The Effect of Sporting Events on Medical Transport Time at a Level 1 Trauma Center: a Retrospective Cohort Study

Abstract

Background

Emergency medical transport (EMS) has evolved drastically since the 1970s. The resources available now such as Global Positioning Systems (GPS), helicopter transport, and a central facility to monitor transport decisions have revolutionized the approach to rapid patient transport. Providing optimal care for patients from adequately trained healthcare providers requires a quick trauma to hospital transport.¹ It has been shown that rapid transportation of severely injured patients from the scene directly to a Level I trauma center is associated with a reduction in mortality and morbidity.² Adequate identification of patients with life-threatening trauma or injury is vitally important in rural care settings.³ Often patients in predominantly rural states are transported to one of only a few major hospitals in the state and surrounding area.⁴ In states like West Virginia, air transport is limited and ground transport is subject to traffic congestion during mass gatherings. Unfortunately, the transport time is often increased during mass gatherings in rural areas leading to detriment for the patient.⁵

Mass gatherings, such as those that occur at sporting events, place a unique strain on the provision of quality healthcare during emergency situations in rural settings. This strain is especially observed when a mass gathering impedes travel during an emergency. Large sporting events redefine the traffic infrastructure and increase the traffic burden.⁶ West Virginia University offers a unique environment to investigate the traffic burden on medical transport during football games. Ruby Memorial Hospital is the predominant medical center for West Virginia. The hospital and Milan Puskar Football Stadium in Morgantown, WV share an adjoining parking lot. Game day traffic therefore has a profound and measurable effect on medical transport because of the single road leading to both the hospital and stadium.

Although some groups have looked at medical emergencies requiring transfer to a hospital during large sporting events, few groups have looked at how the traffic from a large event might hinder emergency transport vehicles trying to reach a nearby hospital. Weekly sporting events and special situations including the Olympics, Super Bowl, and World Cup redefine the set infrastructure of given cities and augments the traffic burden during the given time period of the event.^7,8 In order to increase awareness and to improve patient care, it is important to examine the effects of game day traffic on medical transport.

Methods

A retrospective chart review of a trauma registry at a rural based American College of Surgeons level 1 trauma center was conducted for home and away West Virginia University Football games from 2007–2011. Home games served as the time period of interest and away games served as a control time period. Patient demographics, trauma related data, hospital data, and game data were collected for a 36-hour period surrounding the event (8 a.m. on game day until 12 p.m. the following day). Specific time points were analyzed in relation to the start of the game including: time of trauma, time of Emergency Medical System arrival, and time of arrival to Ruby Memorial Hospital for direct admission. Data collected for each patient included: sex, Emergency Department (ED) status, mode of transport, ED disposition, and Injury Severity Score. ED status refers to the clinical state in which the patient arrives to the ER whereas ED disposition refers to whether the patient was discharged or is receiving further care.

Data was reviewed for 1006 patients. This was a complete case analysis where those missing values were excluded. 250 patient charts were complete for home games and 185 patient charts were complete for away games. Patient charts were excluded when time of trauma or time of transport was not reported. 16 transfer patients were included for home games and 18 transfer patients were included for away games. Data was collected about the counties where patients were most frequently transferred from as well as type of transportation (helicopter vs. ambulance). During the period of investigation there were 34 home games and 26 away games.

Statistics

Data were analyzed using SAS Software version 9.4. Means were estimated and hypothesis tests performed using ANCOVA controlling for age, sex, helicopter use, ISS > 15, type of football game and type of transport. Least Squares Means were used to calculate all means adjusting for all other variables. P<0.05 was considered statistically significant for all tests.

Results

Trauma Demographics

During our study, there were a total of 34 home games and 26 away games. Home games are associated with a large influx of spectators that fill the parking lot and roadways (Fig. 1) connecting the hospital and football stadium (Fig. 2). A total of 1006 patients were treated during these events, and 435 patient charts were complete for these games after excluding charts where trauma and transport times were unknown. Age, sex, use of air transport, and injury severity score were similar between patients during home and away games (Fig. 3). The majority of the 32 patients transferred from nearby facilities were from adjacent counties in north central West Virginia and southwest Pennsylvania (Fig. 4). ED disposition and ED status were similar between patients during home and away games (Fig. 5).

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Figure 1

Schematic of roadways around the hospital and stadium.

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Figure 2

Picture of the mass gathering that occurs during game days. The filled parking lot is shared by both the hospital and stadium.

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Figure 3

Demographic and injury data similar between patients admitted during home and away games. Abbreviations: ISS= injury severity score. No significant difference was observed between groups for age, sex, use of air transport, or ISS. Patients were further subdivided based on whether they were transported directly from scene or transferred from another institution.

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Figure 4

Map of north central West Virginia and southwest Pennsylvania showing which counties patients were transferred from. The darker blue indicates greater number of transfers.

