More than half of severely injured patients in the U.S. who are first treated at a Level III trauma center or a hospital without a trauma designation are never transferred to a Level I or Level II trauma center, according to a recent study published in the Journal of the American College of Surgeons.

The study — Secondary Undertriage of Severely Injured Trauma Patients Across the US — identified several independent predictors of non-transfer.

One of the main findings of the study is that secondary undertriage is not driven primarily by small, rural hospitals. The authors found that the risk of non-transfer was greatest for patients treated at urban hospitals, hospitals with high trauma volumes, and Level III trauma centers.

Based on NEDS database

The secondary undertriage study was a retrospective cohort study using the 2019 Nationwide Emergency Department Sample (NEDS), an administrative claims database that includes ED visit discharge records from 989 hospitals in 41 states, representing about 85% of the U.S. population.

The study included all trauma patients age 18 or older with an ISS greater than 15 who first presented to a Level III trauma center or a non-trauma center (NTC). It excluded patients released from the ED without admission, patients who died in the ED, and patients transferred in to the Level III or NTC from a different hospital.

The researchers found that out of 146,816 encounters involving severely injured patients presenting at a Level III or a non-trauma center, 84,695 patients — or 58% — were not transferred to a Level I or Level II trauma center.

In this study, independent predictors of non-transfer to a higher level of care were:

In addition, patients with severe chest, abdomen and extremity injuries had increased odds of non-transfer. However, patients with penetrating injury (versus blunt injury) had decreased odds of non-transfer to a higher level of care.

The trauma volume quartile analysis included all hospitals, not just Level III centers and NTCs. Though not discussed within the paper, the patient volume finding could be interpreted in two ways:

• The practice of not transferring out severely injured patients contributes to higher trauma patient volumes at Level III centers.
• Level III centers with higher trauma patient volumes are better equipped (via a volume-outcome effect) to treat more severely injured patients in house.

Findings and suggestions

The study noted that, overall, one in every three severely injured patients in the U.S. are initially treated at a Level III trauma center or an NTC. In their discussion of the findings, the authors noted that secondary undertriage appears to be increasingly common:

“While the factors underlying transfer decisions cannot be discerned in retrospective analysis using registry or claims data, it appears that a substantial — and likely increasing — portion of trauma care occurs outside designated trauma centers. Moreover, our results suggest that it is not small, rural hospitals that are primarily failing to re-triage patients to high-resource trauma centers, but rather metropolitan hospitals, which likely have fewer geographic and logistical barriers to overcome.”

The authors also noted that their findings are aligned with other research demonstrating increased rates of undertriage among geriatric trauma patients. They referenced recent literature showing that key factors in undertriage for older trauma patients are inadequate provider training, provider unfamiliarity with protocols, and patient/family preference.

The authors advocate for more state-level adoption of triage guidelines and better integration of Level III centers into trauma systems.

“Trauma systems are decentralized and managed at the state level. Currently, less than half of states have secondary triage guidelines that help clinicians determine who should be transferred to a Level I or Level II trauma center,” said study co-author Marta L. McCrum, MD, FACS, associate professor in the department of surgery at the University of Utah in Salt Lake City, in an ACS press release.

“Overall, Level III hospitals need to be brought into what we consider to be high-level trauma systems so that we can better support these centers in the trauma care that they do provide and ensure the best possible outcomes for all patients,” Dr. McCrum said.

Need to strengthen systems

The ACS press release includes comments from Avery Nathens, MD, PhD, FACS, medical director of the ACS Trauma Quality Programs:

“The ACS Committee on Trauma is dedicated to ensuring that patients receive the right care in the right place based on their needs; in many cases, this might be care closer to home,” Dr. Nathans said. “These findings show that while Level III trauma centers play an important role for the communities in which they are located, we have work to do to strengthen our trauma systems to ensure all patients get the care they need.”

Dr. Nathans was not involved in this study.