1
|
Scaife JH, Bryce JR, Iantorno SE, Yang M, McCrum ML, Bucher BT. Secondary Undertriage of Pediatric Trauma Patients Across the United States Emergency Departments. J Surg Res 2024; 293:37-45. [PMID: 37703702 DOI: 10.1016/j.jss.2023.07.054] [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: 01/24/2023] [Revised: 06/28/2023] [Accepted: 07/24/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION The American College of Surgeons has developed evidence-based guidelines to triage the care of severely injured children to Level 1 and 2 trauma centers. Undertriage is the treatment of patients at facilities not equipped to treat the patient's injuries appropriately. We sought to evaluate the association between patient and hospital characteristics and secondary undertriage in children after major trauma. METHODS We performed a retrospective cohort study using the 2019 Nationwide Emergency Department Sample. Patients aged less than 18 y were included if they presented to a Level 3 or nontrauma center (NTC) and were diagnosed with a traumatic injury with an injury severity score >15 based on International Classification of Diseases 10 codes. Our primary outcome was secondary undertriage, defined as inpatient admission to a Level 3 or NTC. We developed generalized linear models with inverse-probability survey weighting to determine the association between patient and hospital characteristics and the primary outcome. RESULTS Of 6572 weighted patients, 982 (15%) were undertriaged. Undertriage was significantly associated with older age (13 versus 7, P value < 0.001), metropolitan location (86% versus 68%, P < 0.001), and major abdominal injuries (19% versus 11%, P = 0.011). After multivariable adjustment, secondary undertriage was significantly associated with patients aged 6-10 y (adjusted odds ratio [aOR]: 2.47, P = 0.002) compared to patients aged 15-17 y, penetrating injury (aOR: 1.70, P = 0.011), major chest injury (aOR: 2.10, P = 0.014), and presentation at a teaching hospital (aOR: 5.66, P < 0.001). CONCLUSIONS After major trauma, a significant proportion of children are secondarily undertriaged at teaching NTCs. Level 1 and 2 trauma centers must partner with lower-level trauma centers to ensure children receive equitable care.
Collapse
Affiliation(s)
- Jack H Scaife
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Jacoby R Bryce
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Stephanie E Iantorno
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Meng Yang
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Marta L McCrum
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Brian T Bucher
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| |
Collapse
|
2
|
Lupton JR, Davis‐O'Reilly C, Jungbauer RM, Newgard CD, Fallat ME, Brown JB, Mann NC, Jurkovich GJ, Bulger E, Gestring ML, Lerner EB, Chou R, Totten AM. Mechanism of injury and special considerations as predictive of serious injury: A systematic review. Acad Emerg Med 2022; 29:1106-1117. [PMID: 35319149 PMCID: PMC9545392 DOI: 10.1111/acem.14489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/17/2022] [Accepted: 03/19/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The Centers for Disease Control and Prevention's field triage guidelines (FTG) are routinely used by emergency medical services personnel for triaging injured patients. The most recent (2011) FTG contains physiologic, anatomic, mechanism, and special consideration steps. Our objective was to systematically review the criteria in the mechanism and special consideration steps that might be predictive of serious injury or need for a trauma center. METHODS We conducted a systematic review of the predictive utility of mechanism and special consideration criteria for predicting serious injury. A research librarian searched in Ovid Medline, EMBASE, and the Cochrane databases for studies published between January 2011 and February 2021. Eligible studies were identified using a priori inclusion and exclusion criteria. Studies were excluded if they lacked an outcome for serious injury, such as measures of resource use, injury severity scores, mortality, or composite measures using a combination of outcomes. Given the heterogeneity in populations, measures, and outcomes, results were synthesized qualitatively focusing on positive likelihood ratios (LR+) whenever these could be calculated from presented data or adjusted odds ratios (aOR). RESULTS We reviewed 2418 abstracts and 315 full-text publications and identified 42 relevant studies. The factors most predictive of serious injury across multiple studies were death in the same vehicle (LR+ 2.2-7.4), ejection (aOR 3.2-266.2), extrication (LR+ 1.1-6.6), lack of seat belt use (aOR 4.4-11.3), high speeds (aOR 2.0-2.9), concerning crash variables identified by vehicle telemetry systems (LR+ 4.7-22.2), falls from height (LR+ 2.4-5.9), and axial load or diving (aOR 2.5-17.6). Minor or inconsistent predictors of serious injury were vehicle intrusion (LR+ 0.8-7.2), cardiopulmonary or neurologic comorbidities (LR+ 0.8-3.1), older age (LR+ 0.6-6.8), or anticoagulant use (LR+ 1.1-1.8). CONCLUSIONS Select mechanism and special consideration criteria contribute positively to appropriate field triage of potentially injured patients.
