Putting a Halt to Unnecessary Transfers: Do Patients with Isolated Subarachnoid Hemorrhage and GCS 13 to 15 Need a Trauma Center?

OBJECTIVES: Trauma patients with isolated subarachnoid hemorrhage (iSAH) presenting to non-trauma centers are typically transferred to an institution with neurosurgical availability. However, recent studies suggest that iSAH is a benign clinical entity with an excellent prognosis. This investigation aims to evaluate the neurosurgical outcomes of traumatic iSAH with GCS 13-15 who were transferred to a higher level of care. METHODS: The American College of Surgeon (ACS) Trauma Quality Improvement Program was retrospectively analyzed from 2010-2015 for transferred patients >/= 16 yo with blunt trauma, iSAH, and GCS >/= 13. Those with any other body region abbreviated injury score (AIS) >/= 3, positive or unknown alcohol/drug status, and requiring mechanical ventilation were excluded. The primary outcome was need for neurosurgical intervention (i.e. intracranial monitor or craniotomy/craniectomy). RESULTS: A total of 11,380 patients with blunt trauma, iSAH, and GCS 13-15 were transferred to an ACS Level I/II from 2010-2015. These patients were >/= 65 yo [Median: 72 (IQR 59-81)], white (83%), and had one or more comorbidities (72%). 18% reported a bleeding diathesis/chronic anticoagulation on admission. Most patients had fallen (80%), had a GCS of 15 (84%), and were mildly injured [Median Injury Severity Score (ISS): 9 (IQR 5-14)]. Only 1.7% required neurosurgical intervention with 55% of patients being admitted to the ICU for a median of 2 days (IQR 1-3). 2.2% of the patients died. The median hospital LOS was only 3 days (IQR 2-5) and the most common discharge location was home with self-care (62%). Patient factors favoring neurosurgical intervention included high ISS, low GCS, and chronic anticoagulation. CONCLUSIONS: Trauma patients transferred for isolated subarachnoid hemorrhage with GCS 13-15 are at very low risk for requiring neurosurgical intervention. LEVEL OF EVIDENCE: Level IIIType of Study:Therapeutic/Care Management.