AEM Early Access 48: The Effect of Trauma Center Verification Level on Outcomes in Traumatic Brain Injury Patients Undergoing Interfacility Transfer

Welcome to the forty-eighth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to a recent AEM Article or Article in Press, with an author interview podcast.

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DISCUSSING (OPEN ACCESS THROUGH March 31, 2021; CLICK ON TITLE TO ACCESS)

The Effect of Trauma Center Verification Level on Outcomes in Traumatic Brain Injury Patients Undergoing Interfacility Transfer David S Plurad, Glenn Geesman, Ahmed Mahmoud, Nicholas Sheets, Bhani Chawla-Kondal, Napatkamon Ayutyanont, Samer Ghostine, Gregory Guldner

LISTEN NOW: INTERVIEW WITH author

David Plurad, MD, MBA, FACS is Chairman, Section of Trauma at Riverside Community Hospital, Riverside CA and Professor of Surgery, University of California-Riverside School of Medicine. He has an extensive clinical, educational, and research experience in trauma and surgical critical care. He served as a US Navy fight surgeon, trauma surgeon and Director, Navy Trauma Training Center at LAC+USC Medical Center. Dr. Plurad received his medical degree from the University of Missouri-Columbia, completed residency at the University of Illinois-Chicago, and fellowships in Surgical Critical Care and Trauma at USC. He received an Executive MBA from University of Tennesse-Knoxville. He has authored numerous peer reviewed studies, reviews and book chapters. Dr. Plurad is a member of EAST, AAST and the ACS-COT. 

Abstract

Background: 

Previous literature demonstrates increased mortality for traumatic brain injury (TBI) with transfer to a Level II versus Level I trauma center. Our objective was to determine the effect of the most recent American College of Surgeons-Committee on Trauma (ACS-COT) "Resources for the Optimal Care of the Injured Patient" resources manual ("The Orange Book") on outcomes after severe TBI after interfacility transfer to Level I versus Level II center.

Methods: 

Utilizing the Trauma Quality Program Participant Use File of the American College of Surgeons admission year 2017, we identified patients with isolated TBI undergoing interfacility transfer to either Level I or Level II trauma center. Logistic regression was performed to determine independent associations with mortality.

Results: 

There were 10,268 (71.6%) transferred to a Level I center and 4,025 (28.4%) were transferred to a Level II center. They were mostly male (61.4%) with a mean ± SD age of 61 ± 20.8 years. Mean Injury Severity Score was 16.3 ± 6.3 and most were injured in a single-level fall (51.5%). Patients transferred to a Level I center were less likely to be White (82.3% vs. 84.7%, 0.002) and more likely to have sustained penetrating trauma (2.7% vs. 1.6%, <0.001). The incidence of severe TBI (Glasgow Coma Scale [GCS] = 3-8) was similar (9.3% vs. 8.3%, 0.068). On logistic regression, severity of TBI predicted death; however, there was no difference in adjusted mortality outcome with admission to a Level II versus a Level I center (0.998 [0.836-1.192], 0.985).

Conclusions: 

There is no mortality discrepancy in patients with isolated TBI transferred to a Level II versus Level I center despite previous contrary evidence and thus no reason to bypass a Level II in favor of a Level I. This relative improvement potentially relates to the new requirements as defined in the latest version of the ACS-COT's resources manual.