Research & Development, Prehospital Emergency Medical Services, Central Denmark Region, Brendstrupgårdsvej 7, Aarhus N, Denmark.
Department of Clinical Medicine, Aarhus University, Incuba Skejby, bld. 2, Palle Juul-Jensens Blvd. 82, Aarhus, Denmark.
Scand J Trauma Resusc Emerg Med. 2024 Jun 19;32(1):58. doi: 10.1186/s13049-024-01229-7.
Traumatic brain injury (TBI) is a potential high-risk condition, but appropriate care pathways, including prehospital triage and primary referral to a specialised neurosurgical centre, can improve neurological outcome and survival. The care pathway starts with layman triage, wherein the patient or bystander decides whether to contact a general practitioner (GP) or emergency services (1-1-2 call) as an entryway into the health care system. The GP or 112-health care professional then decides on the level of urgency and dispatches emergency medical services (EMS) when needed. Finally, a decision is made regarding referral of the TBI patient to a specialised neurotrauma centre or a local hospital. Recent studies have shown that injuries are generally more severe in patients entering the health care system through EMS (112-calls) than through GPs; however, no information exists on whether mortality and morbidity outcomes differ depending on the referral choice. The aim of this study was to examine triage pathways, including the method of entry into the health care system, as well as patient characteristics and place of primary referral, to determine the associated 30-day and 1-year mortality rates in TBI patients with confirmed intracranial lesions.
This retrospective observational population-based follow-up study was conducted in the Central Denmark Region from 1 February 2017 to 31 January 2019. We included all adult patients who contacted hospitals and were ascribed a predefined TBI ICD-10 diagnosis code in the Danish National Patient Register. The obtained TBI cohort was merged with prehospital data from the Prehospital Emergency Medical Services, Central Denmark Region, and vital status from the Danish Civil Registration System. Binary logistic regression analysis of mortality was conducted. In all patients with TBI (including concussions), the primary outcome was primary referral to a specialised centre based on mode of entry ('GP/HCP', '112-call' or 'Unreferred') into the health care system. In the subgroup of patients with confirmed intracranial lesions, the secondary outcomes were the relative risk of death at day 30 and 1 year based on the place of primary referral.
Of 5,257 first TBI hospital contacts of adult patients included in the cohort, 1,430 (27.2%) entered the health care system via 1-1-2 emergency medical calls. TBI patients triaged by 112-calls were more likely to receive the highest level of emergency response (15.6% vs. 50.3%; p < 0.001) and second-tier resources and were more frequently referred directly to a specialised centre than were patients entering through GPs or other health care personnel. In the subgroup of 1188/5257 (22.4%) patients with confirmed intracranial lesions, we found no difference in the risk ratio of 30 day (RR 1.04 (95%CI 0.65-1.63)) or 1 year (RR 0.96 (95%CI 0.72-1.25)) all-cause mortality between patients primarily referred to a regional hospital or to a specialised centre when adjusting for age, sex, comorbidities, antiplatelet/anticoagulant treatment and type of intracranial lesions.
TBI patients mainly enter the health system by contact with GPs or other health care professionals. However, patients entering through 112-calls are more frequently triaged directly to specialised centres. We were unable to demonstrate any significant difference in the adjusted 30-day and 1-year mortality based on e primary referral to a specialised centre. The inability to demonstrate an effect on mortality based on primary referral to a specialised centre may reflect a lack of clinical data in the registries used. Considerable differences may exist in nondocumented baseline characteristics (i.e., GCS, blood pressure and injury severity) between the groups and may limit conclusions about differences in mortality. Further research providing high-quality evidence on the effect of primary referral is needed to secure early neurosurgical interventions in TBI patients.
创伤性脑损伤（TBI）是一种潜在的高危病症，但适当的治疗途径，包括院前分诊和向专门的神经外科中心的初步转诊，可改善神经功能预后和生存率。治疗途径始于平民分诊，即患者或旁观者决定是联系全科医生（GP）还是拨打紧急服务电话（1-1-2 电话）进入医疗保健系统。GP 或 112-医疗保健专业人员然后根据紧急程度决定是否派遣紧急医疗服务（EMS）。最后，决定将 TBI 患者转介到专门的神经创伤中心或当地医院。最近的研究表明，通过 EMS（112 电话）进入医疗保健系统的患者的伤势通常比通过 GP 更严重；然而，没有关于死亡率和发病率是否因转诊选择而异的信息。本研究的目的是检查分诊途径，包括进入医疗保健系统的方法，以及患者特征和初步转诊的地点，以确定有颅内病变的 TBI 患者的 30 天和 1 年死亡率。
这是一项在丹麦中部地区进行的回顾性观察性基于人群的随访研究，时间为 2017 年 2 月 1 日至 2019 年 1 月 31 日。我们纳入了所有联系医院并在丹麦国家患者登记处被预定义为 TBI ICD-10 诊断代码的成年患者。获得的 TBI 队列与来自丹麦中部地区的院前紧急医疗服务的院前数据以及丹麦民事登记系统的生存状态合并。使用二元逻辑回归分析死亡率。在所有 TBI（包括脑震荡）患者中，主要结局是根据进入医疗保健系统的方式（“GP/HCP”、“112 电话”或“未转诊”）进行的专科中心初步转诊。在有明确颅内病变的患者亚组中，次要结局是基于初步转诊地点的 30 天和 1 年的死亡相对风险。
在包括的队列中，有 5257 名成年患者的首次 TBI 医院就诊中，有 1430 名（27.2%）通过 1-1-2 紧急医疗电话进入医疗保健系统。通过 112 电话分诊的 TBI 患者更有可能获得最高级别的应急响应（15.6%比 50.3%；p<0.001）和二线资源，并且比通过 GP 或其他医疗保健人员进入的患者更频繁地直接转诊到专门中心。在有明确颅内病变的 1188/5257 名（22.4%）患者亚组中，我们发现 30 天（RR 1.04（95%CI 0.65-1.63））或 1 年（RR 0.96（95%CI 0.72-1.25））全因死亡率的风险比在调整年龄、性别、合并症、抗血小板/抗凝治疗和颅内病变类型后，患者主要转诊到区域医院或专门中心之间没有差异。
TBI 患者主要通过与 GP 或其他医疗保健专业人员联系进入医疗系统。然而，通过 112 电话进入的患者更频繁地直接分诊到专门中心。我们无法证明根据专门中心的初步转诊调整后 30 天和 1 年死亡率有任何显著差异。根据专门中心的初步转诊不能证明死亡率有差异，这可能反映了所使用的登记处缺乏临床数据。两组之间可能存在相当大的未记录基线特征差异（即 GCS、血压和损伤严重程度），这可能限制了对死亡率差异的结论。需要进一步提供高质量证据的研究，以确保 TBI 患者早期接受神经外科干预。
