Secondary overtriage in a statewide rural trauma system

Abstract

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.

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

“…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.…”

“…We believe we were the first ones to directly study the decision these rural hospitals make to transfer a seemingly uninjured patient to a higher level of care. 15 Our calculated SO rate was 9.8% for our rural state. 15 …”

“…15 The precise etiology of this discrepancy is unclear, but a variety of explanations are possible. First, our statewide study was completed in West Virginia, which has one of the oldest populations of any state according to the US census (15.3% of the population are age >65 y compared with 12.4% of the national population).…”

“…These injuries may be isolated to a single extremity and therefore be considered less life threatening. 15 Furthermore, transferred orthopedic injuries may be more likely to require operative management and would therefore not meet criteria for SO. Finally, the vast majority of US hospitals (96%) have both an orthopedic surgeon and CT scanner at their disposal and are thus equipped to handle uncomplicated orthopedic injuries without the need for transfer.…”

“…2-4,7,15 Recently, we published a study on SO from the perspective of the rural hospitals in our state, namely the level 3 and 4 trauma centers. Most authors calculate SO rates using single-institution databases and some variant of Equation 1 (Fig.…”