Collapse
Affiliation(s)
- Joshua R. Lupton
- Department of Emergency MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Cynthia Davis‐O'Reilly
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Rebecca M. Jungbauer
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Craig D. Newgard
- Department of Emergency MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Mary E. Fallat
- Department of SurgeryUniversity of Louisville School of MedicineLouisvilleKentuckyUSA
| | - Joshua B. Brown
- Department of SurgeryUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - N. Clay Mann
- Department of PediatricsUniversity of UtahSalt Lake CityUtahUSA
| | | | - Eileen Bulger
- Department of SurgeryUniversity of WashingtonSeattleWashingtonUSA
| | - Mark L. Gestring
- Department of SurgeryUniversity of RochesterRochesterNew YorkUSA
| | - E. Brooke Lerner
- Department of Emergency MedicineUniversity at BuffaloBuffaloNew YorkUSA
| | - Roger Chou
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Annette M. Totten
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| |
Collapse
|
3
|
Paediatric patients in mass casualty incidents: a comprehensive review and call to action. Br J Anaesth 2021; 128:e109-e119. [PMID: 34862001 DOI: 10.1016/j.bja.2021.10.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 12/16/2022] Open
Abstract
The paediatric population is disproportionately affected during mass casualty incidents (MCIs). Several unique characteristics of children merit special attention during natural and man-made disasters because of their age, physiology, and vulnerability. Paediatric anaesthesiologists play a critical part of MCI care for this population, yet there is a deficit of publications within the anaesthesia literature addressing paediatric-specific MCI concerns. This narrative review article analyses paediatric MCI considerations and compares differing aspects between care provision in Australia, the UK, and the USA. We integrate some of the potential roles for anaesthesiologists with paediatric experience, which include preparation, command consultation, in-field care, pre-hospital transport duties, and emergency department, operating theatre, and ICU opportunities. Finally, we propose several methods by which anaesthesiologists can improve their contribution to paediatric MCI care through personal education, training, and institutional involvement.
Collapse
|
4
|
Pediatric trauma triage: A Pediatric Trauma Society Research Committee systematic review. J Trauma Acute Care Surg 2020; 89:623-630. [PMID: 32301877 DOI: 10.1097/ta.0000000000002713] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Significant variability exists in the triage of injured children with most systems using mechanism of injury and/or physiologic criteria. It is not well established if existing triage criteria predict the need for intervention or impact morbidity and mortality. This study evaluated existing evidence for pediatric trauma triage. Questions defined a priori were as follows: (1) Do prehospital trauma triage criteria reduce mortality? (2) Do prehospital trauma scoring systems predict outcomes? (3) Do trauma center activation criteria predict outcomes? (4) Do trauma center activation criteria predict need for procedural or operative interventions? (5) Do trauma bay pediatric trauma scoring systems predict outcomes? (6) What secondary triage criteria for transfer of children exist? METHODS A structured, systematic review was conducted, and multiple databases were queried using search terms related to pediatric trauma triage. The literature search was limited to January 1990 to August 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was applied with the methodological index for nonrandomized studies tool used to assess the quality of included studies. Qualitative analysis was performed. RESULTS A total of 1,752 articles were screened, and 38 were included in the qualitative analysis. Twelve articles addressed questions 1 and 2, 21 articles addressed question 3 to 5, and five articles addressed question 6. Existing literature suggest that prehospital triage criteria or scoring systems do not predict or reduce mortality, although selected physiologic parameters may. In contrast, hospital trauma activation criteria can predict the need for procedures or surgical intervention and identify patients with higher mortality; again, physiologic signs are more predictive than mechanism of injury. Currently, no standardized secondary triage/transfer protocols exist. CONCLUSION Evidence supporting the utility of prehospital triage criteria for injured children is insufficient, while physiology-based trauma system activation criteria do appropriately stratify injured children. The absence of strong evidence supports the need for further prehospital and secondary transfer triage-related research. LEVEL OF EVIDENCE Systematic review study, level II.
