Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona.
JAMA Surg. 2024 Nov 1;159(11):1282-1288. doi: 10.1001/jamasurg.2024.3254.
Wide variations exist in traumatic brain injury (TBI) management strategies and transfer guidelines across the country.
To assess the outcomes of patients with TBI transferred to the American College of Surgeons (ACS) level I (LI) or level II (LII) trauma centers (TCs) on a nationwide scale.
DESIGN, SETTING, AND PARTICIPANTS: In this secondary analysis of the ACS Trauma Quality Improvement Program database (2017 to 2020), adult patients with isolated TBI (nonhead abbreviated injury scale = 0) with intracranial hemorrhage (ICH) who were transferred to LI/LII TCs we re included. Data were analyzed from January 1, 2017, through December 31, 2020.
Outcomes were rates of head computed tomography scans, neurosurgical interventions (cerebral monitors, craniotomy/craniectomy), hospital length of stay, and mortality. Descriptive statistics and hierarchical mixed-model regression analyses were performed.
Of 117 651 patients with TBI with ICH managed at LI/LII TCs 53 108; (45.1%; 95% CI, 44.8%-45.4%) transferred from other centers were identified. The mean (SD) age was 61 (22) years and 30 692 were male (58%). The median (IQR) Glasgow Coma Scale score on arrival was 15 (14-15); 5272 patients had a Glasgow Coma Scale score of 8 or less on arrival at the receiving trauma center (10%). A total of 30 973 patients underwent head CT scans (58%) and 2144 underwent repeat head CT scans at the receiving TC (4%). There were 2124 patients who received cerebral monitors (4%), 6862 underwent craniotomy/craniectomy (13%), and 7487 received mechanical ventilation (14%). The median (IQR) hospital length of stay was 2 (1-5) days and the mortality rate was 6.5%. There were 9005 patients (17%) who were discharged within 24 hours and 19 421 (37%) who were discharged within 48 hours of admission without undergoing any neurosurgical intervention. Wide variations between and within trauma centers in terms of outcomes were observed in mixed-model analysis.
In this study, nearly half of the patients with TBI managed at LI/LII TCs were transferred from lower-level hospitals. Over one-third of these transferred patients were discharged within 48 hours without any interventions. These findings indicate the need for systemwide guidelines to improve health care resource use and guide triage of patients with TBI.
全国各地在创伤性脑损伤 (TBI) 管理策略和转移指南方面存在广泛差异。
评估 TBI 患者转移至美国外科医师学会 (ACS) 一级 (LI) 或二级 (LII) 创伤中心 (TC) 的治疗结果，这是一项全国性研究。
设计、地点和参与者：这是对 ACS 创伤质量改进计划数据库（2017 年至 2020 年）的二次分析，纳入了在 LI/LII TC 接受治疗的伴有颅内出血 (ICH) 的孤立性 TBI（非头部简略损伤量表=0）的成年患者。数据分析于 2017 年 1 月 1 日至 2020 年 12 月 31 日进行。
结局指标包括头部计算机断层扫描 (CT) 检查、神经外科干预（脑监测仪、开颅术/去骨瓣减压术）、住院时间和死亡率。采用描述性统计和分层混合模型回归分析。
在 117651 例在 LI/LII TC 接受治疗的伴有 ICH 的 TBI 患者中，有 53108 例（45.1%；95%CI，44.8%-45.4%）是从其他中心转来的。患者的平均（标准差）年龄为 61（22）岁，30692 例为男性（58%）。到达接收创伤中心时的格拉斯哥昏迷量表评分中位数（IQR）为 15（14-15）；5272 例患者在到达接收 TC 时格拉斯哥昏迷量表评分在 8 分或以下（10%）。共有 30973 例患者接受了头部 CT 扫描（58%），2144 例患者在接收 TC 时进行了重复头部 CT 扫描（4%）。有 2124 例患者接受了脑监测仪（4%），6862 例行开颅术/去骨瓣减压术（13%），7487 例接受了机械通气（14%）。中位（IQR）住院时间为 2（1-5）天，死亡率为 6.5%。有 9005 例患者（17%）在入院后 24 小时内出院，19421 例患者（37%）在入院后 48 小时内出院，期间未进行任何神经外科干预。混合模型分析显示，不同 TC 之间以及同一 TC 内部的结局存在显著差异。
在这项研究中，LI/LII TC 治疗的 TBI 患者中近一半是从低级别医院转来的。这些转院患者中，有超过三分之一在 48 小时内出院，没有接受任何干预措施。这些发现表明需要制定全系统指南，以改善医疗资源利用并指导 TBI 患者的分诊。
