Frequency and costs of laboratory and radiograph repetition in trauma patients undergoing interfacility transfer

Should We Keep or Transfer Our Severely Injured Geriatric Patients to Higher Levels of Care?

INTRODUCTION

Interfacility transfer to higher levels of care is becoming increasingly common. This study aims to evaluate the association between transfer to higher levels of care and prolonged transfer times with outcomes of severely injured geriatric trauma patients compared to those who are managed definitively at lower-level trauma centers.

METHODS

Severely injured (Injury Severity Score >15) geriatric (≥60 y) trauma patients in the 2017-2018 American College of Surgeons Trauma Quality Improvement Program database managing at an American College of Surgeons/State Level III trauma center or transferring to a level I or II trauma center were included. Outcome measures were 24-h and in-hospital mortality and major complications.

RESULTS

Forty thousand seven hundred nineteen patients were identified. Mean age was 75 ± 8 y, 54% were male, 98% had a blunt mechanism of injury, and the median Injury Severity Score was 17 [16-21]. Median transfer time was 112 [79-154] min, and the most common transport mode was ground ambulance (82.3%). Transfer to higher levels of care within 90 min was associated with lower 24-h mortality (adjusted odds ratio [aOR]: 0.493, P < 0.001) and similar odds of in-hospital mortality as those managed at level III centers. However, every 30-min delay in transfer time beyond 90 min was progressively associated with increased odds of 24-h (aOR: 1.058, P < 0.001) and in-hospital (aOR: 1.114, P < 0.001) mortality and major complications (aOR: 1.127, P < 0.001).

CONCLUSIONS

Every 30-min delay in interfacility transfer time beyond 90 min is associated with 6% and 11% higher risk-adjusted odds of 24-h and in-hospital mortality, respectively. Estimated interfacility transfer time should be considered while deciding about transferring severely injured geriatric trauma patients to a higher level of care.

A multicenter evaluation on the impact of non-therapeutic transfer in rural trauma

INTRODUCTION

Trauma transfers are a common occurrence in rural areas, where critical access and lower-level trauma centers routinely transfer to tertiary care centers for specialized care. Transfers are non-therapeutic (NTT) when no specialist intervention occurs, leading to transfer that were futile (FT) or secondary overtriage (SOT). This study aimed to evaluate the prevalence of NTT among four trauma centers providing care to rural Appalachia.

METHODS

This retrospective review was performed at four, ACS verified, Level 1 trauma centers. All adult trauma patients, transferred during 2018 were included for analysis. Transfers were considered futile if in <48 h the patient died or was discharged to hospice, without operative intervention. SOT transfers were discharged in <48 h, without major intervention, with an ISS< 15. Cost analysis was performed to describe the impact of NTT on EMS use.

RESULTS

4,189 patients were analyzed during the study period. 105 (2.5%) met criteria for futility. Futile patients had a median ISS of 25 (IQR 9-26), and 48% had an AIS head ≥4. These were significantly greater (p<0.001) than non-futile transfers, median ISS 5 (IQR 2-9), 3% severe head injury. SOT occurred in 1371 (33%), median ISS of 5, and lower AIS scores by region. Isolated facial injuries resulted in 165 transfers. 13% of FT+SOT were admitted to the ICU. Only 22% of FT+SOT came from a trauma center. 68% were transported by ALS and 13% transported by air transport. FT+SOT traveled on average 70 miles from their home to receive care.

CONCLUSIONS

Non-therapeutic transfers account for more than 1/3 of transfers in this rural environment. There was a significant use of advanced life support and aeromedical transport. The utility of these transfers should be questioned. With the recent increases in telehealth there is an opportunity for trauma systems to improve regional care and decrease transfers for futile cases.

Redundant laboratory testing on referral from general practice to the outpatient clinic: a post-hoc analysis

Background

Inappropriately repeated laboratory testing is a commonly occurring problem. However, this has not been studied extensively in the outpatient clinic after referral by GPs.

