CT scans at outlying hospitals improve understanding of advanced trauma life support noncompliance

Abstract

Introduction: We investigated the incidence, determinants, and consequences of CT scans performed at outlying hospitals on patients who met the criteria for immediate transfer to a level I or II trauma center. Guidelines disseminated through advanced trauma life support (ATLS) facilitate the movement of patients to the appropriate level of care, contributing to a 25% reduction in mortality [1]. Acquisition of CT scans of severely injured patients at outlying nontrauma hospitals violates those guidelines. Methods: We conducted a retrospective review of trauma patients transferred from outlying hospitals to UPMC Presbyterian Hospital between 1 January 2000 and 31 December 2007 who met criteria for immediate transfer to a level I trauma center (n = 5,707). We used multivariable random-effect logistic regression to explore the association between pretransfer CT scanning and mortality. Secondary outcomes included medical costs attributable to duplicate CT scanning and the clinical outcomes of duration of ventilator dependence, ICU length of stay (LOS), and total LOS. Covariables included patient (age, race, gender, insurance, mechanism of injury, injury severity score (ISS)), provider (ATLS certification) and hospital (trauma level designation) characteristics. Results: Of 3,219 patients who received scans prior to leaving the outlying hospital, 2,411 patients had their scans repeated. In our analysis, patients with age >80 years or with an ISS >16 had a higher odds of receiving a scan (OR = 2.23, 95% CI = 1.72 to 2.88; OR = 1.55, 95% CI = 1.31 to 1.83). Patients after a motorcycle collision, after a penetrating injury, or without insurance had a lower odds of receiving a CT scan (OR = 0.78, 95% CI = 0.63 to 0.96; OR = 0.15, 95% CI = 0.11 to 0.21; OR = 0.62, 95% CI = 0.53 to 0.73). Acquisition of CT scans prior to transfer did not improve mortality, ICU LOS, total LOS or duration of mechanical ventilation. Using the 2008 Medicare physician fee schedule allowance, we estimated that the duplication of scans resulted in a cost of $2,091,817. Conclusions: Despite robust evidence supporting the immediate transfer of severely injured patients, over one-half of the cohort transferred to UPMC Presbyterian received a CT scan prior to their transfer. Performance of scans at outlying facilities increased costs but did not improve outcomes.