Departments of1Emergency Medicine and.
2Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
J Neurosurg. 2024 Jul 12;141(6):1723-1729. doi: 10.3171/2024.4.JNS24256. Print 2024 Dec 1.
Previous studies of neurosurgical transfers indicate that substantial numbers of patients may not need to be transferred, suggesting an opportunity to provide more patient-centered care by treating patients in their communities, while probably saving thousands of dollars in transport and duplicative workup. This study of neurosurgical transfers, the largest to date, aimed to better characterize how often transfers were potentially avoidable and which patient factors might affect whether transfer is needed.
This was a retrospective cohort study of neurosurgical transfers to an urban, tertiary-care, level I trauma center between October 1, 2017, and October 1, 2022. Prior to data analysis, the authors devised criteria to differentiate necessary neurosurgical transfers from potentially avoidable ones. A transfer was considered necessary if 1) the patient went to the operating room within 12 hours of arrival at the emergency department (ED); 2) a neurological MRI study was conducted in the ED; 3) the patient was admitted to the ICU from the ED; or 4) the patient was admitted to either neurology or a surgical service (including neurosurgery). Transfers not meeting any of the above criteria were deemed potentially avoidable. Patient and clinical characteristics, including diagnostic groupings from Clinical Classification Software categories, were collected retrospectively via electronic health record data abstraction and stratified by whether the transfer was necessary or potentially avoidable. Statistical differences were assessed with a chi-square test.
A total of 5113 neurosurgical transfers were included in the study, of which 1701 (33.3%) were classified as potentially avoidable. Four percent of all transferred patients went to the operating room within 12 hours of reaching the receiving ED, 23.4% were admitted to the ICU from the ED, 26.6% had a neurological MRI study performed in the ED, and 54.4% were admitted to a surgical service or to neurology. Potentially avoidable transfers had a higher proportion of traumatic brain injury, headache, and syncope (p < 0.0001), as well as of spondylopathies/spondyloarthropathies (p = 0.0402), whereas patients needing transfer had a higher proportion of acute hemorrhagic cerebrovascular disease and cerebral infarction (p < 0.0001).
This study demonstrates that a large number of neurosurgical transfers can probably be treated in their home hospitals and highlights that the vast majority of patients transferred for neurosurgical conditions do not receive emergency neurosurgery. Further research is needed to better guide transferring and receiving facilities in reducing the burden of excessive transfers.
先前关于神经外科转院的研究表明，大量患者可能无需转院，这为在社区为患者提供更以患者为中心的治疗提供了机会，同时可能节省数千美元的运输和重复检查费用。这项迄今为止最大规模的神经外科转院研究旨在更好地描述转院是否可以避免，并确定哪些患者因素可能影响是否需要转院。
这是一项回顾性队列研究，纳入了 2017 年 10 月 1 日至 2022 年 10 月 1 日期间到一家城市三级创伤中心的神经外科转院患者。在数据分析之前，作者制定了区分必要和潜在可避免转院的标准。如果患者在到达急诊科 12 小时内进入手术室、在急诊科进行神经学 MRI 检查、从急诊科转入 ICU 或入住神经内科或外科服务（包括神经外科），则认为转院是必要的。不符合上述任何标准的转院被认为是潜在可避免的。通过电子病历数据提取回顾性收集患者和临床特征，包括临床分类软件类别中的诊断分组，并根据转院是否必要或潜在可避免进行分层。采用卡方检验评估统计学差异。
共纳入 5113 例神经外科转院患者，其中 1701 例（33.3%）被归类为潜在可避免。所有转院患者中，有 4%在到达接收急诊科 12 小时内进入手术室，23.4%从急诊科转入 ICU，26.6%在急诊科进行神经学 MRI 检查，54.4%入住外科服务或神经内科。潜在可避免转院患者中创伤性脑损伤、头痛和晕厥的比例较高（p<0.0001），脊柱疾病/脊柱关节炎的比例也较高（p=0.0402），而需要转院的患者中急性出血性脑血管病和脑梗死的比例较高（p<0.0001）。
本研究表明，大量神经外科转院患者可能可以在其所在地医院接受治疗，并强调大多数因神经外科疾病转院的患者并未接受紧急神经外科治疗。需要进一步研究以更好地指导转院和接收机构减少过度转院的负担。
