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Study objective: Patients with minor traumatic intracranial hemorrhage are frequently admitted to the ICU, although many never require critical care interventions. To describe ICU resource use in minor traumatic intracranial hemorrhage, we assess (1) the variability of ICU use in a cohort of patients with minor traumatic intracranial hemorrhage across multiple trauma centers, and (2) the proportion of adult patients with traumatic intracranial hemorrhage who are admitted to the ICU and never receive a critical care intervention during hospitalization. In addition, we evaluate the association between ICU admission and key independent variables. Methods: A structured, historical cohort study of adult patients (aged 18 years and older) with minor traumatic intracranial hemorrhage was conducted within a consortium of 8 Level I trauma centers in the western United States from January 2005 to June 2010. The study population included patients with minor traumatic intracranial hemorrhage, defined as an emergency department (ED) Glasgow Coma Scale (GCS) score of 15 (normal mental status) and an Injury Severity Score less than 16 (no other major organ injury). The primary outcome measure was initial ICU admission. The secondary outcome measure was a critical care intervention during hospitalization. Critical care interventions included mechanical ventilation, neurosurgical intervention, transfusion of blood products, vasopressor or inotrope administration, and invasive hemodynamic monitoring. ED disposition and the proportion of ICU patients not receiving a critical care intervention were compared across sites with descriptive statistics. The association between ICU admission and predetermined independent variables was analyzed with multivariable regression. Results: Among 11,240 adult patients with traumatic intracranial hemorrhage, 1,412 (13%) had minor traumatic intracranial hemorrhage and complete ED disposition data (mean age 48 years; SD 20 years). ICU use within this cohort across sites ranged from 50% to 97%. Overall, 847 of 888 patients (95%) with minor traumatic intracranial hemorrhage who were admitted to the ICU did not receive a critical care intervention during hospitalization (range between sites 80% to 100%). Three of 524 (0.6%) patients discharged home or admitted to the observation unit or ward received a critical care intervention. After controlling for severity of injury (age, blood pressure, and Injury Severity Score), study site was independently associated with ICU admission (odds ratios ranged from 1.5 to 30; overall effect P

Objectives Reasons for undertriage (transporting seriously injured patients to nontrauma centers) and the apparent lack of benefit of trauma centers among older adults remain unclear; understanding emergency medical services (EMS) provider reasons for selecting certain hospitals in trauma systems may provide insight to these issues. In this study, the authors evaluated reasons cited by EMS providers for selecting specific hospital destinations for injured patients, stratified by age, injury severity, field triage status, and prognosis. Methods This was a retrospective cohort study of injured children and adults transported by 61 EMS agencies to 93 hospitals (trauma and nontrauma centers) in five regions of the western United States from 2006 through 2008. Hospital records were probabilistically linked to EMS records using trauma registries, state discharge data, and emergency department data. The seven standardized reasons cited by EMS providers for selecting hospital destinations included closest facility, ambulance diversion, physician choice, law enforcement choice, patient or family choice, specialty resource center, and other. “Serious injury” was defined as an Injury Severity Score (ISS) ≥ 16, and unadjusted in-hospital mortality was considered as a marker of prognosis. All analyses were stratified by age in 10-year increments, and descriptive statistics were used to characterize the findings. Results A total of 176,981 injured patients were evaluated and transported by EMS over the 3-year period, of whom 5,752 (3.3%) had ISS ≥ 16 and 2,773 (1.6%) died. Patient or family choice (50.6%), closest facility (20.7%), and specialty resource center (15.2%) were the most common reasons indicated by EMS providers for selecting destination hospitals; these frequencies varied substantially by patient age. The frequency of patient or family choice increased with increasing age, from 36.4% among 21- to 30-year-olds to 75.8% among those older than 90 years. This trend paralleled undertriage rates and persisted when restricted to patients with serious injuries. Older patients with the worst prognoses were preferentially transported to major trauma centers, a finding that was not explained by field triage protocols. Conclusions Emergency medical services transport patterns among injured patients are not random, even after accounting for field triage protocols. The selection of hospitals appears to be heavily influenced by patient or family choice, which increases with patient age and involves inherent differences in patient prognosis. Resumen La Eleccion del Paciente Influye en la Seleccion del Centro Traumatologico que Realizan los Sistemas de Emergencias Medicas Objetivos Las razones para el infratriaje (el transporte de pacientes gravemente lesionados a centros no traumatologicos) y la aparente falta de beneficios de los centros traumatologicos en los pacientes ancianos permanecen no aclaradas. El conocimiento de las razones por las que los sistemas de emergencias medicas (SEM) seleccionan ciertos hospitales entre todos los que atienden pacientes con traumatismos (centros traumatologicos) puede proporcionar reflexiones acerca de estos problemas. En este estudio, se evaluaron las razones citadas por los proveedores de SEM para la seleccion de determinados destinos hospitalarios para los pacientes lesionados, estratificados por edad, gravedad de la lesion, estados del triaje de campo y pronostico. Metodologia Estudio de cohorte retrospectivo de ninos y adultos lesionados transportados por 61 SEM a 93 hospitales (centros traumatologicos y no traumatologicos) en cinco regiones del Oeste de Estados Unidos desde 2006 a 2008. Las historias clinicas hospitalarias se vincularon probabilisticamente a las historias clinicas del SEM mediante registros de traumatologia, datos del estado al alta y datos de los servicios de urgencias (SU). Las siete razones estandarizadas citadas por los proveedores del SEM para la seleccion de los destinos hospitalarios incluyeron: el centro mas cercano, la derivacion de la ambulancia, la eleccion del medico, la eleccion de los cuerpos de seguridad, la eleccion del paciente o la familia, los recursos de especialistas del centro y otras. Lesion grave se definio como una puntuacion del Injury Severity Score (ISS) ≥ 16, y se considero la mortalidad intrahospitalaria no ajustada como un marcador pronostico. Todos los analisis se estratificaron por la edad en intervalos de 10 anos, y se utilizo la estadistica descriptiva para caracterizar los resultados. Resultados Un total de 176.981 pacientes lesionados se evaluaron y transportaron por los SEM en los 3 anos del periodo, de los cuales 5.752 (3,3%) tuvieron un ISS ≥ 16 y 2.773 (1,6%) fallecieron. Las razones mas comunes aducidas por los proveedores del SEM para la seleccion de los hospitale de destino fueron la eleccion del paciente o la familia (50,6%), la cercania del centro (20,7%) y los recursos de especialistas del centro (15,2%). Estas frecuencias variaron sustancialmente segun la edad del paciente. La frecuencia de eleccion del paciente o la familia se incremento con el aumento de la edad, de un 36,4% entre los pacientes de 21 a 30 anos a un 75,8% entre los mayores de 90 anos. Esta tendencia igualo los porcentajes de infratriaje, y persistio cuando se restringio a los pacientes con lesiones graves. Los pacientes mayores con los peor pronostico fueron trasportados preferentemente a los centros traumatologicos mayores, un resultado que no se explica por los protocolos de triaje de campo. Conclusiones Los patrones de transporte de los SEM en los pacientes con lesiones no son aleatorios, incluso tras tener en cuenta los protocolos de triaje de campo. La seleccion de hospitales parece estar mas fuertemente influida por la eleccion del paciente o la familia, hecho que se acentua con la edad del paciente, y conlleva diferencias inherentes en el pronostico de paciente.