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Open Access

Is it a matter of time? The effect of transfer time on femur fracture outcomes

Leah E Larson, Melissa L Harry, Paul K Kosmatka, Kristin P Colling
DOI: 10.1136/tsaco-2021-000701 Published 17 June 2021
Leah E Larson
1University of Minnesota Medical School Twin Cities, Minneapolis, Minnesota, USA
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Melissa L Harry
2Essentia Institute of Rural Health, Duluth, Minnesota, USA
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Paul K Kosmatka
3Orthopedic Surgery, Essentia Health Saint Mary's Medical Center, Duluth, Minnesota, USA
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Kristin P Colling
4Trauma Surgery, Essentia Health Saint Mary's Medical Center, Duluth, Minnesota, USA
5Surgery, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
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    Figure 1

    Heat map identifying locations of initial hospitals transfer patients with femur fractures to Saint Mary’s Medical Center (black star). Hospitals located in rural localities are in light gray, and urban/suburban hospitals are in black. The size of the circles corresponds to the relative number of patients transferred. The coverage area of our trauma system is quite large, spanning three states (Minnesota, Wisconsin, and Michigan) and serves a large rural population.

Tables

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  • Table 1

    Descriptive statistics for all trauma transfers during the study period and the femur fracture subgroup

    DemographicsAll transfers
    n=1837
    Femur fracture subgroup
    n=398
    Sex (female), n (%)784 (42.7)247 (61.6)
    Age, mean (SD)56.9 (24.6)71.39 (20.92)
    Race (Caucasian), n (%)1681 (91.5)378 (94.3)
    ISS, median (IQR)9 (5–9)9 (9–9)
    Rural, n (%)1391 (74.1)323 (81.7)
    Blunt mechanism, n (%)1749 (92.7)401 (100)
    Alcohol involved in trauma, n (%)304 (16.1)145 (36.2)
    In-hospital mortality, n (%)57 (3.0)7 (1.8)
    • Patient and injury variables for all patients transferred to our trauma center between May 2016 and April 2019 and the femur fracture subgroup. Femur fracture patients were older, more likely to be female, and had more alcohol use.

    • IQR, Interquartile range; ISS, Injury Severity Score; n, number of patients.

  • Table 2

    Patient demographic and injury data for patients with femur fractures, comparing those who underwent fixation within 24 hours of admission to trauma center and those repaired more than 24 hours from admission

    DemographicsFemur fracture repaired <24 hoursFemur fracture repaired >24 hoursP value
    n=296n=102
    Sex (female), n (%)187 (63)59 (58)0.34
    Age, median (IQR)76 (63–85)78.5 (67–98)0.1
    Race (Caucasian), n (%)280 (95)95 (93)0.84
    ISS, median (IQR)9 (9–9)9 (9–10)0.3
    Rural, n (%)238 (81)85 (83)0.55
    Local hospital ACS trauma designation, n (%)0.63
     Level III56 (19)16 (16)
     Level IV198 (66)68 (67)
     Undesignated44 (15)18 (17)
    Alcohol involved in trauma, n (%)24 (8)7 (7)0.67
    Median Elixhauser score (IQR)0 (0–2)1 (0–2)0.11
    Elilxhauser Score >2, n (%)46 (20)16 (22)0.71
    Transfer time, hours, median (IQR)4.4 (3.8–5.8)4.8 (3.8–6.1)0.28
    Initial hospital LOS, hours, median (IQR)2.8 (2.2–4.0)3.2 (2.4–5.6)0.1
    Time to fracture repair, hours, median (IQR)14.5 (8.8–18.0)40.6 (30.9–49.7)0.027
    Primary admitting service, n (%)0.009
     Orthopedic trauma247 (77)74 (23)
     Trauma surgery31 (72)12 (27)
     Medicine18 (53)16 (47)
    Trauma center LOS, days, median (IQR)4 (3–6)5 (5–8)<0.001
    ICU admission, n (%)15 (5)10 (10)0.08
    ICU LOS, days, median (IQR)2 (1–4)4 (2.75–8)0.08
    Discharge disposition, n (%)0.021
     Home94 (32)19 (19)
     Nursing home165 (56)76 (75)
     Acute rehabilitation unit28 (10)6 (6)
    Complication during stay, n (%)36 (12)23 (23)0.01
    In-hospital mortality, n (%)6 (2)1 (1)0.49
    30-day hospital mortality, n (%)17 (6)5 (5)0.75
    • ACS, American College of Surgeons; ICU, intensive care unit; ISS, Injury Severity Score; LOS, length of stay; n, number of patients.

