B. Tracy1, M. E. Barnett1, C. Spencer1, A. Butcher1, M. Brown1, Z. Stombaugh1, J. Dunne1 1Memorial University Medical Center-Mercer University School Of Medicine,Surgery,Savannah, GEORGIA, USA
Introduction: Recent studies support direct transport of patients sustaining TBI to Level 1 trauma centers (L1TC) due to decreased morbidity and mortality. However, in some rural areas, TBI patients are triaged to the closest non-trauma center (NTC), then transferred to a L1TC. Therefore, we sought to determine the effectiveness of our rural trauma system by comparing the outcomes of TBI patients initially triaged to a NTC compared to those transported directly to a L1TC.
Methods: Prospective data were collected on 8,558 patients admitted to a rural L1TC over a 3- year period from 2012–2015. TBI was identified in 1,719 patients and comprised the study cohort. Patients were stratified by age, GCS, ISS, and transfer status. Outcome variables included # of TBI interventions, hospital length of stay (HLOS), ICU length of stay (ICU LOS) and mortality. In addition, multivariate regression was used to determine risk factors for time to transfer, HLOS and mortality.
Results: The mean age of the study cohort was 51±21, mean ISS was 15±9, mean GCS was 13±4, with 49.7% of patients transferred from other facilities. The most common mechanisms of injury included MVC (45%), falls (37%) and other blunt trauma (18%). Overall mortality was 7%. Patients transported directly to a L1TC were significantly younger (47±20 vs 56±23, p < 0.001), more severely injured based on ISS (14±8 vs 12±7, p < 0.001) and had increased mortality (8% vs 5%, p < 0.01) compared to patients initially triaged to a NTC. The study cohort was then stratified into 3 categories based on GCS to further delineate these differences: severe TBI (GCS 3-8), moderate TBI (GCS 9-12) and mild TBI (GCS 13-15). Patients with severe TBI were significantly younger, more severely injured, more often transported directly to a L1TC and had a higher mortality when compared to patients with mild and moderate TBI (p< 0.01). Severe TBI patients also had significantly longer HLOS and ICU LOS and more TBI interventions compared to patients with mild and moderate TBI (p < 0.001). Multivariate regression revealed decreasing age, decreasing GCS and increasing ISS as risk factors for direct transport to L1TC and decreasing GCS, increasing ISS and decreased transport time as risk factors for increased HLOS and mortality.
Conclusion: Patients transported directly to a L1TC were significantly younger, more severely injured and had increased mortality when compared to patients initially triaged to a NTC. Risk factors for transport directly to a L1TC include decreasing age, worsening neurologic status and increasing injury severity. Finally, worsening neurologic status, increasing injury severity and shorter transport times were risk factors for increased HLOS and mortality. In summary, the most critically injured patients were transported to the L1TC directly indicating that the right patients were being transported to the proper facility at the appropriate time.