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Castillo Diaz F, Anand T, Khurshid MH, Kunac A, Al Ma'ani M, Colosimo C, Hejazi O, Ditillo M, Magnotti LJ, Joseph B. Look me in the face and tell me that I needed to be transferred: Defining the criteria for transferring patients with isolated facial injuries. J Trauma Acute Care Surg 2025:01586154-990000000-00983. [PMID: 40341445 DOI: 10.1097/ta.0000000000004651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2025]
Abstract
OBJECTIVES Despite the known burden of inappropriate overtriage of patients with facial injuries on the health care system, no comprehensive guidelines for the transfer of these patients exist. The aim of this study was to define guidelines regarding which patients with isolated craniomaxillofacial trauma require transfer to higher levels of care. METHODS We performed a 5-year review at a Level I trauma center (2017-2021). We included all transferred patients with isolated facial fractures. Patients were stratified into appropriate (those who received any emergency [taken directly to operating room] or urgent intervention [intervention in same admission] for facial injuries or were admitted to the ward for observation) and potentially inappropriate (patients who did not require any emergent or urgent intervention or admission to the facial trauma service [FTS]) transfers. Three independent experts reviewed the reason for the transfer and required interventions during the hospitalization and defined if the transfer was appropriate. RESULTS We identified 511 patients transferred to our Level I trauma center with isolated facial injuries. Over half (n = 259, 51%) of these transfers were potentially unnecessary, as these patients did not require intervention or admission. Overall, FTS was consulted for 89% of patients. A total of 252 patients (49%) were identified as appropriate transfers, of which 54% were admitted to the floor, 15% received emergency intervention, and 79% underwent urgent intervention. Eighty-two percent of potentially inappropriate transfers received an FTS consultation, and 81% were discharged from ED with a median length of stay of 6 hours. After a review of patient's hospitalization events, the Facial Injury Guidelines were defined. CONCLUSION More than half of the patients with isolated facial fractures did not require any intervention or admission. The proposed guidelines could significantly reduce unnecessary transfers and health care costs for patients with isolated craniomaxillofacial trauma. Prospective validation of the Facial Injury Guidelines is warranted before it could be considered for implementation. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Francisco Castillo Diaz
- From the Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
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Lee SY, Jackson JE, Stokes SC, Vukcevich O, Leshikar H, Rinderknecht T, Kohler JE, Hirose S, Brown EG. Pediatric trauma transfer patients have low rates of additional traumatic injuries. Am J Surg 2025; 243:116259. [PMID: 40048987 DOI: 10.1016/j.amjsurg.2025.116259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2024] [Revised: 01/31/2025] [Accepted: 02/18/2025] [Indexed: 04/16/2025]
Abstract
BACKGROUND Pediatric trauma patients often require interfacility transfer for subspecialty management of presumed isolated injuries. Understanding the frequency of additional injury in these low-acuity patients may improve resource utilization. METHODS Pediatric trauma patients transferred to a level 1 trauma center in 2019 were compared by type of presenting injury in a retrospective review. Primary outcome was additional traumatic injuries identified. RESULTS 530 pediatric trauma patients were transferred, most commonly for an isolated orthopedic injury (56.5 %). The overall rate of additional injuries identified was 2.8 %, with the highest rate in patients transferred with neurosurgical injuries (6.7 %). When compared to other transfer patients, patients with isolated orthopedic injuries were least likely to have any additional injuries (1.0 % vs. 4.8 %, p = 0.01). CONCLUSIONS Pediatric trauma patients transferred with isolated injuries rarely had additional injuries identified after transfer. Streamlining care for this population while maintaining vigilance for missed injuries is a target for future interventions.
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Affiliation(s)
- Su Yeon Lee
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA
| | - Jordan E Jackson
- Department of Surgery, University of San Francisco- East Bay, 1411 East 31st St, Oakland, CA, 94602, USA
| | - Sarah C Stokes
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA
| | - Olivia Vukcevich
- University of California Riverside School of Medicine, 92521 Botanic Gardens Dr., Riverside, CA, 92507, USA
| | - Holly Leshikar
- Division of Pediatric Orthopedic Surgery, 2425 Stockton Blvd, Sacramento, CA 95817, USA
| | - Tanya Rinderknecht
- Division of Trauma, Acute Care Surgery, and Critical Care, 2315 Stockton Blvd, Sacramento, CA, 95817, USA
| | - Jonathan E Kohler
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA
| | - Shinjiro Hirose
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA
| | - Erin G Brown
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA, 95817, USA.
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Edelstein MS, Kiang K, Henry A. Assessing the need for specialty consultation for isolated medial orbital wall fractures. Oral Surg Oral Med Oral Pathol Oral Radiol 2025; 139:409-412. [PMID: 39753431 DOI: 10.1016/j.oooo.2024.10.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 09/20/2024] [Accepted: 10/21/2024] [Indexed: 02/26/2025]
Abstract
OBJECTIVE This objective was to assess if the current practice of interfacility transfer and immediate specialty consult is justified by the rate of surgical repair for isolated medial orbital wall fractures. STUDY DESIGN This is a retrospective descriptive study utilizing the records of all patients with isolated medial orbital wall fractures who presented to the ED at Boston Medical Center from January 2014 to December 2022. A descriptive analysis was completed. RESULTS A total of 65 patients with isolated medial orbital wall fractures were identified. No patient underwent surgical intervention for repair of their fracture. 15% of the patients were transferred from an outside facility. The facial trauma team was consulted for 70% of the patients. Concomitant consultation of the ophthalmology and facial trauma teams occurred for 54% of the patients. Patients with no specialty consult had the shortest average length of ED stay. The no-show rate for follow-up appointments was 70%. CONCLUSIONS The absence of surgical repair for isolated medial orbital wall fractures across multiple surgical specialties, multiple attending providers, a wide age range, and all mechanisms of injury along with a 70% follow-up no-show rate may call into question the conventional approach of interfacility transfer and immediate specialty consult for these fractures.
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Affiliation(s)
- Morris S Edelstein
- Oral & Maxillofacial Surgery, Boston Medical Center, Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts, USA.
| | - Kevin Kiang
- Oral & Maxillofacial Surgery, Boston Medical Center, Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts, USA
| | - Andrew Henry
- Oral & Maxillofacial Surgery Department, Boston Medical Center, Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts, USA
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Hashmi ZG, Park C. Using Teletrauma to Improve Access to Trauma Care in the US: A Call for Action. J Am Coll Surg 2025; 240:212-219. [PMID: 39268968 DOI: 10.1097/xcs.0000000000001210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2024]
Abstract
Nearly 30 million, mostly rurally located Americans lack timely access to level I or II trauma center care, resulting in inefficient resource use and potentially preventable death. Although significant progress has been made in the care of the injured patient during the last few decades, rural trauma patients continue to face significant challenges in accessing high-quality trauma care with resultant outcomes disparities and increased expenditures associated with potentially avoidable interfacility transfers. Current mitigation strategies have not sufficiently improved access to trauma care among this population, necessitating a search for alternative strategies such as integration of telehealth for trauma care or teletrauma. Telehealth is well-established in several healthcare areas resulting in improved patient- and system-level outcomes. Although telehealth has been used in trauma with some success, it remains underused. Members of a 2023 American College of Surgeons Committee on Trauma Spotlight Session on the role of teletrauma present an introduction to the applications, potential benefits, and future directions for telehealth use in trauma care.
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Affiliation(s)
- Zain G Hashmi
- From the Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham and Center for Injury Science, University of Alabama at Birmingham, Birmingham, AL (Hashmi)
| | - Caroline Park
- Division of Acute Care Surgery, Department of General Surgery, University of Texas Southwestern Medical Center, Dallas, TX (Park)
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Wycech Knight J, Fokin AA, Menzione N, Puente I. Inter-facility transfers to an urban level 1 trauma center and rates of secondary overtriage. Eur J Trauma Emerg Surg 2025; 51:48. [PMID: 39853467 DOI: 10.1007/s00068-024-02741-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Accepted: 12/25/2024] [Indexed: 01/26/2025]
Abstract
PURPOSE Many patients originally transported to non-trauma centers (NTC) require transfer to a trauma center (TC) for treatment. The aim was to analyze injury characteristics and outcomes of transfer patients and investigate the secondary overtriage (SOT). METHODS Study included 2,056 transfers to an urban level 1 TC between 01/2016 and 06/2020. Analyzed variables included: demographics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), transfer reason and timing, computed tomography (CT) scans, surgery rate, intensive care unit (ICU) admissions, hospital lengths of stay (HLOS), mortality and SOT. SOT was defined as discharge within 48 h without surgery or ICU admission. RESULTS Transfers constituted 32.1% of TC admissions. Mean age was 66.7 and 60.7% were geriatric (≥ 65 years). Mean ISS was 11.6 and GCS was 14.3. The average time between NTC and TC admission was 4.2 h. Main reason for transfer was a head injury (57.9%), followed by a spine injury (19.2%). CT scans were repeated at the TC in 76.1% of patients. Surgical interventions were necessary in 18.5% of patients, with lowest rate in head (13.8%) and spine (15.4%) injuries. 45.9% of patients required ICU admissions. Overall mortality was 7.2%. SOT was 30.5%, being the highest in patients with spine (43.0%) and head (29.4%) injuries. Short HLOS affected SOT rates the most. CONCLUSIONS Transfers constituted a third of all TC admissions. The main reasons for transfer were head and spine injuries. SOT accounted for one third of transfers and occurred primarily in patients with spine and head injuries.
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Affiliation(s)
- Joanna Wycech Knight
- Delray Medical Center, Division of Trauma and Critical Care Services, 5352 Linton Boulevard, Delray Beach, FL, 33484, USA
- Division of Trauma and Critical Care Services, Broward Health Medical Center, 1600 S Andrews Ave, Fort Lauderdale, FL, 33316, USA
| | - Alexander A Fokin
- Delray Medical Center, Division of Trauma and Critical Care Services, 5352 Linton Boulevard, Delray Beach, FL, 33484, USA.
- Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, 777 Glades Rd, Boca Raton, FL, 33431, USA.
| | - Nicholas Menzione
- Delray Medical Center, Division of Trauma and Critical Care Services, 5352 Linton Boulevard, Delray Beach, FL, 33484, USA
| | - Ivan Puente
- Delray Medical Center, Division of Trauma and Critical Care Services, 5352 Linton Boulevard, Delray Beach, FL, 33484, USA
- Division of Trauma and Critical Care Services, Broward Health Medical Center, 1600 S Andrews Ave, Fort Lauderdale, FL, 33316, USA
- Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, 777 Glades Rd, Boca Raton, FL, 33431, USA
- Department of Surgery, Florida International University, Herbert Wertheim College of Medicine, 11200 SW 8th St, Miami, FL, 33199, USA
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Hashmi ZG, Rokayak O, Boggs KM, Zachrison KS, Espinola JA, Jarman MP, Jansen JO, Locke JE, Kerby JD, Camargo CA. Teletrauma Use in US Emergency Departments. JAMA Surg 2024; 159:1383-1391. [PMID: 39292475 PMCID: PMC11411445 DOI: 10.1001/jamasurg.2024.3758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/05/2024] [Indexed: 09/19/2024]
Abstract
Importance Nearly 30 million predominantly rural US residents lack timely access to trauma care expertise available at level I or II trauma centers. Telehealth is an established approach to improve access to health care expertise using remote consultation; however, the prevalence of use of telehealth in trauma (teletrauma) across the US is not known. Objective To examine the prevalence of, trends in, and factors associated with teletrauma use and adoption among US emergency departments (EDs). Design, Setting, and Participants This survey study included data from the National Emergency Department Inventory (NEDI)-USA survey from January 1, 2016, to December 31, 2020. Each year, a 1-page survey was sent to the directors of nonfederal, nonspecialty EDs by mail and email up to 3 times; nonresponders were further contacted via telephone to complete the survey. Data were analyzed from January to March 2023. Main Outcomes and Measures The primary outcome was self-reported ED use of teletrauma for each year studied. Additional measures included data regarding self-reported use of any other telehealth service and ED characteristics. Multivariable logistic regression analyses were performed to assess ED characteristics associated with teletrauma use in 2020 and teletrauma adoption between 2017 and 2020. Results Of 5586 EDs in the US in 2020, 4512 had available teletrauma survey data (80.8% response rate); 379 (8.4%) of these EDs reported teletrauma use. In contrast, 2726 (60.4%) reported use of any other telehealth service. Teletrauma use (among EDs with any telehealth use) ranged between 0% in Alabama; Connecticut; Washington, DC; Indiana; New Jersey; Nevada; Oklahoma; Oregon; Rhode Island; and South Carolina to more than 60% in Arkansas (39 of 64 [60.9%]), South Dakota (31 of 41 [75.6%]), and North Dakota (30 of 35 [85.7%]). Factors associated with teletrauma use included rural location (odds ratio [OR], 2.44; 95% CI, 1.77-3.36), critical access hospital (OR, 2.67; 95% CI, 1.83-3.88), and basic stroke hospital vs nonstroke hospital (OR, 1.74; 95% CI, 1.32-2.30) designations. Factors associated with adoption of teletrauma by 2020 included critical access hospital (OR, 1.98; 95% CI, 1.35-2.90) and basic stroke hospital vs nonstroke hospital (OR, 1.42; 95% CI, 1.04-1.94) designation. Conclusion and Relevance This survey study found that teletrauma use lagged significantly behind use of other telehealth services in US EDs in 2020. While most EDs using teletrauma were located in rural areas, there was significant state-level variation in teletrauma use. Future research is needed on how teletrauma is being used and to identify barriers to its wider implementation.
