Determine the referral pattern of acute spinal cord injury patients in an US state.

Despite increasing evidence supporting early decompression of the spinal cord after injury with better neurologic recovery, early referral patterns continue to be dominated by referral to nearest hospital (“time is spine”). However, the nearest hospital may not be equipped for spinal decompression, particularly at night. This requires a secondary referral and can substantially delay decompression, leading to poor neurologic outcomes and/or increased occurrence of secondary complications.

Multicenter cohort study including hospitals in Central Ohio. Referral patterns of acutely injured SCI patients (N=1683) were assessed ranging from 2009 to 2018. Data was assembled at Central Ohio Trauma Society (COTS). The relative frequency of patients requiring secondary referrals to another hospital served as a marker for imperfect primary referral destination.

COTS data included 1683 patients who incurred SCI between 2009 and 2018. Of those patients, 52% were directly transported to a Level I/II trauma center, typically by ambulance regardless of ISS score. EMS dispatch time to hospital arrival was 73.6 minutes. 43% were transported initially to a Level III trauma center or non-trauma center (NTC) and later transferred to a Level I/II. The remaining 5% stayed at the level III/NTC for unknown reasons. Transfer time between Level III/NTC to a Level I/II was 100.2 minutes average, with more patients having transport times >180minutes, suggesting transfers from rural hospitals. 

Acute care of SCI patients is considerably fragmented. Almost half of the patients required a second referral for specialized care. Our data indicates a need to restructure the pre-hospital care decision tree. Directing patients to Level I trauma centers with 24/7 decompression capabilities and specialized SCI care is a reasonable approach to reduce secondary referrals, thus improvement of neurologic outcomes and reduction of associated complications in this particularly fragile population.