The Effect of Trauma Center Verification Level on Outcomes in Traumatic Brain Injury Patients Undergoing Interfacility Transfer

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 AE SD age of 61 AE 20.8 years. Mean Injury Severity Score was 16.3 AE 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.

Traumatic Brain Injury Under Triage Risk: A Rural Trauma System Experience

“…2 The American College of Surgeons Committee on Trauma (ACS-COT) has issued specific guidelines that emphasize the importance of a regional collaborative system-based approach to interfacility transfer. 4 Level I trauma centers are expected to yield a lower proportion of morbidity and improved outcomes among the severely injured. 4,5 The ACS-COT considers an under triage rate of <5% and over triage rate of 25% to 50% should be considered acceptable.…”

“…4 Level I trauma centers are expected to yield a lower proportion of morbidity and improved outcomes among the severely injured. 4,5 The ACS-COT considers an under triage rate of <5% and over triage rate of 25% to 50% should be considered acceptable. 6 However, in this trauma system, under triage rates have been as high as 10% by the Cribari matrix method (Figure 1).…”