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Affiliation(s)
- Zain G. Hashmi
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham
- Center for Injury Science, University of Alabama at Birmingham
| | - Omar Rokayak
- Division of Acute Care Surgical Services, Department of Surgery, Virginia Commonwealth University, Richmond
| | - Krislyn M. Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Janice A. Espinola
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Molly P. Jarman
- Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health and Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jan O. Jansen
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham
- Center for Injury Science, University of Alabama at Birmingham
| | - Jayme E. Locke
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham
| | - Jeffrey D. Kerby
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham
- Center for Injury Science, University of Alabama at Birmingham
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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Chui KKK, Chan YY, Leung LY, Hau ESS, Leung CY, Ha PPK, Cheng CH, Cheung NK, Hung KKC, Graham CA. Factors influencing secondary overtriage in trauma patients undergoing interhospital transfer: A 10-year multi-center study in Hong Kong. Am J Emerg Med 2024; 86:30-36. [PMID: 39316872 DOI: 10.1016/j.ajem.2024.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 08/08/2024] [Accepted: 09/13/2024] [Indexed: 09/26/2024] Open
Abstract
BACKGROUND With the development of regionalised trauma networks, interhospital transfer of trauma patients is an inevitable component of the trauma system. However, unnecessary transfer is a common phenomenon, and it is not without risk and cost. A better understanding of secondary overtriage would enable emergency physicians to make better decisions about trauma transfers and allow guidelines to be developed to support this decision making. This study aimed to describe the pattern of secondary overtriage in Hong Kong and identify its associated factors. METHODS This was a retrospective review of 10-years of prospectively collected multi-center data from two trauma registries in the New Territories of Hong Kong (2013-2022). The primary outcome is secondary overtriage, which was defined as early discharge alive within 48 h, Injury Severity Score (ISS) <15, and no surgical operation done. Patient characteristics, physiology, anatomy and investigation variables were compared against secondary overtriage using univariate and multivariable analyses. RESULTS During the study period, 3852 patients underwent interhospital transfer from a non-trauma center to a trauma center, and 809 (21 %) of the transfers were considered secondary overtriage. The secondary overtriage rate was higher in pediatric age groups at 34.8 % (97/279). Logistic regression analysis showed secondary overtriage to be associated with blunt trauma and an Abbreviated Injury Scale (AIS) score of <3 for head or neck, thorax, abdomen and extremities. CONCLUSION Interhospital transfer is an essential component of the trauma system. However, over one-fifth of the transfers were considered unnecessary in Hong Kong, and this could be considered to be an inefficient use of resources as well as cause inconvenience to patients and their families. We have identified related factors including blunt trauma, AIS <3 scores for head or neck, thorax, abdomen and extremities, and opportunities to establish and improve on transfer protocols. Further research should be aimed to safely reduce interhospital transfers in the future to improve the efficiency of the Hong Kong trauma system.
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Affiliation(s)
- Kenneth Ka Kam Chui
- Trauma & Emergency Centre, Prince of Wales Hospital, Hong Kong; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong.
| | - Yan Yi Chan
- Accident and Emergency Department, Tin Shui Wai Hospital, Hong Kong.
| | - Ling Yan Leung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong.
| | | | - Chun Yu Leung
- Accident and Emergency Department, Tuen Mun Hospital, Hong Kong.
| | | | - Chi Hung Cheng
- Trauma & Emergency Centre, Prince of Wales Hospital, Hong Kong; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong.
| | - Nai Kwong Cheung
- Trauma & Emergency Centre, Prince of Wales Hospital, Hong Kong; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong.
| | - Kevin Kei Ching Hung
- Trauma & Emergency Centre, Prince of Wales Hospital, Hong Kong; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong.
| | - Colin A Graham
- Trauma & Emergency Centre, Prince of Wales Hospital, Hong Kong; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong.
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Morocho B, Meinert J, Stirpe S, Paramore CG, Behm R. Retrospective Validation of Brain Injury Guidelines in a Rural Level II Trauma Center. J Surg Res 2024; 302:259-262. [PMID: 39116824 DOI: 10.1016/j.jss.2024.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 06/08/2024] [Accepted: 07/03/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION The routine transfer of mild to moderate traumatic brain injuries (TBIs) to trauma centers with neurosurgical capabilities has recently been re-evaluated. The Brain Injury Guidelines (BIG) were developed to categorize TBI patients into three categories (BIG-1, BIG-2, and BIG-3), each representing a progressively increasing risk of clinical deterioration. This classification system has been previously validated at both level I and level III trauma centers. The authors hypothesized the population of their rural level II trauma center would further validate the BIG criteria. METHODS Using the institutional trauma registry, a retrospective analysis was performed on all patients with isolated TBIs who presented to our rural level II trauma center from 2018 to 2022. Patients were categorized according to the previously validated BIG criteria. All head computed tomography (CT) imaging studies were reviewed by one neurosurgeon. Outcomes and adverse events were compared to previously published data. RESULTS Four hundred fifty four patients were captured with our inquiry; 138 matched BIG-1 criteria, 51 matched BIG-2 criteria, and 263 matched BIG-3 criteria. Two patients in BIG-1 (6%) and two patients in BIG-2 (12.5%) showed progression of their bleed on CT. No patients in BIG-1 or BIG-2 groups, including those showing progression on repeat CT, required a neurosurgical intervention. CONCLUSIONS Our results support the suppositions of the BIG authors who suggest patients categorized as BIG-1 or BIG-2 do not require repeat head CT scans, neurosurgery consultation, or transfer to a tertiary center.
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Affiliation(s)
- Bryant Morocho
- Department of Surgery, Guthrie Robert Packer Hospital, Sayre, Pennsylvania.
| | - Justin Meinert
- Department of Surgery, Guthrie Robert Packer Hospital, Sayre, Pennsylvania
| | | | | | - Robert Behm
- Division of Trauma/Surgical Critical Care, Department of Surgery, Guthrie Robert Packer Hospital, Sayre, Pennsylvania
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Osher J, Archer A, Heard MA, McBride ME, Leonard M, Burns JB. Evaluation of Secondary Overtriage at a Rural Level 1 Trauma Center. Am Surg 2024; 90:2244-2248. [PMID: 38877738 DOI: 10.1177/00031348241262429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024]
Abstract
OBJECTIVE To retrospectively assess the prevalence of secondary overtriage (SO) within a rural regional Appalachian health care system. METHODS Trauma registry data was extracted for all trauma activation transfer patients from 2017 to 2022. Transferred patients were then stratified into two groups, non-secondary overtriage (non-SO) or SO. Patients were considered SO if they met three criteria following transfer: an Injury Severity Score (ISS) of less than 15, no required operative intervention, and discharge within 48 hours of arrival. Descriptive statistics were compared for age, length of stay (LOS), ICU LOS, and ISS. Surgical subspecialty consultations were compared between the two groups. Patients in the SO group were further assessed by body region of injury and Abbreviated Injury Score (AIS). RESULTS Among 3,291 trauma activation transfer patients, 43% (1,407) were considered SO transfers. Patients in the SO group were significantly younger, had shorter average hospital and ICU LOS, and lower ISS compared to the non-SO group. Additionally, 25.7% of patients in the SO group had injuries to the head or neck of which 8.96% have an AIS ≥3. 21% of patients had injuries to the face, with 0.14% having an AIS ≥3. CONCLUSIONS 43% of transfer patients in this study met our definition of SO. Although no optimal rate of SO has been universally established, limiting SO stands to benefit both patients and trauma systems. This study highlights how institutional analysis of transfer patients may help inform transfer protocols to reduce secondary overtriage and overutilization of scarce resources.
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Affiliation(s)
- Jennifer Osher
- Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Allen Archer
- Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Matthew A Heard
- Department of Surgery, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Mary E McBride
- Department of Surgery, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Matthew Leonard
- Department of Surgery, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - J Bracken Burns
- Department of Surgery, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
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Shen A, Mizraki N, Maya M, Torbati S, Lahiri S, Chu R, Margulies DR, Barmparas G. Reducing low-value interhospital transfers for mild traumatic brain injury. J Trauma Acute Care Surg 2024; 96:944-948. [PMID: 38523124 DOI: 10.1097/ta.0000000000004291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
BACKGROUND The modified Brain Injury Guidelines (mBIG) were developed to stratify traumatic brain injuries (TBIs) and improve health care utilization by selectively requiring repeat imaging, intensive care unit admission, and neurosurgical (NSG) consultation. The goal of this study is to assess safety and potential resource savings associated with the application of mBIG on interhospital patient transfers for TBI. METHODS Adult patients with TBI transferred to our Level I trauma center from January 2017 to December 2022 meeting mBIG inclusion criteria were retrospectively stratified into mBIG1, mBIG2, and mBIG3 based on initial clinicoradiological factors. At the time, our institution routinely admitted patients with TBI and intracranial hemorrhage (ICH) to the intensive care unit and obtained a repeat head computed tomography with NSG consultation, independent of TBI severity or changes in neurological examination. The primary outcome was progression of ICH on repeat imaging and/or NSG intervention. Secondary outcomes included length of stay and financial charges. Subgroup analysis on isolated TBI without significant extracranial injury was performed. RESULTS Over the 6-year study period, 289 patients were classified into mBIG1 (61; 21.1%), mBIG2 (69; 23.9%), and mBIG3 (159; 55.0%). Of mBIG1 patients, 2 (2.9%) had radiological progression to mBIG2 without clinical decline, and none required NSG intervention. Of mBIG2, 2 patients (3.3%) progressed to mBIG3, and both required NSG intervention. More than 35% of transferred patients had minor isolated TBI. For mBIG1 and mBIG2, the median hospitalization charges per patient were $152,296 and $149,550, respectively, and the median length of stay was 4 and 5 days, respectively, with the majority downgraded from the intensive care unit within 48 hours. CONCLUSION Clinically significant progression of ICH occurred infrequently in 1.5% of patients with mBIG1 and mBIG2 injuries. More than 35% of interfacility transfers for minor isolated TBI meeting mBIG1 and 2 criteria are low value and may potentially be safely deferred in an urban health care setting. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Aricia Shen
- From the Department of Surgery (A.S., D.M., G.B.), Division of Acute Care Surgery and Surgical Critical Care, Department of Radiology (N.M., M.M.), Department of Emergency Medicine (S.T.), Department of Neurology (S.L.), Department of Biomedical Sciences (S.L.), and Department of Neurosurgery (S.L., R.C.), Cedars-Sinai Medical Center, Los Angeles, California
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Jung S, Yi Y. Incidence of overtriage and undertriage and associated factors: A cross-sectional study using a secondary data analysis. J Adv Nurs 2024; 80:1405-1416. [PMID: 37828736 DOI: 10.1111/jan.15895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/06/2023] [Accepted: 09/20/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Improving triage accuracy for accurate patient identification and appropriate resource allocation is essential. Little is known about the trend of triage accuracy, and factors associated with mistriage vary from study to study. AIM To identify incidence and risk factors of mistriage, such as overtriage and undertriage. DESIGN This is a cross-sectional study. METHODS The data came from the National Emergency Department Information System database in 2016-2020. All patients 15 years and older visiting emergency departments in Korea were assessed for eligibility, and 20,641,411 emergency patients' data were used. Multivariable logistic regressions were conducted to confirm the associated factors with overtriage and undertriage compared to expected triage. Demographic characteristics, disease-related signs and triage-related factors were independent variables. RESULTS Expected triage decreased from 96.8% in 2016 to 95.7% in 2020. Overtriage (0.5%-0.7%) and undertriage (2.4%-3.3%) increased. The occupation that performed triage the most (over 85%) was nurses. Associated factors with overtriage were demographic characteristics (40-64 age group, female), disease-related signs (known disease, direct visit) and triage-related factors (regional emergency medical centre). Risk factors to undertriage were disease-related signs (systolic/diastolic blood pressure and pulse rates within normal range). CONCLUSIONS While the acuity degree remained within the recommended range, the accuracy of triage decreased, and there was a gradual increase in mistriaged cases. Nurses have performed most of the triage and played a key role in expected triage. Associated factors with overtriage were demographic characteristics, disease-related signs and triage-related factors and risk factors to undertriage were disease-related signs. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution. IMPLICATIONS FOR THE PROFESSION Nurses should be aware of what factors are associated with mistriage and why the factors cause mistriage to improve the triage accuracy because they are responsible for the majority of the triage assessments.
