1 October 2014-30 September 2016) was analyzed using logistic regression to control for patient age and injury severity. Subsequent analyses were conducted by whether care was provided Monday – Friday versus Saturday – Sunday across the entire study period and for each of the two periods of interest.
Results:
A total of 7005 patients were admitted to the trauma service of which 1968 TBI patients were identified: 959 pre-hospitalist NS (PRE) and 1009 post-hospitalist NS (POST) with mortalities of 8.76% and 7.04%, respectively. Patients were slightly older and had significantly greater ISS score in POST group. After adjusting for the confounding effect of age and ISS, POST patients were significantly less likely to die than PRE patients (OR = 0.62; 95% CI = 0.42, 0.90). Stratification by weekend or weekday treatment identified an even stronger protective effect among patients with TBI during the weekdays when the dedicated neurosurgeon was available (OR = 0.55; 95% CI = 0.34, 0.89).
Conclusion: This study demonstrates significant decreased mortality after instituting a designated hospitalist neurosurgeon readily available for emergent consultation and rapid operative intervention for patients with TBI. When restricted to weekday treatment, the effect was more pronounced, lending support for expanding the designated NS hospitalist role within our hospital as well as encouraging other TCs to explore the potential benefit of a dedicated hospitalist NS at their centers.
