Introduction: With acute intra-cranial pathology, a patient’s condition can deteriorate quickly in the absence of rapid intervention. We sought to evaluate the patterns of decline in neurological examination during patient transfer to a tertiary care center, and define predictors of such decline.
Methods: This is a retrospective study of all deceased patients from the Department of Neurosurgery at a tertiary institution between January 2012-December 2013. Variables evaluated included age, hydrocephalus, neurological diagnosis, prior anticoagulant and/or anti-platelet treatment, time-to-transfer from outside hospital (OSH) defined as time interval between OSH emergency room (ER) admission and arrival to Neurosurgical Intensive Care Unit (NSICU), and Glasgow Coma Scale (GCS) on arrival at OSH and at our NSICU.
Results: A total of 99 deceased patients were identified (mean age 62 years; 53.5% females). Majority (85/99) were transferred from an OSH ER; of those 81 cases had intracranial pathology. The overall mortality rate for all neurosurgical admissions during this period was 3.28% (1% non-transfer including our ER admissions vs. 4.9% transfer; p<0.05). Sixteen-patients (19.7%) had decline in their neurological status during the transfer interval. Mean transfer time for non-deteriorated patients was 5.7 hours (median 3.7, range 1.35-38.5 hours) vs. 5.6 hours (median 4, range 2.5-18.5 hours) for the deteriorated patients (p=0.78). Twenty-two of the transferred patients (27%) were on anticoagulant and/or anti-platelet therapy. On univariate analysis, only the anticoagulant/anti-platelet therapy was associated with higher rate of decline during transfer (62.5% vs. 25%; p=0.016). The rest of the variables including diagnosis (intracranial hemorrhage, subarachnoid hemorrhage, subdural hematoma, stroke or tumors), hydrocephalus, age, and transfer duration did not correlate with neurological decline.
Conclusions: Anticoagulation/anti-platelet therapy is associated with a higher rate of neurological decline during patient transfer to a tertiary institution. It is conceivable that rapid correction of this issue prior to transfer might lead to a decrease in transfer-associated mortality rates.
Patient Care: By Understanding the risks associated with neurological decline during transfer of critical ill patients, one can intervene to alter that.
Learning Objectives: 1-Understand the incidence of neurological decline upon transfer to tertiary centers.
2-Identify the risk factors associated with neurological decline.