Traumatology

Time from hospital presentation to head imaging in White, Black, and Hispanic geriatric trauma patients

a b s t r a c t

Background: Health care disparities have been shown to negatively affect non-White people sustaining traumas, leading to increased morbidity and mortality. One possible explanation could be delays in emergent medical care. This study aims to assess if a disparity between races exists amongst acutely head-injured Geriatric patients, as evidenced by the time it takes from emergency department (ED) presentation to performance of head comput- erized tomography (CT) imaging.

Methods: A prospective cohort study was conducted from August 15, 2019 to August 14, 2020 at the two trauma centers in a south Florida county covering 1.5 million residents. Patients aged >= 65 years who sustained a head injury were identified daily. Patients who had a head injury >24 h prior, sustained penetrating trauma, or were transferred from another hospital were excluded. The primary outcome was time measured between ED presentation and CT head performance. Patients were grouped by race as selected from White, Black, Hispanic, and other. Comparisons were made using ANOVA analysis.

Results: 4878 patients were included. 90% were White. The mean times to CT head were 90.3 min for White pa- tients, 98.1 min for black patients, and 86.6 min for Hispanic patients. There was a significant difference compar- ing time to CT between the three groups (F = 2.892, p = 0.034). Comparing each group to a combined others, there were no significant differences for White vs non-White (90.3 vs 91.3, F = 0.154, p = 0.695) or Hispanic vs non-Hispanic (86.6 vs 90.5, F = 0.918, p = 0.338); however Black vs non-Black (98.1 vs 89.9, F = 4.828, p = 0.028) was significant.

Conclusions: Geriatric Black patients who sustained head trauma were found to have a longer time from ED presentation to performance of head CT than their non-Black counterparts.

(C) 2022 Published by Elsevier Inc.

  1. Introduction

racial disparities in medical care have been identified across all medical specialties, as studies have shown differences in mortality, out- comes, and standard of care in White and non-White individuals in the acute care setting [1-5]. One study at the Cincinnati Children’s Hospital Medical Center indicated a 3.1 times higher likelihood of death in Black

* Corresponding author at: Florida Atlantic University at Bethesda Hospital East, Department of Emergency Medicine, GME Suite, Lower Level, 2815 South Seacrest Blvd, Boynton Beach, FL 33435, USA.

E-mail addresses: [email protected] (S.M. Alter), [email protected] (C.A. Temple), [email protected] (J.J. Solano), [email protected] (P.G. Hughes), [email protected] (L.M. Clayton), [email protected] (R.D. Shih).

pediatric Traumatic brain injury patients than their white counter- parts [3]. Other data shows that Black patients are more likely to die from subarachnoid hemorrhage than their white counterparts [6]. The Centers for Disease Control and Prevention (CDC) demonstrated that Black stroke survivors report more functional impairment than white stroke survivors [7]. Data on Hispanic populations show a lower or sim- ilar mortality after stroke compared to non-Hispanic whites [8].

While disparities in mortality after head trauma are well established, less is known about what contributes to this increased mortality. One study found that cognitive stressors in the emergency department (overcrowding and patient volume) led to increased implicit Racial bias amongst resident physicians [9]. Several studies have demon- strated that Black and Hispanic patients are less likely to be familiar with stroke signs and symptoms and tend to have lower scores on knowledge tests of stroke [10-12].

https://doi.org/10.1016/j.ajem.2022.06.056 0735-6757/(C) 2022 Published by Elsevier Inc.

Although the racial disparities in head trauma outcomes have been well-defined in the literature, there is a gap in knowledge of whether this may be attributed to delays in care for non-White individuals. Stud- ies have demonstrated that Black and Hispanic patients face longer wait times in the emergency department (ED), which could lead to delays in care for these individuals [13,14]. The time it takes for a head-injured patient to obtain Computerized tomography imaging of the head is an important metric, as rapid diagnosis of intracranial hemorrhages can lead to more prompt treatment. Identifying a potential difference in time to obtain this diagnostic test between races could shed light on a disparity present in trauma settings.

This investigation aims to determine if there exists a difference in time from ED presentation to head CT between races in geriatric indi- viduals after presentation for head trauma.

