Secondary Overtriage Research Articles

Trauma Secondary Overtriage and Cost

Trauma Secondary Overtriage and Cost

Factors influencing secondary overtriage in trauma patients undergoing interhospital transfer: A 10-year multi-center study in Hong Kong

BackgroundWith the development of regionalised trauma networks, interhospital transfer of trauma patients is an inevitable component of the trauma system. However, unnecessary transfer is a common phenomenon, and it is not without risk and cost. A better understanding of secondary overtriage would enable emergency physicians to make better decisions about trauma transfers and allow guidelines to be developed to support this decision making. This study aimed to describe the pattern of secondary overtriage in Hong Kong and identify its associated factors. MethodsThis was a retrospective review of 10-years of prospectively collected multi-center data from two trauma registries in the New Territories of Hong Kong (2013−2022). The primary outcome is secondary overtriage, which was defined as early discharge alive within 48 h, Injury Severity Score (ISS) <15, and no surgical operation done. Patient characteristics, physiology, anatomy and investigation variables were compared against secondary overtriage using univariate and multivariable analyses. ResultsDuring the study period, 3852 patients underwent interhospital transfer from a non-trauma center to a trauma center, and 809 (21 %) of the transfers were considered secondary overtriage. The secondary overtriage rate was higher in pediatric age groups at 34.8 % (97/279). Logistic regression analysis showed secondary overtriage to be associated with blunt trauma and an Abbreviated Injury Scale (AIS) score of <3 for head or neck, thorax, abdomen and extremities. ConclusionInterhospital transfer is an essential component of the trauma system. However, over one-fifth of the transfers were considered unnecessary in Hong Kong, and this could be considered to be an inefficient use of resources as well as cause inconvenience to patients and their families. We have identified related factors including blunt trauma, AIS <3 scores for head or neck, thorax, abdomen and extremities, and opportunities to establish and improve on transfer protocols. Further research should be aimed to safely reduce interhospital transfers in the future to improve the efficiency of the Hong Kong trauma system.

Evaluation of Secondary Overtriage at a Rural Level 1 Trauma Center.

To retrospectively assess the prevalence of secondary overtriage (SO) within a rural regional Appalachian health care system. Trauma registry data was extracted for all trauma activation transfer patients from 2017 to 2022. Transferred patients were then stratified into two groups, non-secondary overtriage (non-SO) or SO. Patients were considered SO if they met three criteria following transfer: an Injury Severity Score (ISS) of less than 15, no required operative intervention, and discharge within 48hours of arrival. Descriptive statistics were compared for age, length of stay (LOS), ICU LOS, and ISS. Surgical subspecialty consultations were compared between the two groups. Patients in the SO group were further assessed by body region of injury and Abbreviated Injury Score (AIS). Among 3,291 trauma activation transfer patients, 43% (1,407) were considered SO transfers. Patients in the SO group were significantly younger, had shorter average hospital and ICU LOS, and lower ISS compared to the non-SO group. Additionally, 25.7% of patients in the SO group had injuries to the head or neck of which 8.96% have an AIS ≥3. 21% of patients had injuries to the face, with 0.14% having an AIS ≥3. 43% of transfer patients in this study met our definition of SO. Although no optimal rate of SO has been universally established, limiting SO stands to benefit both patients and trauma systems. This study highlights how institutional analysis of transfer patients may help inform transfer protocols to reduce secondary overtriage and overutilization of scarce resources.

Defining futile and potentially avoidable interhospital trauma transfers

PurposeInterhospital transfer of critically injured patients to a major trauma service reduces preventable death in major trauma. Yet some of those transferred die without intervention. These ‘futile’ interhospital trauma transfers (IHTs), and other potentially avoidable IHTs place enormous stress on families of trauma victims, can delay care, and incur great cost to public health resources. This study sought to characterise these IHTs using current state guidelines for interhospital transfer. MethodsA retrospective cohort study was conducted using our institution's trauma registry from January 2016–December 2020. All adult patients transferred to our major trauma service were analysed. Futile IHTs were defined as death or transfer to hospice care without surgical, endoscopic, or radiological intervention, and without ICU admission, within 72 h of admission. Potentially avoidable IHTs were defined as all patients discharged alive without intervention or ICU care, and secondary over-triage patients are a subset of these patients who were discharged within 72 h of admission. Patient demographics, injuries, and treatments were categorised from electronic records and analysed. ResultsOf 2,837 IHTs, seven (0.2 %) met criteria for futility. The majority were female, median age of 80 (IQR 85–75) and had a median Injury Severity Score (ISS) of 16 (IQR 25.5–11.5). By contrast, 1391 patients (49 %) were classified as potentially avoidable and 513 (18 %) were considered secondary over-triage. The majority were male, median age of 43 (IQR 62–28), and had a median ISS of 9 (IQR 13–4). Of these potentially avoidable IHTs, 984 (70.7 %) were discharged directly home. ConclusionFutile IHTs were infrequent, however over half of all trauma patients transferred from other hospitals were discharged without tertiary-level intervention. Trauma services should consider developing systems such as telehealth to support regional general and orthopaedic surgeons to co-manage lower risk trauma, particularly minor head and minor spinal trauma patients. This could be an integral part of safely reducing potentially avoidable IHTs and their associated costs while maintaining a low rate of preventable mortality in trauma.

