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Excessive overtriage in US trauma centers overwhelming system resources, delaying patient care

January 25, 2008

Research in the January issue of the Journal of the American College of Surgeons (JACS) shows that many patients with minimal injuries are being transferred from community hospitals to Level I and II trauma centers, despite the ability of the community hospitals to treat such injuries. The study concludes that overuse of trauma centers threatens to limit the availability of resources to injured patients truly in need; increase overall system costs; and burden higher-level trauma centers with the routine care of minor injuries.

"We were surprised to discover that a substantial proportion of the patients transferred to our trauma center had only minor skin and soft-tissue injuries, which could have been treated at any community hospital," according to lead author of the study David J. Ciesla, MD, FACS, who currently serves as the director of trauma and surgical care services at Tampa (FL) General Hospital but had been director of trauma services at Washington Hospital Center in Washington, DC at the time the study was conducted. "A comprehensive effort must be made to develop a regional inclusive trauma system with pre-established transfer guidelines to specify what patients need trauma care and to ensure that the nation's trauma centers can keep pace with the increasing demands being placed on them," he explained.

Trauma systems - regionalized plans for coordination of emergency care based upon proper organization of existing health care resources - are designed to bring the appropriate level of care to an injured patient in the shortest amount of time. Although trauma systems have been shown to substantially reduce injury-related deaths, researchers found that patients located in regions without a formal trauma system are increasingly being transferred to trauma centers for non-medical reasons, such as gender, age, race, and time of day.

Researchers suggest that this trend could be a result of recent changes in the Emergency Medical and Active Labor Treatment Act (EMTALA) that no longer require community hospitals to provide emergency specialty coverage. Furthermore, because emergency specialty coverage is not funded to the same degree as routine specialty care, many physicians view emergency coverage as a threat to their practice and in turn, forego emergency room call. As a result, hospitals are facing ongoing shortage of on-call emergency room physicians and are in the difficult position of having to transfer patients with minor injuries to regional trauma centers for evaluation.

In the JACS study, researchers conducted a retrospective cohort study based on institutional trauma registry data for 9,064 patients. Of those patients, 76 percent (n=6,875) arrived directly from the accident scene and 24 percent (n=2,189) were transferred from community hospitals. Although the patients who were transferred from community hospitals were on average more severely injured than those that were not transferred, the majority of these patients (64 percent) had minor injuries; 824 (39 percent) met secondary overtriage criteria, which were defined as an Injury Severity Score of less than 10 (on a scale of 75), not requiring an operation and discharge within 48 hours of arrival at the trauma center. Although this number is less than the 54 percent of patients who arrive directly from the accident scene meeting these criteria, it represents a substantial proportion of transferred patients and accounts for 9 percent of all trauma encounters.

Weber Shandwick Worldwide