Collapse
|
5
|
Candy S, Schuurman N, MacPherson A, Schoon R, Rondeau K, Yanchar NL. "Who is the right patient?" Insights into decisions to transfer pediatric trauma patients. J Pediatr Surg 2020; 55:930-937. [PMID: 32063372 DOI: 10.1016/j.jpedsurg.2020.01.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 01/25/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We aim to determine what variables may influence physician decision-making about transfer of pediatric patients from a Level III Trauma Center (L3TC) to a Pediatric Trauma Center (PTC). METHODS Emergency L3TC physicians and PTC emergency physicians/TTLs were surveyed with clinical scenarios of children presenting to a L3TC with 5 injury parameters: age, hemodynamic status, GCS, intra-abdominal injury, femur/ pelvic fracture, and asked if the patient should be transferred to a PTC. Associations between parameters and physician demographics in the decision to transfer were examined. RESULTS One hundred seven and 94 surveys were completed at L3TCs and PTCs, respectively. Parameters associated with decision to transfer: pelvic and GI tract injuries, GCS < 12, and age < 4 years. L3TCs were significantly less likely vs. PTCs to recommend transfer with femur fracture, solid organ / GI injury, or a GCS of <13. Increasing town size, access to an experienced surgeon, and formal training in emergency medicine among L3TC physicians were associated with a decision not to transfer. CONCLUSIONS Injuries requiring potential surgery or critical care influenced the decision to transfer. For cases with lesser severity or older ages, input of L3TCs on developing triage criteria is vital to allow families to stay in their home communities while ensuring optimal clinical outcomes. TYPE OF STUDY Prospective Cross Sectional Survey. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Sydney Candy
- Queen's University, School of Medicine, Kingston, ON, Canada; University of Calgary, Department of Surgery, Calgary, AB, Canada
| | - Nadine Schuurman
- Simon Fraser University, Department of Geography, Vancouver, BC, Canada
| | - Alison MacPherson
- York University, Faculty of Kinesiology and Health Sciences, Toronto, ON, Canada
| | | | - Kimberly Rondeau
- University of Calgary, Department of Surgery, Calgary, AB, Canada
| | | |
Collapse
|
6
|
Anderson KT, Bartz-Kurycki MA, Garwood GM, Martin R, Gutierrez R, Supak DN, Wythe SN, Kawaguchi AL, Austin MT, Huzar TF, Tsao K. Let the right one in: High admission rate for low-acuity pediatric burns. Surgery 2019; 165:360-364. [DOI: 10.1016/j.surg.2018.06.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/11/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
|
7
|
Doud AN, Schoell SL, Talton JW, Barnard RT, Petty JK, Stitzel JD, Weaver AA. Characterization of the occult nature of frequently occurring pediatric motor vehicle crash injuries. ACCIDENT; ANALYSIS AND PREVENTION 2018; 113:12-18. [PMID: 29367055 DOI: 10.1016/j.aap.2017.12.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 11/27/2017] [Accepted: 12/31/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Occult injuries are those likely to be missed on initial assessment by first responders and, though initially asymptomatic, they may present suddenly and lead to rapid patient decompensation. No scoring systems to quantify the occultness of pediatric injuries have been established. Such a scoring system will be useful in the creation of an Advanced Automotive Crash Notification (AACN) system that assists first responders in making triage decisions following a motor vehicle crash (MVC). STUDY DESIGN The most frequent MVC injuries were determined for 0-4, 5-9, 10-14 and 15-18 year olds. For each age-specific injury, experts with pediatric trauma expertise were asked to rate the likelihood that the injury may be missed by first responders. An occult score (ranging from 0-1) was calculated by averaging and normalizing the responses of the experts polled. RESULTS Evaluation of all injuries across all age groups demonstrated greater occult scores for the younger age groups compared to older age groups (mean occult score 0-4yo: 0.61 ± 0.23, 5-9yo: 0.53 ± 0.25, 10-14yo: 0.48 ± 0.23, and 15-18yo: 0.42 ± 0.22, p < 0.01). Body-region specific occult scores revealed that experts judged abdominal, spine and thoracic injuries to be more occult than injuries to other body regions. CONCLUSIONS The occult scores suggested that injuries are more difficult to detect in younger age groups, likely given their inability to express symptoms. An AACN algorithm that can predict the presence of clinically undetectable injuries at the scene can improve triage of children with these injuries to higher levels of care.
