Undertriage in trauma: Does an organized trauma network capture the major trauma victim? A statewide analysis

Exploring patient and system factors impacting undertriage of injured patients meeting national field triage guideline criteria

BACKGROUND

Trauma systems save lives by coordinating timely and effective responses to injury. However, trauma system effectiveness varies geographically, with worse outcomes observed in rural settings. Prior data suggest that undertriage may play a role in this disparity. Our aim was to explore potential driving factors for decision making among clinicians for undertriaged trauma patients.

METHODS

We performed a retrospective analysis of the National Emergency Medical Services Information System database among patients who met physiologic or anatomic national field triage guideline criteria for transport to the highest level of trauma center. Undertriage was defined as transport to a non-level I/II trauma center. Multivariable logistic regression was used to determine demographic, injury, and system characteristics associated with undertriage. Undertriaged patients were then categorized into "recognized" and "unrecognized" groups using the documented reason for transport destination to identify underlying factors associated with undertriage.

RESULTS

A total of 36,094 patients were analyzed. Patients in urban areas were more likely to be transported to a destination based on protocol rather than the closest available facility. As expected, patients injured in urban regions were less likely to be undertriaged than their suburban (adjusted odds ratio [aOR], 2.69; 95% confidence interval [95% CI], 2.21-3.31), rural (aOR, 2.71; 95% CI, 2.28-3.21), and wilderness counterparts (aOR, 3.99; 95% CI, 2.93-5.45). The strongest predictor of undertriage was patient/family choice (aOR, 6.29; 5.28-7.50), followed by closest facility (aOR, 5.49; 95% CI, 4.91-6.13) as the reason for hospital selection. Nonurban settings had over twice the odds of recognizing the presence of triage criteria among undertriaged patients ( p < 0.05).

CONCLUSION

Patients with injuries in nonurban settings and those with less apparent causes of severe injury are more likely to experience undertriage. By analyzing how prehospital clinicians choose transport destinations, we identified patient and system factors associated with undertriage. Targeting these at-risk demographics and contributing factors may help alleviate regional disparities in undertriage.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

A Systematic Literature Review of Trauma Systems: An Operations Management Perspective

Background

Trauma systems provide comprehensive care across various settings, from prehospital services to rehabilitation, integrating clinical and social care aspects. Established in the 1970s, these systems are pivotal yet under-researched in their operational management. This study aims to fill this gap by focussing on the integration of operations management (OM) techniques to enhance the efficiency and effectiveness of trauma systems. By leveraging proven OM strategies from other healthcare sectors, we seek to improve patient outcomes and optimise system performance, addressing a crucial need for innovation in trauma care operations.

Methodology

A systematic literature review was conducted using the PICOTS framework to explore operational aspects of trauma systems across varied settings, from emergency departments to specialised centres. Searches were performed in 5 databases, focussing on articles published from 2006 to 2024. Keywords related to operational research and management targeted both trauma systems and emergency management services. Our method involved identifying, synthesising, and summarising studies to evaluate operational performance, with a specific emphasis on articles that applied operational research/management techniques in trauma care. All eligible articles were critically appraised using 2 quality assessment tools.

Results

Employing Donabedian's framework to analyse the quality of trauma systems through structure, process, and outcome dimensions, our systematic review included 160 studies. Of these, 5 studies discussed the application of the Donabedian evaluation framework to trauma systems, and 14 studies examined structural elements, focussing on the location of healthcare facilities, trauma resource management, and EMS logistics. The 63 studies on process indicators primarily assessed triage procedures, with some exploring the timeliness of trauma care. Meanwhile, the 78 outcome-oriented studies predominantly evaluated mortality rates, alongside a smaller number assessing functional outcomes.

Conclusion

Existing evaluation metrics primarily focussed on triage accuracy and mortality are inadequate. We propose expanding these metrics to include patient length of stay (LOS) and rehabilitation trajectory analyses. There is a critical gap in understanding patient flow management and long-term outcomes, necessitating focussed research on LOS modelling and improved rehabilitation data collection. Addressing these areas is essential for optimising trauma care and improving patient recovery outcomes.

Impact of lower level trauma center proliferation on patient outcomes

Background

In attempt to increase trauma system coverage, our state added 21 level 3 (L3TC) and level 4 trauma centers (L4TC) to the existing 7 level 1 trauma centers from 2008 to 2012. This study examined the impact of adding these lower-level trauma centers (LLTC) on patient outcomes.

Methods

Patients in the state trauma registry age ≥ 15 from 2007 to 2012 were queried for demographic, injury, and outcome variables. These were compared between 2007 (PRE) and 2008-2012 (POST) cohorts. Multivariate logistic regression was performed to assess independent predictors of mortality. Subgroup analyses were performed for Injury Severity Score (ISS) ≥15, age ≥ 65, and trauma mechanisms.

