In by helicopter out by cab: the financial cost of aeromedical overtriage of trauma patients.

BACKGROUND: Helicopter transport of injured patients is controversial and costly. This study aims to show that a complex trauma algorithm leads to significant aeromedical overtriage at substantial cost. Our secondary outcomes were to compare adjusted mortality and outcomes between air and ground transport and determine predictors of overtriage. MATERIALS AND METHODS: A 6-y retrospective analysis was conducted of all trauma activations at a Level I center. Patients were dichotomized by transportation method as well as trauma activation criteria. Overtriage was defined as those who were discharged from the emergency department, medically admitted without injuries, or admitted to observation status only. Overtriage and associated charges were calculated for each patient cohort, and multivariate regression models were created to derive adjusted mortality rates and predictors of overtriage. RESULTS: A total of 4218 patients were treated with 28% arriving by helicopter. Overtriage increased significantly from 51% to 77% with lower tier activation criteria (P < 0.001). Median charges for air-evacuated patients was $10,478 (versus $1008 ground). Eliminating overtriage of air patients would result in a cost savings of $1,316,036 annually. Adjusted mortality between air and ground transport was not significantly different (8.5% versus 10.9%, P = 0.548). Predictors of overtriage included decreasing age, Injury Severity Score, Head Abbreviated Injury Score, nonoperative treatment, and lower tier activation criteria. CONCLUSIONS: Significant overtriage (52%) and unnecessary air evacuation of minimally injured patients occurs at great financial cost. Revision of trauma activation protocols may result in more judicious air transport use and significant reductions in health care costs.

Dabigatran bleed risk with closed head injuries: are we prepared?

OBJECT: The direct thrombin inhibitor dabigatran has recently been approved in the US as an alternative to warfarin. The lack of guidelines, protocols, and an established specific antidote to reverse the anticoagulation effect of dabigatran potentially increases the rates of morbidity and mortality in patients with closed head injury (CHI). Confronted with this new problem, the authors reviewed their initial clinical experience. METHODS: The authors retrospectively reviewed all cases of adult patients (age ≥ 18 years) who sustained CHI secondary to ground-level falls and who presented to the authors' provisional regional Level I trauma center between February 2011 and May 2011. The authors divided these patients into 3 groups based on anticoagulant therapy: dabigatran, warfarin, and no anticoagulants. RESULTS: Between February 2011 and May 2011, CHIs from ground-level falls were sustained by 5 patients while on dabigatran, by 15 patients on warfarin, and by 25 patients who were not on anticoagulants. The treatment of the patients on dabigatran at the authors' institution had great diversity. Repeat CT scans obtained during reversal showed 4 of 5 patients with new or expanded hemorrhages in the dabigatran group, whereas the warfarin group had 3 of 15 (p = 0.03). The overall mortality rate for patients sustaining CHI on dabigatran was 2 (40%) of 5, whereas that of the warfarin group was 0 (0%) of 15 (p = 0.05). CONCLUSIONS: It is critical for physicians involved in the care of patients with CHI on dabigatran to be aware of an elevated mortality rate if no treatment protocol or guideline is in place. The authors will soon implement a reversal management protocol for patients with CHI on dabigatran at their institution in an attempt to improve efficacy and safety in their treatment approach.