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Does destination make a difference? Outcomes after a policy change affecting cutoff times for prehospital transport
Elizabeth Renaud1, Olivia Cummings, Melissa Vanover
1From the Division of Pediatric Surgery, Department of Surgery, Hasbro Children's Hospital (E.R., M.V.), and Warren Alpert Medical School at Brown University (O.C.); Lifespan Biostatistics, Epidemiology, Research Design, and Informatics Core (J.R.T.); and Division of Pediatric Surgery, Department of Surgery, Hasbro Children's Hospital (A.M.), Providence, Rhode Island.
Insights
Increasing pediatric trauma center transport time from 30 to 45 minutes did not change overall complication rates. However, direct scene admission for severely injured pediatric patients (ISS ≥15) was linked to fewer complications after the policy change.
Area of Science:
- Pediatric Trauma Care
- Emergency Medical Services
- Public Health Policy
Background:
- Pediatric trauma centers (PTCs) improve outcomes, but initial care at non-PTCs is common due to location and EMS regulations.
- This study evaluated the impact of extending the transport time cutoff from 30 to 45 minutes on pediatric patient outcomes.
Purpose of the Study:
- To assess the effect of an increased transport time cutoff on pediatric patient outcomes at a Level 1 Pediatric Trauma Center.
- To compare complication rates and transport status before and after the policy change.
Main Methods:
- A retrospective analysis of the Pediatric Trauma Database from a Level 1 PTC.
- Compared patient outcomes (ISS, complications) for periods before (2015-2017) and after (2018-2020) the transport time policy change.
- Used generalized linear regression to analyze outcomes by transport status and Injury Severity Score (ISS).
Main Results:
- Average transport time increased from 20 to 29 minutes post-policy change (p=0.0252).
- Overall complication rates for severely injured patients (ISS ≥15) did not significantly decrease.
- Severely injured patients admitted directly from the scene had significantly lower complication rates post-policy change (76% to 59%, p=0.0319).
Conclusions:
- Direct scene admission to a PTC is associated with better outcomes for pediatric trauma patients with high Injury Severity Scores.
- Adherence to transport time thresholds for emergency medical services may positively influence patient outcomes.
Background:
Facilitating primary triage and care at pediatric trauma centers (PTCs) can improve outcomes for children after trauma. However, scene location and regional emergency medical services regulations may result in initial evaluation occurring at nonpediatric facilities with later transportation to PTCs for definitive care. In this study, we assessed the results of a change in transport time cutoff from 30 to 45 minutes on pediatric patient outcomes.
Methods:
After institutional review board approval, the Pediatric Trauma Database at a level 1 PTC was queried for patients seen before (January 1, 2015, to December 31, 2017) and after (January 1, 2018, to December 31, 2020) the implementation of a policy increasing transport cutoff time from 30 to 45 minutes. Patient outcomes were compared by transport status and Injury Severity Score (ISS) using generalized linear regression analysis.
Results:
A total of 505 patients were seen before policy changes, and 413 patients, after policy changes. Both groups had similar numbers of severely injured patients (ISS, ≥15; pre, 64 [13%]; post, 61 [15%]). Average transport time increased after change (pre, 20 minutes [95% confidence interval, 18-22 minutes]; post, 29 minutes [95% confidence interval, 26-33 minutes]; p = 0.0252), consistent with policy compliance. The proportion of transferred patients did not change after policy implementation ( p = 0.5856), and the complications among all patients with an ISS of ≥15 did not significantly decrease (pre, 75%; post, 65.6%). However, those patients with an ISS of ≥15 admitted directly from the scene had a lower frequency of complications after the policy changes (pre, 76%; post, 59%; p = 0.0319), and in the postperiod, transferred patients with an ISS of ≥15 had a higher complication rate than those admitted directly from the scene ( p < 0.0001).
Conclusion:
Direct scene admission to a PTC is associated with a lower complication profile for patients with higher ISS. Methods to ensure adherence to cutoff thresholds for emergency medical services transport may have a positive benefit on patient outcomes.
Level Of Evidence:
Prognostic and Epidemiological; Level IV.