  • Table 3

    Univariate analysis comparing patient variables and complication rates

    DemographicsNo complicationComplicationP value
    n=339n=59
    Sex (female), n (%)212 (63)34 (58)0.47
    Age, median (IQR)76 (63–85)82 (72–89)0.003
    Race (Caucasian), n (%)322 (95)53 (90)0.39
    ISS, median (IQR)9 (9–10)9 (9–10)0.83
    Rural, n (%)272 (81)51 (86)0.28
    Alcohol involved in trauma, n (%)27 (8)4 (7)0.75
    Elixhauser score, median (IQR)
    Elixhauser Score >2 n (%)
     0 (0-2)
    41 (16)
    2 (0-4)
    24 (41)
    < 0.001
    < 0.001
    Total transfer time, hours, median (IQR)4.5 (3.7–5.9)4.7 (3.8–5.7)0.8
    Time at initial hospital, median (IQR)2.9 (2.2–4.1)3.2 (2.4–4.3)0.38
    Time to fracture repair, median (IQR)16.6 (10.8–23.1)22.3 (16.0–36.6)0.03
    Hospital LOS, days, median (IQR)4 (3–6)7 (6–10)<0.0001
    ICU admission, n (%)8 (2)17 (29)<0.0001
    ICU LOS, days, median (IQR)3.5 (2.25–7.25)2 (1–4.5)0.34
    Discharge disposition, n (%) <0.0001
     Home105 (31)8 (14)
     Nursing home202 (60)39 (66)
     Acute rehabilitation30 (9)4 (7)
    In-hospital mortality, n (%)1 (0.3)6 (10)<0.0001
    30-day hospital mortality, n (%)12 (4)10 (17)<0.0001
    • Older age, longer time to fracture repair, and longer hospital stays were all associated with complications. Patients with complications were more likely to need intensive care, had higher mortality rates, and were less likely to be discharged home.

    • ICU, intensive care unit; ISS, Injury Severity Score; LOS, length of stay; n, number of patients.

  • Table 4

    Multivariate analysis for risk of complication after femur fracture repair using binary logistic regression

    Adjusted OR for complications (95% CI)P value
    Sex (female)0.76 (0.39 to 1.49)0.42
    Age (per year increase)1.04 (1.01 to 1.07)0.003
    Elixhauser score >23.45 (1.75 to 6.80)<0.001
    Fixation performed >24 hours after trauma center admission2.08 (1.1 to 4.1)0.04
    Transfer time (per hour increase)0.94 (0.80 to 1.09)0.41
    • When including patients’ age, sex, presence of more than 2 comorbidities on the Elixhauser score, and time to fixation greater than 24 hours, we found that age, comorbidities, and delayed repair of fracture were independent risk factors for complications. Transfer time was not associated with increased risk of complications in this model.

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Is it a matter of time? The effect of transfer time on femur fracture outcomes
Leah E Larson, Melissa L Harry, Paul K Kosmatka, Kristin P Colling
Trauma Surg Acute Care Open Jun 2021, 6 (1) e000701; DOI: 10.1136/tsaco-2021-000701

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Is it a matter of time? The effect of transfer time on femur fracture outcomes
Leah E Larson, Melissa L Harry, Paul K Kosmatka, Kristin P Colling
Trauma Surg Acute Care Open Jun 2021, 6 (1) e000701; DOI: 10.1136/tsaco-2021-000701
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Is it a matter of time? The effect of transfer time on femur fracture outcomes
Leah E Larson, Melissa L Harry, Paul K Kosmatka, Kristin P Colling
Trauma Surgery & Acute Care Open Jun 2021, 6 (1) e000701; DOI: 10.1136/tsaco-2021-000701
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