How often are interfacility transfers of spine injury patients truly necessary?

Abstract

Background context: Traumatic spine injuries are often transferred to regional tertiary trauma centers from outside hospitals (OSHs) and subsequently discharged from the trauma center's emergency department (ED) suggesting secondary overtriage of such injuries.

Purpose: The aim of the study was to investigate the definitive treatment and disposition of traumatic spine injuries transferred from OSH, particularly those without other trauma injuries or neurologic symptoms.

Study design: This was a retrospective study.

Patient sample: Adult patients presenting to a single Level 1 trauma center with spine injuries were included.

Outcome measures: The outcome measures considered in the study were appropriateness of transfer, treatment, and cost.

Methods: Four thousand five-hundred consecutive adult patients presenting to a single Level 1 trauma center with spine injuries (isolated or polytrauma) were reviewed. This consisted of 1,427 patients (32%) transferred from an OSH ED. All OSH, emergency medical services, and receiving institution (RI) patient records and imaging were reviewed.

Results: Patients who were neurologically intact, nonpolytrauma, and without critical medical issues at the OSH (isolated intact spine transfers) comprised 29% of transfers. Helicopters transported 13% of these patients. The most frequent injuries were compression (26%), burst (17%), and transverse process (10%) fractures. Seventy-eight percent were discharged directly from the RI's ED. Similarly, 15% were not given any formal treatment, 13% had surgery, and 72% given orthosis treatment. The average cost for transportation and ED costs for those discharged from the RI ED were $1,863 and $12,895, respectively. Of the isolated intact spine transfers, 42% were considered to be inappropriate to warrant transfer. This was defined as those sent from an OSH with an orthopedic or neurosurgeon on staff and clearly stable injuries with minimal chance of progressing to instability. Isolated intact spine transfers whose OSH spine imaging was not considered unstable was 25% of transfers with a helicopter used to transport 14% of these patients. Eighty-seven percent were discharged from the ED, whereas only 3% went onto surgery.

Conclusions: This study is the first to investigate interfacility transfers with spine injuries and found high rate of secondary overtriage of neurologically intact patients with isolated spine injuries. Potential solutions include increasing spine coverage in community EDs, increasing direct communication between the OSH and the spine specialist at the tertiary center, and utilization of teleradiology.

Keywords: ED; EMTALA; Overtriage; Spine; Transfer; Trauma.