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Effect of teleradiology upon pattern of transfer of head injured patients from a rural general hospital to a neurosurgical referral centre: follow-up study
  1. I Ashkenazi1,
  2. A R Zeina1,
  3. B Kessel1,
  4. K Peleg2,
  5. A Givon2,
  6. T Khashan1,
  7. M Dudkiewicz1,
  8. M Oren1,
  9. R Alfici1,
  10. O Olsha3
  1. 1Hillel Yaffe Medical Center, Hadera, Israel
  2. 2Israel National Center for Trauma & Emergency Medicine Research, Gertner Institute, Tel Hashomer, Israel
  3. 3Shaare Zedek Medical Center, Jerusalem, Israel
  1. Correspondence to Dr I Ashkenazi, Surgery B Department, Hillel Yaffe Medical Center, POB 169, Hadera 38100, Israel; i_ashkenazi{at}yahoo.com

Abstract

Introduction The optimal management strategy for patients with head injury admitted to a non-specialist hospital is uncertain. The aim of this study was to evaluate the outcomes of victims of head injury requiring hospitalisation but initially admitted to a rural level II trauma centre without a neurosurgical facility but with a system for neurosurgical consultation via teleradiology.

Methods Patients admitted for head injury during 2006–2011 were included. Late transfer of patients initially hospitalised in the level II trauma centre was evaluated for treatment failure, defined as clinical or radiological deterioration.

Results Five hundred and sixty-two patients were initially hospitalised in the level II trauma centre. Evaluation of late transfers showed that only 23 (4.1%) represented real treatment failures due to clinical or radiological deterioration. The clinical course was altered by primary intent to hospitalise patients in the level II trauma centre in only one patient.

Conclusions Selected patients with head trauma who have a pathological CT scan may be safely managed in level II trauma centres following neurosurgical consultation using teleradiology. Review of treatment failures is necessary to ensure proper ongoing management of a system in which neurosurgical patients are selectively transferred to trauma centres with neurosurgical capacity.

  • Trauma, head
  • risk management

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Key messages

What is already known on this subject?

  • In a 2-year pilot study conducted between 2003 and 2005 we previously demonstrated that selective head injured patients with pathological CT scan may be safely managed in level II trauma centres following neurosurgical consultation made available via teleradiology. However, the safety of this type of care over a long period had not been evaluated.

What might this study add?

  • A 6-year follow-up study conducted between 2006 and 2011 in the same institution found that the majority of head trauma patients, most of whom have Abbreviated Injury Scale (AIS) >2, may be safely observed in level II trauma centres without further need to transfer the patients for evaluation by a neurosurgeon when they are afforded neurosurgical consultation via teleradiology.

  • Instituting a system to investigate patients qualifying as having adverse events is necessary to allow proper utilisation of a system in which not all patients with severe head injury are secondarily transferred to specialist centres.

Introduction

There are currently eight trauma centres with neurosurgical facilities in Israel. These include all six level I trauma centres and two more level II trauma centres. This is a follow-up long-term study of our experience with head trauma patients initially treated in our level II regional trauma centre, the Hillel Yaffe Medical Center (HYMC), without neurosurgical services. Until 2003, most patients with head injury referred to our emergency department were transferred for further evaluation to a level I trauma centre. Patients who were not transferred had minor head trauma, were fully conscious, had no neurological deficit and were without CT findings other than linear fractures.

Retrospective evaluation of neurosurgical patients transferred to a level I centre in 2002 showed that only 17 of 116 patients (15%) transferred that year were in need of specialised neurosurgical treatment. Fourteen were operated and three underwent intracranial pressure (ICP) monitoring. Ninety-nine other patients (85%) were hospitalised for 2–3 days for observation. Fifty-seven of the 116 patients (49%) were not even admitted for neurosurgical monitoring in the level I centre but were admitted instead to general surgery or paediatrics.

In August 2003 a collaboration was established with a level I trauma centre, the Sheba Medical Center (SMC).1 Head injury patients admitted to the emergency department are evaluated clinically by the HYMC trauma team. If indicated by history and physical findings, a CT of the head is performed. All abnormal and equivocal CT scans are transferred via teleradiology to SMC. A consultation is then carried out between the HYMC's trauma surgeon and SMC's neurosurgeon. A decision is made whether to transfer the patient to SMC or to hospitalise in HYMC for observation. The neurosurgeon is then consulted regarding the necessity to repeat the CT. Following discharge, all patients are referred for follow-up to the neurosurgical outpatient clinic in SMC. According to protocol, consultation with neurosurgery in SMC is mandated in all cases with evidence of intracranial bleeding and/or depressed skull fractures. Patients with abnormal neurological examinations in which pathological changes in CT are minimal or not observed also undergo consultation. Since the implementation of this protocol, no changes have been made to the criteria mandating neurosurgical consultation.