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Affiliation(s)
- Sookyung Jung
- College of Nursing, Hanyang University, Seoul, Republic of Korea
- Out-Patient Nursing Team, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Yeojin Yi
- College of Nursing, Hanyang University, Seoul, Republic of Korea
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O'Guinn ML, Martino AM, Ourshalimian S, Holliday-Carroll MC, Chaudhari PP, Spurrier R. Association Between Hospital Arrival Time and Avoidable Transfer in Pediatric Trauma. J Pediatr Surg 2024; 59:310-315. [PMID: 37973422 DOI: 10.1016/j.jpedsurg.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/13/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Avoidable transfers (AT) in pediatric trauma can increase strain on healthcare resources and families. We sought to identify characteristics of patients and their injuries that are associated with AT. METHODS A multicenter retrospective cross-sectional study of the regional Trauma Registry was conducted from 1/1/10-12/31/21 of children <18 years-old who experienced an interfacility transfer. AT was defined as receiving hospital length of stay (LOS) < 48 hrs without procedure or intervention performed. Patient demographics, mechanism of injury, and arrival time were analyzed with descriptive statistics. A multivariable logistic regression was performed to analyze demographic and clinical factors associated with AT. RESULTS We included 5438 trauma transfers, of which 2187 (40.2%) were AT. Patients experiencing AT had a median [IQR] age of 5 years [1-12] and most were male (67%) and Hispanic/Latino (46.3%). The odds of experiencing AT decreased as age increased and were less likely in females and Non-Hispanic Black children. Injuries from falls (ground level (OR = 2.48; 95%CI = 1.89-3.28) and >10 ft (OR = 3.20; 95%CI = 2.35-4.39)), sports/recreational activities (OR = 2.36; 95%CI = 1.78-3.16), MVCs (OR = 1.44; 95%CI = 1.05-1.98), and firearms (OR = 1.74; 95%CI = 1.15-2.62) were associated with an increased odds of AT. Time of arrival at the receiving facility in early hours (00:00-07:59) (OR = 1.48; 95%CI = 1.24-1.76) and evening hours (17:00-23:59) (OR = 1.75; 95%CI = 1.47-2.07) were associated with an increased odds of AT. CONCLUSION Younger patients, injuries from falls, sports/recreational activities, MVCs, and firearms as well as arrival time outside of standard work hours are more likely to result in AT. Knowing these results, we can begin working with our referral centers to improve communication and strengthen institutional transfer criteria for pediatric trauma patients. Further investigation will then be needed to determine if the changes implemented have influenced care and lowered rates of avoidable transfer. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- MaKayla L O'Guinn
- Children's Hospital Los Angeles, Division of Pediatric Surgery, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Alice M Martino
- Children's Hospital Los Angeles, Division of Pediatric Surgery, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Shadassa Ourshalimian
- Children's Hospital Los Angeles, Division of Pediatric Surgery, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Mary C Holliday-Carroll
- Children's Hospital Los Angeles, Division of Pediatric Surgery, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA
| | - Pradip P Chaudhari
- Children's Hospital Los Angeles, Division of Emergency Medicine &Transport Medicine, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA; Keck School of Medicine of University of Southern California, Department of Pediatrics, 1975 Zonal Ave, Los Angeles, CA 90033, USA
| | - Ryan Spurrier
- Children's Hospital Los Angeles, Division of Pediatric Surgery, 4650 W Sunset Blvd, Los Angeles, CA 90027, USA; Keck School of Medicine of University of Southern California, Department of Surgery, 1975 Zonal Ave, Los Angeles, CA 90033, USA.
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Asti L, Chisolm DJ, Xiang H, Deans KJ, Cooper JN. Association of the Affordable Care Act Medicaid Expansion With Secondary Overtriage among Young Adult Trauma Patients. J Surg Res 2023; 283:161-171. [PMID: 36410232 DOI: 10.1016/j.jss.2022.10.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/01/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous work has shown that the Affordable Care Act (ACA) Medicaid expansion decreased the uninsured rate and improved some trauma outcomes among young adult trauma patients, but no studies have investigated the impact of ACA Medicaid expansion on secondary overtriage, namely the unnecessary transfer of non-severely injured patients to tertiary trauma centers. METHODS Statewide hospital inpatient and emergency department discharge data from two Medicaid expansion and one non-expansion state were used to compare changes in insurance coverage and secondary overtriage among trauma patients aged 19-44 y transferred into a level I or II trauma center before (2011-2013) to after (2014-quarter 3, 2015) Medicaid expansion. Difference-in-difference (DD) analyses were used to compare changes overall, by race/ethnicity, and by ZIP code-level median income quartiles. RESULTS Medicaid expansion was associated with a decrease in the proportion of patients uninsured (DD: -4.3 percentage points; 95% confidence interval (CI): -7.4 to -1.2), an increase in the proportion of patients insured by Medicaid (DD: 8.2; 95% CI: 5.0 to 11.3), but no difference in the proportion of patients who experienced secondary overtriage (DD: -1.5; 95% CI: -4.8 to 1.8). There were no differences by race/ethnicity or community income level in the association of Medicaid expansion with secondary overtriage. CONCLUSIONS In the first 2 y after ACA Medicaid expansion, insurance coverage increased but secondary overtriage rates were unchanged among young adult trauma patients transferred to level I or II trauma centers.
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Affiliation(s)
- Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205
| | - Deena J Chisolm
- Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Department of Pediatrics, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210; Division of Health Services Management & Policy, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, Ohio 43210
| | - Henry Xiang
- Department of Pediatrics, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210; Center for Pediatric Trauma Research and Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Department of Surgery, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Department of Pediatrics, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210; Division of Epidemiology, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, Ohio 43210.
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Lee CC, Wang TT, Hajibandeh JT, Peacock ZS. Interfacility Emergency Department Transfer for Midface Fractures in the United States. J Oral Maxillofac Surg 2023; 81:172-183. [PMID: 36403659 DOI: 10.1016/j.joms.2022.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 10/19/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE Interfacility hospital transfer for isolated midfacial fractures is common but rarely clinically necessary. The purpose of this study was to generate nationally representative estimates regarding the incidence, risk factors, and cost of transfer for isolated midface fractures. METHODS This was a retrospective cohort study using the Nationwide Emergency Department Sample 2018 to identify patients with isolated midface fractures. The primary predictor variable was hospital trauma center designation (Level I, Level II, Level III, and nontrauma center). The primary outcome variable was hospital transfer. Total emergency department (ED) charges were also assessed. Covariates were demographic, medical, injury-related, and hospital characteristics. Descriptive, bivariate, and multiple logistic regression statistics were used to evaluate the incidence and predictors of interfacility transfer. RESULTS During the study period, there were 161,022 ED encounters with a midface fracture as primary diagnosis, of which 5,680 were transferred (3.53%). In an unadjusted analysis, evaluation at a nontrauma center, level III trauma center, nonteaching hospital, and numerous demographic, medical, and injury-related variables were associated with transfer (P ≤ .001). In the adjusted model, the strongest independent predictors for hospital transfer were evaluation at a nontrauma center (odds ratio [OR] = 16.2, 95% confidence interval [CI] = 13.6-19.4), level III trauma center (OR = 13.4, 95% CI = 11.1-16.1) or level II trauma center (OR = 3.25, 95% CI = 2.66-3.98), any Le Fort fracture (OR = 12.0, 95% CI = 10.4-14.0), orbital floor fracture (OR = 3.73, 95% CI = 3.48-4.00), history of cerebrovascular event (OR = 2.74, 95% CI = 2.18-3.45), and cervical spine injury (OR = 5.87, 95% CI = 4.79-7.20) (P ≤ .001). The average ED charge per encounter was $7,206 ± 9,294 for a total nationwide charge of approximately 1.16 billion dollars. Transferred subjects had total ED charges of $97 million, not including additional charges at the recipient hospital. CONCLUSION Isolated midface fractures are transferred infrequently, but given the high incidence have substantial healthcare costs. Predictors of transfer were mixed rather than clustered within one variable type, although it is likely that transfers are driven in part by lack of access to maxillofacial specialists given the predominance of hospital covariates. Programs evaluating necessity of transfer and facilitating specialist evaluation in the outpatient setting may reduce healthcare expenditures for these injuries.
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Affiliation(s)
- Cameron C Lee
- Head and Neck Oncology Fellow, Oral & Maxillofacial Surgery, University of Maryland Medical Center, Baltimore, MD and Clinical Research Fellow, Oral & Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA
| | - Tim T Wang
- Resident, Oral & Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA
| | - Jeffrey T Hajibandeh
- Instructor, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA
| | - Zachary S Peacock
- Associate Professor, Oral & Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA.
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15
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Lee CC, Wang TT, Gandotra S, Hajibandeh JT, Peacock ZS. Interfacility Emergency Department Transfer for Mandibular Fractures in the United States. J Oral Maxillofac Surg 2022; 80:1757-1768. [DOI: 10.1016/j.joms.2022.07.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/21/2022] [Accepted: 07/27/2022] [Indexed: 11/30/2022]
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16
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Resource utilization and secondary overtriage for patients with traumatic renal injuries in a regional trauma system. J Trauma Acute Care Surg 2022; 92:1061-1065. [PMID: 34882595 DOI: 10.1097/ta.0000000000003489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND While renal trauma management has shifted to conservative nonoperative management, insufficient data exist to guide interhospital renal trauma transfer protocols. Secondary overtriage is defined as the potentially avoidable transfer of patients from a lower to a higher-level trauma center despite the lack of need for higher-level care. The goal of this study was to determine the prevalence and predictors of secondary overtriage in renal trauma patients to a level 1 trauma center. METHODS A retrospective cohort study was performed of all renal trauma patients transferred to a level 1 institution between 2005 and 2017. Secondary overtriage was defined as a potentially avoidable transfer that consisted of hospital stay <72 hours with survival, no surgical or interventional radiology procedure, and all nonabdominal Abbreviated Injury Scale scores of <3 after transfer. Multivariate logistic regression was performed to estimate odds of secondary overtriage based on predefined clinical criteria. RESULTS Of the 612 renal trauma patients transferred between 2005 and 2017, 71 (11.6%) met the criteria for secondary overtriage. Female patients and patients coming from level IV/V trauma centers were more likely to have potentially avoidable transfers (p = 0.01 and p < 0.001, respectively). Mean (SD) Injury Severity Score was 10 (4.2) and 30.7 (14.3) in overtriaged and appropriately triaged patients, respectively (p < 0.001). Of the 71 overtriaged patients, 70.4% had isolated renal injuries. Patients with isolated renal injuries (odds ratio, 39.0; 95% confidence interval, 16.44-105.39) and those transferred from a level IV/V trauma center (odds ratio, 3.85; 95% confidence interval, 1.64-9.61) had a higher likelihood of secondary overtriage. CONCLUSION Within our regional trauma system, the majority of secondary overtriage was due to potentially avoidable transfers from level IV/V centers and of patients with isolated renal injuries. By implementing strategies to reduce the secondary overtriage burden on major trauma centers, regional trauma systems can avoid unnecessary costs while maintaining patient safety and ensuring appropriate care. LEVEL OF EVIDENCE Therapeutic/care management, Level III.