Aim

The aim of this study was to investigate how often laboratory tests ordered by the GP were repeated on referral to the outpatient clinic, and how many of the normal test results remained normal on repetition.

Design & setting

This is a post-hoc analysis of a study on laboratory testing strategies in patients newly referred to the outpatient clinic between April 2015 and April 2017.

Method

All patients who had a referral letter including laboratory test results ordered by the GP were included. These results were compared with the laboratory test results ordered in the outpatient clinic.

Results

Data were available for 295 patients, 191 of which had post-visit testing done. In this group, 56% of tests ordered by the GP were repeated. Tests with abnormal results were repeated more frequently than tests with normal results (65% versus 53%; P<0.001). A longer test interval was associated with slightly smaller odds of tests being repeated (odds ratio [OR] 0.97, 95% confidence interval [CI] = 0.95 to 0.99; P = 0.003). Of the tests with normal test results that were repeated, 90% remained normal. This was independent of testing interval or testing strategy.

Conclusion

Laboratory tests ordered by the GP are commonly repeated on referral to the outpatient clinic. The number of test results remaining normal on repetition suggests a high level of redundancy in laboratory test repetition.

Education and Visual Reminders Fail to Reduce Overuse and Waste in Interhospital Transfers to a Pediatric Intensive Care Unit

Introduction:

As healthcare costs continue to rise, initiatives to reduce costs while maintaining high-quality care become a priority. Nonclinically indicated studies add to this cost, especially during interfacility transfers when studies are often repeated. Also, unnecessary evaluations add to nonmonetary costs such as pain, radiation exposure, and iatrogenic anemia. This study aimed to establish the frequency of redundant testing on interfacility transfers to the pediatric intensive care unit (PICU) and then implement an education-based quality improvement strategy for waste reduction.

Methods:

In the preintervention period (September 2018–February 2019), we collected data on patients transferred to the PICU from any outside facility. Investigators evaluated studies repeated within 6 hours and deemed them redundant or indicated. We then determined a rate of patients with redundant studies as the first aim. This result prompted an educational intervention focused on testing stewardship. Investigators then collected data in the postintervention period (July–December 2019) and compared the rate of redundant studies.

Results:

Study efforts identified 150 patients in the preintervention period and 131 in the postintervention period, establishing a 21%–25% frequency of redundant testing. Education and visual reminders failed to reduce this testing.

Conclusion:

This study established a baseline rate of redundant testing on transferred patients to the PICU. An educational intervention alone did not produce significant change.

Inappropriateness of Repeated Laboratory and Radiological Tests for Transferred Emergency Department Patients

Background: Laboratory and radiographic tests are often repeated during inter-hospital transfers from secondary to tertiary emergency departments (ED), despite available data from the sending structure. The aim of this study was to identify the proportion of repeated tests in patients transferred to a tertiary care ED, and to estimate their inappropriateness and their costs. Methods: A retrospective chart review of all adult patients transferred from one secondary care ED to a tertiary care ED during the year 2016 was carried out. The primary outcome was the redundancy (proportion of procedure repeated in the 8 h following the transfer, despite the availability of the previous results). Factors predicting the repetition of procedures were identified through a logistic regression analysis. Two authors independently assessed inappropriateness. Results: In 2016, 432 patients were transferred from the secondary to the tertiary ED, and 251 procedures were repeated: 179 patients (77.2%) had a repeated laboratory test, 34 (14.7%) a repeated radiological procedure and 19 (8.2%) both. Repeated procedures were judged as inappropriate for 197 (99.5%) laboratory tests and for 39 (73.6%) radiological procedures. Conclusion: Over half of the patients transferred from another emergency department had a repeated procedure. In most cases, these repeated procedures were considered inappropriate.