  1. Methods
    1. Study design

A prospective cohort study was conducted at the two level-1 trauma centers in a south Florida county covering 1.5 million residents. In this setting, most patients travel to the hospital nearest to their location for all their Acute medical care. Emergency medical services (EMS) pro- tocols mirror the CDC field triage of Injured Patients Guidelines when determining if a patient warrants transport to a trauma center, and thus might bypass a local non-trauma center hospital. This study was approved by the IRB of the university affiliated with both hospitals.

    1. Selection of participants

Between August 2019 and August 2020, trained research assistants screened ED patients 65 years and older with head injuries daily. Pa- tients with either an ICD-10 diagnosis of head injury (S00-S09) or head CT performed in the ED for purposes of trauma were evaluated. Concurrent with the screening process, research assistants examined physician notes in the patient’s electronic medical record. To be in- cluded, patients must have had a CT of their head in the ED for purposes of definite trauma or suspected trauma by the treating physician. Defi- nite trauma was defined as a patient having clearly sustained a head in- jury either with head trauma reported in the history of present illness or signs of head trauma on physical exam. Suspected trauma was defined as the patient not recalling or not able to state if they had a head injury, but the treating physician had concern that a head injury may have oc- curred based on history of present illness. Patients who sustained head injuries >24 h prior to ED presentation, had a penetrating injury, or were transferred from another hospital were excluded. Patients with multiple or unknown races or ethnicities were also excluded.

    1. Measurements

Time of registration was defined as when a new patient encounter was inputted into the hospitals’ electronic medical record (EMR). For patients entering through triage or by ambulance for non-trauma alerts, this occurred when the patients first stepped foot in the ED. For trauma alerts, the registration times often occurred when EMS made initial radio notifications to the hospital, prior to the patients’ arrival (typically 1-20 min). Time of CT performance was defined as when the imaging was obtained, as noted in the EMR.

Race and ethnicity classification were asked of patients upon ED pre- sentation by registration clerks. Race options included: Asian, Black, Na- tive American, Pacific Islander, White, multiple, and other. Ethnicity options included: Hispanic, non-Hispanic, and multiple.

Additional variables were also collected, including presence of pri- mary intracranial hemorrhage (ICH; acute hemorrhage on CT scan as read by the attending radiologist), trauma status (activation by EMS versus upgrade in ED versus none), reason for head CT (definite head

trauma versus suspected head trauma), Physical exam findings (evi- dence of head trauma on physician physical exam), and GCS category (mild 14-15, moderate 9-13, severe 3-8). Trained research assistants performed chart reviews. Data were extracted and the variables were entered into REDCap, a secure, HIPAA-compliant, web-based data man- agement platform.

The primary outcome measure, time to CT, was defined as the num- ber of minutes between times of registration and CT performance.

    1. Analysis

A combined race and ethnicity variable was created from the indi- vidual variables. Patients were grouped into one of: Hispanic (of any race), Black (non-Hispanic), White (non-Hispanic), and other (Asian, Native American, Pacific Islander, and other). The time to CT was calcu- lated for each group. A two-way analysis of variance (ANOVA) was used to compare these values. Multiple factors ANOVA models were created for the additional variables: presence of primary ICH, trauma status, rea- son for head CT, physical exam findings, and GCS category. Analyses were performed using SPSS 27.0 (IBM Corporation, Armonk, NY).

  1. Results
    1. Characteristics of study subjects

5207 patients were screened and 4878 were included. 329 were ex- cluded due to missing documentation of race or ethnicity: 147 of un- known race or ethnicity and 182 with multiple races or ethnicities. The racial/ethnic breakdown was: 4371 White, 256 Black, 202 Hispanic, and 49 other (13 Asian, 2 Pacific Islander, 0 Native American, and 34 other).

    1. Main results

The overall average time from registration to head CT was 90.4 min (SD 57.5). There was a significant difference when comparing all of the groups to each other by ANOVA (F = 2.892, p = 0.034; Table 1). When looking at each group compared to a combined others, there was no dif- ference for White vs non-White (90.3 vs 91.3, F = 0.154, p = 0.695) or Hispanic vs non-Hispanic (86.6 vs 90.5, F = 0.918, p = 0.338), but there was a significantly longer time to CT for Black vs non-Black (98.1 vs 89.9, F = 4.828, p = 0.028).