In 2007 we reported preliminary data concerning this arrangement.1 Between 1 August 2003 and 31 August 2005, 83 patients were admitted to HYMC for observation. Of these, two patients were considered treatment failures. Both patients deteriorated neurologically and were transferred to SMC for further evaluation. Neither patient was in need of surgery. Following several days of observation, both were eventually discharged.

Based on these results, we decided our system was safe and worth pursuing. The aim of this study was to evaluate the safety of a telemedicine system supporting the management of significant head injury patients in an Israeli trauma network over a long period of time. Specific objectives were to: examine the change in referral patterns since introduction of the telemedicine system; describe contemporary referral patterns; examine differences in patient characteristics between transferred and non-transferred patients; and describe clinical features and outcomes of treatment failures in initially non-transferred patients.

Methods

This case series describes patients presenting to HYMC with significant head injury between 1 January 2006 and 31 December 2011. They were identified through the Israel National Trauma Registry which has been described in detail elsewhere.2

All patients with neurosurgical pathology in need of hospitalisation but referred first to HYMC were included. These comprised three groups of patients: (1) those secondarily transferred immediately to neurosurgery in SMC; (2) patients hospitalised in HYMC for observation and discharged; and (3) patients hospitalised initially in HYMC but eventually transferred to SMC for further evaluation and treatment. Patients with mild head injury who were not admitted and were discharged for ambulatory follow-up were excluded. Patients with equivocal CT findings, judged as negative following consultation with the neurosurgeons, were also excluded.

Patients in the third group, requiring late transfer, were classified as possible treatment failures since the underlying intention of the collaboration was to hospitalise and eventually discharge them from HYMC. These were evaluated for reasons for late transfer and for adverse outcomes. We identified those patients who specifically failed intention to treat in HYMC because of neurosurgical deterioration rather than other causes. Most patients with intracranial bleeding had a second CT and neurosurgeons were consulted again using the same system. Patients failing observation due to neurosurgical deterioration were classified as having either clinical or radiological deterioration. Clinical deterioration was defined as worsening signs or symptoms requiring secondary transfer to SMC regardless of the second CT findings. Radiological deterioration was diagnosed if repeat CT showed worsening haemorrhage requiring transfer in patients without clinical evidence of worsening symptoms or signs.

Several analyses were done. Differences in age, Injury Severity Score (ISS) and Abbreviated Injury Scale (AIS) of the head region were compared between the three groups. The number of patients transferred was stratified according to AIS. Hospital files from HYMC of patients transferred late were reviewed. Real treatment failure was considered if patients were transferred late due to either clinical or radiological deterioration. Hospital files from SMC were further evaluated for possible adverse outcome. Age, ISS and AIS were compared between those who succeeded and those who had treatment failure according to intention to treat in HYMC.

Differences in patterns of transfer, age, ISS and AIS of the head region between patients transferred initially, patients transferred late and those hospitalised and discharged from HYMC were analysed with the χ2 or Fisher exact probability test (GraphPad InStat Statistical Software V.3.10). The study was approved by the HYMC ethics committee.

Results

Between 2006 and 2011, 819 patients were evaluated. Of these, 257 (31.4%) were initially transferred to SMC for neurosurgical evaluation and treatment and 562 (68.6%) were initially hospitalised in HYMC. Of those initially hospitalised in HYMC in this study, 48 (8.5%) patients were later transferred to the level I trauma centre.

Twenty-four patients died in HYMC. These included 12 agonal patients who were declared dead soon after arriving at the emergency department. Four others died within the first day of treatment from associated injuries. One patient who initially responded to resuscitation died within the first day from severe head injury from shot wounds. Three agonal patients were stabilised following resuscitation or surgery. Neurosurgical evaluation following stabilisation revealed complete loss of brain function and these patients eventually died. Four elderly patients with severe comorbidities suffered from diffuse subarachnoid bleeding and oedema. Following neurosurgical consultation, it was decided to hospitalise them in HYMC. After several days of hospitalisation, two patients died from associated injuries and two others died from complications of their comorbidities. For the purposes of this study, these patients who died in HYMC were not considered treatment failures. We assume that transferring these patients to SMC would not have changed the course of their disease.

Table 1 compares the age, ISS and head AIS of the three groups. The proportion of elderly patients was similar across the groups, while more children were hospitalised in HYMC without transfer (p=0.003). ISS in early and late transfers was higher than in those initially hospitalised in HYMC and not transferred later (p<0.0001). Although higher ISS proved to be a risk factor for need for later transfer, 163 (38.4%) of 424 patients with ISS ≥16 were hospitalised in HYMC without later transfer.

