title: Impact of transfer distance and time on rural brain injury outcomes.
abstract: After rural injury, evaluation at local hospitals with transfer to regional trauma centres may delay definitive care. This study sought to determine the impact of such delays on outcomes in patients with TBI within a mature regional trauma system.
  
  
  
  The ETMC Level 1 Trauma registry was queried from 2008-2013 for patients with blunt TBI, aged ≥ 18 and admitted ≤ 24 hours from injury and stratified them as 'transfer' vs 'direct' admission. Demographics, transfer distance, transfer times and outcomes were compared using Chi-square, t-test and multivariable logistic regression; p < 0.05 was significant.
  
  
  
  During the study period, 1845 patients met inclusion criteria: 947 'direct' and 898 'transfers'. For transfers, median distance was 60.1 miles; mean time to initial care was 1.2 ± 2.7 hours and time to Level 1 care was 5.0 ± 2.4 hours. Transfer patients were older (56 vs 49 years; p < 0.01) and had more comorbidities, but had lower mean ISS (15.9 vs 18.8; p < 0.01) and lower mortality (7.0 vs 10.3%; p < 0.03), complications and LOS. Neurosurgical intervention was comparable (p = 0.88), as was mortality for patients with ISS ≥ 15 (12.4% vs 14.8%; p = 0.28). After regression analysis, advanced age and increasing ISS, not distance or time, predicted mortality.
  
  
  
  Neither transfer distance nor time independently contributed to mortality for TBI after rural injury. An established regional trauma system, with initial local stabilization using ATLS principles, may help reduce negative outcomes for injured patients in rural settings.
authors.affiliation: a Department of Surgery, Division of Trauma Services , East Texas Medical Center , Tyler , TX , USA.
authors.forename: Stephen C
authors.initials: SC
authors.lastname: Gale
authors.affiliation: a Department of Surgery, Division of Trauma Services , East Texas Medical Center , Tyler , TX , USA.
authors.forename: Joann
authors.initials: J
authors.lastname: Peters
authors.affiliation: a Department of Surgery, Division of Trauma Services , East Texas Medical Center , Tyler , TX , USA.
authors.forename: Ashley
authors.initials: A
authors.lastname: Hansen
authors.affiliation: b Department of Surgery Rutgers-RWJMS , New Brunswick , NJ , USA.
authors.forename: Viktor Y
authors.initials: VY
authors.lastname: Dombrovskiy
authors.affiliation: a Department of Surgery, Division of Trauma Services , East Texas Medical Center , Tyler , TX , USA.
authors.forename: Paul W
authors.initials: PW
authors.lastname: Detwiler
mesh_terms: D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000368:Aged; D001930:Brain Injuries / Q000453:epidemiology* / Q000523:psychology*; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer; D012189:Retrospective Studies; D013781:Texas / Q000453:epidemiology; D013997:Time Factors; D014193:Trauma Centers; D015599:Trauma Severity Indices; D055815:Young Adult
keywords: Trauma; elderly; inter-hospital transfer; rural; trauma systems; traumatic brain injury