title: Impact of pattern of admission on outcomes after aneurysmal subarachnoid hemorrhage.
abstract: OBJECTIVE
  Patients with aneurysmal subarachnoid hemorrhage (aSAH) require management in centers with neurosurgical expertise necessitating emergent interhospital transfer (IHT). Our objective was to compare outcomes in aSAH IHTs to our institution with aSAH admissions from our institutional emergency department (ED).
  
  
  METHODS
  Data for consecutive patients with aSAH admitted to Johns Hopkins Medical Institutions between 1991 and 2009 were analyzed from a prospectively obtained database. We compared in-hospital mortality and functional outcomes at first clinical appointment post-aSAH (30-120 days) using dichotomized Glasgow Outcome Scale (good outcome: Glasgow Outcome Scale 4-5) in ED admissions with IHTs.
  
  
  RESULTS
  A total of 1134 consecutive patients with aSAH were included in analysis (ED 40.1%, IHT 59.9%). Direct ED admissions had a higher incidence of poor Hunt and Hess grade (4/5) and major medical comorbidities, with no significant differences between the 2 groups in age, intraventricular hemorrhage, and hydrocephalus. In-hospital mortality for ED admissions (14.9%) was significantly lower than that for IHTs (20.5%), with 1.8 times greater adjusted odds of survival after multivariate analysis (P = .001). Emergency department admissions had nearly 2-fold greater odds of good outcomes (odds ratio, 1.89; P < .001) after multivariate analysis.
  
  
  CONCLUSIONS
  Our institutional ED SAH admissions had significantly better outcomes than did IHTs, suggesting that delays in optimizing care before transfer could deleteriously impact outcomes.
authors.affiliation: Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. nnaval1@jhmi.edu
authors.forename: Neeraj S
authors.initials: NS
authors.lastname: Naval
authors.forename: Tiffany
authors.initials: T
authors.lastname: Chang
authors.forename: Filissa
authors.initials: F
authors.lastname: Caserta
authors.forename: Robert G
authors.initials: RG
authors.lastname: Kowalski
authors.forename: Juan Ricardo
authors.initials: JR
authors.lastname: Carhuapoma
authors.forename: Rafael J
authors.initials: RJ
authors.lastname: Tamargo
mesh_terms: D000328:Adult; D000368:Aged; D015897:Comorbidity; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D023261:Glasgow Outcome Scale; D017052:Hospital Mortality; D006782:Hospitals, Special / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer / Q000706:statistics & numerical data*; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D013345:Subarachnoid Hemorrhage / Q000401:mortality*