G. Barmparas2, Z. Cooper1, J. Havens1, R. Askari1, E. Kelly1, A. Salim1 1Brigham And Women’s Hospital,Division Of Acute Care Surgery And Surgical Critical Care-Department Of Surgery,Boston, MA, USA 2Cedars-Sinai Medical Center,Division Of Acute Care Surgery And Surgical Critical Care / Department Of Surgery,Los Angeles, CA, USA
Introduction: As the numbers of injured elders continue to rise dramatically, trauma centers are pressed to identify which older patients benefit from higher level care. The purpose of the current investigation was to delineate whether elderly patients with spinal injuries benefit from transfers to Level I or II centers.
Methods: We used The National Trauma Databank (NTDB) datasets 2007-2011 to identify all patients over 65 (y) old with any spinal fracture or spinal cord injury from a blunt mechanism. Only centers reporting ≥ 80% of AIS and/or ≥ 20% of comorbidities and/or with ≥ 200 subjects in the NTDB, were included. Patients who were transferred to Level I and II centers (TR) were then compared to those who were admitted to Level III or other centers (NTR). Patients who were transferred from Level III or other centers to other acute care facilities were excluded. We used chi-squares and t-tests where appropriate to compare patient characteristics (demographics comorbidities, admission vital signs and GCS, injury severity), and hospital factors (teaching, region, and availability of > 10 orthopedic or neurosurgeons) between groups. We then performed logistic regression to adjust for these differences between patients with any spinal injury and a subgroup analysis for patients with spinal cord injury. The primary outcome was in-hospital mortality. Alpha = p<0.01
Results: Of 3,313,117 eligible patients, 43,637 (1.3%) met inclusion criteria: 19,588 (44.9%) in the TR Group and 24,049 (55.1%) in the Non-TR Group. The majority of patients (95.8%) had a spinal fracture without a spinal cord injury. TR patients were significantly less likely to be ≥ 90 years old (7.0% vs. 8.1%, p<0.01) and had higher injury severity scores (AIS head ≥ 3 (18.9% vs. 15.7%, p<0.01; AIS spine ≥ 3 (5.9% vs. 4.4%, p<0.01). When compared to NTR, TR patients were more likely to have a spinal cord injury at any level (4.7% vs. 3.1%, p<0.01) and to require a spinal surgical procedure within 48 hours from admission (4.8% vs. 2.4%, p<0.01). More TR patients required ICU admission (48.5% vs. 36.0%, p<0.01) and ventilatory support (16.1% vs. 13.3%, p<0.01). Overall mortality was 7.7% (TR 8.6% vs. NTR 7.1%, p<0.01). However, mortality in the subgroup of patients with a spinal cord injury was 21.7% (TR 22.3% vs. NTR 21.0%, p<0.01). After multivariate analysis, there was no difference in the adjusted mortality for patients with any spinal injury (AOR [95% CI]: 0.98 [0.89, 1.08], p=0.70) or for patients with spinal cord injury (AOR [95% CI]: 0.86 [0.62, 1.20], p=0.38) treated at higher-level centers.
Conclusion: Transfer of elderly patients with spinal injuries to higher-level trauma centers is not associated with improved survival. Further research is required in this area to identify those subgroups of elderly patients who benefit from such transfers.