Trauma transfers to a rural level 1 center: a retrospective cohort study

Abstract

BackgroundThe regionalization of trauma care, the Emergency Medical Treatment and Active Labor Act of 1986, the advent of Accountable Care Organizations and bundled payments have brought Level 1 trauma centers (TC) to a new crossroads. By protocol, injured patients are preferentially transferred to designated TCs when a higher level of care is indicated. Trauma transfers frequently come during off hours and may not always appear to be related to injury severity. Based on this observation, we hypothesized patients transferred from regional hospitals to Level 1 TCs would have lower injury severity scores (ISS) and unfavorable payor status.MethodsWe queried our TC registry to identify trauma transfers (TTP) and primary trauma patients (PTP) treated at our level 1 TC between 2004 and 2012. Demographics, payor status, length of stay (LOS), injury severity score (ISS), and discharging service were compared.Results5699 TTP and 11147 PTP were identified. Uninsured patients comprised 11 % (n = 602) of TTP compared with 15 % (n = 1,721) of PTP (P < 0.0001). Surprisingly 52 % of TTP were Medicare or HMO (n = 3008) beneficiaries, versus 42 % of PTP being Medicare or HMO (n = 4614) recipients (P < 0.0001). Patients were discharged predominantly by neurosurgery and orthopedic surgery (i.e.: General Adult and General Pediatric comprised <50 % of discharges) for all trauma admissions. Adult and Pediatric Trauma services accounted for 29 % (n = 1674) of TTP versus 45 % of PTP (n = 5045) discharges (P < 0.0001). Mean Injury Severity Score of TTP was found to be 11.5 ± 0.11, in comparison to 11.6 ± 0.11 in PTP (P = 0.42), while mean LOS was 5.6 ± 0.1 days for TTP and 5.9 ± 0.1 days for PTP (P = 0.06).ConclusionsThese data suggest designated trauma centers should continue to encourage and accept appropriate transfer of trauma patients for surgical subspecialty care. The perception trauma transfers increase institutional fiscal burden is unsubstantiated.

A Comparison of Pediatric Traumatic Injuries on Farms and Residences from 2009 to 2014

“…The air mode of transport likely reflects the distance to trauma centers, as well as the severity of injury. Most children from farms with severe injuries will typically first require stabilization at local hospitals prior to transfer to trauma centers . The data presented indicates that the proportion of children with higher ISS from farm injuries who require rapid transfer to advanced trauma centers either from the field or from a local emergency center is greater than that of children injured at home.…”

“…Most children from farms with severe injuries will typically first require stabilization at local hospitals prior to transfer to trauma centers. [22][23][24] The data presented indicates that the proportion of children with higher ISS from farm injuries who require rapid transfer to advanced trauma centers either from the field or from a local emergency center is greater than that of children injured at home. Previous studies have demonstrated that the requirement for air transport correlates with worse clinical outcome.…”

“…Transport patterns appear different in children injured on farms compared to home . Most children who present to trauma centers arrive by ambulance regardless of locale of injury . However, children injured on farms require helicopter or fixed‐wing transport at greater rates.…”

“…This may result in an underrepresentation of children with farm injuries who presented to their closest emergency department for medical attention, but did not require transfer to a trauma center . The NTDB is not nationally representative of all trauma centers; however, it currently includes over 95% of all US‐certified Level I and II trauma centers . Administrative data collected within the NTDB is subject to coding inaccuracies and misreport through physician documentation and trauma registrar collection of data.…”

“…21 Most children who present to trauma centers arrive by ambulance regardless of locale of injury. [22][23][24] However, children injured on farms require helicopter or fixed-wing transport at greater rates. The air mode of transport likely reflects the distance to trauma centers, as well as the severity of injury.…”