P. P. Parikh1, P. Parikh2, J. A. Pestana2, J. V. Sakran3 1Wright State University,Department Of Surgery, Boonshoft School Of Medicine,Dayton, OH, USA 2Wright State University,Department Of Biomedical, Industrial And Human Factors Engineering,Dayton, OH, USA 3Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA
Introduction: Transfer of the injured patient is centered on improving outcomes. However, at times minimally injured patients are also transferred to Level I/II trauma centers resulting in secondary over-triage (SO). SO is a resource-sensitive challenge to trauma centers. The purpose of this study is to evaluate the burden of SO in a state-wide trauma system and identify factors that may lead to a SO.
Methods: The Ohio Department of Public Safety trauma and EMS registries were used to identify patients during 2008–2012. The inclusion criteria were: patients taken to Level III/non-trauma center (NTC) from the scene, ISS<15, and discharged alive. The subgroup of patients subsequently transferred to Level I/II trauma center, who had no surgical intervention, and were discharged alive within 48 hours of admission were analyzed. This subgroup was defined as SO and the remainder were included in the non-transferred group. The SO group was analyzed descriptively. Multivariable logistic regression was then used to identify factors associated with SO. The analysis included patient level factors (demographics), clinical factors (Glasgow comma scale, respiratory rate, systolic blood pressure, injury type, and pre-existing conditions), and insurance type. We also included system level factors, such as number of LI/LII in the region and EMS reasons for selecting the first facility from the field.
Results:A total of 34,494 trauma patients were identified, and 7,881 (22.85%) patients met the inclusion criteria, out of which 965 (12.2%) met our definition of SO. The median age in the SO group was 40 years and majority (70%) of these patients were discharged home. After adjusting for age, gender, pre-existing conditions, and insurance type, the presence of penetrating injury (adjusted odds ratio [AOR] 1.71; 95% CI, 1.12-2.60; P = 0.01) and burns (AOR 2.82; 95% CI, 1.35-5.76; P = 0.006) were associated with SO (model area under the curve [AUC]=0.88). Further, system level factors, such as number of LI/II in the region (>2 vs ≤2) significantly impacted SO (AOR 1.30; 95% CI, 1.11-1.54; P < 0.001). The reason for destination choice, specifically closest facility (AOR 1.67; 95% CI, 1.40-2.00; P <0.0001) and use of on field trauma triage protocol (AOR 2.20; 95% CI, 1.70-2.85; P <0.0001), significantly increased the likelihood of SO.
Conclusion:A proportion of minimally injured patients are subject to SO that impact regional and statewide trauma system utilization. System level factors, such as number of major trauma centers in the region and taking patients to the closest facility, significantly impacts SO. Subsequent investigation to identify optimal distribution of trauma centers is, therefore, critical. Targeted education and outreach to EMS personnel on the interpretation of triage protocol and further guidance to the NTC on when to transfer an injured patient may further reduce SO.