Results

143,919 adults were evaluated. POST had significantly more female, geriatric, and blunt traumas (all p < 0.001). ISS was similar. Interfacility transfers increased by 10.2 %. Overall mortality decreased by 0.6 % (p < 0.001). Multivariate logistic regression analysis showed that being in POST was not associated with survival (OR: 1.07, CI: 0.96-1.18, p = 0.227). Subgroup analyses showed small reductions in mortality, except for geriatric patients. After adjusting for covariates, POST was not associated with survival in any subgroup, and trended toward being a predictor for death in penetrating traumas (OR: 1.23; 1.00-1.53, p = 0.059).

Conclusions

Unregulated proliferation of LLTCs was associated with increased interfacility transfers without significant increase in trauma patients treated. LLTC proliferation was not an independent protector against mortality in the overall cohort and may worsen mortality for penetrating trauma patients. Rather than simply increasing the number of LLTCs within a region, perhaps more planned approaches are needed.

Key message

This is, to our knowledge, the first work to study the effect of rapid lower level trauma center proliferation on patient outcomes. The findings of our analysis have implications for strategic planning of future trauma systems.

American Trauma Care: A System of Systems

OBJECTIVE

The benefits of organized trauma systems have been well-documented during 50 years of trauma system development in the United States. Unfortunately, despite this evidence, trauma system development has occurred only sporadically in the 50 states.

METHODS

The relevant literature related to trauma system design and development was reviewed based on relevance to the study. Information from these sources was summarized into a SWOT (strengths, weaknesses, opportunities, and threats) analysis.

RESULTS

Strengths discovered were leadership brought forth by the American College of Surgeons Committee on Trauma and meaningful change generated from The National Academy of Sciences, Engineering, and Medicine report addressing the fractionation of the nation's trauma systems, whereas weaknesses included patient outcome disparities due to the lack of a national governing authority, undertriage, underresourced rural trauma, and underfunded trauma research. Opportunities included the creation of level IV trauma centers; telemedicine; the development of rural trauma management courses; air medical transport to bring high-intensity care to the patient, particularly in rural areas; trauma research; and trauma prevention through outreach and educational programs. The following threats were determined: mass casualty incidents, motor vehicle collisions because of the high rate of motor vehicle collision deaths in the United States relative to other developed countries, and underfunded trauma systems.

CONCLUSION

Much work remains to be done in the development of an American trauma system. Recommendations include implementation of trauma care governance at the federal level; national oversight and support of emergency medical services systems, particularly in rural areas with strict reporting processes for emergency medical services programs; national organization of our mass casualty response; increased federal and state funding allocated to trauma centers; a consistent model for trauma system development; and trauma research.

Geospatial Analysis of Prehospital Triage and Early Potential Preventable Traumatic Deaths

Severely injured patients often depend on prompt prehospital triage for survival. This study aimed to examine the under-triage of preventable or potentially preventable traumatic deaths. A retrospective review of Harris County, TX, revealed 1848 deaths within 24 hours of injury, with 186 being preventable or potentially preventable (P/PP). The analysis evaluated the geospatial relationship between each death and the receiving hospital. Out of the 186 P/PP deaths, these were more commonly male, minority, and penetrating mechanisms when compared with NP deaths. Of the 186 PP/P, 97 patients were transported to hospital care, 35 (36%) were transported to Level III, IV, or non-designated hospitals. Geospatial analysis revealed an association between the location of initial injury and proximity to receiving Level III, IV, and non-designated centers. Geospatial analysis supports proximity to the nearest hospital as one of the primary reasons for under-triage.

Undertriage of Geriatric Trauma Patients in Florida

INTRODUCTION

Elderly undertriage rates are estimated up to 55% in the United States. This study examined risk factors for undertriage among hospitalized trauma patients in a state with high volumes of geriatric trauma patients.

MATERIALS AND METHODS

This is a population-based retrospective cohort study of 62,557 patients admitted to Florida hospitals between 2016 and 2018 from the Agency for Healthcare Administration database. Severely injured trauma patients were defined by American College of Surgeons definitions and an International Classification of Disease Injury Severity Score <0.85. Undertriage was defined as definitive care of these severely injured patients at any Florida hospital other than a state-designated trauma center (TC). Univariate analyses were used to identify risk factors associated with inpatient mortality and undertriage. Multiple variable regression was used to estimate risk-adjusted odds of mortality after admission to either a designated or nondesignated TC.

