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Transfer of Children with TBI for Definitive Care, Particularly Without Airway Control, is a Powerful Risk Factor for Mortality
Meredity Halling, MS, Laura D. Cassidy, MS, PhD and Allison Ertl, MS, Medical College of Wisconsin, Milwaukee WI; Joseph H. Piatt, Jr, MD, A I duPont Hospital for Children, Wilmington DE; Schuyler Schmidt, MS, Ohio Department of Public Safety, Columbus OH; Jonathan I. Groner, MD, Nationwide Children's Hospital, Columbus OH

Abstract: Aim: To compare mortality for head injured pediatric patients admitted directly to a level 1 pediatric trauma center (PTC1) to those transferred to a PTC1 from a trauma center (TC) or a non-trauma center (NTC). Methods: A state trauma registry identified 3,139 head injured pediatric patients. Patient characteristics were compared using chi-squared test. A Logistic regression model evaluated mortality for patients admitted directly to a PTC1 and another was created for transferred patients. Results: 984 were admitted directly to a PTC1, 418 transferred from a lower level TC, 1,737 transferred from a NTC. Patients admitted directly to a PTC1 had a higher proportion of non-white, public insurance and severely injured children. Transferred patients <1yr old had higher adjusted odd of mortality (OR=11.39, 95%CI, 2.4-55.1). Patients <1yr admitted directly to PTC1 had no increased odds of mortality (OR=1.7, 95%CI, 0.49-55.8). Transferred patients with an ISS of 9-14 had higher adjusted odds of mortality than those with ISS 1-8 (OR=24.5, 95%CI, 2.7-218.9). Direct admits to a PTC1 (ISS=9-14) had no increased odds of mortality (OR=1.03, 95%CI, 0.28-3.8). Transferred patients who required intubation at the PTC1 ED had 92.7 odds for mortality (95%CI 35.5-336.9) compared to those not requiring intubation upon arrival. Patients directly admitted and intubated in a PTC1 ED had 10.4 odds for mortality (95%CI 4.03-26.89). Conclusions: After adjusting for potential confounders, transferred patients have significantly higher mortality. Transfer without needed airway control occurs with alarming frequency and must be a focus for quality improvement.

Objective: Identify factors associated with mortality differences between transferred patients and direct admits to a PTC1.

Objective Content: The learner will be able to understand the importance of airway management in head injured patients who are being transferred and understand the results of the risk adjusted logistic regression analysis.

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