Repeat radiographic imaging in patients with long bone fractures transferred to a pediatric trauma center

This study sought to determine the proportion of children with long bone fractures who undergo duplicate radiographic imaging after transfer to a pediatric trauma center (PTC) for further management. The secondary objective was to explore provider rationale and diagnostic yield of repeat X-rays. This was a single-site, retrospective cohort study conducted at a PTC. All patients, aged 0-21 years, who were transferred to the PTC for management of a long bone fracture were included. Electronic medical records were reviewed to determine the proportion of children who had repeat radiographic imaging and the provider rationale for obtaining this. T-test and Χ² analyses were used to compare patients who had repeat X-rays with those who did not. During the study period, 309 patients (63% male, mean age 7.2±4.3 years) were transferred from 30 referring hospitals. Of these, 43% (n=133) underwent repeat radiographs. Patient age (p=0.9), gender (p=0.7), fracture location (p=0.19), and type of referring emergency department (pediatric vs general, p=0.3) were not significantly associated with repeat imaging. Rationale for repeat imaging could be ascertained in 31% of cases (n=41); the most common reasons were request by orthopedist (17%, n=23) and suboptimal original imaging (10%, n=13). Repeat imaging at the PTC did not reveal new or additional diagnoses in any case. Nearly half of the children in our study population undergo repeat and likely unnecessary imaging. Strategies to reduce repeat radiographs should be developed, as redundant imaging exposes patients to additional radiation and increases medical expense.

The effect of electronic health record implementation on community emergency department operational measures of performance

STUDY OBJECTIVE

We study the effect of an emergency department (ED) electronic health record implementation on the operational metrics of a diverse group of community EDs.

METHODS

We performed a retrospective before/after analysis of 23 EDs from a single management group that experienced ED electronic health record implementation (with the majority of electronic health records optimized specifically for ED use). We obtained electronic data for 4 length of stay measures (arrival to provider, admitted, discharged, and overall length of stay) and 4 measures of operational characteristics (left before treatment complete, significant returns, overall patient satisfaction, and provider efficiency). We compared the 6-month "baseline" period immediately before implementation with a "steady-state" period commencing 6 months after implementation for all 8 metrics.

RESULTS

For the length of stay measures, there were no differences in the arrival-to-provider interval (difference of -0.02 hours; 95% confidence interval [CI] of difference -0.12 to 0.08), admitted length of stay (difference of 0.10 hours; 95% CI of difference -0.17 to 0.37), discharged length of stay (difference of 0.07 hours; 95% CI of difference -0.07 to 0.22), and overall length of stay (difference of 0.11 hours; 95% CI of difference -0.04 to 0.27). For operational characteristics, there were no differences in the percentage who left before treatment was complete (difference of 0.24%; 95% CI of difference -0.47% to 0.95%), significant returns (difference of -0.04%; 95% CI of difference -0.48% to 0.39%), overall percentile patient satisfaction (difference of -0.02%; 95% CI of difference -2.35% to 2.30%), and provider efficiency (difference of -0.05 patients/hour; 95% CI of difference -0.11 to 0.02).

CONCLUSION

There is no meaningful difference in 8 measures of operational performance for community EDs experiencing optimized ED electronic health record implementation between a baseline and steady-state period.

Transient and sustained changes in operational performance, patient evaluation, and medication administration during electronic health record implementation in the emergency department

STUDY OBJECTIVE

Little is known about the transient and sustained operational effects of electronic health records on emergency department (ED) performance. We quantify how the implementation of a comprehensive electronic health record was associated with metrics of operational performance, test ordering, and medication administration at a single-center ED.

METHODS

We performed a longitudinal analysis of electronic data from a single, suburban, academic ED during 28 weeks between May 2011 and November 2011. We assessed length of stay, use of diagnostic testing, medication administration, radiologic imaging, and patient satisfaction during a 4-week baseline measurement period and then tracked changes in these variables during the 24 weeks after implementation of the electronic health record.

RESULTS

Median length of stay increased and patient satisfaction was reduced transiently, returning to baseline after 4 to 8 weeks. Rates of laboratory testing, medication administration, overall radiologic imaging, radiographs, computed tomography scans, and ECG ordering all showed sustained increases throughout the 24 weeks after electronic health record implementation.

