a b s t r a c t

Objectives: The objective of this study was to determine whether prehospital trauma arrival notification was associated with more head computed tomography scans and image studies performed in patients with minor head trauma and discharged from emergency department (ED).

Methods: A retrospective cross-sectional study based on hospital electronic medical record was performed. Patients with head trauma indicated by their Diagnostic codes or chief complaints, presenting to and discharged from ED in a level I trauma center between January 1, 2010, and June 30, 2014, and triage Glasgow Coma Scale score 14 or greater were selected from electronic medical record. Triage prehospital trauma arrival notifi- cation, number and types of image studies performed, and basic demographics were extracted. ?² Analysis (or Fisher test) was applied to compare the proportions of patients who received image studies between prehospital trauma arrival notification and non-notification groups.

Results: There were 3603 patients with head trauma, triage GCS score 14 or greater, and discharged from ED. Mean age was 43.8 years. Forty-six percent was female. Thirty-two point nine percent was Hispanic, and 28.6% was black. Numbers (proportions) of patients who received prehospital trauma arrival notification, head CT scan, or any image study (x-ray, CT, magnetic resonance imaging, or sonogram) were 287 (8.0%), 1621 (45.0%), and 2267 (63.0%), respectively. Compared with patients without prehospital trauma arrival notifica- tions, patients with prehospital trauma arrival notifications were significantly more likely to receive a head CT scan as well as an image study.

Conclusions: Prehospital trauma arrival notification was associated with significantly more Head CT scans and more image studies in patients with minor head trauma and discharged from ED.

(C) 2015

Introduction

Trauma care involves a chain of actions initiated with the field triage and continued with the definitive care in the hospital. Prehospital trauma arrival notification connects the field triage and the hospital care. In the emergency department (ED), prehospital notification allows the time to organize the trauma team, develop an initial treatment plan, and prepare necessary equipment. Studies have shown that prehospital trauma arrival notification facilitated the trauma care and was associated with decreased mortality in patients with trauma [1,2].

Meanwhile, trauma care is expensive. Trauma team activations, which usually followed prehospital trauma arrival notifications, took significant Hospital resources and caused delayed care for nontraumatic critically ill patients [3-5]. Previous studies have shown that the cost of care for patients with trauma at a trauma center was significantly higher when compared with the cost at a nontrauma center, even after adjusting for injury severity [6,7]. This suggested that same patients

? Funding: none.

* Corresponding author.

E-mail address: [email protected] (S. Xia).

might receive different medical managements, depending on the location of the care (trauma center vs nontrauma center). However, within a trauma center, it remains unknown whether activation of trauma care by prehospital trauma arrival notification will result in different managements, which can increase Medical cost and hospital resource use.

In the current study, we hypothesized that prehospital trauma arrival notification for patients with minor head trauma was associated with significant more head computed tomography scans and more image studies performed in these patients in the ED.

Methods

Study design and setting

We performed a retrospective cross-sectional study based on the chart review of hospital electronic medical record (EMR). We included patients presenting to the ED at an academic level I trauma center hospital over the period of January 1, 2010, through June 30, 2014. Recommendations on quality control in research based on medical chart review were followed [8]. This study was approved by the

http://dx.doi.org/10.1016/j.ajem.2015.02.024

0735-6757/(C) 2015

672 S. Xia et al. / American Journal of Emergency Medicine 33 (2015) 671–673

institutional review board. The hospital is in the network of Health and Hospitals Corporation and has used the EMR since early 1990s. This EMR was used previously to study the contributing factors (weather,

Table 1

Baseline characteristics of the study subjects (n = 3603)

Characteristics Prehospital trauma arrival notification

air pollution, ED visits for upper respiratory tract infection, and asthma) for hospital stroke admission [9].

