Impact of prehospital transfer strategies in major trauma and head injury

Pickering, A; Cooper, Katy; Harnan, S; Sutton, Anthea; Mason, Suzanne; Nicholl, J P

doi:10.1097/ta.0000000000000483

Cited by 41 publications

(14 citation statements)

References 35 publications

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“…While the existing body of literature on the association between transfer and mortality in trauma is inconsistent, this finding stands in contrast to two recent meta-analyses on this topic which did not demonstrate an overall association between interhospital transfer and mortality 19,20 . However, as noted by the authors of these studies and at least one critic 21 , the ability to perform valid meta-analysis is impeded by heterogeneity of the available literature.…”

Section: Discussioncontrasting

confidence: 91%

Lead-Time Bias and Interhospital Transfer after Injury: Trauma Center Admission Vital Signs Underpredict Mortality in Transferred Trauma Patients

Holena

Wiebe

Carr³

et al. 2017

Journal of the American College of Surgeons

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Background Admission physiology predicts mortality after injury but may be improved by resuscitation prior to transfer. This phenomenon, which has been termed lead-time bias, may lead to underprediction of mortality in transferred patients and inaccurate benchmarking in centers receiving large numbers of transfer patients. We sought determine the impact of using vital signs on arrival at the referring center vs. on arrival at the trauma center in mortality prediction models for transferred trauma patients. Study Design We performed a retrospective cohort study using a state-wide trauma registry including all patients age≥16 with Abbreviated Injury Scale scores ≥ 3 admitted to level I and II trauma centers in Pennsylvania from 2011–2014. The primary outcome measure was the risk-adjusted association between mortality and interhospital transfer (IHT) when adjusting for physiology (as measured by Revised Trauma Score, RTS) using the referring hospital arrival vital signs (model 1) compared to trauma center arrival vital signs (model 2). Results After adjusting for patient and injury factors, IHT was associated with reduced mortality (OR 0.85, 95% CI 0.77–0.93) using the RTS from trauma center admission but with increased mortality (OR 1.15, 95% CI 1.05–1.27) using RTS from the referring hospital. The greater the number of transfer patients seen by a center, the greater the difference in center-level mortality predicted by the two models (b −0.044, 95% CI −0.044 - −0.0043, p= <0.001). Conclusions Trauma center vital signs underestimate mortality in transfer patients and may lead to incorrect estimates of expected mortality. Where possible, benchmarking efforts should use referring hospital vital signs to risk-adjust IHT patients.

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Section: Discussioncontrasting

confidence: 91%

Lead-Time Bias and Interhospital Transfer after Injury: Trauma Center Admission Vital Signs Underpredict Mortality in Transferred Trauma Patients

Holena

Wiebe

Carr³

et al. 2017

Journal of the American College of Surgeons

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“…Centralisation of care for extremely preterm babies has been shown to improve outcomes for those babies [1,27,28], but concerns have been raised that this may impact the acquisition of specialised knowledge or skills like intubation that also benefit other babies [29]. Similar concerns have been expressed in other domains such as paediatric intensive care [30] or in relation to transfer strategies for patients with major trauma or head injury [31]. Other services such as those for stroke [32], myocardial infarction [33] and oesophageal cancer surgery [34] have also been centralised, and similar questions might be asked.…”

Section: Study Findings In Contextmentioning

confidence: 99%

Intensity of perinatal care for extremely preterm babies and outcomes at a higher gestational age: evidence from the EPIPAGE-2 cohort study

