title: Opportunity to reduce transfer of patients with mild traumatic brain injury and intracranial hemorrhage to a Level 1 trauma center.
abstract: OBJECTIVE
  Current guidelines do not address the disposition of patients with mild traumatic brain injury (TBI) and resultant intracranial hemorrhage (ICH). Emergency medicine clinicians working in hospitals without neurosurgery coverage typically transfer patients with both to a trauma center with neurosurgery capability. Evidence is accruing which demonstrates that the risk of neurologic decompensation depends on the type of ICH and as a result, not every patient may need to be transferred. The purpose of this study was to identify risk factors for admission among patients with mild TBI and ICH who were transferred from a community hospital to the emergency department (ED) of a Level 1 trauma center.
  
  
  METHODS
  Study subjects were patients ≥18years of age who were transferred from a community hospital to the ED of an urban, academic Level 1 trauma center between April 1, 2015 and March 31, 2016, and with an isolated traumatic ICH. Patients who had an epidural hematoma, were deemed to require a trauma center's level of service, were found to have non-traumatic ICHs, or had a Glasgow Coma Scale of <13 were excluded. Using a multivariable logistic regression model, we sought to determine patient factors and Computed Tomography (CT) findings which were associated with admission (to the floor, intensive care unit, or operating room with neurosurgery) of the Level 1 trauma center.
  
  
  RESULTS
  644 transferred patients were identified; 205 remained eligible after exclusion criteria. Presence of warfarin (odds ratio [OR] 4.09, 95% Confidence Interval [CI] 1.64, 10.25, p=0.0026) and a subdural hematoma (SDH) ≥1 cm (OR 6.28, 95% CI 1.24, 31.71, p=0.0263) were independently statistically significant factors predicting admission. Age, sex, GCS, presence of neurologic deficit, aspirin use, clopidogrel use, SDH <1 cm, IPH, and SAH were each independently not significant predictive factors of an admission.
  
  
  CONCLUSIONS
  After controlling for factors, transferred patients with mild TBI with a SDH ≥1 cm or on warfarin have a higher odds ratio of requiring inpatient admission to a Level 1 trauma center. While these patients may require admission, there may be opportunities to develop and study a low risk traumatic intracranial hemorrhage protocol, which keeps a subgroup of patients with a mild TBI and resultant ICH at community hospitals with access to a nearby Level 1 trauma center.
authors.affiliation: Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States; Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States. Electronic address: byun@partners.org.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Yun
authors.affiliation: Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States; Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States.
authors.forename: Benjamin A
authors.initials: BA
authors.lastname: White
authors.affiliation: Department of Radiology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States.
authors.forename: H
authors.initials: H
authors.lastname: Benjamin Harvey
authors.affiliation: Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States; Department of Radiology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States; Division of Emergency Imaging, Department of Radiology, Massachusetts General Hospital, Boston, 55 Fruit St., Boston, MA 02114, United States.
authors.forename: Anand M
authors.initials: AM
authors.lastname: Prabhakar
authors.affiliation: Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States; Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States; Harvard Affiliated Emergency Medicine Residency Program, 5 Emerson Place, Suite 101, Boston, MA 02114, United States.
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Sonis
authors.affiliation: Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States; Department of Radiology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States; Massachusetts General Physicians Organization, 55 Fruit St., Boston, MA 02114, United States.
authors.forename: McKinley
authors.initials: M
authors.lastname: Glover
authors.affiliation: Department of Radiology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States.
authors.forename: Emily
authors.initials: E
authors.lastname: Vallillo
authors.affiliation: Department of Radiology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States.
authors.forename: Sun
authors.initials: S
authors.lastname: Choi
authors.affiliation: Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States.
authors.forename: Pierre
authors.initials: P
authors.lastname: Borczuk
authors.affiliation: Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States; Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, United States.
authors.forename: Ali S
authors.initials: AS
authors.lastname: Raja
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001924:Brain Concussion / Q000150:complications / Q000453:epidemiology* / Q000628:therapy; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D020198:Intracranial Hemorrhage, Traumatic / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000209:etiology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009493:Neurosurgery; D010360:Patient Transfer / Q000592:standards*; D012189:Retrospective Studies; D012307:Risk Factors; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers; D014481:United States
keywords: Brain concussion; Intracranial hemorrhages; Neurosurgery; Patient transfer; Traumatic brain hemorrhage; Traumatic brain injuries; Traumatic cerebral hemorrhage; Traumatic subarachnoid hemorrhage; Traumatic subdural hematoma