CONCLUSION

Electronic health record implementation in this single-center study was associated with both transient and sustained changes in metrics of ED performance, as well as laboratory and medication ordering. Understanding ways in which an ED can be affected by electronic health record implementation is critical to providing insight about ways to mitigate transient disruption and to maximize potential benefits of the technology.

The frequency and cost of redundant laboratory testing for transferred ED patients

INTRODUCTION

Health care costs continue to rise; reducing unnecessary laboratory testing may reduce costs. The goal of this study was to calculate the frequency and estimated costs of repeat normal laboratory testing of patients transferred to a tertiary care emergency department (ED).

METHODS

This was a retrospective cohort study of patients transferred to a tertiary care, level -one trauma ED with an annual census of 90,000 patients. We defined "repeat normal testing" as laboratory tests repeated within 8 hours that were normal at both the sending hospital and the receiving tertiary care hospital. We estimated the charges associated with repeat normal laboratory testing for 11 common ED tests: basic metabolic panel, calcium, magnesium, phosphorus, lipase, thyroids stimulating hormone, prothrombin time, partial thromboplastin time, complete blood count, liver function test, and urine analysis.

RESULTS

Two hundred thirty-two patients were transferred to the receiving tertiary care hospital from within the hospital's network from May 1, 2011, to October 31, 2011. On average, each transferred patient had one repeat normal laboratory test (245/232=1.06). For all laboratory tests, repeat normal testing occurred at least 40% of the time. Extrapolating the data, the total yearly estimated charges of all repeat normal testing was $580,526.

CONCLUSION

This study provides the first analysis of the frequency of repeated laboratory testing for all transferred ED patients and indicates that repeat normal testing represents a significant cost. Future research needs to determine if such repeat testing is indeed clinically appropriate or redundant.

Trauma Transfers and Definitive Imaging: Patient Benefit but at What Cost?

Many patients undergo computed tomography (CT) scan before transfer to definitive care. Despite this, studies are often repeated on arrival to the trauma center. We evaluated a policy to provide formal in-house interpretation of images performed at outside hospitals. A 3-month retrospective analysis was performed. Two groups were compared. Patients in the in-house interpretation (IHI) group underwent in-house interpretation of outside images. Those images not meeting criteria were placed in the comparison group without in-house radiologic interpretation. Demographics, CT scan data, billing and productivity loss, and extrapolated cancer risk reduction were analyzed. There were no significant differences in demographic or injury data. Fewer total CT scans were performed in the IHI group (223 vs 320, P = 0.04). The IHI group underwent fewer repeated CT scans (25 vs 62, P = 0.02; odds ratio [OR], 0.53). Fewer patients were exposed to repeat CT scans (17 vs 32; OR, 0.48). Total hospital billings decreased by $188,285 ($4,592/patient) in the IHI group. Uncaptured work relative value units totaled 152.19 (3.71/patient) in the IHI group. Radiation exposure decreased by 8 per cent. Use of outside hospital imaging as the definitive evaluation of injured patients is safe and results in an overall decrease in radiation exposure and healthcare cost.

Transfer patient imaging: current status, review of the literature, and the Harborview experience

Patients transferred for higher levels of care often arrive with medical imaging from the outside facility, with or without accompanying radiology reports. The handling of pretransfer studies by receiving radiologists introduces several concerns regarding resource utilization, medicolegal risk, and technical quality control. The authors review the current status of transfer patient imaging, with an emphasis on the role of the receiving emergency radiologist. Practice solutions developed at the authors' level I trauma center are described.

Using the Internet for image transfer in a regional trauma network: effect on CT repeat rate, cost, and radiation exposure

PURPOSE

The aims of this study were to evaluate an Internet-based and compact disc-based image transfer system and to compare this system with others in the literature, specifically regarding effects on repeat imaging rate, cost, and radiation dose to patients transferred to a level I regional trauma center.