Collapse
Affiliation(s)
- Andrea N Doud
- Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, United States; Childress Institute for Pediatric Trauma, 575 N Patterson Ave, Suite 148, Winston-Salem, NC, 27103, United States.
| | - Samantha L Schoell
- Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, United States; Virginia Tech-Wake Forest University Center for Injury Biomechanics, 575 N. Patterson Ave, Suite 120, Winston-Salem, NC, 27101, United States.
| | - Jennifer W Talton
- Wake Forest School of Medicine, Division of Public Health Sciences, Medical Center Blvd, Winston-Salem, NC, 27157, United States.
| | - Ryan T Barnard
- Wake Forest School of Medicine, Division of Public Health Sciences, Medical Center Blvd, Winston-Salem, NC, 27157, United States.
| | - John K Petty
- Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, United States; Childress Institute for Pediatric Trauma, 575 N Patterson Ave, Suite 148, Winston-Salem, NC, 27103, United States.
| | - Joel D Stitzel
- Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, United States; Virginia Tech-Wake Forest University Center for Injury Biomechanics, 575 N. Patterson Ave, Suite 120, Winston-Salem, NC, 27101, United States; Childress Institute for Pediatric Trauma, 575 N Patterson Ave, Suite 148, Winston-Salem, NC, 27103, United States.
| | - Ashley A Weaver
- Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, United States; Virginia Tech-Wake Forest University Center for Injury Biomechanics, 575 N. Patterson Ave, Suite 120, Winston-Salem, NC, 27101, United States.
| |
Collapse
|
8
|
Doud AN, Schoell SL, Talton JW, Barnard RT, Petty JK, Meredith JW, Martin RS, Stitzel JD, Weaver AA. Predicting Pediatric Patients Who Require Care at a Trauma Center: Analysis of Injuries and Other Factors. J Am Coll Surg 2017; 226:70-79.e8. [PMID: 29174350 DOI: 10.1016/j.jamcollsurg.2017.09.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/24/2017] [Accepted: 09/25/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Triage decision correctness for children in motor vehicle crashes can be affected by occult injuries. There is a need to develop a transfer score (TS) metric for children that can help quantify the likelihood that an injury is present that would require transfer to a trauma center (TC) from a non-TC, and improve triage decision making. Ultimately, the TS metric might be useful in an advanced automatic crash notification algorithm, which uses vehicle telemetry data to predict the risk of serious injury after a motor vehicle crash using an approach that includes metrics to describe injury severity, time sensitivity, and predictability. STUDY DESIGN Transfer score metrics were calculated in 4 pediatric age groups (0 to 4, 5 to 9, 10 to 14, 15 to 18 years) for the most frequent motor vehicle crash injuries using the proportions of children transferred to a TC or managed at a non-TC using the National Inpatient Sample years 1998 to 2007. To account for the maximum Abbreviated Injury Scale (MAIS) injury, a co-injury adjusted transfer score (TSMAIS) was calculated. The TS and TSMAIS range from 0 to 1, with 1 indicating highly transferred injuries. RESULTS Injuries in younger patients were more likely to be transferred (median TS 0.48, 0.35, 0.25, and 0.23 for 0 to 4, 5 to 9, 10 to 14, and 15 to 18 years, respectively). Injuries more likely to be transferred in younger children occurred in the thorax and abdomen. Regardless of age, spine (median TSMAIS 0.59), head (median TSMAIS 0.48), and thorax (median TSMAIS 0.46) injuries had the highest frequency for transfer. CONCLUSIONS The TS metrics quantitatively describe age-specific transfer practices for children with particular injuries. This information can be useful in advanced automatic crash notification systems to alert first responders to the possibility of occult injuries and reduce undertriage of commonly missed injuries.
