title: Emergency access to neurosurgical care for patients with traumatic brain injury.
abstract: BACKGROUND
  Traumatic brain injury (TBI) is one of the most common causes of injury-related morbidity and mortality. Access to neurosurgical services is critical to optimal outcomes through reduction of secondary injury. We sought to evaluate variations in access to neurosurgical care across a regional trauma system.
  
  
  METHODS
  This is a population-based retrospective cohort study of patients who sustained isolated severe TBI from 2005 to 2009. Administrative datasets capturing all emergency department visits and hospitalizations were linked deterministically. Differences between access to a trauma center (TC), defined as direct transport from scene or transfer from a nontrauma center (NTC) as opposed to no access, were evaluated; this included patient level determinants of access to TC and delineation of mortality differences between TC and NTC care. Transfer patterns from NTC to TC were also evaluated.
  
  
  RESULTS
  We identified 9,448 patients with isolated severe TBI. Almost two-thirds (60%, n = 5,701) received initial care at an NTC. Of these patients, 30% (n = 1,737) were subsequently transferred to a TC. Thirty-day mortality rates of patients treated at a TC vs NTC were 19% vs 18%, respectively (p = 0.19). Among patients younger than 65 years, 67% received TC care; only 41% of patients older than 65 were treated at a TC (p < 0.01). Mechanism, age, brain hemorrhage, and injury severity were associated with TC care.
  
  
  CONCLUSIONS
  Considerable variation in delivery of initial care to TBI patients was identified. Factors such as age and injury characteristics were associated with TC access. Because early TC care in TBI confers survival benefits, the demonstrated variability necessitates improvements in access to care for patients with severe head injuries.
authors.affiliation: Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. Electronic address: sunjay.sharma@gmail.com.
authors.forename: Sunjay
authors.initials: S
authors.lastname: Sharma
authors.affiliation: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Gomez
authors.forename: Charles
authors.initials: C
authors.lastname: de Mestral
authors.affiliation: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
authors.forename: Charles
authors.initials: C
authors.lastname: deMestral
authors.affiliation: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
authors.forename: Marvin
authors.initials: M
authors.lastname: Hsiao
authors.affiliation: Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
authors.forename: James
authors.initials: J
authors.lastname: Rutka
authors.affiliation: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
authors.forename: Avery B
authors.initials: AB
authors.lastname: Nathens
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001930:Brain Injuries / Q000401:mortality / Q000601:surgery*; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D015601:Injury Severity Score; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D019635:Neurosurgical Procedures; D009864:Ontario; D010360:Patient Transfer / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014193:Trauma Centers / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: AIS; Abbreviated Injury Score; ED; EDH; ISS; Injury Severity Score; MVC; NTC; SAH; SDH; TBI; TC; emergency department; epidural hematoma; motor vehicle collision; nontrauma center; subarachnoid hemorrhage; subdural hematoma; trauma center; traumatic brain injury