Nationwide secondary overtriage in level 3 and level 4 trauma centers: are these transfers necessary?

Abstract

Background Secondary overtriage (SO) refers to the interfacility transfer of trauma patients who are rapidly discharged home without surgical intervention by the receiving institution. SO imposes a financial hardship on patients and strains trauma center resources. Most studies on SO have been conducted from the perspective of the receiving hospital, which is usually a level 1 trauma center. Having previously studied SO from the referring rural hospital’s perspective, we sought to identify variables contributing to SO at the national level. Methods Using data from the 2008-2012 National Trauma Data Bank, we isolated patients transferred to level 1 trauma centers who were: (1) discharged home within 48 h and (2) did not undergo any surgical procedure. This population was subsequently compared with similar patients treated at and discharged directly from level 3 and 4 centers. Multivariate logistic regression analysis was used to isolate variables that independently influenced a patient’s risk of undergoing SO. Injury patterns were characterized by use of subspecialty consultants. Results A total of 99,114 patients met inclusion criteria, of which 13.2% were discharged directly from level 3 or 4 trauma centers, and 86.8% of them were transferred to a level 1 trauma center before discharge. The mean Injury Severity Score of the nontransfer and transfer groups was 5.4 ± 4.5 and 7.3 ± 5.7, respectively. Multivariate regression analysis showed that Injury Severity Score > 15, alcoholism, smoking, drug use, and certain injury patterns involving the head, vertebra, and face were associated with being transferred. In this minimally injured population, factors protective against transfers were: age > 65 y, female gender, systolic blood pressure <80, a head computed tomography scan and orthopedic injuries. Conclusions SO results from the complex interplay of variables including patient demographics, facility characteristics, and injury type. The inability to exclude a potentially devastating neurologic injury seems to drive SO.

Secondary overtriage of pediatric neurosurgical trauma at a Level I pediatric trauma center

“…Our high rate of PATs may have followed from our 8,9,26,41 hours; and nonreceipt of an "operation," 8,9,15,20,26,31,41,43 which can denote an operating room-level intervention, 43 any additional medical or surgical intervention, 17 or select procedures. 28 Additional criteria, such as no critical care admission 20 or advanced imaging studies, 15 have also been requirements of a PAT.…”

“…From the perspective of the referring hospital, it has been shown that head CT prior to pediatric transfer reduces the odds of unnecessary transfer (OR 0.33), 24 an observation consistent with studies involving adult populations (OR 0.30-0.49). 9,26 We limited our study population to individuals with imaging because we suspected the primary predictor of an avoidable transfer would be pretransfer CT results, and interpreting the need for transfer in light of the outside hospital CT results would best reflect clinical practice. In point of fact, we observed that 86% of both patients with isolated, nondisplaced skull fractures and patients who did not undergo imaging were discharged within 1 hospital day in contrast to 54% of patients whose imaging denoted significant cranial pathology.…”

Effect of team training on efficiency of trauma care in a Chinese hospital

“… 1 – 3 There are several scoring systems to triage trauma patients and permit efficient allocation of medical resources to the most severely injured individuals. 4 , 5 Clinical investigators have made great efforts to improve medical outcomes in severely injured patients. The key to successful treatment of such patients is prompt initiation of necessary tests and procedures; 6 – 8 delayed initiation of these can be fatal in certain circumstances.…”

Evaluating trauma care, outcomes and costs in a system in crisis: the necessity of a Greek National Trauma Database

“…Trauma patients who were admitted to the hospital and were hospitalized for more than 48 hours, or received operative management, or whose injury resulted into death were considered accurately triaged. Patients with length of stay ≤48 hours who did not receive operative management and were discharged alive were considered not accurately triaged, as they could have been successfully treated at lower level of healthcare facilities 13–17. To determine whether the observed overtriage and undertriage could be reduced by setting certain prehospital criteria for the transfer of trauma patients, the US trauma transfer’s (EMS) field triage algorithm was applied to all of our trauma patients 18…”