title: Is ED disposition associated with intracerebral hemorrhage mortality?
abstract: BACKGROUND
  Early deterioration is common in intracerebral hemorrhage (ICH). Treatment at tertiary care centers has been associated with lower ICH mortality. Guidelines recommend aggressive care for 24 hours irrespective of the initial outlook. We examined the frequency of and factors associated with transfer to tertiary centers in ICH patients who initially presented at nontertiary emergency departments (EDs). We also compared observed with expected mortality in transferred and nontransferred patients using published short-term mortality predictors for ICH.
  
  
  METHODS
  Adult patients who resided in a 5-county region and presented to nontertiary EDs with nontraumatic ICH in 2005 were identified. Intracerebral hemorrhage score and ICH Grading Scale (ICH-GS) were determined. Of 16 local hospitals, 2 were designated tertiary care centers. Logistic regression was used to assess factors associated with transfer.
  
  
  RESULTS
  Of 205 ICH patients who presented to nontertiary EDs, 80 (39.0%) were transferred to a tertiary center. In multivariate regression, better baseline function (modified Rankin scale 0-2 versus 3-5; odds ratio, 0.42, 95% confidence interval, 0.21-0.85, P = .016) and black race (odds ratio, 2.28, 95% confidence interval 1.01-5.12, P = .046) were associated with transfer. A trend toward higher 30-day mortality was observed in nontransferred patients (32.5% versus 45.6%, P = .06). The ICH-GS overestimated mortality for all patients, while the ICH Score adequately predicted mortality.
  
  
  CONCLUSIONS
  We found no significant difference in mortality between transferred and nontransferred patients, but the trend toward higher mortality in nontransferred patients suggests that further evaluation of ED disposition decisions for ICH patients is warranted. Expected ICH mortality may be overestimated by published tools.
authors.affiliation: UC Neuroscience Institute, Cincinnati, OH 45267, USA. opeolu.adeoye@uc.edu
authors.forename: Opeolu
authors.initials: O
authors.lastname: Adeoye
authors.forename: Mary
authors.initials: M
authors.lastname: Haverbusch
authors.forename: Daniel
authors.initials: D
authors.lastname: Woo
authors.forename: Padmini
authors.initials: P
authors.lastname: Sekar
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Moomaw
authors.forename: Dawn
authors.initials: D
authors.lastname: Kleindorfer
authors.forename: Brian
authors.initials: B
authors.lastname: Stettler
authors.forename: Brett M
authors.initials: BM
authors.lastname: Kissela
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Broderick
authors.forename: Matthew L
authors.initials: ML
authors.lastname: Flaherty
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002543:Cerebral Hemorrhage / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D004636:Emergency Service, Hospital; D005260:Female; D017052:Hospital Mortality; D006782:Hospitals, Special; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer; D012189:Retrospective Studies; D015996:Survival Rate; D015599:Trauma Severity Indices; D016896:Treatment Outcome
references.citation: Stroke. 2003 Sep;34(9):e150-1; author reply e150-1
references.pmid: 12947164
references.citation: Stroke. 2006 Apr;37(4):1038-44
references.pmid: 16514104
references.citation: Circulation. 2007 Oct 16;116(16):e391-413
references.pmid: 17938297
references.citation: Neurol Res. 2009 May;31(4):425-9
references.pmid: 19099673
references.citation: Circulation. 2009 Jan 27;119(3):e21-181
references.pmid: 19075105
references.citation: Crit Care Med. 2001 Mar;29(3):635-40
references.pmid: 11373434
references.citation: Stroke. 1996 Aug;27(8):1304-5
references.pmid: 8711791
references.citation: Crit Care Med. 2004 Nov;32(11):2311-7
references.pmid: 15640647
references.citation: Stroke. 2001 Apr;32(4):891-7
references.pmid: 11283388
references.citation: Stroke. 2002 May;33(5):1190-5
references.pmid: 11988589
references.citation: J Stroke Cerebrovasc Dis. 2006 Jul-Aug;15(4):144-50
references.pmid: 17904067
references.citation: Neurology. 2001 Mar 27;56(6):766-72
references.pmid: 11274312
references.citation: Stroke. 2003 Jul;34(7):1717-22
references.pmid: 12805488
references.citation: Stroke. 2007 May;38(5):1641-4
references.pmid: 17379820