K. C. Gallagher1, A. J. Medvecz1, B. T. Craig1, O. C. Guillamondegui1, B. M. Dennis1 1Vanderbilt University Medical Center,Division Of Trauma & Critical Care,Nashville, TN, USA
Introduction:
With advancing technology and rapidly increasing availability, computed tomography (CT) has become a standard radiologic adjunct in the evaluation of a trauma patient. However, the appropriate timing of initial cross-sectional imaging has not yet been established and the utility of imaging at the referring hospital (RH) remains controversial. The American College of Surgeons (ACS) Advanced Trauma Life Support (ATLS) course emphasizes that imaging should never interrupt or delay resuscitation of the injured patient. Despite these guidelines, several studies have identified delays of 60-90 minutes when patients are scanned at referring hospitals prior to arriving at the treating facility. We study the effect of CT scans at referring hospitals on in-hospital mortality at a receiving trauma center.
Methods:
A retrospective cohort study was performed with adult patients transferred to a level one trauma center from non-trauma center regional hospitals between 2012 and 2017. Inpatient-to-inpatient transfers, transfers from other state-designated level one or level two trauma centers, and patients with transfer times over 10 hours were excluded from analysis. Demographics and baseline characteristics were compared with Student’s t-test and Pearson’s Chi-squared testing. The primary endpoint was in-hospital mortality. Cox regression, controlling for transfer time, was used to evaluate the effect of CT scanning on mortality.
Results:
3415 adult trauma patients were included in the analysis: 1135 (33.2%) received a CT scan at the RH prior to transfer while 2280 (66.8%) did not. Patients who received a CT scan at the RH were more likely to be older, female, white, with a higher Charlson comorbidity index, less severely injured (lower ISS and intubation rate; higher systolic blood pressure and GCS), have a blunt mechanism, and be transferred by ground. There was no difference in “as the crow flies” distance (58.3 miles versus 57.0 miles, P = 0.34), but there were significantly longer times at RH and transport times for those that did receive a CT scan (288 minutes versus 213 minutes, P < 0.005). The unadjusted hazard ratio (HR) for mortality after receiving a CT scan at the RH is 0.32 (95% CI 0.26-0.39, P < 0.005). The adjusted model controlling for age, sex, race, mechanism of injury, transport method, ISS, heart rate, intubation status, comorbidity index, GCS, and transport time, has a hazard ratio of 0.533 (95% CI 0.42-0.68, P < 0.005).
Conclusion:
There is a survival advantage for patients that receive CT scan prior to transfer to level one trauma center despite having significantly longer transport times. This finding contradicts both current ATLS recommendations and previous data, necessitating further investigation and discussion.