Effective Regionalization of Care for Traumatic Brain Injury in Southeastern Georgia

An estimated 17 million people sustain a traumatic brain injury each year. Of those 17 million, 1.3 million are treated in an emergency room, 275,000 are hospitalized, and more than 50,000 die each year.1 In addition, traumatic brain injuries contribute to one-third of all injury-related deaths in the United States. The cost of treating these injuries is significant. In the year 2000, the direct and indirect costs of traumatic brain injuries totaled more than 60 billion dollars.2 Multiple studies have shown a reduction in mortality for patients treated in designated trauma centers compared with non-designated centers. A national evaluation of the North American Trauma Systems revealed an overall reduction in mortality of between 15 and 20 per cent for patients treated in designated trauma centers.3 Furthermore, Kelly et al.4 demonstrated improved survival for a large region in Ohio with a single designated trauma center acting as catchment for a coordinated trauma system. The authors concluded that regionalization of trauma care reduced mortality for patients with traumatic brain injury (TBI). They identified a 24 per cent reduction in mortality for all patients who sustained a TBI and a 28 per cent reduction in mortality for those patients sustaining a severe TBI. Our facility, a Level I trauma center located in Savannah, Georgia, serves as a referral center for community hospitals in 24 counties. Our large service area, Region 9, is the most rural in the state of Georgia. This retrospective review was conducted to examine the effectiveness of regionalization of rural trauma care for TBI patients in Southeastern Georgia. This research was reviewed and approved by the Institutional Review Board. Our trauma registry was queried for all patients sustaining a TBI between January 2010 and December 2012. Patients were identified using ICD-9 codes 800–804 and 850–854. Excluded patients were those younger than 18 years of age, anyone transferred from outside the region, or those with incomplete data. The study cohort was stratified by age, gender, race, injury severity (ISS), Glasgow coma score (GCS), abbreviated injury score of the head, mechanism of injury, and time from injury to arrival at the Level I trauma center. Outcome variables included hospital length of stay, intensive care unit length of stay, ventilator days, and mortality. Descriptive statistics were calculated for demographic data and are presented as mean ± SD or frequencies. Discrete variables were compared using Pearson’s chisquared analysis or Fisher’s exact tests, where appropriate. Continuous variables were compared using Student t tests and analysis of variance, where appropriate. A multiple logistic regression analysis was used to identify risk factors for mortality. Findings were considered statistically significant if the P value was less than 0.05. A query of our trauma registry identified a total of 3752 patients with TBI admitted to trauma service during the study period. Of those identified, 1419 were excluded from the study. The remaining patients constituted the analysis group (n 4 2333). Descriptive statistics for the entire study population are presented in Table 1. An additional analysis comparing those who were directly transported to the facility versus those who were referred after presenting to an outlying facility revealed that those who were directly transported were on average younger (46.8 ± 20.3 vs 55.3 ± 22.6, P < 0.001), more severely injured (ISS 15.9 ± 10.1 vs 14.0 ± 7.6, P < 0.001), and had a lower GCS on arrival to the emergency department (12.7 ± 4.2 vs 13.4 ± 3.5), P < 0.001. Hospital length of stay (8.1 ± 11.3 vs 5.8 ± 6.8, P < 0.001), intensive care unit length of stay (2.9 ± 5.6 vs 2.07 ± 4.3, P < 0.001), days spent on the ventilator (2.1 ± 5.2 vs 1.2 ± 4.0, P < 0.001), and the mortality rate (6.8% vs 4.7%, P < 0.001) were significantly greater among those transported directly to the hospital versus those who were transferred from an outlying facility (Table 1). A multiple regression analysis identified several factors which confer an increased mortality risk to TBI Address correspondence and reprint requests to James R. Dunne, M.D., F.A. C.S. , Director of Trauma/Critical Care Services, Memorial Health University Medical Center, 4700 Waters Avenue, Savannah, GA 31404. E-mail: dunnejal@memorialhealth.com.