METHODS

Five hundred consecutive trauma patients transferred to a level I trauma center between June 1 and July 15, 2009, were included in the study. Images were transferred from an outside facility to the trauma center using the Internet and compact discs and uploaded to the trauma center's PACS. Radiographic studies and CT scans at the trauma center were classified as outside studies, completion studies, or repeat studies. Repeat rate, costs, and radiation doses of transferred and repeated CT scans were calculated.

RESULTS

Four hundred ninety-one patients met the inclusion criteria. The patients' average age was 40.5 years, and 70% were men. The average Injury Severity Score was 14.7. Three hundred eighty-three patients had 852 CT studies and 380 nonextremity radiographs imported into the trauma center's PACS. At the trauma center, 494 completion CT scans and 2,924 radiographic studies were performed on these patients. Sixty-nine repeat CT scans were performed on 55 patients, equalling a 17% repeat rate. The total value of imported CT studies was $244,373.69. Repeat imaging totaled $20,495.95, or $84.65 per patient with transferred CT studies.

CONCLUSIONS

Using a combination of the Internet and compact discs to transfer images during inter-hospital transfer is associated with much lower repeat rates than those in the literature, suggesting that regional PACS networks may be useful for reducing cost and radiation exposure associated with trauma.

Repeat Computed Tomography for Trauma Patients Undergoing Transfer to a Level I Trauma Center

Our goal was to determine the characteristics of trauma transfer patients with repeat imaging. A retrospective trauma registry review was performed to evaluate trauma patients who were transferred from referring institutions between January 2005 and December 2009. Patients were divided into those who had a duplicate computed tomography (CT) scan versus those who did not. There were 2678 patients included of whom 559 (21%) had at least one repeat CT scan, whereas 2119 (79%) did not have any repeat CT scans. Those with repeat CT scans were older (42.3 ± 27.3 years vs 37.3 ± 25.6 years), had a higher Injury Severity Score (ISS) (13.7 ± 8.7 vs 11.9 ± 8.8), and more likely to have blunt trauma (odds ratio, 4.7; confidence interval, 2.3 to 9.6) (P for all < 0.0007). Those with CT scans done only at the referring facility were younger, had a lower ISS, and shorter lengths of stay (P for all < 0.0003). ISS and age were independent predictors for repeat CT scans. Transfer patients had imaging repeated one-fifth of the time. The younger, less injured patient went without repeat imaging suggesting that they may have been adequately cared for at the outside institution.

Inefficiencies in a rural trauma system: the burden of repeat imaging in interfacility transfers

BACKGROUND

Local hospitals (LHs) transferring patients to regional trauma centers (TCs) often obtain CT scans to diagnose injuries and justify transfer. However, these imaging studies are often repeated at the receiving TCs. This study was performed to examine how frequently computed tomography (CT) scans were repeated in interfacility transfers in a rural trauma system and to identify the most common reason for repeating the studies.

METHODS

Patients transferred to a rural Level I TC from October 2007 through February 2008 were prospectively evaluated. Data abstracted included CT scans performed at LHs and CT scans repeated at the TC. Additionally, the reason for repeating each study was recorded as follows: (1) scan not sent, (2) software not compatible, (3) inadequate technique (no intravenous contrast), (4) inadequate technique (no reconstructions), and (5) clinically indicated.

RESULTS

During the study period, 138 patients were transferred to the TC. Of these, 104 (75%) underwent CT imaging before transfer. Sixty of these patients (58%) underwent repeat CT imaging at the TC. Overall, 98 of 243 (40%) scans were repeated. Head CT scans were repeated predominantly because of clinical indications. All other body region CT scans were repeated predominantly because of inadequate technique at the LHs.

CONCLUSIONS

CT scans were repeated in 58% of interfacility transfers. Repeat CT scans inevitably result in increased radiation exposure to patients as well as additional charges and may be an important patient safety and cost issue for trauma systems.

