241EMF Identifying Impacts of Undertriage Among Severe Pediatric Trauma Patients

Abstract

The objective of this study was to detect factors associated with undertriage of pediatric trauma and establish the influence of undertriage on inter-facility transfer and mortality. This is a retrospective cohort study of all-payer administrative claims data of all emergency department (ED) and inpatient visits in a large, southeastern state between 2010 – 2015. Pediatric (<15 years) trauma patients were identified by ED diagnostic codes and restricted to severe injury using validated injury severity score (≥ 15). Undertriage was defined as initial care in a nontrauma (Level 3 or higher) center (pediatric or adult), as assigned by the state. Univariable and multivariable regression were used to identify risk factors for undertriage and the impact of undertriage on mortality and length of stay. Covariates included age, sex, race, ethnicity, expected primary payer, rurality, injury severity (ISS 15-25 or >25), admission timing (weekend versus weekday), and quartile of median household income (by zip code). Overall, 4,382 pediatric severe trauma subjects were included and 74.4% (n=3,260) were initially managed outside of an ED in a Level I or Level II trauma center. These subjects were more likely to be white, privately or non-insured, and reside in non-metro zip codes. Rural residence was the greatest risk factor for presenting at a nontrauma center (aOR: 4.10 [95% CI 2.62 to 6.43]). Eleven percent (n=482) of the subjects died during the initial hospital encounter, and initial assessment at a nontrauma center compared to trauma center was not associated with mortality (aOR: 0.81 [95% CI 0.60 to 1.09]). Length of stay, including ED and hospital stay, did not differ between subjects presenting to EDs at trauma or nontrauma centers (adjusted β: 1.05 [95% CI 0.96 to 1.15]). Additionally, 5.0% of subjects were transferred, but inter-hospital transfer was not associated with undertriage (aOR: 0.86 [95% CI 0.62 to 1.19]). Initial presentation at EDs that are not pediatric or adult trauma centers is common among severe pediatric trauma patients. Mortality, length of stay, and transfer patterns do not differ between trauma patients initially presenting to trauma versus nontrauma centers, even after adjusting for patient and facility characteristics. The high proportion of pediatric trauma patients seen outside of trauma centers is in line with previous reports in other state trauma systems. Absence of an observed impact of undertriage on mortality in this study may be due to differences in rural-urban disparities, a more mature trauma system and transfer protocols, or increased capability to manage trauma in nontrauma centers within the state. Future work will focus on incorporating emergency medical services availability and restricting the population to a more specific (ISS>25) definition of severe trauma.