Collapse
Affiliation(s)
- Andrea N Doud
- Wake Forest University School of Medicine, Winston-Salem, NC; Childress Institute for Pediatric Trauma, Winston-Salem, NC
| | - Samantha L Schoell
- Wake Forest University School of Medicine, Winston-Salem, NC; Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC
| | - Jennifer W Talton
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ryan T Barnard
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - John K Petty
- Wake Forest University School of Medicine, Winston-Salem, NC; Childress Institute for Pediatric Trauma, Winston-Salem, NC
| | - J Wayne Meredith
- Wake Forest University School of Medicine, Winston-Salem, NC; Childress Institute for Pediatric Trauma, Winston-Salem, NC
| | - R Shayn Martin
- Wake Forest University School of Medicine, Winston-Salem, NC; Childress Institute for Pediatric Trauma, Winston-Salem, NC
| | - Joel D Stitzel
- Wake Forest University School of Medicine, Winston-Salem, NC; Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC
| | - Ashley A Weaver
- Wake Forest University School of Medicine, Winston-Salem, NC; Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC.
| |
Collapse
|
9
|
Consequences of pediatric undertriage and overtriage in a statewide trauma system. J Trauma Acute Care Surg 2017; 83:662-667. [DOI: 10.1097/ta.0000000000001560] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
10
|
Hamilton EC, Miller CC, Cotton BA, Cox C, Kao LS, Austin MT. The association of insurance status on the probability of transfer for pediatric trauma patients. J Pediatr Surg 2016; 51:2048-2052. [PMID: 27686481 DOI: 10.1016/j.jpedsurg.2016.09.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 09/12/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this study was to evaluate the association of insurance status on the probability of transfer of pediatric trauma patients to level I/II centers after initial evaluation at lower level centers. METHODS A retrospective review of all pediatric trauma patients (age<16years) registered in the 2007-2012 National Trauma Data Bank was performed. Multiple regression techniques controlling for clustering at the hospital level were used to determine the impact of insurance status on the probability of transfer to level I/II trauma centers. RESULTS Of 38,205 patients, 33% of patients (12,432) were transferred from lower level centers to level I/II trauma centers. Adjusting for demographics and injury characteristics, children with no insurance had a higher likelihood of transfer than children with private insurance. Children with public or unknown insurance status were no more likely to be transferred than privately insured children. There were no variable interactions with insurance status. CONCLUSIONS Among pediatric trauma patients, lack of insurance is an independent predictor for transfer to a major trauma center. While burns, severely injured, and younger patients remain the most likely to be transferred, these findings suggest a triage bias influenced by insurance status. Additional policies may be needed to avoid unnecessary transfer of uninsured pediatric trauma patients. LEVEL OF EVIDENCE Case-control study, level III.
Collapse
Affiliation(s)
- Emma C Hamilton
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Charles C Miller
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Bryan A Cotton
- Department of Surgery and Center for Translational Injury Research, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Charles Cox
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX
| | - Lillian S Kao
- Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX; Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Mary T Austin
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX; Department of Pediatric Patient Care, Children's Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, TX.
| |
Collapse
|
11
|
Leung A, Bonasso P, Lynch K, Long D, Vaughan R, Wilson A, Con J. Pediatric Secondary Overtriage in a Statewide Trauma System. Am Surg 2016. [DOI: 10.1177/000313481608200928] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Secondary overtriage is a term that describes patients who are discharged home shortly after being transferred, an indication that transfer and hospitalization were unnecessary. The study goal was to identify factors associated with secondary triage. A statewide trauma registry was used to identify trauma patients aged less than 18 years during a 6-year period (2007–2012) who were discharged within 48 hours from arrival and did not undergo a surgical procedure. We compared those that were treated at initial facility and those transferred to a second facility using clinical indices including patterns of injury pattern using multivariate logistic regression. Of the 4441 patients who fit our inclusion criteria, 801 (18%) were transferred. Younger age groups were more likely to be transferred. Factors associated with being transferred included head, spinal, and facial injuries, and patient arrival during the nighttime work shifts. In conclusion, young patients who have signs of possible neurological or spinal injuries and those who arrive during nondaytime shifts during the workday are more likely to be transferred to another trauma center. These may reflect the comfort level and resources of the local facility.
