Under-triage in Trauma: Does an Organized Trauma Network Capture the Major Trauma Victim? A Statewide Analysis

ABSTRACTBACKGROUNDProper triage of critically injured trauma patients to accredited trauma centers (TCs) is essential for survival and patient outcomes. We sought to determine the percentage of patients meeting trauma criteria who received care at non-trauma centers (NTCs) within the statewide trauma system that exists in the state of Pennsylvania. We hypothesized that a substantial proportion of the trauma population would be undertriaged to NTCs with undertriage rates (UTR) decreasing with increasing severity of injury.METHODSAll adult (age ≥15) hospital admissions meeting trauma criteria (ICD-9: 800-959; Injury Severity Score [ISS]>9 or ISS>15) from 2003-2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database, and compared with the corresponding trauma population within the Pennsylvania Trauma Systems Foundation (PTSF) registry. PHC4 contains all hospital admissions within PA while PTSF collects data on all trauma cases managed at designated TCs (Level I-IV). The percentage of patients meeting trauma criteria who are undertriaged to NTCs was determined and Network Analyst Location-Allocation function in ArcGIS Desktop was used to generate geospatial representations of undertriage based on injury severity scores throughout the state.RESULTSFor ISS>9, 173,022 cases were identified from 2003-2015 in PTSF, while 255,263 cases meeting trauma criteria were found in the PHC4 database over the same timeframe suggesting UTR of 32.2%. For ISS>15, UTR was determined to be 33.6%. Visual geospatial analysis suggests regions with limited access to trauma centers comprise the highest proportion of undertriaged trauma patients.CONCLUSIONSDespite the existence of a statewide trauma framework for over 30 years, approximately, a third of severely-injured trauma patients are managed at hospitals outside of the trauma system in PA. Intelligent trauma system design should include an objective process like geospatial mapping rather than the current system which is driven by competitive models of financial and healthcare system imperatives.LEVEL OF EVIDENCELevel III epidemiological study BACKGROUND Proper triage of critically injured trauma patients to accredited trauma centers (TCs) is essential for survival and patient outcomes. We sought to determine the percentage of patients meeting trauma criteria who received care at non-trauma centers (NTCs) within the statewide trauma system that exists in the state of Pennsylvania. We hypothesized that a substantial proportion of the trauma population would be undertriaged to NTCs with undertriage rates (UTR) decreasing with increasing severity of injury. METHODS All adult (age ≥15) hospital admissions meeting trauma criteria (ICD-9: 800-959; Injury Severity Score [ISS]>9 or ISS>15) from 2003-2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database, and compared with the corresponding trauma population within the Pennsylvania Trauma Systems Foundation (PTSF) registry. PHC4 contains all hospital admissions within PA while PTSF collects data on all trauma cases managed at designated TCs (Level I-IV). The percentage of patients meeting trauma criteria who are undertriaged to NTCs was determined and Network Analyst Location-Allocation function in ArcGIS Desktop was used to generate geospatial representations of undertriage based on injury severity scores throughout the state. RESULTS For ISS>9, 173,022 cases were identified from 2003-2015 in PTSF, while 255,263 cases meeting trauma criteria were found in the PHC4 database over the same timeframe suggesting UTR of 32.2%. For ISS>15, UTR was determined to be 33.6%. Visual geospatial analysis suggests regions with limited access to trauma centers comprise the highest proportion of undertriaged trauma patients. CONCLUSIONS Despite the existence of a statewide trauma framework for over 30 years, approximately, a third of severely-injured trauma patients are managed at hospitals outside of the trauma system in PA. Intelligent trauma system design should include an objective process like geospatial mapping rather than the current system which is driven by competitive models of financial and healthcare system imperatives. LEVEL OF EVIDENCE Level III epidemiological study Corresponding Author: Frederick B. Rogers, MD, MS, FACS, Penn Medicine Lancaster General Health, 555 N. Duke St., Lancaster, PA, 17604, +1 (717) 544-5945 (tel); +1 (717) 544-5944 (fax); frogers2@lghealth.org Conflicts of Interest and Source of Funding: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. This study was funded in part by a grant from the Louise von Hess Medical Research Institute. This study was presented as a QuickShot presentation at the 76th Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery from September 13-16, 2017 in Baltimore, Maryland. © 2017 Lippincott Williams & Wilkins, Inc.

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