A preliminary look at duplicate testing associated with lack of electronic health record interoperability for transferred patients

Duplication of medical testing results in a financial burden to the healthcare system. Authors undertook a retrospective review of duplicate testing on patients receiving coordinated care across two institutions, each with its own electronic medical record system. In order to determine whether duplicate testing occurred and if such testing was clinically indicated, authors analyzed records of 85 patients transferred from one site to the other between January 1, 2006 and December 31, 2007. Duplication of testing (repeat within 12 hours) was found in 32% of the cases examined; 20% of cases had at least one duplicate test not clinically indicated. While previous studies document that inaccessibility of paper records leads to duplicate testing when patients are transferred between care facilities, the current study suggests that incomplete electronic record transfer among incompatible electronic medical record systems can also lead to potentially costly duplicate testing behaviors. The authors believe that interoperable systems with integrated decision support could assist in minimizing duplication of testing at time of patient transfers.

Imaging may delay transfer of rural trauma victims: a survey of referring physicians

BACKGROUND

Delayed transfer to a trauma center due to unnecessary imaging results in suboptimal patient outcome and increases healthcare costs. Unnecessary imaging may result from beliefs regarding trauma center requirements and legal concerns. We hypothesized that referring physicians consider factors other than clinical criteria when deciding to order imaging studies before transfer of trauma patients.

METHODS

A mail survey of 218 referring physicians to a level I trauma center elicited factors affecting decision to obtain imaging studies before transfer. Graded answers to six questions were obtained and demographics of the physician respondent. Statistical analysis was performed using Fisher's exact test.

RESULTS

One hundred forty-nine of 218 surveys were returned (68.3%). One-third (33.1%) of respondents obtain imaging because of perceived expectations of the receiving trauma center, independent of patient acuity. Twenty percent incorrectly think that the law prohibits transfer before patients are stabilized. Twenty-eight percent obtain imaging because of liability concerns, even if that imaging delays transfer. Overall, 45% obtain imaging for either perceived requirement or liability concern. Non-advanced trauma life support (ATLS)-certified physicians are more likely to use all available resources before transfer than ATLS-certified physicians.

CONCLUSIONS

Factors other than patient care dictate imaging acquisition in almost half of those surveyed. Misperception of expectations, misunderstanding of legal imperatives, and liability concerns all delay transport of the injured. ATLS-certified individuals use imaging more appropriately, thus, promoting more timely transfer. State-wide protocols, education, and liability reform may reduce transport delays.

Trauma systems and timing of patient transfer: are we improving?

INTRODUCTION

The regionalization of trauma services is based on the premise that injured persons presenting to nontertiary facilities will be stabilized and rapidly transported to a more definitive center. Although trauma systems seem to improve outcomes for urban patients, this same benefit has not been shown for rural patients. There are many factors associated with the decision to transfer injured patients to a regional trauma center, including referral hospital and patient age, for example. The purpose of this study is to examine factors that influence the timing of transfer of trauma patients and specifically to determine if establishing specific trauma systems has led to any changes in transfer timing over time.

METHODS

The trauma registry at the University of Wisconsin was queried for all patients admitted between July 1, 1999, and June 30, 2005. Patients were included in this study if they had been transferred to the university hospital after evaluation at an outside hospital. The registry variables that were abstracted were age, referring hospital, emergency department (ED) time at referring hospital, injury severity score (ISS), the presence of a head injury, performance of a head computed tomography (CT), mode of transport, and the date of ED evaluation.

RESULTS

There were 1656 patients with ISS higher than 9 transferred during the period. The mean ED time was 153 +/- 82 minutes. Emergency department time was significantly shorter for those with ISS higher than 25 and for those transported by helicopter. Four hundred ninety-two (30%) patients had a head CT performed at the outside hospital, of which 221 (44%) were repeated at the trauma center. The mean ED time for those in whom a CT was performed was significantly longer than those without CT (179 +/- 81 vs 142 +/- 84 minutes). The ED times were slightly longer for level III hospitals (158 +/- 82 minutes) than for level IV hospitals (137 +/- 74 minutes). Emergency department times were longer for older patients. The times in the ED showed an upward, but not statistically significant, trend. After controlling for all other variables, ED times were not significantly different over the period studied.

