Interhospital Transfer Predicts Mortality Risk in Blunt Trauma

Taking patients with major blunt trauma injury to hospitals that lack a high-level trauma center rather than straight to a level I trauma center may be associated with a higher odds of death, according to findings from a retrospective study.

Although the time interval between injury and reaching definitive care has been positively associated with mortality, no other study has found interhospital transfer to be a predictor of mortality, independent of a delay in care, according to Dr. Raminder Nirula of the department of surgery at the University of Utah, Salt Lake City.

Injured patients often are brought to a nearby facility, but little treatment is done until they are sent elsewhere for a higher level of care, he explained. “Does that pose a risk to the patient, and would it be better to take the patient straight to the higher level of care if it's recognized [by the EMS team] that they're going to need it?” Dr. Nirula said in an interview.

At the core of this question is when and how often it is beneficial to stop at the nearest facility to perform interventions that EMS personnel cannot do. If a lower-level facility is not going to begin definitive treatment, “why stop?” he asked.

Dr. Nirula and his colleagues examined the outcomes of 787 patients who were initially triaged to eight level I trauma centers (including one at the University of Utah Health Sciences Center) and 318 who were initially taken to a nontrauma center and later transferred to one of these level I trauma centers. The patients were part of the Inflammation and Host Response to Injury cohort study, an ongoing multicenter, prospective analysis of the relationship between the inflammatory response to injury and posttraumatic multiple organ failure.

The institutions classified as “nontrauma centers” by the investigators were level II-V trauma centers or community hospitals without a designated trauma center.

Patients who went to a nontrauma center before going to a level I trauma center had about a threefold increase in odds of death, compared with those who were sent directly to a level I trauma center, according to Dr. Nirula, who presented the study at the annual meeting of the American Association for the Surgery of Trauma in Maui, Hawaii.

In multivariate logistic regression analyses, this association remained largely the same regardless of whether clinically relevant factors (trauma center site, significant traumatic brain injury, and receipt of crystalloid or blood transfusion before arrival at a trauma center) were included along with independent predictors of mortality (age, injury severity score, interhospital transfer, time from injury to arrival at the trauma center, and APACHE II score). Exclusion of patients who died within 24 hours did not change the association.

Even though Dr. Nirula and his coinvestigators controlled their analysis for injury severity and physiologic status, no data were available about any interventions performed at the receiving hospital before patient transfer. Such data would help to determine if triage to a nontrauma center were necessary.

A prospective study will help to answer why interhospital transfer is an independent predictor of mortality. It will be important to determine the influence of interventions (or lack thereof) that patients undergo at hospitals before being transferred to a higher-level trauma center, Dr. Nirula said.

The level of EMS training and the type of medical care provided by EMS vary across locations, which may influence transport decisions. Studies of prehospital life support from EMS have reported mixed results on the reduction of mortality. Some studies have shown benefits to advanced trauma life support, whereas others have shown benefits to basic life support alone.

Taking patients with major blunt trauma injury to hospitals that lack a high-level trauma center rather than straight to a level I trauma center may be associated with a higher odds of death, according to findings from a retrospective study.

Although the time interval between injury and reaching definitive care has been positively associated with mortality, no other study has found interhospital transfer to be a predictor of mortality, independent of a delay in care, according to Dr. Raminder Nirula of the department of surgery at the University of Utah, Salt Lake City.

Injured patients often are brought to a nearby facility, but little treatment is done until they are sent elsewhere for a higher level of care, he explained. “Does that pose a risk to the patient, and would it be better to take the patient straight to the higher level of care if it's recognized [by the EMS team] that they're going to need it?” Dr. Nirula said in an interview.

At the core of this question is when and how often it is beneficial to stop at the nearest facility to perform interventions that EMS personnel cannot do. If a lower-level facility is not going to begin definitive treatment, “why stop?” he asked.

Dr. Nirula and his colleagues examined the outcomes of 787 patients who were initially triaged to eight level I trauma centers (including one at the University of Utah Health Sciences Center) and 318 who were initially taken to a nontrauma center and later transferred to one of these level I trauma centers. The patients were part of the Inflammation and Host Response to Injury cohort study, an ongoing multicenter, prospective analysis of the relationship between the inflammatory response to injury and posttraumatic multiple organ failure.

