Increased Mortality in Patients Transferred to a Level 1 Trauma Center With Blunt and Penetrating Extremity Vascular Injuries: A 10-year Analysis

Abstract

Trauma centers serve a uniquely vulnerable population. These patients depend on a complex transfer system to ensure timely and adequate care at major trauma centers. Patient outcomes depend on the reliability of their management between a local or community hospital and a tertiary or quaternary trauma institution. Patients with polytrauma, extremity trauma, and vascular injuries require multidisciplinary management at a trauma hospital. Our study investigates outcomes in this population at a level one trauma center covering the largest geographic county in the contiguous United States. A retrospective review of all extremity trauma patients that presented to a high-capacity level 1 trauma center over 10 years was collected. This cohort was divided into two groups: (1) transferred from another medical center for higher level of care; or (2) those who presented directly. Overall, 19,417 patients were identified, with 15,317 that presented directly and 3830 patients transferred from an outside hospital. Vascular injuries were seen in 268 patients. Demographic data was ascertained which included injury severity score (ISS), mechanism of injury, response level, arrival method, tertiary center emergency department disposition, and presence of vascular injury in upper or lower extremities. Univariate and multivariate analyses were performed to assess patient mortality. A total of 268 vascular injury patients were analyzed, with 207 non-transferred and 61 transferred patients. In the univariate analysis, ISS was an average 11.4 in non-transferred patients vs 8.4 in transferred (P < .001), 50% of blunt injury in the non-transferred group and 28% in the transferred group (P < .001), in-hospital mortality was 4% in non-transferred patients vs 28% in the transferred group (P < .001). A multivariate logistic regression demonstrated mortality is eight times more likely if a patient with vascular extremity injuries was transferred (Table). A 10% mortality rate was seen in patients without blood transfusion within 4 hours of arrival to the trauma center (compared with 3% mortality in transferred patients transfused blood). Extremity trauma with vascular injuries can be lethal if not triaged appropriately. Transferred patients to our level 1 trauma center had a substantial increase in mortality compared with non-transferred patients. Blood transfusion within the first 4 hours of arrival to the trauma center was associated with better survival. More research efforts are needed to treat this vulnerable patient population.TableBinary logistic regression with mortality and transfer status as dependent variablesCharacteristicClinical variables of mortality in vascular patients (binary logistic regression analysis)aClinical variables of transfer status in vascular patients (binary logistic regression analysis)aOdds ratio (n = 266)95% Confidence intervalPaOdds ratio (n = 266)95% Confidence intervalPaAge1.0150.985-1.046.3270.9890.969-1.009.284Injury Severity Score0.9850.906-1.070.7190.9650.912-1.021.220Location of injury (upper and lower extremity)0.3940.095-1.640.2012.6921.058-6.484.038Injury type5.0211.338-18.845.0171.9830.984-3.997.056Response level0.7860.476-1.295.3441.3540.962-1.907.082Transfer status7.9012.933-21.286.001–––Mortality–––8.2543.115-21.868.001Packed red blood cells (1st 4 hours) (%)0.5340.061-4.654.5700.0750.009-0.623.016aTotal cases analyzed = 268. Open table in a new tab