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Understanding secondary overtriage for neurosurgical patients in a rural tertiary care setting. Clin Neurol Neurosurg 2021; 213:107101. [PMID: 34959106 DOI: 10.1016/j.clineuro.2021.107101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/17/2021] [Accepted: 12/18/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Excessive interfacility transfer to a tertiary care facility of minimally injured patients for subspecialty evaluation leads to overuse of resources and is referred to as secondary overtriage (SO). Little is known regarding the epidemiology of SO in rural settings, particularly for patients with a mild head injury who may be safely managed without admission to level I trauma centers. METHODS In order to determine the rate of SO for neurosurgical patients with Glasgow Coma Scale (GCS) of 13-15 referred to a rural level 1 trauma center, we conducted a retrospective chart review of 224 patients evaluated for potential transfer to Dartmouth-Hitchcock Medical Center from January 1, 2014 through December 31, 2014. SO was defined as any admission where a patient was transferred from an outside facility, had a length of stay shorter than 48 h, did not require neurosurgical intervention, and was alive at the time of discharge. RESULTS Of the 224 patients evaluated, 163 patients were transferred. Of the 163 patients included in this study, 43 (26.4%) met criteria for SO, 59 (36.2%) patients met criteria for intervention, and 61 (37.2%) patients met criteria for observation. CONCLUSIONS Approximately a quarter of the total patients who are transferred to a rural level I trauma center for neurosurgical evaluation are minimally injured, do not require neurosurgical intervention, and are discharged within 48 h of presentation. Management at their referring facility with remote neurosurgical consultation is likely safe in this population. Understanding the rate of SO in neurosurgical patients and risk factors present in this group can better guide future transfer policies at rural medical centers.
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Secondary overtriage in a pediatric level one trauma center. J Pediatr Surg 2021; 56:2337-2341. [PMID: 33972088 DOI: 10.1016/j.jpedsurg.2021.03.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/19/2021] [Accepted: 03/30/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Previous studies have explored under- and overtriage, and the means by which to optimize these rates. Few have examined secondary overtriage (SO), or the unnecessary transfer of minimally injured patients to higher level trauma centers. We sought to determine the incidence and impact of SO in our pediatric level one trauma center. METHODS We performed a retrospective analysis of all trauma activations at our institution from 2015 through 2017. SO was defined as transferred patients who required neither PICU admission nor an operation, with ISS ≤ 9 and LOS ≤ 24 h. We compared SO patients against all trauma activation transfers, and against similar non-transferred patients. RESULTS We identified 1789 trauma activations, including 766 (42.8%) transfers. Of the transfers, 335 (43.7%) met criteria for SO. Compared to other transfers, SO patients had a shorter mean travel distance (52.9 v 58.1 mi; p = 0.02). Compared to similar patients transported from the trauma scene, SO patients were more likely to be admitted (52.2% v 29.2%; p < 0.001), with longer inpatient stay and greater hospital charges. CONCLUSIONS SO represents an underrecognized burden to trauma centers which could be minimized to improve resource allocation. Future research should evaluate trauma activation criteria for transferred pediatric patients.
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Khan FA, Apple CG, Caldwell KJ, Larson SD, Islam S. Prehospital personnel discretion pediatric trauma team activations: Too much of a good thing? J Pediatr Surg 2021; 56:2052-2057. [PMID: 33814181 DOI: 10.1016/j.jpedsurg.2021.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/08/2021] [Accepted: 03/01/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Trauma team activation is essential to provide rapid assessment of injured patients, however excessive utilization can overburden systems. We aimed to identify predictors of over triage and evaluate impact of prehospital personal discretion trauma activations on the over triage rate. METHODS Retrospective comparative study of pediatric trauma patients (<18 years) evaluated after activation of the trauma team to those evaluated as a trauma consult treated between 2010 and 2013. Cohort matching of trauma activated and consult patients was done on the basis of patients' age and ISS. RESULTS 1363 patients including 359 trauma team activations were evaluated. Median age was 6 years, Injury Severity Score (ISS) 4, 116 (8.5%) required operative intervention and 20 (1.4%) died. Matched analysis using age and ISS showed trauma activated patients were more likely to have penetrating MOI (4.7% vs.1.7%; p = 0.03) and need ICU admission(32.9% vs.16.7%; p = 0.0001). State of Florida discrete criteria based trauma activated patients when compared to paramedic discretion activations had a higher ISS (9 vs.5; p = 0.014), need for ICU admission (36.5% vs.20.4%; p = 0.004), ICU LOS(2 vs.0 days; p = 0.02), hospital LOS(2 vs.2 days; p = 0.014) and higher likelihood of death(4.9% vs.0%;p = 0.0001). Moreover, paramedic discretion trauma activated patients were similar to trauma consult patients in terms of ISS score(p = 0.86), need for ICU admission(p = 0.86), operative intervention(p = 0.86), death(p = 0.86) and hospital LOS(p = 0.86), with a considerably higher cost of care(p = 0.0002). CONCLUSION Discrete criteria-based trauma team activations appear to more reliably identify patients likely to benefit from initial multidisciplinary management.
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Affiliation(s)
- Faraz A Khan
- Division of Pediatric Surgery, Department of Surgery, Loma Linda University School of Medicine., 11175 Campus Street, CP21111, Loma Linda, CA 923502, USA.
| | - Camille Gd Apple
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Rd. P.O. Box 10019, Gainesville, FL, USA
| | - Kenneth J Caldwell
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine., 1600 SW Archer Rd. P.O. Box 10019, Gainesville, FL, USA
| | - Shawn D Larson
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine., 1600 SW Archer Rd. P.O. Box 10019, Gainesville, FL, USA
| | - Saleem Islam
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine., 1600 SW Archer Rd. P.O. Box 10019, Gainesville, FL, USA
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Pontell M, Mount D, Steinberg JP, Mackay D, Golinko M, Drolet BC. Interfacility Transfers for Isolated Craniomaxillofacial Trauma: Perspectives of the Facial Trauma Surgeon. Craniomaxillofac Trauma Reconstr 2021; 14:201-208. [PMID: 34471476 PMCID: PMC8385630 DOI: 10.1177/1943387520962276] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
STUDY DESIGN Secondary overtriage is a burden to the medical system. Unnecessary transfers overload trauma centers, occupy emergency transfer resources, and delay definitive patient care. Craniomaxillofacial (CMF) trauma, especially in isolation, is a frequent culprit. OBJECTIVE The aim of this study is to assess the perspectives of facial trauma surgeons regarding the interfacility transfer of patients with isolated CMF trauma. METHODS A 31-item survey was developed using Likert-type scale and open-ended response systems. Internal consistency testing among facial trauma surgeons yielded a Cronbach's α calculation of .75. The survey was distributed anonymously to the American Society of Maxillofacial Surgeons, the North American Division of AO Craniomaxillofacial, and the American Academy of Facial Plastic and Reconstructive Surgery. Statistical significance in response plurality was determined by nonoverlapping 99.9% confidence intervals (P < .001). Sum totals were reported as means with standard deviations and z scores with P values of less than .05 considered significant. RESULTS The survey yielded 196 responses. Seventy-seven percent of respondents did not believe that most isolated CMF transfers required emergency surgery and roughly half (49%) thought that most emergency transfers were unnecessary. Fifty-four percent of respondents agreed that most patients transferred could have been referred for outpatient management and 87% thought that transfer guidelines could help decrease unnecessary transfers. Twenty-seven percent of respondents had no pre-transfer communication with the referring facility. Perspectives on the transfer of specific fracture patterns and their presentations were also collected. CONCLUSION Most facial trauma surgeons in this study believe that emergent transfer for isolated CMF trauma is frequently unnecessary. Such injuries rarely require emergent surgery and can frequently be managed in the outpatient setting without activating emergency transfer services. The fracture-specific data collected are a representation of the national, multidisciplinary opinion of facial trauma surgeons and correlate with previously published data on which specific types of facial fractures are most often transferred unnecessarily. The results of this study can serve as the foundation for interfacility transfer guidelines, which may provide a valuable resource in triaging transfers and decreasing associated health-care costs.
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Affiliation(s)
- Matthew Pontell
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Delora Mount
- Division of Plastic Surgery, University of Wisconsin Hospital, Madison, WI, USA
| | - Jordan P. Steinberg
- Department of Plastic and Reconstructive Surgery, Pediatric Plastic and Craniofacial Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Donald Mackay
- Division of Plastic Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Michael Golinko
- Division of Pediatric Plastic Surgery, Division of Cleft and Craniofacial Surgery, Monroe Carrell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
| | - Brian C. Drolet
- Department of Plastic Surgery, Department of Medical Bioinformatics, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
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Sturms LM, Driessen MLS, van Klaveren D, Ten Duis HJ, Kommer GJ, Bloemers FW, den Hartog D, Edwards MJ, Leenhouts PA, van Zutphen S, Schipper IB, Spanjersberg R, Wendt KW, de Wit RJ, Poeze M, Leenen LP, de Jongh M. Dutch trauma system performance: Are injured patients treated at the right place? Injury 2021; 52:1688-1696. [PMID: 34045042 DOI: 10.1016/j.injury.2021.05.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 05/09/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The goal of trauma systems is to match patient care needs to the capabilities of the receiving centre. Severely injured patients have shown better outcomes if treated in a major trauma centre (MTC). We aimed to evaluate patient distribution in the Dutch trauma system. Furthermore, we sought to identify factors associated with the undertriage and transport of severely injured patients (Injury Severity Score (ISS) >15) to the MTC by emergency medical services (EMS). METHODS Data on all acute trauma admissions in the Netherlands (2015-2016) were extracted from the Dutch national trauma registry. An ambulance driving time model was applied to calculate MTC transport times and transport times of ISS >15 patients to the closest MTC and non-MTC. A multivariable logistic regression analysis was performed to identify factors associated with ISS >15 patients' EMS undertriage to an MTC. RESULTS Of the annual average of 78,123 acute trauma admissions, 4.9% had an ISS >15. The nonseverely injured patients were predominantly treated at non-MTCs (79.2%), and 65.4% of patients with an ISS >15 received primary MTC care. This rate varied across the eleven Dutch trauma networks (36.8%-88.4%) and was correlated with the transport times to an MTC (Pearson correlation -0.753, p=0.007). The trauma networks also differed in the rates of secondary transfers of ISS >15 patients to MTC hospitals (7.8% - 59.3%) and definitive MTC care (43.6% - 93.2%). Factors associated with EMS undertriage of ISS >15 patients to the MTC were female sex, older age, severe thoracic and abdominal injury, and longer additional EMS transport times. CONCLUSIONS Approximately one-third of all severely injured patients in the Netherlands are not initially treated at an MTC. Special attention needs to be directed to identifying patient groups with a high risk of undertriage. Furthermore, resources to overcome longer transport times to an MTC, including the availability of ambulance and helicopter services, may improve direct MTC care and result in a decrease in the variation of the undertriage of severely injured patients to MTCs among the Dutch trauma networks. Furthermore, attention needs to be directed to improving primary triage guidelines and instituting uniform interfacility transfer agreements.
