Transportation Time In A Rural State Following Splenic Injury: Does Time Matter

Abstract

Background: Failure rates remain high following attempted non-operative treatment of spleen injuries despite progress made in identifying risk factors. Over the past thirty years, transportation times were excluded from predictive models although rapid transportation was advocated to improve patient outcomes. For patients living in a rural environment, this time may prove critical. The purpose of this study was to assess the effect of transport time on survival rates and hospital length of stay for patients selected to receive non-operative versus operative treatment. Methods: A 10-year retrospective review was conducted of patients ages 13 years and older who presented to an American College of Surgeons-verified Level 1 trauma center between January 1, 2003 to December 31, 2012. Non-operative management (NOM) was defined as observation with or without the adjunctive use of angiography (AE) or splenic artery embolization (SAE) performed less than 2 hours from admission. Failed non-operative management (FNOM) was defined as AE or SAE performed greater than two hours from admission, or a planned operation greater than two hours from admission (POR) for any reason. Cox proportional hazard regression and logistic regression analysis were conducted to identify factors associated with hospital length of stay (H-LOS) and mortality. Covariates included: age, gender, injury severity score (ISS), injury type (blunt versus penetrating), treatment group (POR, NOM, or FNOM), time from admission to procedure, and transportation time from the time EMS received the 911 phone call to emergency department admission. Results: Among the 364 patients included in the final analysis, 11.0% (n=40) died before hospital discharge. The median transport time was 64 minutes (average=92.6 ± 81 minutes, range=6 to 480 minutes). The majority (92.9%, n=338) of patients underwent NOM, with 7.1% (n=26) receiving POR. Among those 338 NOM patients, 92.3% (n=312) remained NOM after 2 hours, and others had FNOM after 2 hours (7.7%, n=26). Those who received POR or NOM were associated with 45.5% and 47.4% of the transportation time being less than 60 minutes, respectively. After two hours, average ISS score by treatment group (POR, NOM, or FNOM) of 23.83, 21.96, and 28.07, respectively. Cox proportional hazard regression analysis reported that ISS score was the only significant predictor for H-LOS. Logistic regression revealed that ISS score and age were associated with mortality. Transport time was not statistically associated with H-LOS or mortality. Conclusion: While not predictive of H-LOS or mortality, transportation time demonstrated that in rural environments longer transportation times allow physiologic symptoms to manifest prior to admission. Our results demonstrated that the majority (96%) of our FNOMs occurred less than six hours following admission and 100% less than 48 hours. We recommend intensive observation during hospital days one, with less robust surveillance through hospital day two. Discharge can be considered on hospital day three based on other injuries.