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Figure 5

Emergency department disposition and status data. No significant differences were observed between groups. Abbreviations: ED = emergency department, OR = operating room, ICU = intensive care unit, AMA = against medical advice, DA = death upon arrival. The majority of patients were sent to a floor bed upon arrival (51.34%). ED status was based on the P1, P2, and non-page system. Briefly, P1 is an emergency requiring immediate medical attention due to risk for imminent demise. P2 is an emergency where the patient is severely ill but the situation is not immediately life threatening. Non-page is for minor emergency. Trauma consult is called when patient is likely to require emergent surgery. Information about use of air transport and if the game was nationally televised was also reported. More away games were nationally televised than home games.

ED disposition was divided according to whether the patient was sent home, to the operating room, to the intensive care unit, to a floor bed, to step-down, or observation. Additional data was collected regarding if the patient left against medical advice, was transferred to another facility, or expired. Factors evaluated for ED status were if the patient was classified as P1, P2, non-page, or trauma consults. P1 patients were those that required resuscitation, were at risk for imminent cardiovascular demise, or required immediate medical attention. P2 patients did not need immediate resuscitation but were severely ill and non-ambulatory. Non-page patients had a minor emergency or were ambulatory and did not require immediate medical attention. Patients requiring urgent surgical care received a trauma consult. A small number of patients were announced dead upon arrival.

The use of air transport was recorded and there was no difference in number of times it was utilized between home and away games. Air transport is a limited commodity that is reserved for the most severe emergencies. Information was also obtained about national television coverage of the game. Away games received more national coverage than home games (84.56% vs. 39.2%). The lack of national coverage may facilitate the large population surge into Morgantown on home game days.

Game Start Time Negatively Affects Transport Time

For patients coming from the scene during a home game, overall time of air or ground transport was not statistically different than away game transport times (Fig. 6). If the game kickoff, start of the football game, occurred after the trauma but before arrival to the trauma center, the average time of ground transport increased from 44.9 minutes to 120 minutes (p<0.0001). 34 transfers occurred from outside facilities during game days. The number of times air transportation was utilized increased when inter-facility transfers occurred during home games (5/16, 31.3% vs. 4/18, 22.2%). Patients also traveled a further distance (avg. 66.6 vs. 50.25 air miles). Overall time of ground transport during home games for transfer patients was 23.5 minutes greater compared to away games (76.4 minutes vs. 52.9 minutes). Likewise time of air transport was increased by 13.4 minutes for transfer patients during home games compared to away games (37.4 minutes vs. 24 minutes).

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Figure 6

Table showing the average time for air and ground transport for home and away games. Further data was collected for transfer patients and included time spent at outside facility. Transfer patients spent more time in transit during home games than away games.

Discussion

We found that if the start of the game, kick-off, occurred after the trauma but before arrival the transport time increased from 44.9 minutes to 120 minutes. Clinical indicators of functional status, such as the Glasgow coma score, can decrease rapidly if the patient does not reach the hospital quickly.⁹ Patients with severe trauma that are not directly taken to a level 1 trauma center can have a delay in life-saving interventions that are not available at tertiary centers.¹⁰ Future studies will confirm the delay in transport time and evaluate clinical outcomes related to this delay such as morbidity, mortality, type of interventions required, and length of stay in the ED. If a clinically significant delay in trauma patient transport is confirmed, a transport system altered by a mass gathering will not be ensuring the appropriate patient care.

Carr and colleagues developed national estimates for transport times from trauma scene to emergency departments at various centers across the nation. For the United States, the average percentage of the population with access to any ED within 30 and 60 minutes was 70.8 and 98.4 percent, respectively. For a Teaching hospital, it was 15.7 and 44.7 percent respectively. In comparison, West Virginia’s percentage of population with access to any ED within 30 and 60 minutes was 58.7 and 99 percent, respectively. For a Teaching hospital it was 27 and 44.3 percent respectively.¹¹ No previous study has examined how a game day mass gathering affects transport time. In a rural state, traffic would impede rapid and efficient care due to the long distances medical transport vehicles must often travel.

If it is determined that the statistically significant delay observed during WVU sporting events disrupts patient care, additional resources will be necessary to improve outcomes for the patients. The most productive option would be a population-based engineering approach. Lerner and colleagues describe the use of a novel geographic information system (GIS). Historical transport data was used to create a map identifying routes that either helicopter or ambulance drivers can use to minimize out-of-hospital time.¹² This resource could be utilized at our level 1 trauma center in order to find a better means for patient transport during football games or other large mass gatherings. Another option is to change state protocols to increase the use of sirens by medical transport vehicles in non life-threatening emergencies to improve transport times.

Conclusion

Game day traffic significantly increased the time for ground transport crews to reach the trauma center. Mass gathering that occurs during WVU collegiate football games impedes rapid and efficient patient transport. Changing the current trauma transport standards to increase the use of sirens and GIS in non life-threatening emergencies will likely foster a decrease in the more expensive and limited air transport. The question that still remains is: Is it clinically significant? This question warrants further investigation in future studies.

Acknowledgments

List of Abbreviations

Footnotes

References