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Affiliation(s)
| | | | - David van Klaveren
- Erasmus University Medical Centre, Department of Public Health, Rotterdam, The Netherlands
| | - Henk-Jan Ten Duis
- Erasmus University Medical Centre, Department of Public Health, Rotterdam, The Netherlands
| | - Geert Jan Kommer
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, Amsterdam University Medical Center, location VU, Amsterdam, the Netherlands
| | - Dennis den Hartog
- Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Michael J Edwards
- Department of Trauma surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Peter A Leenhouts
- Department of Surgery, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - S van Zutphen
- Department of Surgery, ETZ Two Cities Hospital, Tilburg, The Netherlands
| | - Inger B Schipper
- Department of Trauma surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Klaus W Wendt
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen
| | - Ralph J de Wit
- Department of Trauma Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Luke P Leenen
- Department of Trauma surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mariska de Jongh
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, the Netherlands
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Reply: Unnecessary Interfacility Transfers for Craniomaxillofacial Trauma. Plast Reconstr Surg 2021; 147:170e-171e. [PMID: 33044280 DOI: 10.1097/prs.0000000000007466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Slain KN, Wurtz MA, Rose JA. US children of minority race are less likely to be admitted to the pediatric intensive care unit after traumatic injury, a retrospective analysis of a single pediatric trauma center. Inj Epidemiol 2021; 8:14. [PMID: 33840382 PMCID: PMC8040210 DOI: 10.1186/s40621-021-00309-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/16/2021] [Indexed: 11/23/2022] Open
Abstract
Background The public health impact of pediatric trauma makes identifying opportunities to equalize health related disparities imperative. The influence of a child’s race on the likelihood of admission to the pediatric intensive care unit (PICU) is not well described. We hypothesized that traumatically injured children of minority race would have higher rates of PICU admission, compared to White children. Methods This was a retrospective review of a single institution’s trauma registry including children ≤18 years of age presenting to the emergency department (ED) whose injury necessitated pediatric trauma team activation at a Level 1 Pediatric Trauma Center from July 1, 2011 through June 30, 2016. Demographics, injury characteristics and hospital utilization data were collected. Race was categorized as White or racial minority, which included patients identifying as Black, Hispanic ethnicity, Native American or “other.” The primary outcome measure was admission to the PICU. Chi square or Mann Whitney rank sum tests were used, as appropriate, to compare differences in demographics and injury characteristics between those children who were and were not admitted to the PICU setting. Variables associated with PICU admission in univariate analyses were included in a multivariate analysis. Data are presented as median values and interquartile ranges, or numbers and percentages. Results The median age of the 654 included subjects was 8 [IQR 4–13] years; 55.2% were a racial minority. Nine (1.4%) children died in the ED and 576 (88.1%) were admitted to the hospital. Of the children requiring hospitalization, 195 (33.9%) were admitted to the PICU. Children admitted to the PICU were less likely to be from a racial minority group (26.1% vs 42.5%, p < 0.001). After adjusting for age and injury characteristics in a multivariable analysis, racial minority children had a lower odds of PICU admission compared to White children (OR 0.492 [95% C.I. 0.298–0.813, p = 0.006]). Conclusions In this retrospective analysis of traumatically injured children, minority race was associated with lower odds of PICU admission, suggesting that health care disparities based on race persist in pediatric trauma-related care. Supplementary Information The online version contains supplementary material available at 10.1186/s40621-021-00309-x.
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Affiliation(s)
- Katherine N Slain
- Department of Pediatrics, Division of Pediatric Critical Care, University Hospitals Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Mailstop RBC 6010, Cleveland, OH, 44106, USA. .,Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Morgan A Wurtz
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Jerri A Rose
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Department of Pediatrics, Division of Pediatric Emergency Medicine, UH Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Mailstop RBC 6002, Cleveland, OH, 44106, USA
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Lee C, Yugendra P, Wee CPJ, Pek JH. Necessity of trauma referrals to the emergency department. PROCEEDINGS OF SINGAPORE HEALTHCARE 2020. [DOI: 10.1177/2010105820932611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Patients with traumatic injuries presenting to the emergency department (ED) may be referred to another hospital for further management. Unnecessary referrals can inflate health-care costs and workload, as well as reduce provider and patient satisfaction. Objectives: In this study, we determined the proportion of unnecessary trauma referrals and described the characteristics of this patient population. Methods: A retrospective chart review was carried out between 1 January and 31 December 2016. Data regarding demographics, diagnosis and clinical course at the ED were collected in standardised forms. A referral was defined as unnecessary if the patient was discharged from the ED without a therapeutic procedure performed. Results: There were 121 trauma referrals. The mean age was 39.0±18.3 years old, and 94 (77.7%) patients were male. Seventy-eight (64.5%) of the referrals were from EDs in the same health-care cluster. Overall, 15 (12.3%) referrals were unnecessary, and of these, nine patients had sustained burns or were suffering from smoke inhalation. The length of stay of these unnecessary referrals was 197.0±96.2 minutes. Referring ED outside the health-care cluster was significantly associated with unnecessary referrals (odds ratio=4.42, 95% confidence interval 1.40–13.97, p=0.007). Conclusion: More than 1 in 10 trauma referrals were unnecessary. Further collaborative prospective studies with other EDs are needed to elucidate the underlying reasons for such unnecessary referrals so that targeted solutions can be implemented to reduce them in the future.
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Affiliation(s)
- Chengjie Lee
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
| | - Paul Yugendra
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | | | - Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
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Morgan JM, Calleja P. Emergency trauma care in rural and remote settings: Challenges and patient outcomes. Int Emerg Nurs 2020; 51:100880. [PMID: 32622226 DOI: 10.1016/j.ienj.2020.100880] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 04/16/2020] [Accepted: 05/07/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Trauma is a global public health concern, with higher mortality rates acknowledged in rural and remote populations. Research to understand this phenomenon and to improve patient outcomes is therefore vital. Trauma systems have been developed to provide specialty care to patients in an attempt to improve mortality rates. However, not all trauma systems are created equally as distance and remoteness has a significant impact on the capabilities of the larger trauma systems that service vast geographical distances. The primary objective of this integrative literature review was to examine the challenges associated with providing emergency trauma care to rural and remote populations and the associated patient outcomes. The secondary objective was to explore strategies to improve trauma patient outcomes. METHODS An integrative review approach was used to inform the methods of this study. A systematic search of databases including CINAHL, Medline, EmBase, Proquest, Scopus, and Science Direct was undertaken. Other search methods included hand searching journal references. RESULTS 2157 articles were identified for screening and 87 additional papers were located by hand searching. Of these, 49 were included in this review. Current evidence reveals that rural and remote populations face unique challenges in the provision of emergency trauma care such as large distances, delays transferring patients to definitive care, limited resources in rural settings, specific contextual challenges, population specific risk factors, weather and seasonal factors and the availability and skill of trained trauma care providers. Consequently, rural and remote populations often experience higher mortality rates in comparison to urban populations although this may be different for specific mechanisms of injury or population subsets. While an increased risk of death was associated with an increase in remoteness, research also found it costs substantially less to provide care to rural patients in their rural environment than their urban counterparts. Other factors found to influence mortality rates were severity of injury and differences in characteristics between rural and urban populations. Trauma systems vary around the world and must address local issues that may be affected by distance, geography, seasonal population variations, specific population risk factors, trauma network operationalisation, referral and retrieval and involvement of hospitals and services which have no trauma designation. CONCLUSIONS The challenges acknowledged for rural and remote trauma patients may be lessened and mortality rates improved by implementing strategies such as telemedicine, trauma training and the expansion of trauma systems that are responsive to local needs and resources. Additional research to determine which of these challenges has the most significant impact on health outcomes for rural patients is required in an effort to reduce existing discrepancies. Emphasis on embracing and expanding inclusive planning for complex trauma systems, as well as strategies aimed at understanding the issues rural and remote clinicians face, will also assist to achieve this.
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Affiliation(s)
- Janita M Morgan
- School of Nursing and Midwifery, Griffith University, 170 Kessels Road, Nathan 4111, QLD, Australia; Gympie Hospital, Queensland Health, 12 Henry Street, Gympie 4570, QLD, Australia.
| | - Pauline Calleja
- School of Nursing and Midwifery, Griffith University, 170 Kessels Road, Nathan 4111, QLD, Australia; School of Nursing Midwifery & Social Sciences, CQUniversity, Level 3 Cairns Square, Corner Abbott and Shields Street, Cairns 4870, QLD, Australia; Retrieval Services Queensland, Department of Health, 125 Kedron Park Road, Kedron 4031, QLD, Australia.
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Seegert S, Redfern RE, Chapman B, Benson D. Efforts to Improve Appropriate Trauma Activation for Patients Transferred to a Level 1 Trauma Center From Outside Hospitals. Am Surg 2020; 86:467-475. [DOI: 10.1177/0003134820919732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Trauma centers monitor under- and overtriage rates to comply with American College of Surgeons Committee on Trauma verification requirements. Efforts to maintain acceptable rates are often undertaken as part of quality assurance. The purpose of this project was to improve the institutional undertriage rate by focusing on appropriately triaging patients transferred from outside hospitals (OSHs). Trauma physicians received education and pocket cards outlining injury severity score (ISS) calculation to aid in prospectively estimating ISS for patients transferred from OSHs, and activate the trauma response expected for that score. Under- and overtriage rates before and after the intervention were compared. The postintervention period saw a significant decrease in overall overtriage rate, with simultaneous trend toward lower overall undertriage rate, attributable to the significant reduction in undertriage rate of patients transferred from OSHs. Prospectively estimating ISS to assist in determining trauma activation level shows promise in managing appropriate patient triage. However, questions arose regarding the necessity for full trauma activation for transferred patients, regardless of ISS. It may be necessary to reconsider how patients transferred from OSHs are evaluated. Full trauma activation can be a financial and resource burden, and should not be taken lightly.
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Affiliation(s)
- Sara Seegert
- ProMedica Research, ProMedica Toledo Hospital, Toledo, OH, USA
| | | | | | - Daniel Benson
- Trauma Services, ProMedica Toledo Hospital, Toledo, OH, USA
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Prionas A, Tsoulfas G, Tooulias A, Papakoulas A, Piachas A, Papadopoulos V. Evaluating trauma care, outcomes and costs in a system in crisis: the necessity of a Greek National Trauma Database. Trauma Surg Acute Care Open 2020; 5:e000401. [PMID: 32373714 PMCID: PMC7193741 DOI: 10.1136/tsaco-2019-000401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/21/2020] [Accepted: 02/13/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND At present there is no organized trauma system in Greece and no national trauma database. The objective of this study was to record and evaluate trauma management at our university hospital and to measure the associated healthcare costs, while laying the foundations for a national database and the organization of regional trauma networks. METHODS Retrospective study of trauma patients (n=2320) between 2014 and 2015, through our single-center registry. Demographic information, injury patterns, hospital transfer, investigations, interventions, duration of hospitalization, Injury Severity Score (ISS), outcomes, complications and cost were recorded. RESULTS Road traffic collisions (RTC) accounted for 23.2% of traumas. The proportion of patients who were transferred to the hospital by the National Emergency Medical Services decreased throughout the study (n2015=76/1192 (6.38%), n2014=109/1128 (9.7%)) (p<0.05). 1209 (52.1%) of our trauma patients did not meet the US trauma field triage algorithm criteria. Overtriage of trauma patients to our facility ranged from 90.7% to 96.7%, depending on the criteria used (clinical vs. ISS criteria). Ninety-one (3.9%) of our patients received operative management. Intensive care unit admissions were 21 (0.1%). Seventy-six (3.3%) of our patients had ISS>15 and their mortality was 31.6%. The overall non-salary cost for trauma management was €623 140. 53% of these costs were attributed to RTCs. The cost resulting from the observed overtriage ranged from €121 000 to €315 000. Patients who did not meet the US trauma triage algorithm criteria accounted for 10.5% of total expenses. DISCUSSION Our results suggest that RTCs pose a significant financial burden. The prehospital triage of trauma patients is ineffective. A reduction of costs could have been achieved if prehospital triage was more effective. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Apostolos Prionas
- General Surgery, Queen's Hospital, Barking Havering and Redbridge Univesity Hospitals NHS Trust, Romford, London, UK
- Surgery and Cancer, Imperial College London, London, UK
- First General Surgery Department of Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - George Tsoulfas
- First General Surgery Department of Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Andreas Tooulias
- First General Surgery Department of Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Apostolos Papakoulas
- First General Surgery Department of Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Athanasios Piachas
- First General Surgery Department of Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Vasileios Papadopoulos
- First General Surgery Department of Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
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Dengler BA, Plaza-Wüthrich S, Chick RC, Muir MT, Bartanusz V. Secondary Overtriage in Patients with Complicated Mild Traumatic Brain Injury: An Observational Study and Socioeconomic Analysis of 1447 Hospitalizations. Neurosurgery 2020; 86:374-382. [PMID: 30953054 DOI: 10.1093/neuros/nyz092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 02/27/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Secondary overtriage is a problematic phenomenon because it creates unnecessary expense and potentially results in the mismanagement of healthcare resources. The rates of secondary overtriage among patients with complicated mild traumatic brain injury (cmTBI) are unknown. OBJECTIVE To determine the rate of secondary overtriage among patients with cmTBI using the institutional trauma registry. METHODS An observational study using retrospective analysis of 1447 hospitalizations including all consecutive patients with cmTBI between 2004 and 2013. Data on age, sex, race/ethnicity, insurance status, GCS, Injury Severity Score (ISS), Trauma Injury Severity Score, transfer mode, overall length of stay (LOS), LOS within intensive care unit, and total charges were collected and analyzed. RESULTS Overall, the rate of secondary overtriage among patients with cmTBI was 17.2%. These patients tended to be younger (median: 41 vs 60.5 yr; P < .001), have a lower ISS (9 vs 16; P < .001), and were more likely to be discharged home or leave against medical advice. CONCLUSION Our findings provide evidence to the growing body of literature suggesting that not all patients with cmTBI need to be transferred to a tertiary care center. In our study, these transfers ultimately incurred a total cost of $13 294 ($1337 transfer cost) per patient.