CONCLUSION

Development of a statewide trauma system and outreach education has not significantly affected transfer times from nontrauma centers in our system. Outreach educational efforts should focus on systematic trauma evaluation, prompt transfer, and limitation of nontherapeutic testing.

Transfer of Pediatric Trauma Patients to a Tertiary Pediatric Trauma Centre: Appropriateness and Timeliness

OBJECTIVE

To study the appropriateness of, and time taken, to transfer pediatric trauma patients in New South Wales to The Children's Hospital at Westmead (CHW), a pediatric trauma center.

METHODS

All trauma patients transferred to CHW from June 2003 to July 2004 were included in the study. Indications and time periods relevant to the transfer of the patient from the referring institute were retrieved and analyzed. Pediatric and adult retrieval services were compared.

RESULTS

Three hundred ninety-eight patients were transferred to CHW, of whom 332 were from the metropolitan region. Falls and burns were the commonest mechanism of injury. Burn was the commonest indication for transfer (107 of 398). Mean Injury Severity Score was eight. Nearly half the patients had minor injuries (Injury Severity Score<9). Patients spent an average of 5 hours at the referring hospital. Pediatric retrieval ambulances had significantly longer mean transfer times than did nonpediatric ambulance services with a total time spent of about 2.64 hours versus 1.30 hours, respectively. For aeromedical transfers, on the other hand, the difference between pediatric retrieval services and nonpediatric air ambulances was not significant.

CONCLUSIONS

The majority of the patients transferred had minor injuries. Pediatric trauma patients spend considerable time in their referring hospitals. Pediatric retrieval services appear to take significantly longer to transfer patients than nonpediatric ambulance transfers even after allowing for patient age and injury severity. Although this did not result in mortality or morbidity, there appears to be considerable scope for a reduction in transfer times through better coordination of these services.

Trauma and falls in the elderly

The number of people living longer and staying active continues to rise, resulting in an increase in the incidence of trauma-related vis-its by older persons to emergency departments. The elderly sustain a disproportionate share of fractures and serious injury, and represent a unique subset of patients with special needs and considerations. This article reviews the current literature on the management of elderly patients with trauma, including the physiologic changes of aging relevant to the management of trauma, injury patterns unique to geriatric victims of trauma, and aspects particular to resuscitation and general management of geriatric trauma victims. We include a discussion of the evaluation and management of falls in the elderly, including assessment of fall risk.

Characteristics of twice-transferred, rural trauma patients

OBJECTIVE

Undertriage has seldom been evaluated in the trauma population. In rural states patients often go to the nearest hospital first, where they are evaluated and, if necessary, transferred to another hospital. If they are undertriaged when transferred to the second hospital, they will require a second transfer to a higher-level trauma center.

METHODS

The authors retrospectively reviewed the charts of all trauma patients at a level I trauma center from 1996 to 1999 who were seen at two acute care facilities because of a single acute traumatic event before reaching the trauma center. Ninety-three patient charts were analyzed.

RESULTS

Forty-six percent of the patients were victims of a motor vehicle crash. Patients were mostly transferred to the level I trauma center for non-spine orthopedic injuries (28%), followed by spine injuries (14%) and head injuries (13%). These patients were stable, as manifested by an average trauma score of 11.6. However, there was a significant positive interaction between injury severity score and time to definitive care.

CONCLUSIONS

The authors infer from the data analysis that more serious or complex injuries took longer to evaluate. Since these patients were physiologically stable, reducing the number of twice-transferred trauma patients will involve refining transfer protocols concerning the need for specialty care.