Table 1

Age, Injury Severity Score and head Abbreviated Injury Scale distribution in the three groups of patients: early transfers, not transferred and late transfers (percentages rounded to nearest whole number)

Head AIS was higher in transferred patients whether transferred initially or later (p<0.0001). Relatively more patients were transferred for each increase in head AIS (figure 1). Overall, 366 (44.7%) of 819 patients evaluated in this study had a head AIS ≥4. Of these, 201 were immediately transferred to SMC and 165 were initially hospitalised in HYMC, of whom 36 (21.8%) required later transfer to SMC. Thus, of 366 patients with AIS ≥4, 129 (35.2%) were hospitalised in HYMC and did not require transfer at any stage.

Figure 1

Number of patients transferred and not transferred stratified by head Abbreviated Injury Scale (AIS).

The 48 late transfers were evaluated to determine if these patients specifically failed intention to treat in HYMC because of neurosurgical deterioration rather than other causes. Only 23 (4.1% of 562 hospitalised for observation) were found to be real failures (figure 2). Thirteen patients were transferred due to neurological (clinical) deterioration while 10 patients were transferred following a repeat routine CT scan which revealed worsening intracranial haemorrhage demanding neurosurgical follow-up and treatment (radiological deterioration).

Figure 2

Reason for later transfer in 48 patients.

Of the 13 patients transferred following clinical deterioration, follow-up data were available for 12 patients. One of these patients, 16 years old, was intubated at the site of a motor vehicle accident. Head CT revealed contusions in the corpus calossum and right pons. It was decided to wake this patient but he did not regain consciousness, which was the reason for his transfer to SMC. Following admission in the level I trauma centre, the patient underwent ICP insertion. He never regained full consciousness and was eventually discharged to a nursing home.

The other 11 patients who deteriorated clinically were admitted for observation and none was operated upon immediately. Two underwent craniotomy for chronic subdural haematoma at a later date. One died during the hospitalisation. This patient, who had subarachnoid and small epidural haematomas, deteriorated following admission to HYMC but was not operated on following his transfer to SMC due to significant severe comorbidities. Eight other patients were discharged following several days of observation.

Ten patients were transferred following worsening of CT findings and follow-up data were available in nine of these patients. All were admitted for observation and none were in need of immediate surgery. Two were eventually operated on for chronic subdural haematoma. The rest were discharged following 1–4 days of observation.

Twenty-five other patients were transferred late for reasons not considered as treatment failures for the purposes of this study. These included 11 unstable patients who needed to be treated initially in HYMC for their associated injuries to allow safe transfer. Three other patients had later development of neurosurgical pathology in need of transfer. Two of these were hospitalised for associated injuries and were not assessed initially for head injury. CT scans were performed due to evolving neurological symptoms and signs, revealing neurological pathologies in need of immediate transfer to SMC. A third patient, an elderly person on chronic anticoagulation who had hit his head following a fall, did undergo CT during his initial evaluation which was interpreted as non-pathological. During hospitalisation his mental status deteriorated and repeat CT revealed a large subdural haematoma resulting in his transfer.

The 23 late transfers due to clinical and radiological deterioration were compared with the 514 patients who did not fail intention to treat in HYMC (table 2). Both ISS and head AIS were higher in those who failed intention to treat in HYMC (p<0.001). Nevertheless, 163 (88.1%) of 185 patients with severe ISS and 129 (86.6%) of 149 patients with head AIS ≥4 were successfully treated in HYMC.

Table 2

Comparison of 23 real failures (clinical and radiological) with 514 patients who did not fail intention to treat in Hillel Yaffe Medical Center (HYMC)

Discussion

Neurosurgical care in many countries is centralised. Nevertheless, a significant proportion of head injury patients are transported initially and treated in non-specialist acute hospitals.3 The need for routine secondary transfer to specialist centres is strongly debated between those who claim better outcome for all neurosurgical cases and those who claim that there is limited evidence to support such a strategy for patients whose head injury will not be treated surgically.3–6 Secondary transfer is not without cost to both the non-specialist hospital transferring the patient and the specialist centre at the admitting end.7–9

Teleradiology is an important tool allowing neurosurgical evaluation in hospitals that admit trauma patients but do not have neurosurgical capacity within the institution. Evaluation of the CT scan together with the clinical information afforded by the trauma team treating the patient allows the neurosurgeon on call in the specialist centre to make decisions on both the need for secondary transport and its urgency.10 Several studies have been published on neurosurgical trauma patients consulted via teleradiology (table 3). Most of these originated from neurosurgical specialist centres. The emphasis in these studies is on the proper utilisation of limited neurosurgery resources. Our study is unique in that it summarises the experience from the point of view of the admitting hospital without a neurosurgical service. We wanted to assess how different factors such as age and AIS would influence the decision whether or not to transfer to the specialist centre. Unlike other studies, we placed an emphasis on those who failed intention to treat in HYMC in order to assess the safety of this system.