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Affiliation(s)
- Bradley A Dengler
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Sonia Plaza-Wüthrich
- Division of Spine Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Robert C Chick
- Department of Surgery, Brooke Army Medical Center, San Antonio, Texas
| | - Mark T Muir
- Department of Surgery, University of Texas Health San Antonio, Texas
| | - Viktor Bartanusz
- Department of Neurosurgery, University of Texas Health San Antonio, Texas
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Abstract
INTRODUCTION Secondary overtriage (OT) is the unnecessary transfer of injured patients between facilities. In low- and middle-income countries (LMICs), which shoulder the greatest burden of trauma globally, the impact of wasted resources on an overburdened system is high. This study determined the rate and associated characteristics of OT at a Malawian central hospital. METHODS A retrospective analysis of prospectively collected data from January 2012 through July 2017 was performed at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. Patients were considered OT if they were discharged alive within 48 h without undergoing a procedure, and were not severely injured or in shock on arrival. Factors evaluated for association with OT included patient demographics, injury characteristics, and transferring facility information. RESULTS Of 80,915 KCH trauma patients, 15,422 (19.1%) transferred from another facility. Of these, 8703 (56.2%) were OT. OT patients were younger (median 15, IQR: 6-31 versus median 26, IQR: 11-38, p < 0.001). Patients with primary extremity injury (5308, 59.9%) were overtriaged more than those with head injury (1991, 51.8%) or torso trauma (1349, 50.8%), p < 0.001. The OT rate was lower at night (18.9% v 28.7%, p < 0.001) and similar on weekends (20.4% v 21.8%, p = 0.03). OT was highest for penetrating wounds, bites, and falls; burns were the lowest. In multivariable modeling, risk of OT was greatest for burns and soft tissue injuries. CONCLUSIONS The majority of trauma patients who transfer to KCH are overtriaged. Implementation of transfer criteria, trauma protocols, and interhospital communication can mitigate the strain of OT in resource-limited settings.
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Ryan JL, Pracht E, Langland-Orban B, Crandall M. Association of mechanism of injury with overtriage of injured youth patients as trauma alerts. Trauma Surg Acute Care Open 2019; 4:e000300. [PMID: 31922017 PMCID: PMC6937421 DOI: 10.1136/tsaco-2019-000300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 11/04/2019] [Accepted: 12/05/2019] [Indexed: 11/07/2022] Open
Abstract
Background Trauma alert criteria include physiologic and anatomic criteria, although field triage based on injury mechanism is common. This analysis evaluates injury mechanisms associated with pediatric trauma alert overtriage and estimates the effect of overtriage on patient care costs. Methods Florida’s Agency for Health Care Administration inpatient and financial data for 2012–2014 were used. The study population included mildly and moderately injured patients aged 5–15 years brought to a trauma center and had an International Classification of Diseases-based Injury Severity Score survival probability ≥0.90, a recorded mechanism of injury, no surgery, a hospital stay less than 24 hours, and discharged to home. Overtriaged patients were those who had a trauma alert. Logistic regression was used to analyze the odds of overtriage relative to mechanism of injury and multivariable linear regression was used to analyze cost of overtriage. Results Twenty percent of patients were overtriaged; yet these patients accounted for 37.2% of total costs. The mechanisms of injury related to firearms (OR 11.99) and motor vehicle traffic (2.25) were positively associated with overtriage as a trauma alert. Inpatient costs were 131.8% higher for overtriaged patients. Discussion Firearm injuries and motor vehicle injuries can be associated with severe injuries. However, in this sample, a proportion of patients with this mechanism suffered minimal injuries. It is possible that further identifying relevant anatomic and physiologic criteria in youth may help decrease overtriage without compromising outcomes. Level of evidence Economic, level IV.
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Affiliation(s)
- Jessica Lynn Ryan
- Health Sciences and Administration, University of West Florida, Pensacola, Florida, USA
| | - Etienne Pracht
- College of Public Health, University of South Florida, Tampa, Florida, USA
| | | | - Marie Crandall
- Surgery, University of Florida College of Medicine–Jacksonville, Jacksonville, Florida, USA
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Yamamoto R, Kurihara T, Sasaki J. A novel scoring system to predict the requirement for surgical intervention in victims of motor vehicle crashes: Development and validation using independent cohorts. PLoS One 2019; 14:e0226282. [PMID: 31821375 PMCID: PMC6903719 DOI: 10.1371/journal.pone.0226282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 11/24/2019] [Indexed: 11/29/2022] Open
Abstract
Background Given that there are still considerable number of facilities which lack surgical specialists round the clock across the world, the ability to estimate the requirement for emergency surgery in victims of motor vehicle crashes (MVCs) can ensure appropriate resource allocation. In this study, a surgical intervention in victims of MVC (SIM) score was developed and validated, using independent patient cohorts. Methods We retrospectively identified MVC victims in a nationwide trauma registry (2004–2016). Adults ≥ 15 years who presented with palpable pulse were included. Patients with missing data on the type/date of surgery were excluded. Patient were allocated to development or validation cohorts based on the date of injury. After missing values were imputed, predictors of the need for emergency thoracotomy and/or laparotomy were identified with multivariate logistic regression, and scores were then assigned using odds ratios. The SIM score was validated with area under the receiver operating characteristic curve (AUROC) and calibration plots of SIM score-derived probability and observed rates of emergency surgery. Results We assigned 13,328 and 12,348 patients to the development and validation cohorts, respectively. Age, motor vehicle collision and vital signs on hospital arrival were identified as independent predictors for emergency thoracotomy and/or laparotomy, and SIM score was developed as 0–9 scales. The score has a good discriminatory power (AUROC = 0.79; 95% confidence interval = 0.77–0.81), and both estimated and observed rates of emergency surgery increased stepwise from 1% at a score ≤ 1 to almost 40% at a score ≥ 8 with linear calibration plots. Conclusions The SIM score was developed and validated to accurately estimate the need for emergent thoracotomy and/or laparotomy in MVC victims.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
- * E-mail:
| | - Tomohiro Kurihara
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
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Parikh PP, Parikh P, Mamer L, McCarthy MC, Sakran JV. Association of System-Level Factors With Secondary Overtriage in Trauma Patients. JAMA Surg 2019; 154:19-25. [PMID: 30325989 DOI: 10.1001/jamasurg.2018.3209] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Importance Studies show that secondary overtriage (SO) contributes significantly to the economic burden of injured patients; thus, the association of SO with use of the trauma system has been examined. However, the association of the underlying trauma system design with such overtriage has yet to be evaluated. Objectives To evaluate whether the distribution of trauma centers in a statewide trauma system is associated with SO and to identify clinical and demographic factors that may lead to SO. Design, Setting, and Participants A retrospective cohort study was performed using 2008-2012 data from the Ohio Trauma and Emergency Medical Services registries. All patients taken to level III or nontrauma centers from the scene of the injury with an Injury Severity Score less than 15 and discharged alive were included. Among these patients, those with SO were identified as those who were subsequently transferred to a level I or II trauma center, had no surgical intervention, and were discharged alive within 48 hours of admission. The SO group was analyzed descriptively. Multiple logistic regression was used to identify system-level factors associated with SO. Statistical analysis was performed from August 1, 2017, to January 31, 2018. Main Outcomes and Measures The primary outcome was the occurrence of SO. Results Of 34 494 trauma patients able to be matched in the 2 registries, 7881 (22.9%) met the inclusion criteria, of whom 965 (12.2%) had SO. The median age in the SO group was 40 years (interquartile range, 26-55 years), with 299 women and 666 men. After adjusting for age, sex, comorbidities, injury type, and insurance status, the study found that system-level factors (number of level I or II trauma centers in the region [>1]) were significantly associated with SO (adjusted odds ratio, 1.98; 95% CI, 1.64-2.38; P < .001; area under the curve, 0.89). The reasons for choice of destination by emergency medical services (specifically, choosing the closest facility: adjusted odds ratio, 1.65; 95% CI, 1.37-1.98; P < .001) and use of a field trauma triage protocol (adjusted odds ratio, 2.21; 95% CI, 1.70-2.87; P < .001), significantly increased the likelihood of SO. Conclusions and Relevance This study's findings suggest that the distribution of major trauma centers in the region is significantly associated with SO. Subsequent investigation to identify the optimal number and distribution of trauma centers may therefore be critical. Specific outreach and collaboration of level III trauma centers and nontrauma centers with level I and II trauma centers, along with the use of telemedicine, may provide further guidance to level III trauma centers and nontrauma centers on when to transfer injured patients.
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Affiliation(s)
- Priti P Parikh
- Department of Surgery, Wright State University, Dayton, Ohio
| | - Pratik Parikh
- Department of Surgery, Wright State University, Dayton, Ohio.,Department of Biomedical, Industrial, and Human Factors Engineering, Wright State University, Dayton, Ohio
| | - Logan Mamer
- Department of Biomedical, Industrial, and Human Factors Engineering, Wright State University, Dayton, Ohio
| | - Mary C McCarthy
- Department of Surgery, Wright State University, Dayton, Ohio
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
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Baimas-George M, Cunningham KW, Ross SW, Savell A, Monteruil K, Christmas AB, Sing RF. Filled to the brim: The characteristics of over-triage at a level I trauma center. Am J Surg 2019; 218:1074-1078. [PMID: 31540682 DOI: 10.1016/j.amjsurg.2019.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Interfacility transfers are necessary and valuable for the trauma system, but despite regional guidelines, many patients are inappropriately transferred. We evaluated over-triage at our Level I center and identified risk factors for over-triage. METHODS Retrospective analysis at our Level I urban trauma center assessed patients transferred from regional facilities during 2017. Over-triage was defined as patients discharged <48 h without procedures. Exclusion criteria were leaving against medical advice or no outside records. RESULTS Overall, 2352 patients met criteria. Nine hundred thirty (39.5%) with complete hospital records were discharged in <48 h; 498 (53.5%) received no procedural intervention and 909 (97.7%) were ultimately discharged home. CONCLUSION Many patients are inappropriately transferred to tertiary care centers without a definitive need for advanced services. Studies are needed to improve triage criteria without increasing under-triage.
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Affiliation(s)
- Maria Baimas-George
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Kyle W Cunningham
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Samuel W Ross
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Anita Savell
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Kelly Monteruil
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - A Britton Christmas
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Ronald F Sing
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
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Adzemovic T, Murray T, Jenkins P, Ottosen J, Iyegha U, Raghavendran K, Napolitano LM, Hemmila MR, Gipson J, Park P, Tignanelli CJ. Should they stay or should they go? Who benefits from interfacility transfer to a higher-level trauma center following initial presentation at a lower-level trauma center. J Trauma Acute Care Surg 2019; 86:952-960. [PMID: 31124892 DOI: 10.1097/ta.0000000000002248] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Interfacility transfer of patients from Level III/IV to Level I/II (tertiary) trauma centers has been associated with improved outcomes. However, little data are available classifying the specific subsets of patients that derive maximal benefit from transfer to a tertiary trauma center. Drawbacks to transfer include increased secondary overtriage. Here, we ask which injury patterns are associated with improved survival following interfacility transfer. METHODS Data from the National Trauma Data Bank was utilized. Inclusion criteria were adults (≥16 years). Patients with Injury Severity Score of 10 or less or those who arrived with no signs of life were excluded. Patients were divided into two cohorts: those admitted to a Level III/IV trauma center versus those transferred into a tertiary trauma center. Multiple imputation was performed for missing values, and propensity scores were generated based on demographics, injury patterns, and disease severity. Using propensity score-stratified Cox proportional hazards regression, the hazard ratio for time to death was estimated. RESULTS Twelve thousand five hundred thirty-four (5.2%) were admitted to Level III/IV trauma centers, and 227,315 (94.8%) were transferred to a tertiary trauma center. Patients transferred to a tertiary trauma center had reduced mortality (hazard ratio, 0.69; p < 0.001). We identified that patients with traumatic brain injury with Glasgow Coma Scale score less than 13, pelvic fracture, penetrating mechanism, solid organ injury, great vessel injury, respiratory distress, and tachycardia benefited from interfacility transfer to a tertiary trauma center. In this sample, 56.8% of the patients benefitted from transfer. Among those not transferred, 49.5% would have benefited from being transferred. CONCLUSION Interfacility transfer is associated with a survival benefit for specific patients. These data support implementation of minimum evidence-based criteria for interfacility transfer. LEVEL OF EVIDENCE Therapeutic/Care Management, Level IV.