Are Pediatric Trauma Transfers Justified?: A Unique Viewpoint From a Transferring Institution.

Definitions of pediatric overtriage and unnecessary transfers for injured children have been instituted from a viewpoint of referral centers and have doubtful value for effecting interventions at referring centers. This study provides a unique insight into the factors prompting transfers at a peripheral institution. The trauma registry of a level 2 pediatric trauma center was accessed, and pediatric transfers out to 2 level 1 pediatric trauma centers were identified over a period of 4 years. The outcomes of these patients at the accepting institutions were charted for descriptive analysis. The study identified 46 patients transferred out with a transfer rate of 6.6% when compared with total admissions. The mean Injury Severity Score (ISS) was 6.5, and the mean length of stay (LOS) at the receiving institution was 2.8 days. The reason for transfer from a specialty standpoint revealed 21 neurosurgical, 12 burn, 6 orthopedic, 4 faciomaxillary, and 2 ophthalmology patients. Overall transfer rate was 6.6%. Pediatric overtriage when defined as LOS < 24 hours at the receiving institution was 46.7%. Fifty percent of pediatric overtriage was prompted by need for a pediatric neurosurgery consult with medicolegal concern being cited as reason for transfer. Secondary overtriage when defined as LOS < 24 hours, no pediatric intensive care admission, no surgical intervention, and ISS < 9 was found in 13 patients (30.9%). The proportion of patients with Medicaid insurance was not different for the admissions (43.5%) when compared with the transfers (42.7%). Existing definitions of overtriage have limited value in effecting interventions to reduce unnecessary transfers. Identifying specific factors at referring institutions including providing local availability of pediatric surgical specialists will potentially help mitigate injury-related pediatric overtriage.

Association of the Affordable Care Act Medicaid Expansion With Secondary Overtriage among Young Adult Trauma Patients

BackgroundPrevious work has shown that the Affordable Care Act (ACA) Medicaid expansion decreased the uninsured rate and improved some trauma outcomes among young adult trauma patients, but no studies have investigated the impact of ACA Medicaid expansion on secondary overtriage, namely the unnecessary transfer of non-severely injured patients to tertiary trauma centers. MethodsStatewide hospital inpatient and emergency department discharge data from two Medicaid expansion and one non-expansion state were used to compare changes in insurance coverage and secondary overtriage among trauma patients aged 19-44 y transferred into a level I or II trauma center before (2011-2013) to after (2014-quarter 3, 2015) Medicaid expansion. Difference-in-difference (DD) analyses were used to compare changes overall, by race/ethnicity, and by ZIP code-level median income quartiles. ResultsMedicaid expansion was associated with a decrease in the proportion of patients uninsured (DD: -4.3 percentage points; 95% confidence interval (CI): -7.4 to -1.2), an increase in the proportion of patients insured by Medicaid (DD: 8.2; 95% CI: 5.0 to 11.3), but no difference in the proportion of patients who experienced secondary overtriage (DD: -1.5; 95% CI: -4.8 to 1.8). There were no differences by race/ethnicity or community income level in the association of Medicaid expansion with secondary overtriage. ConclusionsIn the first 2 y after ACA Medicaid expansion, insurance coverage increased but secondary overtriage rates were unchanged among young adult trauma patients transferred to level I or II trauma centers.