et al. 2020

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Background: Perinatal decision-making affects outcomes for extremely preterm babies (22-26 weeks' gestational age (GA)): more active units have improved survival without increased morbidity. We hypothesised such units may gain skills and expertise meaning babies at higher gestational ages have better outcomes than if they were born elsewhere. We examined mortality and morbidity outcomes at age two for babies born at 27-28 weeks' GA in relation to the intensity of perinatal care provided to extremely preterm babies. Methods: Fetuses from the 2011 French national prospective EPIPAGE-2 cohort, alive at maternal admission to a level 3 hospital and delivered at 27-28 weeks' GA, were included. Morbidity-free survival (survival without sensorimotor (blindness, deafness or cerebral palsy) disability) and overall survival at age two were examined. Sensorimotor disability and Ages and Stages Questionnaire (ASQ) result below threshold among survivors were secondary outcomes. Perinatal care intensity level was based on birth hospital, grouped using the ratio of 24-25 weeks' GA babies admitted to neonatal intensive care to fetuses of the same gestation alive at maternal admission. Sensitivity analyses used ratios based upon antenatal steroids, Caesarean section, and newborn resuscitation. Multiple imputation was used for missing data; hierarchical logistic regression accounted for births nested within centres. Results: 633 of 747 fetuses (84.7%) born at 27-28 weeks' GA survived to age two. There were no differences in survival or morbidity-free survival: respectively, fully adjusted odds ratios were 0.96 (95% CI: 0.54 to 1.71) and 1.09 (95% CI: 0.59 to 2.01) in medium and 1.12 (95% CI: 0.63 to 2.00) and 1.16 (95% CI: 0.62 to 2.16) in high compared to low-intensity hospitals. Among survivors, there were no differences in sensorimotor disability or ASQ below threshold. Sensitivity analyses were consistent with the main results.

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“…Prehospital emergency medical service is an evolving field essential in the initial phase of acute patient care. Focus has traditionally been on highly acute conditions such as cardiac arrest [ 1 , 2 ], myocardial infarction [ 3 ], stroke [ 4 , 5 ], and major trauma [ 6 ]. However, these conditions only represent a minor fraction of prehospital patients; thus focus on more prevalent conditions or symptoms is needed in order to optimize diagnostics and treatments beneficial for larger groups of prehospital patients.…”

Section: Introductionmentioning

confidence: 99%

Acute pain in the prehospital setting: a register-based study of 41.241 patients

Friesgaard

Riddervold

Kirkegaard

et al. 2018

Scand J Trauma Resusc Emerg Med

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BackgroundAcute pain is a frequent symptom, but little is known about the frequency and causes of acute pain in the prehospital population. The objectives of this study were to investigate the frequency of moderate to severe pain among prehospital patients and the underlying causes according to primary hospital diagnose codes.MethodsThis was a register-based study on 41.241 patients transported by ambulance. Information on moderate to severe pain [Numeric Rating Scale (NRS, 0–10) > 3 or moderate pain or higher on 4-point likert scale] was extracted from a national electronic prehospital patient record. Patient information was merged with primary hospital diagnose codes based on the 10th version of the International Classification of Diseases (ICD-10) to investigate underlying causes of pain.Results11.430 patients (27.7%) reported moderate to severe pain during ambulance transport. As a measure of opioid demanding acute pain, 3.275 of 41.241 patients (7.9%) were treated with intravenous fentanyl. Underlying causes of pain were heterogenic according to ICD-10 chapters with injuries being the largest group of patients with moderate to severe pain (XIX: 42.8% of 8.041 patients), followed by non-specific diagnoses (XVIII: 28.5% of 7.101 patients and XXI: 31.6% of 5.148 patients), diseases of the circulatory system (IX: 22.1% of 4.812 patients) and other (20.3% of 16.139 miscellaneous patients).DiscussionDue to the high frequency of moderate to severe pain affecting a wide range of patients, more attention on acute pain is necessary. Whether ambulance personnel have sufficient options for treating various pain conditions might be a subject of future evaluation. Non-specific diagnoses accounted for surprisingly many patients with moderate to severe pain, of which many were treated with intravenous fentanyl. This may be substance of further investigation.ConclusionsModerate to severe pain is a highly frequent and probably underestimated symptom among patients transported by ambulance. Underlying causes of pain are heterogenic as described by primary hospital diagnose codes. More focus on the treatment of acute pain is needed.

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Impact of prehospital transfer strategies in major trauma and head injury

Cited by 41 publications

References 35 publications

Lead-Time Bias and Interhospital Transfer after Injury: Trauma Center Admission Vital Signs Underpredict Mortality in Transferred Trauma Patients

Lead-Time Bias and Interhospital Transfer after Injury: Trauma Center Admission Vital Signs Underpredict Mortality in Transferred Trauma Patients

Intensity of perinatal care for extremely preterm babies and outcomes at a higher gestational age: evidence from the EPIPAGE-2 cohort study

Acute pain in the prehospital setting: a register-based study of 41.241 patients

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