Computed tomography scans prior to transfer to a pediatric trauma center: transfer time effects, neurosurgical interventions, and practice variability.

BACKGROUND: Many non-trauma centers perform computed tomography (CT) on injured children prior to transfer to a pediatric trauma center (PTC), but the institutional variability and clinical impact of this practice is unclear. This study evaluated the association of pre-transfer CT with transfer delays, the likelihood of emergent neurosurgical intervention among patients who underwent pre-transfer head CT, and the effects of transfer distance on prevalence and regional variability of pre-transfer CT.

METHODS: All injured children transferred from outlying non-trauma centers to a single freestanding PTC from 2009-2017 were included. Patients were categorized by undergoing pre-transfer CT head alone, CT of multiple/other areas, or no CT. Transfer time (referring hospital arrival to PTC arrival) was compared between CT groups, using multivariable modeling to adjust for covariates. Neurosurgical interventions were compared between patients with normal and abnormal Glasgow Coma Scale (GCS) scores. The prevalence of pre-transfer CT among referring centers was compared, with stratification by transfer distance.

RESULTS: Of 2,947 transfer patients, 1,225 (42%) underwent pre-transfer CT (29% head CT alone, 13% other/multiple CT). Transfer times were significantly longer for patients who underwent pre-transfer head CT or multiple CT (287 or 298 vs. 260 minutes, p<0.0001) after adjustment for baseline characteristics, injury severity, and transfer distance. Among patients with normal pre-transfer GCS who received a pre-transfer head CT, the likelihood of urgent neurosurgical intervention was 1.3%. Prevalence rates of pre-transfer CT by referring center varied from 15-94%; prevalence increased with increasing transfer distance but demonstrated wide variability among centers of similar distance.

CONCLUSIONS: Pre-transfer CT, whether of the head alone or multiple areas, is associated with delays in transfer to definitive care. Among patients with pre-transfer GCS 15, the risk of urgent neurosurgical intervention is very low. Wide variability in pre-transfer CT use between referring centers suggests opportunity for development of standardized protocols.

LEVEL OF EVIDENCE: III, economic/decision.