A multicenter evaluation on the impact of non-therapeutic transfer in rural trauma

IntroductionTrauma transfers are a common occurrence in rural areas, where critical access and lower-level trauma centers routinely transfer to tertiary care centers for specialized care. Transfers are non-therapeutic (NTT) when no specialist intervention occurs, leading to transfer that were futile (FT) or secondary overtriage (SOT). This study aimed to evaluate the prevalence of NTT among four trauma centers providing care to rural Appalachia. MethodsThis retrospective review was performed at four, ACS verified, Level 1 trauma centers. All adult trauma patients, transferred during 2018 were included for analysis. Transfers were considered futile if in <48 h the patient died or was discharged to hospice, without operative intervention. SOT transfers were discharged in <48 h, without major intervention, with an ISS< 15. Cost analysis was performed to describe the impact of NTT on EMS use. Results4,189 patients were analyzed during the study period. 105 (2.5%) met criteria for futility. Futile patients had a median ISS of 25 (IQR 9–26), and 48% had an AIS head ≥4. These were significantly greater (p<0.001) than non-futile transfers, median ISS 5 (IQR 2–9), 3% severe head injury. SOT occurred in 1371 (33%), median ISS of 5, and lower AIS scores by region. Isolated facial injuries resulted in 165 transfers. 13% of FT+SOT were admitted to the ICU. Only 22% of FT+SOT came from a trauma center. 68% were transported by ALS and 13% transported by air transport. FT+SOT traveled on average 70 miles from their home to receive care. ConclusionsNon-therapeutic transfers account for more than 1/3 of transfers in this rural environment. There was a significant use of advanced life support and aeromedical transport. The utility of these transfers should be questioned. With the recent increases in telehealth there is an opportunity for trauma systems to improve regional care and decrease transfers for futile cases.

Interfacility Transfer Guidelines for Isolated Facial Trauma: A Multidisciplinary Expert Consensus.

The objective of this study was to develop guidelines for the transfer of patients with isolated craniomaxillofacial trauma. A national, multidisciplinary expert panel was assembled from leadership in national organizations and contributors to published literature on facial reconstruction. The final panel consisted of five plastic surgeons, four otolaryngologist-head and neck surgeons, and four oral and maxillofacial surgeons. The expert panelists' opinions on transfer guidelines were collected using the modified Delphi process. Consensus was predefined as 90 percent or greater agreement per statement. After four Delphi consensus building rounds, 13 transfer guidelines were established, including statements on fractures of the frontal sinus, orbit, midface, and mandible, as well as soft-tissue injuries. Twelve guidelines reached consensus. The decision to transfer a patient with craniomaxillofacial trauma to another facility is complex and multifactorial. While a percentage of overtriage is acceptable to promote safe disposition of trauma patients, unnecessarily high rates of secondary overtriage divert emergency medical services, increase costs, delay care, overload tertiary trauma centers, and result in tertiary hospital staff providing primary emergency coverage for referring hospitals. These craniomaxillofacial transfer guidelines were designed to serve as a tool to improve and streamline the care of facial trauma patients. Such efforts may decrease the additional health care expenditures associated with secondary overtriage while decompressing emergency medical systems and tertiary emergency departments.

Less Operating and More Overtriage: National Trends in Interfacility Transfer of Facial Fracture Patients.

The purpose of this study was to characterize demographics, injury patterns, and initial management trends of facial fracture patients who were subject to interfacility transfer. Using the National Trauma Data Bank from 2007 to 2015, facial fracture patients arriving by interfacility transfer were included in the study. Over 9 years, 171,618 patients were included, with 37.5 percent having an isolated facial injury. Isolated facial injury patients tended to be younger, less frequently white, more frequently assaulted, and more frequently underwent facial fracture operative repair during the index admission (all, p < 0.001). From 2007 to 2015, insurance coverage increased from 54.6 to 79.0 percent (R2 = 0.90, p < 0.001). In addition, there was a 45 percent proportional increase in patients 50 to 89 years of age compared to a 20 percent decrease in patients 0 to 39 years of age (both, R2 = 0.99, p < 0.001). The proportion of transfer patients with isolated facial injury increased over the study period (32.0 to 39.4 percent, R2 = 0.90, p < 0.001); however, there was a decline in operative intervention (29.5 to 22.1 percent, R2 = 0.94, p < 0.001) and a 151 percent increase in the proportion discharged from the emergency department upon transfer arrival (R2 = 0.99, p < 0.001). Facial fracture patients subject to interfacility transfer comprise a wide array of demographics and injury patterns, with most having concomitant injuries and only a minority undergoing immediate operative intervention. Over time, this demographic has become older, sustained more isolated facial injury, and undergone fewer immediate operative interventions and is more frequently insured and more frequently discharged from the emergency department upon transfer arrival, reflecting increasing rates of secondary overtriage.

