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Hospital resources do not predict accuracy of secondary trauma triage: a population-based analysis

Tillmann BW, Nathens AB, Guttman M, Pequeno P, Scales DC, Pechlivanoglou P, Haas B. J Trauma Acute Care Surg. 2020; 88(2):230-41. Epub 2019 Nov 20. DOI:

Background — The identification of patients who require transfer from non-trauma centers to trauma centers (secondary triage) is complicated by high rates of under- and overtriage. The objective of this study was to evaluate variations in secondary triage accuracy across non-trauma centers and identify factors associated with highly accurate secondary triage.

Methods — We performed a population-based study of injured patients who presented to non-trauma centers in a large regional trauma system. Patients were categorized as undertriaged, overtriaged, or appropriately triaged based on transfer status and presence of a severe injury (ISS > 15, death within 24h, or critical injury as defined by the American College of Surgeons). Mixed effect models, adjusted for case-mix and hospital resource, were used to compare triage accuracy across hospitals, and identify factors associated with high-performing centers.

Results — Among 118,973 patients identified at 182 non-trauma centers, 37,528 (31.5%) had severe injuries. The majority of severely injured patients (76.9%) were not transferred to a trauma center (undertriaged), while 9.6% of non-severely injured patients were transferred to a trauma center (overtriaged). Mixed effect models demonstrated that at the average hospital severely injured patients were 3.76-times more likely to be transferred than non-severely injured patients (DOR 3.76; 95% CI 3.20 – 4.31). Despite significant variation in triage accuracy across hospitals, adjusted analyses suggested that local resources bore no relationship to triage accuracy.

Conclusions — Triage accuracy varies significantly across non-trauma centers, after adjusting for hospital resources. These findings suggest that other, potentially modifiable factors play a key role in transfer decisions.