Additional factors were evaluated for their impact on time to CT for patients of different races or ethnicities (Table 2). Presence of primary ICH on head CT (F = 43.05, p < 0.001), GCS grouping (F = 23.09, p < 0.001), definite trauma as reason for imaging (F = 53.4, p < 0.001), signs of head trauma on physical exam (F = 154.1, p < 0.001), and Trauma activation status (F = 72.7, p < 0.001) all had significant inter- actions with time to CT. When introduced into the models, racial group only had a significant factor with signs of head trauma on physical exam (F = 2.63, p = 0.049). For the other variables, race did not have a signif- icant interaction. Black patients were less likely to have definite head trauma as the reason for head CT (OR 0.55, 95% CI: 0.43-0.71, p < 0.001) and less likely to have head trauma on physical exam (OR 0.56, 95% CI: 0.43-0.74, p < 0.001). There was no difference in rate of primary ICH on head CT, GCS grouping, or trauma activation status (Table 3).

Table 1

Race/ethnicity by time to CT.

N (%) Time, min (95% CI)

White

4371 (89.6%)

90.3 (88.6-92.0)

Black

256 (5.2%)

98.1 (90.7-105.4)

Hispanic

202 (4.1%)

86.6 (78.4-94.7)

Other

49 (1.0%)

75.7 (62.1-89.3)

Total

4878 (100%)

90.4 (88.8-92.0)

Table 2

Additional variables and race/ethnicity by time to CT,

min (SD).

White

Black

Hispanic

Other

Total

(N = 4371)

(N = 256)

(N = 202)

(N = 49)

(N = 4878)

Presence of primary ICH

No

91.7 (57.5)

99.9 (59.7)

88.5 (59.7)

79.6 (47.6)

91.9 (57.6)

Yes

72.9 (53.3)

56.1 (34.9)

65.2 (45.4)

41.0 (28.7)

71.5 (52.3)

GCS

Mild (13-15)

92.4 (59.9)

97.0 (56.6)

92.3 (59.6)

70.8 (43.0)

92.5 (59.7)

Moderate (9-12)

68.0 (53.7)

57.9 (31.5)

38.0 (17.6)

71.0 (-)

64.0 (49.6)

Severe (3-8)

58.1 (48.8)

55.7 (6.7)

54.5 (30.4)

25.0 (-)

57.4 (46.9)

Reason for head CT

Potential head trauma

103.2 (66.0)

103.6 (62.8)

96.1 (69.4)

74.8 (50.0)

102.7 (65.8)

Definite head trauma

84.0 (51.6)

93.1 (56.1)

81.6 (52.2)

76.2 (46.7)

84.2 (51.8)

Sign of head trauma on physical exam

No

103.0 (65.9)

108.7 (66.6)

99.2 (71.7)

67.4 (42.3)

102.9 (66.1)

Yes

81.9 (49.4)

86.1 (51.3)

77.9 (48.4)

76.0 (47.1)

81.8 (49.4)

Trauma status None

96.1 (57.5)

104.4 (59.9)

94.2 (58.9)

84.2 (49.0)

96.3 (57.6)

EMS activation

69.4 (49.0)

84.7 (55.9)

66.1 (55.4)

52.7 (35.6)

69.8 (49.6)

ED upgrade

85.8 (61.2)

62.0 (43.3)

68.8 (45.4)

64.5 (53.0)

84.0 (60.0)

  1. Discussion

Comparing the time from ED presentation to CT head performance for geriatric patients with head injuries, we found that Black patients had a mean 8.2 min significantly longer wait when compared to non- Black patients. We did not find a difference for other racial groups.

When controlling for other variables, race was a significant factor with signs of head trauma on physical examination. Whether or not Black patients had signs of head trauma, they had longer wait times for CT than their non-Black counterparts. Race was not a significant con- tributor to time to CT for other independently significant factors includ- ing presence of primary ICH, trauma status, reason for head CT, and GCS category.

