BACKGROUND:As the only Level I trauma center in the state, our hospital has seen an increase in the number of traumas requiring transfer for a higher level of care, placing strain on an already strained health care system. Traumas that are transferred to our facility and subsequently discharged back home indicate a subset of patients who may not be appropriate to transfer. The aim of this study is to identify commonalities between patients who were transferred for a higher level of care but do not require inpatient status and to assess patients who may benefit from a telemedicine evaluation. METHODS:A 2-year retrospective review of a prospective collected database of patients who were discharged from the ED following transfer to a Level I trauma center was conducted. Data included demographics, injuries, transferring facility, method of transport, activation criteria and level, additional imaging, consulting services, procedures, and disposition. RESULTS:A total of 2,350 patients were transferred. Of those, 27% (632/2,350) were discharged home directly from the trauma bay. Of those patients, 36% (230/632) required complex bedside intervention or subspecialty consultation prior to discharge including complex laceration repairs 53%, ophthalmology examination 24%, splinting 18%, and joint reduction 5%. Sixty-four percent (402/632) of patients did not require complex bedside procedures prior to discharge. One hundred twenty hospitals transferred patients to our center during this period. The top 10 transferring facilities accounted for 40% (948/2,350) of our transfer volume. CONCLUSION:Our study demonstrates that patients who are transferred to our facility and subsequently discharged have a common pattern of injuries; typically, isolated hand and face/ophthalmology. This is likely attributed to the lack of resources in rural facilities to evaluate and develop treatment plans for these injuries; however, only 36% of discharged patients required a bedside procedure. Excluding Level I traumas, head and spine injuries, and patients requiring complex bedside procedures, there was a 13% inappropriate rate of transfer (310/2,350). Development and implementation of a telemedicine system could potentially reduce the transfer and ED discharge rate, thereby improving efficiency and allowing for reallocation of resources as appropriate.

The authors propose that decreasing unnecessary transfers would have a threefold impact on trauma systems. The second impact is the avoidance of repetition of radiographic workup because these patients are often transferred without adequate or only partial imaging. I believe that the authors are proposing this as a positive outcome, but I would argue that avoiding transferring patients with inadequate imaging is not an ideal goal when attempting to minimize nontherapeutic transfers. Patients with inadequate imaging could be an appropriate population to transfer to a facility where appropriate imaging and expert review/interpretation of imaging can be performed expeditiously. The alternatives include repeating the images at the outside facility or omitting them altogether. Unless there was a specific error that the radiology technicians are addressing, repeat imaging is unlikely to significantly improve the result-each facility is limited by its available equipment and protocols. If imaging is indicated, omitting it just because it cannot be performed optimally is not good patient care.A decrease in nontherapeutic transfers has multiple benefits, but clinical outcomes must also be a consideration. This would be challenging to prospectively study because patients cannot be randomized to transfer or not transfer. However, if there is a decrease in nontherapeutic transfers, it would be important to demonstrate that there is not a concurrent increase in poor patient outcomes. I am curious how the authors plan to evaluate the impact of their planned protocol.Again, this is a highly relevant topic and one that will likely be prominent in upcoming publications. I hope we can adopt nonjudgmental language and move forward collaboratively among our trauma systems to bring the benefits of the virtual platform to our patients.

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