Sex, n (%)

Yes

(n = 287, 8.0%)

In our ED, triage nurse received the telephone call for prehospital trauma arrival notification from field triage personnel and then discussed	Age, mean +- SD, y	43.3 +- 18.0	48.8 +- 20.6
the information with ED attending physician. Based on hospital	Female	117 (40.8%)	1543 (46.5%)
preestablished trauma triage guideline, the triage nurse and ED attending physician would estimate the trauma severity and decide whether	Male Race/ethnicity, n (%)	159 (55.4%)	1599 (48.2%)

No

(n = 3316, 92.0%)

trauma team activation was required. This hospital preestablished trauma triage guideline was only used for trauma team activation. It did not include any protocol for automatic laboratory or imaging tests. These tests were ordered by ED physicians after evaluating patients or by both ED physicians and trauma physicians if trauma team was activated.

Hispanic	85 (29.2%)	1108 (33.4%)
White	58 (20.2%)	480 (14.5%)
Black or African American	69 (24.0%)	962 (29.0%)
Asian	3 (1.1%)	83 (2.5%)
Other	72 (25%)	683 (20.6%)

Selection of study subjects

We chose to study patients with minor head trauma with Glasgow Coma Scale (GCS) score of 14 or greater [10]. Our EMR did not include injury severity score. We selected the patients discharged from the ED. This group of patient might have low injury severity scores. Therefore, our inclusion criteria were patients with head trauma, triage GCS score 14 or greater, and presented to and discharged from the ED.

During our data query in the EMR, first, in patients discharged from the ED, we selected patients with head trauma as the cause for their ED visits. We used International Classification of Diseases, Ninth Revision (ICD–9), diagnostic codes, which suggested injury to head (800-804, 850-854, 870-873, 910, 918, 920, 921, 925, and 959) to search the

EMR. Then, because our ICD–9 codes were used mainly for billing purposes, some patients with head trauma might be assigned with a diagnostic code other than aforementioned ones (eg, motor vehicle traffic injury rather than head injury); we also searched the patients’ chief complaints for ED visits. The chief complaint was a free text input and was entered by the triage nurse. If a chief complaint included the words head or brain and injury, trauma, hit, knock, fall, fell, slip, laceration, cut, assault, beat, fight, trip, bump, mva, mvc, punch, pedestrian struck, kick, stab, abrasion, scratch, bruise, wound, gun, puncture, jump, struck, bruising, push, bicycle, accident, or collision, this patient was included as a study subject.

In these patients with head injury as their causes for ED visits, we also obtained the records from the EMR for their statuses of prehospital trauma arrival notification, ED triage GCS score, and image studies performed in the ED as well as their basic demographic information including age, sex, and race/ethnicity.

Lastly, we only kept the patients with ED triage GCS score of 14 or greater. The final data set included patients with head injury as the cause for ED visits, triage GCS score of 14 or greater, discharged from ED, status of prehospital trauma arrival notification, image studies performed, and demographics.

Data analysis

The primary outcome was the proportion of patients who received the head CT scan during the ED visits. The secondary outcome was the proportion of patients who received any image studies.

Data were collected in an Excel spreadsheet (Microsoft, Redmond,

discharged from ED. Mean age was 43.8 years, with 46.0% female, 32.9% Hispanic, and 28.6% black. Eight percent of patients had prehospital trauma arrival notifications (Table 1).

Compared with patients without prehospital trauma arrival noti- fications, patients with prehospital trauma arrival notifications were significantly more likely to receive a head CT or an image study (x-ray, CT, magnetic resonance imaging, or sonogram) (Table 2).

4. Discussion

Our current retrospective cross-sectional study has shown that, compared with patients without prehospital notifications, patients with minor head trauma with prehospital trauma arrival notifications received more head CT scans and more image studies in the ED.

Patients with trauma treated in the trauma centers had better survival chances and more favorable functional outcomes [11,12]. Prehospital trauma arrival notification could also improve mortality in patients with trauma [1]. However, studies have shown that patients with trauma treated in the trauma center cost significant more money compared with those treated in the nontrauma centers, after adjusting for injury severity [6,7]. In the current study, we present the first evidence that, even within a trauma center, prehospital trauma arrival notification was associated with more image studies performed. The increased image studies in patients with trauma not only resulted in increased radiation exposures and costs to patients with trauma but also shifted the hospital resources to patients with trauma. There were several reports that nontrauma patients presenting to the ED con- currently with Trauma activations received delayed and suboptimal medical cares [3-5].