The institutions classified as “nontrauma centers” by the investigators were level II-V trauma centers or community hospitals without a designated trauma center.

Patients who went to a nontrauma center before going to a level I trauma center had about a threefold increase in odds of death, compared with those who were sent directly to a level I trauma center, according to Dr. Nirula, who presented the study at the annual meeting of the American Association for the Surgery of Trauma in Maui, Hawaii.

In multivariate logistic regression analyses, this association remained largely the same regardless of whether clinically relevant factors (trauma center site, significant traumatic brain injury, and receipt of crystalloid or blood transfusion before arrival at a trauma center) were included along with independent predictors of mortality (age, injury severity score, interhospital transfer, time from injury to arrival at the trauma center, and APACHE II score). Exclusion of patients who died within 24 hours did not change the association.

Even though Dr. Nirula and his coinvestigators controlled their analysis for injury severity and physiologic status, no data were available about any interventions performed at the receiving hospital before patient transfer. Such data would help to determine if triage to a nontrauma center were necessary.

A prospective study will help to answer why interhospital transfer is an independent predictor of mortality. It will be important to determine the influence of interventions (or lack thereof) that patients undergo at hospitals before being transferred to a higher-level trauma center, Dr. Nirula said.

The level of EMS training and the type of medical care provided by EMS vary across locations, which may influence transport decisions. Studies of prehospital life support from EMS have reported mixed results on the reduction of mortality. Some studies have shown benefits to advanced trauma life support, whereas others have shown benefits to basic life support alone.

Taking patients with major blunt trauma injury to hospitals that lack a high-level trauma center rather than straight to a level I trauma center may be associated with a higher odds of death, according to findings from a retrospective study.

Although the time interval between injury and reaching definitive care has been positively associated with mortality, no other study has found interhospital transfer to be a predictor of mortality, independent of a delay in care, according to Dr. Raminder Nirula of the department of surgery at the University of Utah, Salt Lake City.

Injured patients often are brought to a nearby facility, but little treatment is done until they are sent elsewhere for a higher level of care, he explained. “Does that pose a risk to the patient, and would it be better to take the patient straight to the higher level of care if it's recognized [by the EMS team] that they're going to need it?” Dr. Nirula said in an interview.

At the core of this question is when and how often it is beneficial to stop at the nearest facility to perform interventions that EMS personnel cannot do. If a lower-level facility is not going to begin definitive treatment, “why stop?” he asked.

Dr. Nirula and his colleagues examined the outcomes of 787 patients who were initially triaged to eight level I trauma centers (including one at the University of Utah Health Sciences Center) and 318 who were initially taken to a nontrauma center and later transferred to one of these level I trauma centers. The patients were part of the Inflammation and Host Response to Injury cohort study, an ongoing multicenter, prospective analysis of the relationship between the inflammatory response to injury and posttraumatic multiple organ failure.

The institutions classified as “nontrauma centers” by the investigators were level II-V trauma centers or community hospitals without a designated trauma center.

Patients who went to a nontrauma center before going to a level I trauma center had about a threefold increase in odds of death, compared with those who were sent directly to a level I trauma center, according to Dr. Nirula, who presented the study at the annual meeting of the American Association for the Surgery of Trauma in Maui, Hawaii.

In multivariate logistic regression analyses, this association remained largely the same regardless of whether clinically relevant factors (trauma center site, significant traumatic brain injury, and receipt of crystalloid or blood transfusion before arrival at a trauma center) were included along with independent predictors of mortality (age, injury severity score, interhospital transfer, time from injury to arrival at the trauma center, and APACHE II score). Exclusion of patients who died within 24 hours did not change the association.

Even though Dr. Nirula and his coinvestigators controlled their analysis for injury severity and physiologic status, no data were available about any interventions performed at the receiving hospital before patient transfer. Such data would help to determine if triage to a nontrauma center were necessary.

A prospective study will help to answer why interhospital transfer is an independent predictor of mortality. It will be important to determine the influence of interventions (or lack thereof) that patients undergo at hospitals before being transferred to a higher-level trauma center, Dr. Nirula said.

The level of EMS training and the type of medical care provided by EMS vary across locations, which may influence transport decisions. Studies of prehospital life support from EMS have reported mixed results on the reduction of mortality. Some studies have shown benefits to advanced trauma life support, whereas others have shown benefits to basic life support alone.