Secondary Overtriage

Sorensen, Meredith J.; Recklinghausen, Friedrich M. von; Fulton, Gwendolyn; Burchard, Kenneth W.

doi:10.1001/jamasurg.2013.2132

Cited by 112 publications

(59 citation statements)

References 14 publications

(21 reference statements)

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“…There were no other studies in the literature utilizing our definition, which we believe better allows the study of the decision that the treating physician at the initial facility must make of whether to transfer the patient. We confirm the previous finding that the pediatric population seems to be more often overtriaged than the adults [10]. …”

Section: Discussionsupporting

confidence: 92%

“…Most definitions include a discharge time within 24–48h, with or without limiting the ISS to exclude the more severe injuries, and with or without excluding patients who had an operation. Most studies have been from single institutions comparing the rate of secondary overtriage using the total number of incoming transfers to that institution as the denominator [1, 9, 10]. An exception to the single institution studies was one done by Osen, in which selected all transferred trauma patients form the National Inpatient Sample, and they found the secondary overtriage rate to be 6.9% [11].…”

Section: Introductionmentioning

confidence: 99%

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Secondary overtriage in a statewide rural trauma system

Con

Long

Sasala

et al. 2015

Journal of Surgical Research

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Background Rural hospitals have variable degrees of involvement within the nationwide trauma system because of differences in resources and operational goals. “Secondary overtriage” refers to the patient who is discharged home shortly after being transferred from another hospital. An analysis of these occurrences is useful to determine the efficiency of the trauma system as a whole. Materials and methods Data was extracted from a statewide trauma registry from 2007–2012 to include those who were: 1) discharged home within 48h of arrival, and 2) did not undergo a surgical procedure. We then identified those who arrived as a transfer prior to being discharged (secondary overtriage) from those who arrived from the scene. Factors associated with transfers were analyzed using a logistic regression. Injuries were classified based on the need of a specific consultant. Time of arrival to ED was analyzed using 8-hour blocks, with the 7AM–3PM block as reference. Results 19,319 patients fit our inclusion criteria of which 1,897 (9.8%) arrived as transfers. Descriptive analysis showed a number of differences between transfers and non-transfers due to our large sample size. Thus, we examined variables that had more clinical significance using logistic regression controlling for age, ISS, the type of injury, blood products given, the time of arrival to initial ER, and whether a CT scan was obtained initially. Factors associated with being transferred were ISS>15, transfusion of PRBC’s, graveyard-shift arrivals, and neurosurgical, spine, and facial injuries. Patients having a CT scan were less likely to be transferred. Conclusions Secondary overtriage may result from the hospital’s limited resources. Some of these limitations are the availability of surgical specialists, blood products, and overall coverage during the “graveyard-shift.” More liberal use of the CT scan may prevent unnecessary transfers.

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Section: Discussionsupporting

confidence: 92%

Section: Introductionmentioning

confidence: 99%

Secondary overtriage in a statewide rural trauma system

Con

Long

Sasala

et al. 2015

Journal of Surgical Research

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“…14,15,20 In keeping with this, injury patterns were strongly predictive of SO in our study. Head and neck injuries were the most common cause of SO in a study by Sorensen, 7 whereas orthopedic injuries and neurologic trauma were common reasons for overall transfer in other studies. 3,20 Interestingly, neurosurgical, orthopedic, spine, and facial surgical services at nontrauma centers have been associated with increased risk of “undertriage” in Medicare patients at some centers.…”

Section: Discussionmentioning

confidence: 88%

“…This differs from the findings of other authors, who reported no difference in payer status mix among patients transferred to a level 1 trauma center versus those directly admitted to the center 20 but is in accordance with other studies showing increased risk of SO among patients with Medicare or Medicaid. 7 …”

Section: Discussionmentioning

confidence: 99%

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

Lynch

Essig

Long

et al. 2016

Journal of Surgical Research

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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.

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Impact of Tele-Emergency Consultations on Pediatric Interfacility Transfers

et al. 2023

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ImportancePediatric referral centers are increasingly using telemedicine to provide consultations to help care for acutely ill children presenting to rural and community emergency departments (EDs). These pediatric telemedicine consultations may help improve physician decision-making and may reduce the frequency of overtriage and interfacility transfers.ObjectiveTo examine the use of pediatric critical care telemedicine vs telephone consultations associated with risk-adjusted transfer rates of acutely ill children from community and rural EDs.Design, Setting, and ParticipantsA cluster-randomized crossover trial was conducted between November 18, 2015, and March 26, 2018. Analyses were conducted from January 19, 2018, to July 23, 2022, 2022. Participants included acutely ill children aged 14 years and younger presenting to a participating ED in 15 rural and community EDs in northern California.InterventionsParticipating EDs were randomized to use telemedicine or telephone for consultations with pediatric critical care physicians according to 1 of 4 unbalanced (3 telemedicine:1 telephone) crossover treatment assignment sequences.Main Outcomes and MeasuresIntention-to-treat, treatment-received, and per-protocol analyses were performed to determine the risk of transfer using mixed effects Poisson regression analyses with random intercepts for presenting EDs to account for hospital-level clustering.ResultsA total of 696 children (392 boys [56.3%]; mean [SD] age, 4.2 [4.6] years) were enrolled. Of the 537 children (77.2%) assigned to telemedicine, 251 (46.7%) received the intervention. In the intention-to-treat analysis, patients assigned to the telemedicine arm were less likely to be transferred compared with patients assigned to the telephone arm after adjusting for patient age, severity of illness, and hospital study period (risk rate [RR], 0.93; 95% CI, 0.88-0.99). The adjusted risk of transfer was significantly lower in the telemedicine arm compared with the telephone arm in both the treatment-received analysis (RR, 0.81; 95% CI, 0.71-0.94) and the per-protocol analysis (RR, 0.79; 95% CI, 0.68-0.92).Conclusions and RelevanceIn this randomized trial, the use of telemedicine to conduct consultations for acutely ill children in rural and community EDs resulted in less frequent overall interfacility transfers than consultations done by telephone.Trial RegistrationClinicalTrials.gov Identifier: NCT02877810

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Secondary Overtriage

Cited by 112 publications

References 14 publications

Secondary overtriage in a statewide rural trauma system

Secondary overtriage in a statewide rural trauma system

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

Impact of Tele-Emergency Consultations on Pediatric Interfacility Transfers

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