Patient, hospital and regional characteristics associated with undertriage of injured children in California (2005–2015): a retrospective cohort study

Abstract

Background/objectiveTrauma centers save lives, but they are scarce and concentrated in urban settings. The population of severely injured children in California who do not receive trauma center care (undertriage) is not well understood.MethodsRetrospective observational study of all children (0–17 years) hospitalized for severe trauma in California (2005–2015). We used the California Office of Statewide Health Planning and Development linked Emergency Department and Inpatient Discharge data sets. Logistic regression models were created to analyze characteristics associated with undertriage. The model was clustered on differential distance between distance from residence to primary triage hospital and distance from residence to nearest trauma center. We controlled for body part injured, injury type, intent and year. The a priori hypothesis was that uninsured and publicly insured children and hospitals and regions with limited resources would be associated with undertriage.ResultsTwelve percent (1866/15 656) of children with severe injury experienced undertriage. Children aged >14 years compared with 0–13 years had more than 2.5 times the odds of undertriage (OR 2.58; 95% CI 2.1 to 3.16). Children with private Health Maintenance Organization (HMO) insurance compared with public insurance had 13 times the odds of undertriage (OR 12.62; 95% CI 8.95 to 17.79). Hospitals with >400 compared with <200 beds had more than three times the odds of undertriage (OR 3.64; 95% CI 2.6 to 5.11). Urban versus suburban residence had 1.3 times increased odds of undertriage (OR 1.31; 95% CI 1.02 to 1.67) Undertriage volume was largest in urban areas.ConclusionUndertriage is associated with private HMO insurance, primary triage to large hospitals and urban residence. Understanding the characteristics associated with undertriage can help improve trauma systems.Level of evidenceLevel III (non-experimental retrospective observational study).

Characteristics of Pediatric Patient Transfers From General Emergency Departments in California From 2005 to 2018

“…Our study differed from Barata et al 21 in that we excluded trauma patients because trauma patients are initially often sent to trauma-designated hospitals, and we previously found a high undertriage rate of seriously injured children in California. 20 Unlike Barata et al, 21 we found poisoning had higher odds of transfer when compared with infectious diseases. We found in our study that children with complex medical conditions had lower absolute number of ED visits, but the proportions of children with these disease processes who were transferred were much higher than those with common conditions, and these complex conditions were associated with an increased odds of transfer.…”

“…We found patients with circulatory, mental illness, nervous system, and diseases of the blood and blood-forming organs had higher odds of being transferred than patients with infectious diseases. Our study differed from Barata et al 21 in that we excluded trauma patients because trauma patients are initially often sent to trauma-designated hospitals, and we previously found a high undertriage rate of seriously injured children in California 20 . Unlike Barata et al, 21 we found poisoning had higher odds of transfer when compared with infectious diseases.…”

“…We excluded patients with trauma-related diagnoses. California does not have a fully coordinated trauma system, which leads to undertriage of severely injured children, which may confound the likelihood of transfers 20 . The primary outcome was disposition of transfer to an acute care hospital.…”

Improving pediatric undertriage in a regional trauma network- a registry cohort study

“…Wang observed an undertriage rate of 12%. [10] Children > 14 years had a 2.5 higher Odds of undertriage. Scaife found a 15% rate and an increased risk of undertriage in patients > 13 years, in metropolitan hospitals and abdominal injuries after adjustment for age 6-10 years, penetrating injury, chest injury and presentation to teaching hospital.…”

Predictors of Potentially Unnecessary Transfers to Pediatric Emergency Departments

“…In a recent study of pediatric trauma victims, those from urban residences were more likely to be undertriaged, leading the authors to speculate that larger, urban centers may falsely believe they have the resources to adequately care for pediatric patients. 25 Further studies, particularly on a more regional scale, may provide insight into the reasons for geographic disparity.…”