Institutional and provider factors impeding access to trauma center care

Gomez, David; Haas, Barbara; Mestral, Charles de; Sharma, Sunjay; Hsiao, Marvin; Zagorski, Brandon; Rubenfeld, Gordon D.; Ray, Joel G.; Nathens, Avery B.

doi:10.1097/ta.0b013e318265cec2

Cited by 38 publications

(19 citation statements)

References 16 publications

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“…The problem is particularly acute at non-trauma centers, where fewer than 30% of severely injured patients are transferred as recommended by clinical practice guidelines. 21 22 23 24 25 Our prior experimental and observational work suggests that heuristics play an important role in under-triage. 26 27 We selected one promising method of recalibrating heuristics—narrative engagement—and developed a theoretically grounded intervention delivered through the platform of a video game.…”

Section: Introductionmentioning

confidence: 99%

Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: randomized controlled trial

Mohan

Farris

Fischhoff

et al. 2017

BMJ

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ObjectiveTo determine whether a behavioral intervention delivered through a video game can improve the appropriateness of trauma triage decisions in the emergency department of non-trauma centers.DesignRandomized clinical trial.SettingOnline intervention in national sample of emergency medicine physicians who make triage decisions at US hospitals.Participants368 emergency medicine physicians primarily working at non-trauma centers. A random sample (n=200) of those with primary outcome data was reassessed at six months.InterventionsPhysicians were randomized in a 1:1 ratio to one hour of exposure to an adventure video game (Night Shift) or apps based on traditional didactic education (myATLS and Trauma Life Support MCQ Review), both on iPads. Night Shift was developed to recalibrate the process of using pattern recognition to recognize moderate-severe injuries (representativeness heuristics) through the use of stories to promote behavior change (narrative engagement). Physicians were randomized with a 2×2 factorial design to intervention (game v traditional education apps) and then to the experimental condition under which they completed the outcome assessment tool (low v high cognitive load). Blinding could not be maintained after allocation but group assignment was masked during the analysis phase.Main outcome measuresOutcomes of a virtual simulation that included 10 cases; in four of these the patients had severe injuries. Participants completed the simulation within four weeks of their intervention. Decisions to admit, discharge, or transfer were measured. The proportion of patients under-triaged (patients with severe injuries not transferred to a trauma center) was calculated then (primary outcome) and again six months later, with a different set of cases (primary outcome of follow-up study). The secondary outcome was effect of cognitive load on under-triage.Results149 (81%) physicians in the game arm and 148 (80%) in the traditional education arm completed the trial. Of these, 64/100 (64%) and 58/100 (58%), respectively, completed reassessment at six months. The mean age was 40 (SD 8.9), 283 (96%) were trained in emergency medicine, and 207 (70%) were ATLS (advanced trauma life support) certified. Physicians exposed to the game under-triaged fewer severely injured patients than those exposed to didactic education (316/596 (0.53) v 377/592 (0.64), estimated difference 0.11, 95% confidence interval 0.05 to 0.16; P<0.001). Cognitive load did not influence under-triage (161/308 (0.53) v 155/288 (0.54) in the game arm; 197/300 (0.66) v 180/292 (0.62) in the traditional educational apps arm; P=0.66). At six months, physicians exposed to the game remained less likely to under-triage patients (146/256 (0.57) v 172/232 (0.74), estimated difference 0.17, 0.09 to 0.25; P<0.001). No physician reported side effects. The sample might not reflect all emergency medicine physicians, and a small set of cases was used to assess performance.ConclusionsCompared with apps based on traditional didactic education, exposure ...

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Section: Introductionmentioning

confidence: 99%

Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: randomized controlled trial

Mohan

Farris

Fischhoff

et al. 2017

BMJ

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“…Notably, CT scans at the initial facility were strongly protective against SO, corroborating a Canadian study which reported that nontrauma centers with CT scanners, in addition to general surgery services, had decreased overall rates of transfer to trauma centers. 13 We sought to confirm that the conclusions we reported within our previous study are applicable at the national level and to explore new factors not previously analyzed. The long-term goal of this research is to facilitate the development of targeted strategies to reduce the SO rate and thereby help alleviate the burden of SO on tertiary center resources and improve patient care.…”

Section: Introductionmentioning

confidence: 72%

“…This is consistent with an earlier study of Canadian hospitals and our prior state-level study. 13,15 There may be several explanations for the observed effect. A negative head CT for any pathology may enhance provider comfort in discharging the patient, and patients identified as transfer candidates may have had their imaging studies completed at the receiving facility.…”

Section: Discussionmentioning

confidence: 99%

“…12 Availability of patient care resources, such as neurosurgery services, computed tomography (CT) scanners, residents, and intensive care unit beds at the referring hospital is a third variable that has been reported to affect transfer decisions. 13,14 Thus, it appears that the interplay of patient demographics, injury patterns, and availability of hospital resources may all contribute to SO.…”

Section: Introductionmentioning

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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“…Nonetheless, between 30 and 40 % of patients with moderate-to-severe injuries still receive treatment at non-trauma centers ( under-triage) [5–7]. The problem amplifies among the cohort evaluated by physicians at non-trauma centers—70 to 80 % of whom are under-triaged [8, 9]. …”

Section: Introductionmentioning

confidence: 99%

Testing a videogame intervention to recalibrate physician heuristics in trauma triage: study protocol for a randomized controlled trial

et al. 2016

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BackgroundBetween 30 and 40 % of patients with severe injuries receive treatment at non-trauma centers (under-triage), largely because of physician decision making. Existing interventions to improve triage by physicians ignore the role that intuition (heuristics) plays in these decisions. One such heuristic is to form an initial impression based on representativeness (how typical does a patient appear of one with severe injuries). We created a video game (Night Shift) to recalibrate physician’s representativeness heuristic in trauma triage.MethodsWe developed Night Shift in collaboration with emergency medicine physicians, trauma surgeons, behavioral scientists, and game designers. Players take on the persona of Andy Jordan, an emergency medicine physician, who accepts a new job in a small town. Through a series of cases that go awry, they gain experience with the contextual cues that distinguish patients with minor and severe injuries (based on the theory of analogical encoding) and receive emotionally-laden feedback on their performance (based on the theory of narrative engagement). The planned study will compare the effect of Night Shift with that of an educational program on physician triage decisions and on physician heuristics. Psychological theory predicts that cognitive load increases reliance on heuristics, thereby increasing the under-triage rate when heuristics are poorly calibrated. We will randomize physicians (n = 366) either to play the game or to review an educational program, and will assess performance using a validated virtual simulation. The validated simulation includes both control and cognitive load conditions. We will compare rates of under-triage after exposure to the two interventions (primary outcome) and will compare the effect of cognitive load on physicians’ under-triage rates (secondary outcome). We hypothesize that: a) physicians exposed to Night Shift will have lower rates of under-triage compared to those exposed to the educational program, and b) cognitive load will not degrade triage performance among physicians exposed to Night Shift as much as it will among those exposed to the educational program.DiscussionSerious games offer a new approach to the problem of poorly-calibrated heuristics in trauma triage. The results of this trial will contribute to the understanding of physician quality improvement and the efficacy of video games as behavioral interventions.Trial registrationclinicaltrials.gov; NCT02857348; August 2, 2016.

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Institutional and provider factors impeding access to trauma center care

Abstract: Epidemiologic study, level II.

Cited by 38 publications

References 16 publications

Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: randomized controlled trial

Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: randomized controlled trial

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

Testing a videogame intervention to recalibrate physician heuristics in trauma triage: study protocol for a randomized controlled trial

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