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Affiliation(s)
- Tessa Adzemovic
- From the University of Michigan Medical School (T.A.), Ann Arbor, Michigan; Division of Biostatistics (T.M.), University of Minnesota, Minneapolis, Minnesota; Department of Surgery (P.J.), Indiana University, Indianapolis, Indiana; Department of Surgery (J.O., C.J.T.), University of Minnesota, Minneapolis, Minnesota; Department of Surgery (J.O., J.G.P., C.J.T.), North Memorial Health Hospital, Robbinsdale, Minnesota, Department of Surgery (U.I.), Regions Hospital, St. Paul, Minnesota; Department of Surgery (K.R., L.M.N., M.R.H., P.P.), University of Michigan, Ann Arbor, Michigan; and Institute for Health Informatics (C.J.T.), University of Minnesota, Minneapolis, Minnesota
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Trauma Ecosystems: The Impact of Too Many Trauma Centers. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0231-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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A negative computed tomography may be sufficient to safely discharge patients with abdominal seatbelt sign from the emergency department: A case series analysis. J Trauma Acute Care Surg 2019. [PMID: 29521798 DOI: 10.1097/ta.0000000000001872] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The presence of an abdominal seatbelt sign (ASBS) following a motor vehicle collision (MVC) is associated with a high risk for occult intra-abdominal injury, prompting imaging studies and a prolonged period of clinical observation. The aim of this study was to determine how a negative computed tomography (CT) of the abdomen/pelvis (A/P) can serve in the safe disposition of these patients. Our hypothesis was that in the setting of a negative CT, the presence of occult intra-abdominal injuries requiring a delayed intervention is extremely unlikely. METHODS The medical charts of patients admitted from January 2014 to December 2016 to a Level I trauma center following an MVC were reviewed for a documentation of an ASBS. Patients who did not have a CT A/P upon admission were excluded. The CT A/P of the remaining patients were then classified as negative if there were no findings of acute vascular, visceral or bony injury or positive if any of these findings was present. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of CT A/P for the presence of an intra-abdominal injury were calculated. RESULTS Over the 3-year study period, 1,108 patients were admitted after an MVC. Of those, 196 (17.7%) had an ASBS upon presentation and 183 (93.4%) of 196 underwent a CT A/P. A total of 114 (62.3%) of 183 had a negative CT A/P. These patients remained hospitalized for a median of 2 (1-35) days with none (0.0%) requiring a delayed laparotomy. The sensitivity of CT A/P in identifying patients requiring an exploratory laparotomy was 100.0%, specificity was 67.9%, NPV was 100.0%, and PPV was 21.7%. The negative likelihood ratio was 0.00. CONCLUSION For patients with an ASBS following an MVC, a negative CT A/P may be sufficient for safe discharge from the emergency department without any need for additional clinical observation. LEVEL OF EVIDENCE Therapuetic, level IV.
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Kim EN, Kim MJ, You JS, Shin HJ, Park IC, Chung SP, Kim JH. Effects of an emergency transfer coordination center on secondary overtriage in an emergency department. Am J Emerg Med 2019; 37:395-400. [DOI: 10.1016/j.ajem.2018.05.060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/08/2018] [Accepted: 05/28/2018] [Indexed: 11/16/2022] Open
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Najafi Z, Abbaszadeh A, Zakeri H, Mirhaghi A. Determination of mis-triage in trauma patients: a systematic review. Eur J Trauma Emerg Surg 2019; 45:821-839. [DOI: 10.1007/s00068-019-01097-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 02/18/2019] [Indexed: 11/24/2022]
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Borczuk P, Van Ornam J, Yun BJ, Penn J, Pruitt P. Rapid Discharge After Interfacility Transfer for Mild Traumatic Intracranial Hemorrhage: Frequency and Associated Factors. West J Emerg Med 2019; 20:307-315. [PMID: 30881551 PMCID: PMC6404693 DOI: 10.5811/westjem.2018.12.39337] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 11/01/2018] [Accepted: 12/02/2018] [Indexed: 11/16/2022] Open
Abstract
Introduction Traumatic intracranial hemorrhage (TIH), brain injury with radiographic hemorrhage, is a common emergency department (ED) presentation, and encompasses a wide range of clinical syndromes. Patients with moderate and severe neurotrauma (Glasgow Coma Scale [GCS] < 13) with intracranial hemorrhage require care at a trauma center with neurosurgical capabilities. However, many patients with mild traumatic intracranial hemorrhage (mTIH), defined as radiographic bleeding and GCS ≥ 13, do not require operative intervention or intensive care unit monitoring, but are still routinely transferred to tertiary care centers. We hypothesized that a significant proportion of patients are managed non-operatively and are discharged within 24 hours of admission. Methods This was a retrospective, observational study of consecutive patients age ≥ 16 years, GCS ≥ 13 who were transferred to an urban, medical school-affiliated, 100,000 annual visit ED over a seven-year period with blunt isolated mTIH. The primary outcome was discharge within 24 hours of admission. We measured rates of neurosurgical intervention, computed tomography hemorrhage progression, and neurologic deterioration as well as other demographic and clinical variables. Results There were 1079 transferred patients with isolated mTIH. Of these, 92.4% were treated non-operatively and 35.8% were discharged within 24 hours of presentation to the tertiary ED. Patient characteristics associated with rapid discharge after transfer include a GCS of 15 (odds ratio [OR] 2.9, 95% confidence interval [CI], 1.9 – 4.4), subdural hematoma ≤ 6mm (OR 3.1, 95% CI, 2.2 – 4.5) or the presence of an isolated subarachnoid hemorrhage (OR 1.7, 95% CI, 1.3 – 2.4). Of patients with length of stay < 24 hours, 79.8% were discharged directly from the ED or ED observation unit. Conclusion Patients transferred to tertiary care centers are frequently discharged after brief observation without intervention. Risk can be predicted by clinical and radiographic data. Further prospective research is required to determine a safe cohort of patients who could be managed at community sites.
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Affiliation(s)
- Pierre Borczuk
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Jonathan Van Ornam
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Brian J Yun
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Joshua Penn
- Winchester Hospital, Emergency Services, Winchester, Massachusetts
| | - Peter Pruitt
- Northwestern University, Department of Emergency Medicine, Chicago, Illinois
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Kappy NS, Hazelton JP, Capano-Wehrle L, Gibbs R, Dalton MK, Ross SE. Financial Impact of Minor Injury Transfers on a Level 1 Trauma Center. J Surg Res 2019; 233:403-407. [DOI: 10.1016/j.jss.2018.08.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 07/13/2018] [Accepted: 08/18/2018] [Indexed: 10/28/2022]
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Bang M, Kim YW, Kim OH, Lee KH, Jung WJ, Cha YS, Kim H, Hwang SO, Cha KC. Validation of the Korean criteria for trauma team activation. Clin Exp Emerg Med 2018; 5:256-263. [PMID: 30571904 PMCID: PMC6301863 DOI: 10.15441/ceem.17.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 10/27/2017] [Accepted: 10/29/2017] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE We conducted a study to validate the effectiveness of the Korean criteria for trauma team activation (TTA) and compared its results with a two-tiered system. METHODS This observational study was based on data from the Korean Trauma Data Bank. Within the study period, 1,628 trauma patients visited our emergency department, and 739 satisfied the criteria for TTA. The rates of overtriage and undertriage in the Korean one-tiered system were compared with the two-tiered system recommended by the American College of Surgery-Committee on Trauma. RESULTS Most of the patient's physiologic factors reflected trauma severity levels, but anatomical factors and mechanism of injury did not show consistent results. In addition, while the rate of overtriage (64.4%) was above the recommended range according to the Korean criteria, the rate of undertriage (4.0%) was within the recommended range. In the simulated two-tiered system, the rate of overtriage was reduced by 5.5%, while undertriage was increased by 1.8% compared to the Korean activation system. CONCLUSION The Korean criteria for TTA showed higher rates of overtriage and similar undertriage rates compared to the simulated two-tier system. Modification of the current criteria to a two-tier system with special considerations would be more effective for providing optimum patient care and medical resource utilization.
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Affiliation(s)
- Minhyuk Bang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yong Won Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Oh Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kang Hyun Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Woo Jin Jung
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yong Sung Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Mackel CE, Morel BC, Winer JL, Park HG, Sweeney M, Heller RS, Rideout L, Riesenburger RI, Hwang SW. Secondary overtriage of pediatric neurosurgical trauma at a Level I pediatric trauma center. J Neurosurg Pediatr 2018; 22:375-383. [PMID: 29957140 DOI: 10.3171/2018.5.peds182] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors looked at all of the pediatric patients with a head injury who were transferred from other hospitals to their own over 12 years and tried to identify factors that would allow patients to stay closer to home at their local hospitals and not be transferred. Many patients with isolated, nondisplaced skull fractures or negative CT imaging likely could have avoided transfer. While hospitals should be cautious, this may help families stay closer to home.
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Affiliation(s)
- Charles E Mackel
- 1Department of Neurosurgery, Tufts Medical Center and Floating Hospital for Children, Boston, Massachusetts; and
| | - Brent C Morel
- 1Department of Neurosurgery, Tufts Medical Center and Floating Hospital for Children, Boston, Massachusetts; and
| | - Jesse L Winer
- 1Department of Neurosurgery, Tufts Medical Center and Floating Hospital for Children, Boston, Massachusetts; and
| | - Hannah G Park
- 1Department of Neurosurgery, Tufts Medical Center and Floating Hospital for Children, Boston, Massachusetts; and
| | - Megan Sweeney
- 1Department of Neurosurgery, Tufts Medical Center and Floating Hospital for Children, Boston, Massachusetts; and
| | - Robert S Heller
- 1Department of Neurosurgery, Tufts Medical Center and Floating Hospital for Children, Boston, Massachusetts; and
| | - Leslie Rideout
- 1Department of Neurosurgery, Tufts Medical Center and Floating Hospital for Children, Boston, Massachusetts; and
| | - Ron I Riesenburger
- 1Department of Neurosurgery, Tufts Medical Center and Floating Hospital for Children, Boston, Massachusetts; and
| | - Steven W Hwang
- 2Shriners Hospitals for Children-Philadelphia, Philadelphia, Pennsylvania
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Bukur M, Teurel C, Catino J, Kurek S. The Price of Always Saying Yes: A Cost Analysis of Secondary Overtriage to an Urban Level I Trauma Center. Am Surg 2018. [DOI: 10.1177/000313481808400854] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Level I trauma centers serve as a community resource, with most centers using an inclusive transfer policy that may result in overtriage. The financial burden this imparts on an urban trauma system has not been well examined. We sought to examine the incidence of secondary overtriage (SOT) at an urban Level I trauma center. This was a retrospective study from an urban Level I trauma center examining patients admitted as trauma transfers (TT) from 2010 to 2014. SOT was defined as patients not meeting the “Orange Book” transfer criteria and who had a length of stay of <48 hours. Average ED and transport charges were calculated for total transfer charges. A total of 2397 TT were treated. The number of TT increased over the study interval. The mean age of TT was 59.7 years (SD ± 26.4 years); patients were predominantly male (59.2%), white (83.2%), with at least one comorbidity (71.5%). Blunt trauma accounted for 96.8 per cent of admissions with a median Injury Severity Score of nine (IQR: 5–16). Predominant injuries were isolated closed head trauma (61.4%), skin/soft tissue injury (18.9%), and spinal injury (17.6%). SOT was 48.2 per cent and increased yearly (P < 0.001). The median trauma center charge for SOT was ($27,072; IQR: $20,089–34,087), whereas ED charges were ($40,440; IQR: $26,150–65,125), resulting in a total cost of $67,512/patient. A liberal TT policy results in a high SOT rate adding significant unnecessary costs to the health-care system. Efforts to establish transfer guidelines may allow for significant cost savings without compromising care.
