title: Determinants of compliance with transfer guidelines for trauma patients: a retrospective analysis of CT scans acquired prior to transfer to a Level I Trauma Center.
abstract: OBJECTIVE
  To identify potential determinants of compliance with the American College of Surgeons Committee on Trauma guidelines for the transfer of trauma patients.
  
  
  BACKGROUND
  Guidelines published by the American College of Surgeons Committee on Trauma outline criteria for the immediate transfer of moderately to severely injured patients to Level I/II Trauma Centers. Acquisition of pretransfer computed tomography (CT) scans violates those guidelines.
  
  
  METHODS
  Between January 2000 and December 2007, retrospective review of trauma patients meeting the criteria for immediate transfer to a Level I Trauma Center. We used multivariable analyses to explore the determinants of scan acquisition, the association between CT scans and in-hospital mortality, and the association between CT scans and secondary outcomes, such as duration of ventilator dependence, intensive care unit length of stay, and total length of stay. We calculated the number of scans duplicated upon arrival at the Level I center, and estimated charges using the 2008 Medicare physician fee schedule allowance.
  
  
  RESULTS
  Of 7713 severely injured patients requiring transfer to a Level I center, 4434 patients (57%) had a pretransfer CT scan. Penetrating wounds, physiologic compromise, and Injury Severity Scores>or=34 were associated with fewer pretransfer CT scans, while older age and being female were associated with more. Pretransfer CT scans were not associated with in-hospital death or worsened secondary outcomes, but increased charges by $3,761,389 ($488/person transferred with severe injuries).
  
  
  CONCLUSIONS
  National guidelines for the transfer of severely injured patients are followed less than half the time. Pretransfer CT scans do not improve outcomes yet increase costs.
authors.affiliation: The CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh, and UPMC Presbyterian Hospital, Pittsburgh, PA 15261, USA. mohand@upmc.edu
authors.forename: Deepika
authors.initials: D
authors.lastname: Mohan
authors.forename: Amber E
authors.initials: AE
authors.lastname: Barnato
authors.forename: Derek C
authors.initials: DC
authors.lastname: Angus
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Rosengart
mesh_terms: D019983:Guideline Adherence; D017408:Guidelines as Topic / Q000592:standards*; D006801:Humans; D010360:Patient Transfer / Q000592:standards*; D012042:Registries; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D014193:Trauma Centers; D014481:United States; D014947:Wounds and Injuries / Q000000981:diagnostic imaging* / Q000191:economics