Prehospital notifications might lead to preoccupied impression of higher injury severity in treating physicians, which could result in more image studies ordered for patients with trauma. In addition, prehospital trauma arrival notifications were sometimes followed by trauma team activations in the ED. In our ED, a trauma team consists of both emergency physicians and trauma surgeons. Patients without prehospital notifications were only evaluated by the emergency physi- cians, whereas patients with prehospital notifications and trauma team

Table 2

Association between prehospital trauma arrival notification and number of patients who received image studies in ED

WA) and analyzed with STATA software (Version 12.1; StataCorp, College Station, TX). ?² Analysis (Fisher test) was used to compare the

Head CT n = 1621

Any image study n = 2267 ^a

proportion of patients who received image studies between prehospital

(x-ray, CT, MRI, or ultrasound)

trauma arrival notification and non-notification groups.

3. Results

Our query in the EMR generated 3603 patient visits, with head trauma as the cause for ED visits, triage GCS score of 14 or greater, and

Yes No Yes No

Notification, n (%) Yes 240 (83.6%) 47 (16.4%) 286 (99.7%) 1 (0.3%)

No 1381 (41.7%) 1935 (58.4%) 1981 (59.7%) 1335 (40.3%)

Abbreviation: MRI, magnetic resonance imaging.

^a Total number of images performed = 5108. X-ray = 2579; CT = 2501; MRI = 19; ultrasound = 9.

S. Xia et al. / American Journal of Emergency Medicine 33 (2015) 671–673 673

activation were evaluated by both emergency physicians and trauma surgeons. The differences in the diagnostic tests performed in patients with and without prehospital notifications might be caused by different clinical practice patterns between emergency physicians and trauma surgeons [13,14].

The decision for prehospital trauma arrival notification is made by field triage personnel. Guideline for field triage of injured patients was published and revised by Centers for Disease Control and Prevention [15]. The purpose of the guidelines was to provide outlines to transport patients with trauma to hospitals with different trauma service capabili- ties to receive appropriate trauma care. The goal was to save lives but, at the same time, not to cause excessive burden to the level I trauma centers. Our current study result suggested that prehospital trauma arrival notification could be another research direction to further optimize the balance between saving life and improving hospital resource use within the level I trauma centers.

Level I trauma centers are usually Tertiary care hospitals, which can also be designated stroke centers and cardiac treatment centers. Patients treated in these designated hospitals can receive Specialized cares and have better outcomes. However, ED is commonly the first place when these patients present to the hospitals. If these patients come to the ED simultaneously, it can cause conflicts in hospital resource use. Further studies that focus on the prioritization of the resource use can improve the efficiency of medical care.

4.1. Limitations

Current study was a retrospective study. The research data were re- trieved from the data set that was originally collected for patient clinical care. This could result in biases in the study, such as information bias (visit information might be obtained differently between patients with or without prehospital arrival notifications) and selection bias (patients in the prehospital arrival notification group might have more severe injuries and were more likely to receive image studies. Patients were selected based on ICD–9 and chief complaints. These might not be accurate.). We did not have the injury severity score in the EMR. We tried to minimize the selection bias by selecting only patients discharged from the ED. This group of patients might have low injury severity scores. Further prospective study is needed to confirm our research finding.

Our data only included head trauma, without knowing whether the patients had multiple concurrent injuries or under the influences of substance abuse. According to Nexus or Canada head CT rules, patients with head trauma with distracting injuries or substance abuse would most likely require a head CT scan.

Current study was performed in a single urban ED at a level I trauma center hospital. We only studied patients with head trauma. Different hospitals and trauma centers may have different guidelines and protocols

for trauma cares. Whether the result can be replicated in other institutions or for other injuries requires further investigations.

Our EMR included the type of image studies performed, but it did not have the image study reports. Thus, we could not evaluate the impact of image studies on the clinical managements. In addition, our current cross-sectional study did not investigate the outcomes in patients with or without image studies. Future studies should also address these.

5. Conclusions

Prehospital trauma arrival notification was associated with signifi- cantly more head CT scans and more image studies in patients with minor head trauma and discharged from ED. Future prospective studies to confirm our study result and investigate patients’ outcomes are warranted.

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