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Affiliation(s)
- Marko Bukur
- Division of Acute Care Surgery, Bellevue Hospital Center, NYU School of Medicine, New York, New York
| | - Candace Teurel
- Division of Trauma and Surgical Critical Care, Department of Surgery, Delray Medical Center, Delray Beach, Florida
| | - Joseph Catino
- Division of Trauma and Surgical Critical Care, Department of Surgery, Delray Medical Center, Delray Beach, Florida
| | - Stanley Kurek
- Baylor Scott & White Health, Temple, Texas
- Division of Acute Care Surgery, Texas A&M Health Science Center College of Medicine, Bryan, Texas
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Becker A, Peleg K, Olsha O, Givon A, Kessel B. Analysis of incidence of traumatic brain injury in blunt trauma patients with Glasgow Coma Scale of 12 or less. Chin J Traumatol 2018; 21:152-155. [PMID: 29776836 PMCID: PMC6034161 DOI: 10.1016/j.cjtee.2018.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/20/2018] [Accepted: 02/18/2018] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Early diagnosis of traumatic brain injury (TBI) is important for improving survival and neurologic outcome in trauma victims. The purpose of this study was to assess whether Glasgow Coma Scale (GCS) of 12 or less can predict the presence of TBI and the severity of associated injuries in blunt trauma patients. METHODS A retrospective cohort study including 303,435 blunt trauma patients who were transferred from the scene to hospital from 1998 to 2013. The data was obtained from the records of the National Trauma Registry maintained by Israel's National Center for Trauma and Emergency Medicine Research, in the Gertner Institute for Epidemiology and Health Policy Research. All blunt trauma patients with GCS 12 or less were included in this study. Data collected in the registry include age, gender, mechanism of injury, GCS, initial blood pressure, presence of TBI and incidence of associated injuries. Patients younger than 14 years old and trauma victims with GCS 13-15 were excluded from the study. Statistical analysis was performed by using Statistical Analysis Software Version 9.2. Statistical tests performed included Chi-square tests. A p-value less than 0.05 was considered statistically significant. RESULTS There were 303,435 blunt trauma patients, 8731 (2.9%) of them with GCS of 3-12 that including 6351 (72%) patients with GCS of 3-8 and 2380 (28%) patient with GCS of 9-12. In these 8731 patients with GCS of 3-12, 5372 (61.5%) patients had TBI. There were total 1404 unstable patients in all the blunt trauma patients with GCS of 3-12, 1256 (89%) patients with GCS 3-8, 148 (11%) patients with GCS 9-12. In the 5095 stable blunt trauma patients with GCS 3-8, 32.4% of them had no TBI. The rate in the 2232 stable blunt trauma patients with GCS 9-12 was 50.1%. In the unstable patients with GCS 3-8, 60.5% of them had TBI, and in subgroup of patients with GCS 9-12, only 37.2% suffered from TBI. CONCLUSION The utility of a GCS 12 and less is limited in prediction of brain injury in multiple trauma patients. Significant proportion of trauma victims with low GCS had no TBI and their impaired neurological status is related to severe extra-cranial injuries. The findings of this study showed that using of GCS in initial triage and decision making processes in blunt trauma patients needs to be re-evaluated.
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Affiliation(s)
- Alexander Becker
- Department of Surgery A, Emek Medical Center, Afula, Israel; Rappoport Medical School, Technion, Haifa, Israel.
| | - Kobi Peleg
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel; Disaster Medicine Department, School of Public Health, Faculty of Medicine, TelAviv University, Israel
| | - Oded Olsha
- Surgery Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Adi Givon
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | - Boris Kessel
- Trauma Unit, Hillel Yaffe Medical Center, Hadera, Israel; Rappoport Medical School, Technion, Haifa, Israel
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Schroeder GD, McKenzie JC, Casper DS, Stake S, Buchholz J, Kepler C, Rihn JA, Woods BI, Radcliff KE, Kaye ID, Nicholson K, Anderson DG, Hilibrand AS, Vaccaro AR, Khan S, Kurd MF. Descriptive Analysis of Associated Factors for Urgent Versus Nonurgent Inpatient Spine Transfers to a Tertiary Care Hospital. Am J Med Qual 2018; 33:623-628. [PMID: 29756457 DOI: 10.1177/1062860618776080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patients with spine-associated symptoms are transferred regularly to higher levels of care for operative intervention. It is unclear what factors lead to the transfer of patients with spine pathology to level I care facilities, and which transfers are indicated. All patients with isolated spinal pathology who were transferred from 2011 to 2015 were reviewed. Patients were divided into urgent transfers, defined as anyone who required operative intervention, and nonurgent transfers. Two hundred twenty-seven patients were transferred for isolated spinal pathology over 51 months; 109 (48.0%) patients required urgent intervention and 118 (52.0%) patients required nonurgent care. No significant differences were found between groups in terms of private insurance, age, sex, race, or Charlson comorbidity index. The urgent group was less likely to have a traumatic chief complaint (57.8% vs 78.0%, P = .001). More than half of all spine patients who were transferred to a tertiary care center required minimal intervention.
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Affiliation(s)
| | | | - David S Casper
- 1 Thomas Jefferson University Hospital, Philadelphia, PA
| | - Seth Stake
- 1 Thomas Jefferson University Hospital, Philadelphia, PA
| | | | - Chris Kepler
- 1 Thomas Jefferson University Hospital, Philadelphia, PA
| | - Jeffery A Rihn
- 1 Thomas Jefferson University Hospital, Philadelphia, PA
| | - Barret I Woods
- 1 Thomas Jefferson University Hospital, Philadelphia, PA
| | | | - I David Kaye
- 1 Thomas Jefferson University Hospital, Philadelphia, PA
| | | | | | | | | | | | - Mark F Kurd
- 1 Thomas Jefferson University Hospital, Philadelphia, PA
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Safety and efficacy of brain injury guidelines at a Level III trauma center. J Trauma Acute Care Surg 2018; 84:483-489. [DOI: 10.1097/ta.0000000000001767] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kim JH, Kim MJ, You JS, Song MK, Cho SI. Do Emergency Physicians Improve the Appropriateness of Emergency Transfer in Rural Areas? J Emerg Med 2017; 54:287-294. [PMID: 29074031 DOI: 10.1016/j.jemermed.2017.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/22/2017] [Accepted: 08/08/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Until recently, there have been few studies on the transfer of patients from emergency departments (EDs) overall, as such studies were limited primarily to trauma patients. OBJECTIVES The purpose of this study was to investigate the association between the specialty of the primary referring physician and the appropriateness of the emergency transfer (AET). METHODS This was a retrospective, observational study performed at two level-3 EDs in a rural area. A transfer to a higher-level ED for the purpose of patient stabilization was defined as an emergency transfer, and transfers were classified as "appropriate" when the emergency status of the patient could not be resolved by the referring ED. The primary outcome was AET, which was reviewed by an expert panel for reliability. Statistically significant variables were selected as covariates based on the results of a univariate analysis, and a multivariate logistic regression analysis was performed to estimate the odds ratios (ORs) with 95% confidence intervals (CIs) on the AET. RESULTS A total of 1325 patients underwent transfer to another hospital from the two EDs. Of these, 1003 were classified into the emergency transfer group. In both EDs, the incidence of appropriate emergency transfers was significantly higher when the primary referring physician was an emergency physician (OR 4.005, 95% CI 2.619-6.125 and OR 4.006, 95% CI 1.696-9.459 for each hospital, respectively). CONCLUSION There was a positive association between the specialty of the primary referring physician and the AET among EDs located in rural areas making patient transfers.
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Affiliation(s)
- Ji Hoon Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Epidemiology, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Min Joung Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Je Sung You
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Mi Kyung Song
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Il Cho
- Department of Epidemiology, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
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Medford-Davis LN, Holena DN, Karp D, Kallan MJ, Delgado MK. Which transfers can we avoid: Multi-state analysis of factors associated with discharge home without procedure after ED to ED transfer for traumatic injury. Am J Emerg Med 2017; 36:797-803. [PMID: 29055613 DOI: 10.1016/j.ajem.2017.10.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/07/2017] [Accepted: 10/09/2017] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Among injured patients transferred from one emergency department (ED) to another, we determined factors associated with being discharged from the second ED without procedures, or admission or observation. METHODS We analyzed all patients with injury diagnosis codes transferred between two EDs in the 2011 Healthcare Utilization Project State Emergency Department and State Inpatient Databases for 6 states. Multivariable hierarchical logistic regression evaluated the association between patient (demographics and clinical characteristics) and hospital factors, and discharge from the second ED without coded procedures. RESULTS In 2011, there were a total of 48,160 ED-to-ED injury transfers, half of which (49%) were transferred to non-trauma centers, including 23% with major trauma. A total of 22,011 transfers went to a higher level of care, of which 36% were discharged from the ED without procedures. Relative to torso injuries, discharge without procedures was more likely for patients with soft tissue (OR 6.8, 95%CI 5.6-8.2), head (OR 3.7, 95%CI 3.1-4.6), facial (OR 3.8, 95%CI 3.1-4.7), or hand (OR 3.1, 95%CI 2.6-3.8) injuries. Other factors included Medicaid (OR 1.3, 95%CI 1.2-1.5) or uninsured (OR 1.3, 95%CI 1.2-1.5) status. Treatment at the receiving ED added an additional $2859 on average (95% CI $2750-$2968) per discharged patient to the total charges for injury care, not including the costs of ambulance transport between facilities. CONCLUSION Over a third of patients transferred to another ED for traumatic injury are discharged from the second ED without admission, observation, or procedures. Telemedicine consultation with sub-specialists might reduce some of these transfers.
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Affiliation(s)
- Laura N Medford-Davis
- Department of Emergency Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX 77030, United States.
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 923 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA 19104, United States.
| | - David Karp
- University of Pennsylvania Wharton Geographic Information Systems Lab, 923 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States.
| | - Michael J Kallan
- University of Pennsylvania Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, 523 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States.
| | - M Kit Delgado
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 933 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States; University of Pennsylvania Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, 523 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA 19104, United States.
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Martinez B, Owings JT, Hector C, Hargrove P, Tanaka S, Moore M, Greiffenstein P, Giaimo J, Talebinejad S, Hunt JP. Association Between Compliance with Triage Directions from an Organized State Trauma System and Trauma Outcomes. J Am Coll Surg 2017; 225:508-515. [PMID: 28865685 DOI: 10.1016/j.jamcollsurg.2017.06.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 06/29/2017] [Accepted: 06/30/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Louisiana Emergency Response Network (LERN), a statewide trauma system, has a single communication center with real-time data on hospital capacity across the state. With these data, scene information, and a standardized triage protocol, prehospital providers are directed to the most appropriate hospital. The purpose of our study was to compare outcomes between those patients who complied with the LERN communication center direction and those who did not. STUDY DESIGN Trauma patients directed by LERN from the field in 2014 were included. Patients who followed the LERN communication center direction were considered the compliant group. Patients brought to a hospital inconsistent with the LERN direction were considered the noncompliant group. Chi-square analysis was used to compare differences between groups and a p value of <0.05 was considered statistically significant. RESULTS During the study period, LERN directed 14,071 patients to a destination hospital. Prehospital providers were compliant with the LERN direction in 13,037 (92.7%) patients and noncompliant in 1,034 (7.3%) patients. There were fewer patients in the compliant group (570 of 13,037 [4.3%]) requiring transfer to a second hospital than in the noncompliant group (312 of 1,034 [30.2%]) (p < 0.01). The mortality rate was lower in the compliant group (81 of 13,037 [0.6%]) than in the noncompliant group (21 of 1,034 [2.03%]) (p < 0.01). CONCLUSIONS Following direction from a central communication center with real-time hospital capacity data yielded a 6-fold decrease in secondary transfer and a 3-fold decrease in mortality. These data emphasize the value of an organized statewide trauma network that routes patients to the appropriate facilities.
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Affiliation(s)
- Benjamin Martinez
- Louisiana State University Health Sciences Center, New Orleans, LA Ochsner Medical Center, New Orleans, LA Our Lady of the Lake Regional Medical Center, Baton Rouge, LA Louisiana Emergency Response Network, Baton Rouge, LA
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