RESULTS

Undertriaged patients were more likely to have isolated traumatic brain injuries, lower International Classification of Disease Injury Severity Scores, multiple comorbidities, and older age. Trauma patients aged 65 and older were more than twice as likely to be undertriaged (34% versus 15.7%, P < 0.0001). Undertriaged patients of all ages were also more likely to suffer from pneumonia, urinary tract infection, arrhythmias, and sepsis. After risk adjustment, severely injured trauma patients admitted to non-TC were also more likely to be at risk for mortality (adjusted odds ratio, 1.27; 95% confidence interval, 1.17-1.38).

CONCLUSIONS

Age and multiple comorbidities are significant predictors of mortality among undertriage of trauma patients. As a result, trauma triage guidelines should account for high-risk geriatric trauma patients who would benefit from definitive treatment at designated TCs.

A comprehensive analysis of undertriage in a mature trauma system using geospatial mapping

INTRODUCTION

The correct triage of trauma patients to trauma centers (TCs) is essential. We sought to determine the percentage of patients who were undertriaged within the Pennsylvania (PA) trauma system and spatially analyze areas of undertriage (UTR) in PA for all age groups: pediatric, adult, and geriatric. We hypothesized that there would be certain areas that had high UTR for all age groups.

METHODS

From 2003 to 2015, all admissions from the Pennsylvania Trauma Systems Foundation registry and those meeting trauma criteria (International Classification of Diseases, Ninth Diseases: 800-959) from the Pennsylvania Health Care Cost Containment Council (PHC4) database were included. Admissions were divided into age groups: pediatric (<15 years), adult (15-64 years), and geriatric (≥65 years). All pediatric trauma cases were included from the Pennsylvania Trauma Systems Foundation and PHC4 registry, while only cases with Injury Severity Score of >9 were included in adult and geriatric age groups. Undertriage was defined as patients not admitted to level I/II adult TCs (n = 24), pediatric (n = 3), or adult and pediatric combined facility (n = 3) divided by the total number of patients from the PHC4 database. ArcGIS Desktop (version 10.7; ESRI, Redlands, CA) and GeoDa (version 1.14.0; CSDS, Chicago, IL) open source license were used for geospatial mapping of UTR with a spatial empirical Bayesian smoothed UTR by zip code tabulation area (ZCTA) and Stata (version 16.1; Stata Corp., College Station, TX) for statistical analyses.

RESULTS

There were significant percentages of UTR for all age groups. One area of high UTR for all age groups had TCs and large nontrauma centers in close proximity. There were high rates of UTR for all ages in rural areas, specifically in the upper central regions of PA, with limited access to TCs.

CONCLUSION

It appears there are two patterns leading to UTR. The first is in areas where TCs are in close proximity to large competing nontrauma centers, which may lead to inappropriate triage. The second has to do with lack of access to TCs. Geospatial mapping is a valuable tool that can be used to ascertain where trauma systems should focus scarce resources to decrease UTR.

LEVEL OF EVIDENCE

Epidemiological, level III; Care management, level III.

Dutch trauma system performance: Are injured patients treated at the right place?

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.

Making the call in the field: Validating emergency medical services identification of anatomic trauma triage criteria

BACKGROUND

The National Field Triage Guidelines were created to inform triage decisions by emergency medical services (EMS) providers and include eight anatomic injuries that prompt transportation to a Level I/II trauma center. It is unclear how accurately EMS providers recognize these injuries. Our objective was to compare EMS-identified anatomic triage criteria with International Classification of Diseases-10th revision (ICD-10) coding of these criteria, as well as their association with trauma center need (TCN).

METHODS

Scene patients 16 years and older in the NTDB during 2017 were included. National Field Triage Guidelines anatomic criteria were classified based on EMS documentation and ICD-10 diagnosis codes. The primary outcome was TCN, a composite of Injury Severity Score greater than 15, intensive care unit admission, urgent surgery, or emergency department death. Prevalence of anatomic criteria and their association with TCN was compared in EMS-identified versus ICD-10-coded criteria. Diagnostic performance to predict TCN was compared.

RESULTS

There were 669,795 patients analyzed. The ICD-10 coding demonstrated a greater prevalence of injury detection. Emergency medical service-identified versus ICD-10-coded anatomic criteria were less sensitive (31% vs. 59%), but more specific (91% vs. 73%) and accurate (71% vs. 68%) for predicting TCN. Emergency medical service providers demonstrated a marked reduction in false positives (9% vs. 27%) but higher rates of false negatives (69% vs. 42%) in predicting TCN from anatomic criteria. Odds of TCN were significantly greater for EMS-identified criteria (adjusted odds ratio, 4.5; 95% confidence interval, 4.46-4.58) versus ICD-10 coding (adjusted odds ratio 3.7; 95% confidence interval, 3.71-3.79). Of EMS-identified injuries, penetrating injury, flail chest, and two or more proximal long bone fractures were associated with greater TCN than ICD-10 coding.

