Title:
Factors correlating with delayed trauma center admission following traumatic brain injury.

Abstract:
Delayed admission to appropriate care has been shown increase mortality following traumatic brain injury (TBI). We investigated factors associated with delayed admission to a hospital with neurosurgical expertise in a cohort of TBI patients in the intensive care unit (ICU).
A retrospective analysis of all TBI patients treated in the ICUs of Helsinki University Central Hospital was carried out from 1.1.2009 to 31.12.2010. Patients were categorized into two groups: direct admission and delayed admission. Patients in the delayed admission group were initially transported to a local hospital without neurosurgical expertise before inter-transfer to the designated hospital. Multivariate logistic regression was utilized to identify pre-hospital factors associated with delayed admission.
Of 431 included patients 65% of patients were in the direct admission groups and 35% in the delayed admission groups (median time to admission 1:07h, IQR 0:52-1:28 vs. 4:06h, IQR 2:53-5:43, p <0.001). In multivariate analysis factors increasing the likelihood of delayed admission were (OR, 95% CI): male gender (3.82, 1.60-9.13), incident at public place compared to home (0.26, 0.11-0.61), high energy trauma (0.05, 0.01-0.28), pre-hospital physician consultation (0.15, 0.06-0.39) or presence (0.08, 0.03-0.22), hypotension (0.09, 0.01-0.93), major extra cranial injury (0.17, 0.05-0.55), abnormal pupillary light reflex (0.26, 0.09-0.73) and severe alcohol intoxication (12.44, 2.14-72.38). A significant larger proportion of patients in the delayed admission group required acute craniotomy for mass lesion when admitted to the neurosurgical hospital (57%, 21%, p< 0.001). No significant difference in 6-month mortality was noted between the groups (p= 0.814).
Delayed trauma center admission following TBI is common. Factors increasing likelihood of this were: male gender, incident at public place compared to home, low energy trauma, absence of pre-hospital physician involvement, stable blood pressure, no major extra cranial injuries, normal pupillary light reflex and severe alcohol intoxication. Focused educational efforts and access to physician consultation may help expedite access to appropriate care in TBI patients.