When attributing the increased time to CT for Black patients, one possible explanation may be related to these patients having less Severe head injuries, as Black patients were less likely to have definite head trauma as evidenced by history of present illness or signs of head trauma on physical exam. Additionally, Black patients tended to have lower rates of primary ICH, possibly also due to lesser severity of head trauma, though this was not significant. Due to these attributes, perhaps these patients were not prioritized as highly for more emergent imag- ing.

Alternatively, and more concerningly, the difference in time to CT for Black patients may have been due to an implicit bias of the treating staff. The typical process for an ED patient to obtain a head CT would be 1) pa- tient triaged, 2) patient roomed, 3) patient evaluated by physician, 4) or- ders entered by physician, and 5) patient taken to CT by technician. For trauma alerts, the entire process and time to CT is determined by the at- tending trauma surgeon. Although the final step in the ED process is

entirely blinded to patients’ race and the longest wait, there may have been delays in the prior steps. Unfortunately, this study did not collect the breakdown of times for each individual step to identify if any one step routinely led to delays.

While trauma imaging guidelines advise “early” head CT for poten- tial TBI patients, there are no recommendations of specific times or for non-trauma activated patients [15]. A relatively small statistically signif- icant difference in time to CT between Black and non-Black participants may not have any clinical significance or meaningful impact on out- comes in patients who sustain ICH. To better examine this, a study set- ting with a more even racial distribution may be needed.

One limitation of the study was that 147 patients were missing race and/or ethnicity demographics. It is uncertain why the information was not obtained. Perhaps these patients were unable or unwilling to pro- vide this demographic information to the registration clerks. Because race and ethnicity comprised the independent variable of this study, these patients were excluded. Besides race and ethnicity, there may be other confounding socioeconomic variables that also effect time to CT. Unfortunately, variables such as insurance status, education, and in- come were not collected in this study. Another limitation relates to the racial composition of the population. Almost 90% of patients in- cluded in the study were White, which does approximate the composi- tion of the county where the study was performed where nearly 80% of people aged 65 years and older are White. This led to a small number of non-white patients being enrolled. The skewed makeup of the sample may have led to a type I error, rather than a true positive result.

In conclusion, this study shows an eight-minute additional wait time for black patients in the performance of head CTs in geriatric head trauma patients. Although ICH is a time-sensitive diagnosis, the clinical

Table 3

Comparison of additional variables for Black versus non-Black patients, n (%).

Black

Non-Black

OR (95% CI)

p-value

Primary ICH

11/256 (4.3%)

346/4622 (7.5%)

0.56 (0.30-1.03)

0.057

GCS

0.056

Mild (13-15)

178/192 (92.7%)

3153/3309 (95.3%)

Moderate (9-12)

11/192 (5.7%)

91/3309 (2.8%)

Severe (3-8)

3/192 (1.6%)

65/3309 (2.0%)

Definite head trauma

136/256 (53.1%)

3117/4622 (67.4%)

0.55 (0.43-0.71)

<0.001

Head trauma on exam Trauma status

None

105/216 (48.6%)

192/254 (75.6%)

2637/4209 (62.7%)

3392/4592 (73.9%)

0.56 (0.43-0.74)

<0.001

0.735

EMS activation

51/254 (20.1%)

955/4592 (20.8%)

ED upgrade

11/254 (4.3%)

245/4592 (5.3%)

significance of its detection a few minutes sooner alone may not affect patient outcomes.

Meetings

This research was presented at the 2021 Society of Academic Emer- gency Medicine Annual Meeting, held virtually from May 11-14, 2021.

Funding

This research was funded by the Florida Medical malpractice Joint Underwriting Association Dr. Alvin E. Smith Safety of Health Care Ser- vices Grant, RFA #2018-01.

CRediT authorship contribution statement

Scott M. Alter: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project ad- ministration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. C. Abigail Temple: Writing

  • review & editing, Writing – original draft. Joshua J. Solano: Writing
  • review & editing, Validation, Supervision, Project administration, Methodology, Investigation, Funding acquisition, Data curation, Con- ceptualization. Patrick G. Hughes: Writing – review & editing, Investi- gation, Conceptualization. Lisa M. Clayton: Writing – review & editing, Investigation, Conceptualization. Richard D. Shih: Writing – review & editing, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Funding acquisition, Data curation, Con- ceptualization.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influ- ence the work reported in this paper.

Acknowledgements

None.

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