Rapid Discharge After Transfer: Risk Factors, Incidence, and Implications for Trauma Systems
ABSTRACT The occurrence of discharge to home shortly after transfer from another hospital, also termed "secondary overtriage," needs to be analyzed in trauma patients because it helps to assess the efficiency of triage and transfer criteria. The extent of secondary overtriage and factors associated with it remain largely undescribed.
A retrospective analysis of the Nationwide Inpatient Sample from 2000 to 2004. Inclusion criteria were trauma patients (as identified by ICD-9 diagnosis codes of 800-959 in the primary position, excluding codes representing late effects of injury, foreign body, burn, or early complications) who were admitted as transfers from another hospital. Rapid discharge after transfer (secondary overtriage) was defined as patients who were discharged alive within 1 day after transfer and did not receive any surgical procedure.
The overall rate of secondary overtriage was 6.9% (3,291 of 51,278), with an increasing trend over the years. This rate was significantly higher among patients younger than 18 years (19.5% vs. 4.2%). Patients meeting the definition were more likely to be male (68.3% vs. 50.65%), more likely to be black or Hispanic (25.16% vs. 16.8%), more likely to come from ZIP codes with above-median household incomes (43.4% vs. 38.1%), and more likely to be treated at teaching hospitals (77.3% vs. 61.3%). The majority of these patients (98.7%) were insured, although the proportion of uninsured patients was significantly higher among secondary overtriage (1.3% vs. 0.54%). On multivariate analysis, younger age, uninsured status, and being transferred to a teaching hospital were associated with higher likelihood of rapid discharge after transfer. No association was found with gender, race, and urbanicity.
Secondary overtriage is more common in pediatric patients than in adults. The underlying causes of this occurrence need to be further investigated (e.g., fear of litigation and uneven distribution of resources). There are significant direct and indirect costs associated with these occurrences that must be considered as we identify areas of potential cost savings in our nation's health care.
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ABSTRACT: Background Trauma resuscitations without pre-arrival notification are often initially chaotic, potentially compromising patient care. We hypothesized that trauma resuscitations without pre-arrival notification are performed with more variable adherence to Advanced Trauma Life Support (ATLS) protocol and that implementation of a checklist would improve performance. Study Design We analyzed event logs of trauma resuscitations from two four-month periods before (n=222) and after (n=215) checklist implementation. Using process mining techniques, individual resuscitations were compared to an ideal workflow model of six ATLS primary survey tasks performed by the bedside evaluator and given model fitness scores (range 0 to 1). Mean fitness scores and frequency of conformance (fitness=1) were compared (using Student's t-test or chi-square test, as appropriate) for activations with and without notification both before and after checklist implementation. Multivariable linear regression, controlling for patient and resuscitation characteristics, was also performed to assess the association between pre-arrival notification and model fitness before and after checklist implementation. Results Fifty-five (12.6%) resuscitations lacked pre-arrival notification (n=23 pre-implementation and =32 post-implementation, p=0.15). Before checklist implementation, resuscitations without notification had lower fitness (0.80 vs. 0.90, p<0.001) and conformance (26.1% vs. 50.8%, p=0.03) than those with notification. Following checklist implementation, the fitness (0.80 vs. 0.91, p=0.007) and conformance (26.1% vs. 59.4%, p=0.01) improved for resuscitations without notification, but still remained lower than activations with notification. In multivariable analysis, activations without notification had lower fitness both before (b=-0.11, p<0.001) and after checklist implementation (b=-0.04, p=0.02). Conclusions Trauma resuscitations without pre-arrival notification are associated with a decreased adherence to key components of the ATLS primary survey protocol. The addition of a checklist improves protocol adherence and reduces the effect of notification on task performance.Journal of the American College of Surgeons 09/2013; 218(3). DOI:10.1016/j.jamcollsurg.2013.11.021 · 4.45 Impact Factor
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ABSTRACT: IMPORTANCE Unnecessary interfacility transfer of minimally injured patients to a level I trauma center (secondary overtriage) can cause inefficient use of resources and personnel within a regional trauma system. OBJECTIVE To describe the burden of secondary overtriage in a rural trauma system with a single level I trauma center. DESIGN Retrospective analysis of institutional trauma registry data. SETTING Dartmouth Hitchcock Medical Center, a rural level I trauma center. PATIENTS A total of 7793 injured patients evaluated by the trauma service at Dartmouth Hitchcock Medical Center from January 1, 2007, to December 31, 2011. EXPOSURE Evaluation by the trauma service. MAIN OUTCOMES AND MEASURES Patients transferred from another hospital to Dartmouth Hitchcock Medical Center who did not require an operation, had an Injury Severity Score lower than 15, and were discharged alive within 48 hours of admission. RESULTS Of the 7793 evaluated patients, 4796 (62%) were transferred from other facilities. When compared with scene calls (n = 2997), transferred patients had a similar median Injury Severity Score of 9, but 24% of transferred adult patients and 49% of transferred pediatric patients met our definition of secondary overtriage. The overtriaged patients were most likely to have injuries of the head and neck (56%), followed by skin and soft-tissue injuries (41%). Seventy-two unique institutions transferred trauma patients to Dartmouth Hitchcock Medical Center, but 36% of the overtriaged patients were from 5 institutions. CONCLUSIONS AND RELEVANCE The incidence of secondary overtriage in our rural trauma center is 26%, with head and neck injuries being the most common reason for transfer. Costs for transportation and additional evaluation for such a significant percentage of patients has important resource utilization implications. Effective regionalization of rural trauma care should include methods to limit secondary overtriage.JAMA SURGERY 06/2013; 148(8):1-6. DOI:10.1001/jamasurg.2013.2132 · 4.30 Impact Factor
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ABSTRACT: The objective of this study was to determine the incidence, demographics, and clinical course of pediatric patients rapidly discharged after transfer from outlying emergency departments (EDs) to a tertiary care pediatric ED (PED) with no additional diagnostic or therapeutic actions. All pediatric patient charts from July 2009 to June 2010 who were transferred from 31 outlying EDs to an academic PED were reviewed for patient demographics, (age, sex, race) diagnosis, and disposition (admission, discharge). Primary outcome of interest in this study was percentage of children younger than 18 years discharged home after transfer to the tertiary care center (PED) with no additional medical or surgical procedures. Primary outcomes in terms of transferring physician ED pediatric physician versus ED nonpediatric physician (ED-NPP) and transferring hospital type were also analyzed using Fisher exact test. Three hundred forty-two patients transferred from outlying EDs to PED during the study period met inclusion criteria. Sixty percent (207/342) of overall transfers were in the age group 5 years or younger. Respiratory illness (27.5%) was the most common condition in all transfers. Patients transferred from EDs staffed by nonpediatric physician were more likely to be discharged home without needing additional studies or procedures. Patients transferred from EDs staffed by pediatricians were more likely to be admitted or required additional diagnostic and/or therapeutic interventions before disposition. Pediatric patients transferred from outlying community EDs to a PED frequently required little or no additional care. Referring hospital ED type and physician training type are associated with the need for additional workup at the pediatric emergency room.Pediatric emergency care 12/2013; 30(1). DOI:10.1097/PEC.0000000000000061 · 0.92 Impact Factor