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Primary versus early secondary referral to a specialized neurotrauma center in patients with moderate/severe traumatic brain injury: a CENTER TBI study

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posted on 16.09.2021, 23:17 by CA Sewalt, BY Gravesteijn, D Menon, HF Lingsma, AIR Maas, N Stocchetti, E Venema, FE Lecky, C Åkerlund, K Amrein, N Andelic, L Andreassen, A Anke, A Antoni, G Audibert, P Azouvi, ML Azzolini, R Bartels, P Barzó, R Beauvais, R Beer, BM Bellander, A Belli, H Benali, M Berardino, L Beretta, M Blaabjerg, P Bragge, A Brazinova, V Brinck, J Brooker, C Brorsson, A Buki, M Bullinger, M Cabeleira, A Caccioppola, E Calappi, MR Calvi, P Cameron, GC Lozano, M Carbonara, G Chevallard, A Chieregato, G Citerio, M Cnossen, M Coburn, J Coles, DJ Cooper, M Correia, A Covic, N Curry, E Czeiter, M Czosnyka, C Dahyot-Fizelier, H Dawes, V De Keyser, V Degos, FD Corte, HD Boogert, B Depreitere, Ð Ðilvesi, A Dixit, E Donoghue, J Dreier, GL Dulière, A Ercole, P Esser, E Ezer, M Fabricius, VL Feigin, K Foks, S Frisvold, A Furmanov, P Gagliardo, D Galanaud, D Gantner, G Gao, P George, A Ghuysen, L Giga, B Glocker, J Golubovic, PA Gomez, J Gratz, F Grossi, RL Gruen, D Gupta, JA Haagsma, I Haitsma, R Helbok, E Helseth, L Horton, J Huijben, PJ Hutchinson, B Jacobs, S Jankowski, M Jarrett, JY Jiang, K Jones, Anneliese SynnotAnneliese Synnot
Full list of CENTER TBI Participants and Investigators can be found in publication (p.8-11): https://sjtrem.biomedcentral.com/articles/10.1186/s13049-021-00930-1#Abs1
Background: Prehospital care for patients with traumatic brain injury (TBI) varies with some emergency medical systems recommending direct transport of patients with moderate to severe TBI to hospitals with specialist neurotrauma care (SNCs). The aim of this study is to assess variation in levels of early secondary referral within European SNCs and to compare the outcomes of directly admitted and secondarily transferred patients. Methods: Patients with moderate and severe TBI (Glasgow Coma Scale < 13) from the prospective European CENTER-TBI study were included in this study. All participating hospitals were specialist neuroscience centers. First, adjusted between-country differences were analysed using random effects logistic regression where early secondary referral was the dependent variable, and a random intercept for country was included. Second, the adjusted effect of early secondary referral on survival to hospital discharge and functional outcome [6 months Glasgow Outcome Scale Extended (GOSE)] was estimated using logistic and ordinal mixed effects models, respectively. Results: A total of 1347 moderate/severe TBI patients from 53 SNCs in 18 European countries were included. Of these 1347 patients, 195 (14.5%) were admitted after early secondary referral. Secondarily referred moderate/severe TBI patients presented more often with a CT abnormality: mass lesion (52% vs. 34%), midline shift (54% vs. 36%) and acute subdural hematoma (77% vs. 65%). After adjusting for case-mix, there was a large European variation in early secondary referral, with a median OR of 1.69 between countries. Early secondary referral was not associated with functional outcome (adjusted OR 1.07, 95% CI 0.78–1.69), nor with survival at discharge (1.05, 0.58–1.90). Conclusions: Across Europe, substantial practice variation exists in the proportion of secondarily referred TBI patients at SNCs that is not explained by case mix. Within SNCs early secondary referral does not seem to impact functional outcome and survival after stabilisation in a non-specialised hospital. Future research should identify which patients with TBI truly benefit from direct transportation.

Funding

CENTER-TBI was supported by the European Union 7th Framework program (EC Grant 602150). Additional funding was obtained from the Hannelore Kohl Stiftung (Germany), from OneMind (USA) and from Integra LifeSciences Corporation (USA).

History

Publication Date

04/08/2021

Journal

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Volume

29

Article Number

113

Pagination

11p.

Publisher

BMC

ISSN

1757-7241

Rights Statement

The Author reserves all moral rights over the deposited text and must be credited if any re-use occurs. Documents deposited in OPAL are the Open Access versions of outputs published elsewhere. Changes resulting from the publishing process may therefore not be reflected in this document. The final published version may be obtained via the publisher’s DOI. Please note that additional copyright and access restrictions may apply to the published version.

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