Understanding secondary overtriage for neurosurgical patients in a rural tertiary care setting

ObjectiveExcessive interfacility transfer to a tertiary care facility of minimally injured patients for subspecialty evaluation leads to overuse of resources and is referred to as secondary overtriage (SO). Little is known regarding the epidemiology of SO in rural settings, particularly for patients with a mild head injury who may be safely managed without admission to level I trauma centers. MethodsIn order to determine the rate of SO for neurosurgical patients with Glasgow Coma Scale (GCS) of 13–15 referred to a rural level 1 trauma center, we conducted a retrospective chart review of 224 patients evaluated for potential transfer to Dartmouth-Hitchcock Medical Center from January 1, 2014 through December 31, 2014. SO was defined as any admission where a patient was transferred from an outside facility, had a length of stay shorter than 48 h, did not require neurosurgical intervention, and was alive at the time of discharge. ResultsOf the 224 patients evaluated, 163 patients were transferred. Of the 163 patients included in this study, 43 (26.4%) met criteria for SO, 59 (36.2%) patients met criteria for intervention, and 61 (37.2%) patients met criteria for observation. ConclusionsApproximately a quarter of the total patients who are transferred to a rural level I trauma center for neurosurgical evaluation are minimally injured, do not require neurosurgical intervention, and are discharged within 48 h of presentation. Management at their referring facility with remote neurosurgical consultation is likely safe in this population. Understanding the rate of SO in neurosurgical patients and risk factors present in this group can better guide future transfer policies at rural medical centers.

Resource utilization and secondary overtriage for patients with traumatic renal injuries in a regional trauma system.

While renal trauma management has shifted to conservative nonoperative management, insufficient data exist to guide interhospital renal trauma transfer protocols. Secondary overtriage is defined as the potentially avoidable transfer of patients from a lower to a higher-level trauma center despite the lack of need for higher-level care. The goal of this study was to determine the prevalence and predictors of secondary overtriage in renal trauma patients to a level 1 trauma center. A retrospective cohort study was performed of all renal trauma patients transferred to a level 1 institution between 2005 and 2017. Secondary overtriage was defined as a potentially avoidable transfer that consisted of hospital stay <72 hours with survival, no surgical or interventional radiology procedure, and all nonabdominal Abbreviated Injury Scale scores of <3 after transfer. Multivariate logistic regression was performed to estimate odds of secondary overtriage based on predefined clinical criteria. Of the 612 renal trauma patients transferred between 2005 and 2017, 71 (11.6%) met the criteria for secondary overtriage. Female patients and patients coming from level IV/V trauma centers were more likely to have potentially avoidable transfers (p = 0.01 and p < 0.001, respectively). Mean (SD) Injury Severity Score was 10 (4.2) and 30.7 (14.3) in overtriaged and appropriately triaged patients, respectively (p < 0.001). Of the 71 overtriaged patients, 70.4% had isolated renal injuries. Patients with isolated renal injuries (odds ratio, 39.0; 95% confidence interval, 16.44-105.39) and those transferred from a level IV/V trauma center (odds ratio, 3.85; 95% confidence interval, 1.64-9.61) had a higher likelihood of secondary overtriage. Within our regional trauma system, the majority of secondary overtriage was due to potentially avoidable transfers from level IV/V centers and of patients with isolated renal injuries. By implementing strategies to reduce the secondary overtriage burden on major trauma centers, regional trauma systems can avoid unnecessary costs while maintaining patient safety and ensuring appropriate care. Therapeutic/care management, Level III.

MP04-04 RESOURCE UTILIZATION AND SECONDARY OVERTRIAGE RATES FOR RENAL TRAUMA IN A REGIONAL TRAUMA SYSTEM

INTRODUCTION AND OBJECTIVE:While renal trauma management has shifted to conservative non-operative management, insufficient data exist to guide renal trauma transfer protocols. Secondary overtriage...

Patient Characteristics, Injury Types, and Costs Associated with Secondary Over-Triage of Isolated Cervical Spine Fractures.