CONCLUSION

When evaluating the anatomic criteria, EMS demonstrate greater specificity and accuracy in predicting TCN, as well as reduced false positives compared with ICD-10 coding. Emergency medical services identification is less sensitive for anatomic criteria; however, EMS identify the most clinically significant injuries. Further study is warranted to identify the most clinically important anatomic triage criteria to improve our triage protocols.

LEVEL OF EVIDENCE

Care management, Level IV; Prognostic, Level III.

The geriatric trauma patient: A neglected individual in a mature trauma system

BACKGROUND

Those older than 65 years represent the fastest growing demographic in the United States. As such, their care has been emphasized by trauma entities such as the American College of Surgeons Committee on Trauma. Unfortunately, much of that focus has been of their care once they reach the hospital with little attention on the access of geriatric trauma patients to trauma centers (TCs). We sought to determine the rate of geriatric undertriage (UT) to TCs within a mature trauma system and hypothesized that there would be variation and clustering of the geriatric undertriage rate (UTR) within a mature trauma system because of the admission of geriatric trauma patient to nontrauma centers (NTCs).

METHODS

From 2003 to 2015, all geriatric (age >65 years) admissions with an Injury Severity Score of greater than 9 from the Pennsylvania Trauma Systems Foundation (PTSF) registry and those meeting trauma criteria (International Classification of Diseases, Ninth Revision: 800-959) from the Pennsylvania Health Care Cost Containment Council (PHC4) database were included. Undertriage rate was defined as patients not admitted to TCs (n = 27) divided by the total number of patients as from the PHC4 database. The PHC4 contains all inpatient admissions within Pennsylvania (PA), while PTSF reports admissions to PA TCs. The zip code of residence was used to aggregate calculations of UTR as well as other aggregate patient and census demographics, and UTR was categorized into lower, middle box, and upper quartiles. ArcGIS Desktop: Version 10.7, ESRI, Redlands, CA and GeoDa: Version 1.14.0, Open source license were used for geospatial mapping of UT with a spatial empirical Bayesian smoothed UTR, and Stata: Version 16.1, Stata Corp., College Station TX was used for statistical analyses.

RESULTS

Pennsylvania Trauma Systems Foundation had 58,336 cases, while PHC4 had 111,626 that met the inclusion criteria, resulting in a median (Q1-Q3) smoothed UTR of 50.5% (38.2-60.1%) across PA zip code tabulation areas. Geospatial mapping reveals significant clusters of UT regions with high UTR in some of the rural regions with limited access to a TC. The lowest quartile UTR regions tended to have higher population density relative to the middle or upper quartile UTR regions. At the patient level, the lowest UTR regions had more racial and ethnic diversity, a higher injury severity, and higher rates of treatment at a TC. Undertriage rate regions that were closer to NTCs had a higher odds of being in the upper UTR quartile; 4.48 (2.52-7.99) for NTC with less than 200 beds and 8.53 (4.70-15.47) for NTC with 200 beds or greater compared with zip code tabulation areas with a TC as the closest hospital.

CONCLUSION

There are significant clusters of geriatric UT within a mature trauma system. Increased emphasis needs to focus prehospital on identifying the severely injured geriatric patient including specific geriatric triage protocols.

LEVEL OF EVIDENCE

Epidemiological, Level III.

An analysis of pediatric trauma center undertriage in a mature trauma system

BACKGROUND

Improved mortality as a result of appropriate triage has been well established in adult trauma and may be generalizable to the pediatric trauma population as well. We sought to determine the overall undertriage rate (UTR) in the pediatric trauma population within Pennsylvania (PA). We hypothesized that a significant portion of pediatric trauma population would be undertriaged.

METHODS

All pediatric (age younger than 15) admissions meeting trauma criteria (International Classification of Diseases, Ninth Revision: 800-959) from 2003 to 2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database and the Pennsylvania Trauma Systems Foundation (PTSF) registry. Undertriage was defined as patients not admitted to PTSF-verified pediatric trauma centers (n = 6). The PHC4 contains inpatient admissions within PA, while PTSF only reports admissions to PA trauma centers. ArcGIS Desktop was used for geospatial mapping of undertriage.

RESULTS

A total of 37,607 cases in PTSF and 63,954 cases in PHC4 met criteria, suggesting UTR of 45.8% across PA. Geospatial mapping reveals significant clusters of undertriage regions with high UTR in the eastern half of the state compared to low UTR in the western half. High UTR seems to be centered around nonpediatric facilities. The UTR for patients with a probability of death 1% or less was 39.2%.

CONCLUSION

Undertriage is clustered in eastern PA, with most areas of high undertriage located around existing trauma centers in high-density population areas. This pattern may suggest pediatric undertriage is related to a system issue as opposed to inadequate access.

LEVEL OF EVIDENCE

Retrospective study, without negative criteria, Level III.