Collapse
Affiliation(s)
- Alexander Leung
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Patrick Bonasso
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Kevin Lynch
- School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Dustin Long
- Department of Biostatistics, West Virginia University, Morgantown, West Virginia
| | - Richard Vaughan
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Alison Wilson
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Jorge Con
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| |
Collapse
|
12
|
|
13
|
Goldstein SD, Van Arendonk K, Aboagye JK, Salazar JH, Michailidou M, Ziegfeld S, Lukish J, Stewart FD, Haut ER, Abdullah F. Secondary overtriage in pediatric trauma: can unnecessary patient transfers be avoided? J Pediatr Surg 2015; 50:1028-31. [PMID: 25812448 DOI: 10.1016/j.jpedsurg.2015.03.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 03/10/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND In an era of wide regionalization of pediatric trauma systems, interhospital patient transfer is common. Decisions regarding the location of definitive trauma care depend on prehospital destination criteria (primary triage) and interfacility transfers (secondary triage). Secondary overtriage can occur in any resource-limited setting but is not well characterized in pediatric trauma. METHODS The National Trauma Data Bank from 2008 to 2011 was queried to identify patients 15 years or younger who were transferred to pediatric trauma centers. Secondary overtriage was defined as meeting all 4 of the following criteria: injury severity score (ISS) less than 9, no need for surgical procedure, no critical care admission, and length of stay of less than 24 hours. All other transfers were deemed appropriate triage. RESULTS Our definition of secondary overtriage was met in 32,318 patients out of 144,420 transfers (22.4%). Within this group, 37.5% were discharged directly from the emergency department of the receiving hospital without hospital admission. Appropriately triaged patients required a therapeutic procedure in 43.5% of cases. Differences in age, sex, mechanism of injury, and payer status were modest. CONCLUSIONS Secondary overtriage is prevalent in pediatric trauma systems nationwide and is not associated with any particular patient characteristics. Because clinical outcomes and healthcare spending are increasingly scrutinized, secondary overtriage may reflect unnecessary patient transfer and a source of potential cost savings. Development of better guidelines for secondary triage of pediatric trauma patients may enable timely assessment and treatment of children who require a higher level of care while also preventing inefficient use of available resources.
Collapse
Affiliation(s)
- Seth D Goldstein
- Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD.
| | - Kyle Van Arendonk
- Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD
| | | | - Jose H Salazar
- Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Maria Michailidou
- Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Susan Ziegfeld
- Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Jeffrey Lukish
- Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - F Dylan Stewart
- Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Elliott R Haut
- Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Fizan Abdullah
- Division of Pediatric Surgery, Johns Hopkins Hospital, Baltimore, MD
| |
Collapse
|
14
|
DO HQ, HESSELFELDT R, STEINMETZ J, RASMUSSEN LS. Is paediatric trauma severity overestimated at triage? An observational follow-up study. Acta Anaesthesiol Scand 2014; 58:98-105. [PMID: 24308697 DOI: 10.1111/aas.12222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Severe paediatric trauma is rare, and pre-hospital and local hospital personnel experience with injured children is often limited. We hypothesised that a higher proportion of paediatric trauma victims were taken to the regional trauma centre (TC). METHODS This is an observational follow-up study that involves one level I TC and seven local hospitals. We included paediatric (< 16 years) and adult (≥ 16-≤ 79 years) trauma patients with a driving distance to the TC > 30 minutes. The primary end-point was the proportion of trauma patients arriving in the TC. RESULTS We included 1934 trauma patients, 238 children and 1696 adults. A total of 33/238 children (13.9%) vs. 304/1696 adults (17.9%) were transported to the TC post-injury (P = 0.14). Among these, children were significantly less injured than adults [median Injury Severity Score (ISS) 9 vs. 14, P < 0.01]. There was no significant difference between the groups in the proportion of seriously injured trauma victims (ISS > 15) taken to the TC [8/11 (72.7%) vs. 139/182 (76.4%)]. The corresponding figures for ISS < 15 were 25/227 (11.0%) and 164/1509 (10.9%), respectively. No significant difference was found in intensive care unit length of stay or time to TC arrival. No paediatric vs. 36/1671 (2.2%) adult deaths were observed at 30-day follow-up (P = 0.03). CONCLUSIONS There was no difference in the proportion of paediatric and adult trauma patients transported to the TC, neither overall nor among severely injured patients. Paediatric trauma patients admitted to the TC were, however, significantly less injured than adults.
Collapse
Affiliation(s)
- H. Q. DO
- Department of Anaesthesia; Centre of Head and Orthopaedics; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Trauma Centre; Centre of Head and Orthopaedics; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - R. HESSELFELDT
- Department of Anaesthesia; Centre of Head and Orthopaedics; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - J. STEINMETZ
- Department of Anaesthesia; Centre of Head and Orthopaedics; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Trauma Centre; Centre of Head and Orthopaedics; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
- Helicopter Emergency Medical Service; Ringsted Denmark
| | - L. S. RASMUSSEN
- Department of Anaesthesia; Centre of Head and Orthopaedics; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| |
Collapse
|