Interhospital Transfer Delays Care for Patients With Spinal Cord Injury
Key findings
- The North America Clinical Trials Network for Spinal Cord Injury (SCI) maintains a registry of data on interhospital transfer (IHT), distance traveled for transfer, time of surgery, and patient outcomes
- In this analysis, 295 patients arriving by IHT were more likely to have surgery >24 hours after injury, but length of stay, mortality rate, discharge disposition, and six-month neurological outcomes were similar for the IHT group and 429 directly admits
- Median transfer distance in the IHT did not differ significantly between patients who arrived within 24 hours after injury and patients who arrived later
- 48% of patients in the IHT group had a transfer distance <30 miles and feasibly could have been direct admits; they arrived a median of eight hours post-injury compared with one hour for direct admits
- The field of traumatic SCI care might advance by adopting the model of specialized emergency care for stroke, where patients are brought to dedicated stroke centers for the most timely management
For patients with traumatic spinal cord injury (SCI), "time is spine." Multiple research groups recommend these patients be admitted to a high-level trauma center promptly enough to undergo surgical intervention within 24 hours of injury. Initial presentation to a level II or III trauma center, followed by interhospital transfer (IHT), has been tied to delays in surgery and poorer patient outcomes.
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In a multicenter SCI registry study, researchers at Massachusetts General Hospital found supporting evidence that IHT is associated with a lower chance of surgery within 24 hours. Theresa Williamson, MD, a neurosurgeon in the Department of Neurosurgery at Mass General and teaching faculty at the Harvard Center for Bioethics, Margot Kelly-Hedrick, MPH, a medical student at Duke University, and colleagues report these and related findings in the Journal of Neurotrauma.
Methods
The researchers queried the registry of the North American Clinical Trials Network (NACTN) for Spinal Cord Injury, a network of centers that collect data on patients admitted through their emergency department after first-time SCI. 724 patients were included in this analysis: 429 (59%) were directly admitted to a NACTN center, and 295 (41%) arrived by IHT.
Participant Characteristics
All patients had the severity of their spinal injury scored preoperatively on the American Spinal Injury Association Impairment Scale (AIS), from grade A (complete) to E (normal). 40% of patients presented with AIS grade A.
Patients with AIS grade D were significantly more likely to arrive via IHT, and those with AIS A scores were more likely to be directly admitted. Patients with AIS grade C and those injured by falls were disproportionately represented in the IHT group, suggesting those two groups are under-triaged in the field.
Timing of Surgery
Patients who arrived by IHT and had surgery were significantly more likely to have surgery >24 hours after their injury than direct admits were (62% vs. 48%; P=0.0003). However, the mean times to surgery were not significantly different (36 vs. 22 hours).
Outcomes
There were no significant between-group differences in length of hospital stay, mortality rates, or discharge disposition. Patients who were directly admitted had a significantly higher rate of cardiac complications.
Six-month AIS grades were available for 217 patients. There was no significant difference between the IHT and direct admission groups in AIS grade change from baseline to six months.
Effect of Transfer Distance
Patients in the IHT group traveled a median of 28 miles from the center where they presented initially. The distance traveled did not differ significantly between those who arrived within 24 hours after injury and those who arrived later.
143 ITH patients (48% of the ITH group) had a transfer distance <30 miles and feasibly could have been direct admits. They arrived a median of eight hours post-injury compared with one hour for direct admits, suggesting direct admission when a level 1 trauma center is nearby could reduce delays in care.
The median time to surgery of the 143 patients was comparable to that of the patients directly admitted. The two groups were also statistically equivalent for length of stay, mortality, discharge disposition after acute hospitalization, and six-month change in AIS grade and motor, pinprick, and light touch sensation scores.
Proposing a New Paradigm
Patients with less severe neurological injuries but require a higher level of care could benefit from improved recognition in the field to avoid IHT, particularly when a trauma center is nearby. The field of traumatic SCI care might advance by adopting the model of specialized emergency care for stroke, where patients are taken to dedicated stroke centers for the most timely management.
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