Table 3

Selected references on effect of teleradiology on secondary transfer in head injured patients admitted to regional centres without neurosurgical (NS) capacity

We assumed that age would influence the decision whether to transfer patients or to admit them for observation in HYMC.14 We reasoned that young children would be more readily transferred initially compared with adults for medicolegal concerns. Nevertheless, in this study the proportion of young children initially transferred was actually smaller. The proportion of patients over the age of 65 who were initially transferred to SMC was similar to the proportion of other age groups.

Both ISS and head AIS were indicators for transfer, but as many as 38.4% of patients with ISS ≥16 and 35.2% with head AIS ≥4 were successfully treated in HYMC and were not transferred either early or late. If we consider only patients who were hospitalised in HYMC following the consultation, 88.1% of patients with ISS ≥16 and 86.6% with head AIS ≥4 were successfully treated in HYMC without the need for late transfer. High ISS and high head AIS cannot therefore be considered contraindications for surveillance in level II trauma centres without a neurosurgical service in-house.

Twenty-three patients did not complete their management in HYMC during the study period. Following late transfer, only one patient was in need of immediate neurosurgical intervention. It is unclear whether this patient would have fared differently if transferred initially to SMC. One other patient with clinical deterioration died following transfer without undergoing neurosurgical intervention. It is possible that the decision not to operate in SMC may have been based on his severe comorbidities and also on his neurosurgical status following deterioration. Late transfer did not affect the outcome and treatment of any other patient who was not initially transferred from HYMC to SMC. We can therefore conclude that, following primary evaluation and decision to treat in HYMC, one of 562 patients hospitalised in HYMC for head trauma may have suffered an adverse outcome following the decision not to transfer him initially to another hospital with neurosurgical capacity.

A limitation of this study is the assumption that the final neurological outcome was not influenced by the decision to hospitalise the patients in HYMC and the decision not to intervene surgically would have been the same if the patient had been transferred. Published studies on non-transfer protocols of neurosurgical patients are mostly limited to patients suffering from mild head injury.3 ,15–18 Data concerning the safety of non-transfer protocols in selected head injured patients with moderate and severe traumatic brain injury (AIS ≥4) are insufficient.1 ,3 A second limitation of this study is the assumption that decisions concerning monitoring of patients were not influenced by the patients’ site of observation. Almost all of the patients who were hospitalised in HYMC with traumatic intracranial haemorrhage underwent a second CT. There is always a possibility that the consulting neurosurgeon suggested this follow-up CT just because he/she was not able to evaluate the patients clinically. Initial transfer to SMC could have avoided unnecessary exposure to ionising radiation in some of these patients.19 ,20 A third limitation of this study is the observation that, of 48 patients assessed for treatment failure, in four (8.3%) patients we do not have information regarding their outcome. This emphasises the importance of carrying out timely evaluation of all patients judged as suffering from adverse outcome.

Conclusion

Over a 6-year period, following primary evaluation in the emergency department and neurosurgical consultation via teleradiology, only 257 (31.4%) patients were immediately transferred to a level I trauma centre for further investigation and treatment. Of patients hospitalised for observation, only 23 (4.1%) failed intention to treat in HYMC and only one underwent urgent neurosurgical intervention. We conclude that selected patients with stable moderate to severe head injuries can be admitted to a level II trauma centre following neurosurgical consultation via teleradiology. Review of patients who fail the intention to treat in level II trauma centres is necessary to ensure proper ongoing management of this system.

Acknowledgments

The authors would like to express their very great appreciation to Dr Daniel Simon, who recently passed away, for his valuable contribution in assessing the outcome of patients transferred late from HYMC to SMC detailed in this study. Dr Simon served as the head of the trauma unit in SMC and helped consolidate an effective communication and transfer system between the two hospitals. He was the teacher of the first author and a respected surgeon in his field. He will be sorely missed by all his colleagues.

References

Footnotes

  • Contributors All authors contributed significantly to this study. Conception: IA, OO, RA, MO. Design: IA, OO, ARZ. Execution: IA, BK, TK, MD. Data analysis and interpretation: IA, AG, KP, ARZ. Drafting: IA, ARZ, OO, BK. Revision for intellectual content: AG, KP, TK, MO, MD, RA. Approval: all authors.

  • Competing interests None declared.

  • Ethics approval The study was approved by the HYMC ethics committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement There are no additional data other than those presented in the manuscript.

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