Retrospective cohort. To aim of this study was to identify patient variables, injury characteristics, and costs associated with operative and non-operative treatment following inter-facility transfer of patients with isolated cervical spine fractures. Patients with isolated cervical spine fractures are subject to inter-facility transfer for surgical assessment, yet are often treated nonoperatively. The American College of Surgeons' benchmark rate of "secondary over-triage" is <50%. Identifying patient and injury characteristics as well as costs associated with treatment following transfer of patients with isolated cervical spine fractures may help reduce rates of secondary over-triage and healthcare expenditures. Patients transferred to a Level-1 trauma center with isolated cervical spine fractures between January 2015 and September 2020 were identified. Patient demographics, comorbidities, insurance data, injury characteristics, imaging workup, treatment, and financial data were collected for all patients. Multivariable logistic regression models were constructed to identify patient and injury characteristics associated with surgical treatment. Nearly 75% of patients were treated non-operatively. Over 97% of transfers were accepted by the general surgery trauma service. Multivariable modeling found that higher BMI, presence of any neurologic deficit including spinal cord or isolated spinal nerve root injuries, present smoking status, or cervical spine magnetic resonance imaging obtained post-transfer, were associated with surgical treatment for isolated cervical spine fractures. Among patients with type II dens fractures, increased fracture displacement was associated with surgical treatment. Median charges to patients treated operatively and nonoperatively were $380,890 and $90,734, respectively. Median hospital expenditures for patients treated operatively and nonoperatively were $55,115 and $12,131, respectively. A large proportion of patients with isolated cervical spine fractures are subject to over-triage. Injury characteristics are important for determining need for surgical treatment, and therefore interfacility transfer. Improving communication with spine surgeons when deciding to transfer patients may significantly reduce health care costs and resource use.Level of Evidence: 4.

Secondary overtriage in a pediatric level one trauma center

BackgroundPrevious studies have explored under- and overtriage, and the means by which to optimize these rates. Few have examined secondary overtriage (SO), or the unnecessary transfer of minimally injured patients to higher level trauma centers. We sought to determine the incidence and impact of SO in our pediatric level one trauma center. MethodsWe performed a retrospective analysis of all trauma activations at our institution from 2015 through 2017. SO was defined as transferred patients who required neither PICU admission nor an operation, with ISS ≤ 9 and LOS ≤ 24 h. We compared SO patients against all trauma activation transfers, and against similar non-transferred patients. ResultsWe identified 1789 trauma activations, including 766 (42.8%) transfers. Of the transfers, 335 (43.7%) met criteria for SO. Compared to other transfers, SO patients had a shorter mean travel distance (52.9 v 58.1 mi; p = 0.02). Compared to similar patients transported from the trauma scene, SO patients were more likely to be admitted (52.2% v 29.2%; p < 0.001), with longer inpatient stay and greater hospital charges. ConclusionsSO represents an underrecognized burden to trauma centers which could be minimized to improve resource allocation. Future research should evaluate trauma activation criteria for transferred pediatric patients.

Secondary overtriage of isolated facial trauma

DesignRetrospective chart review. SettingAcademic, tertiary care, level I trauma center in a rural state. BackgroundUnnecessary transfer of certain facial trauma patients results in a burden of time, money, and other resources on both the patient and healthcare system; identification and development of outpatient treatment pathways for these patients is a significant opportunity for cost savings. ObjectivesTo investigate the treatment and disposition of un-complicated, stable, isolated facial trauma injuries transferred from outside hospitals and determine the significance of secondary overtriage. MethodsRetrospective chart review utilizing our institutional trauma database, including patients transferred to our emergency department between January 2012 and December 2017. Patients were identified by ICD9 or ICD10 codes and only those with isolated facial trauma were included. ResultsWe identified 538 isolated facial trauma patients who were transferred to our institution during the study period. The majority of those patients were transferred via ground ambulance for an average of 76 miles. Overall, 82% of patients (N = 440) were discharged directly from our institution's emergency department. Almost 30% of patients did not require any formal treatment for their injuries; the potential savings associated with elimination of these unnecessary transfers was estimated to be between $388,605 and $771,372. ConclusionsWe identified a high rate of patients with stable, isolated facial trauma that could potentially be evaluated and treated without emergent transfer. The minimization of these unnecessary transfers represents a significant opportunity for cost and resource utilization savings. Level of evidence2b- Economic and Cost Analysis.

An Evaluation of Pediatric Secondary Overtriage in the Pennsylvania Trauma System

BackgroundWe sought to determine the secondary overtriage rate of pediatric trauma patients admitted to pediatric trauma centers. We hypothesized that pediatric secondary overtriage (POT) would constitute a large percentage of admissions to PTC. Materials and methodsThe Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2017 for pediatric (age ≤ 18 y) trauma patients transferred to accredited pediatric trauma centers in Pennsylvania (n = 6). Patients were stratified based on discharge within (early) and beyond (late) 24 h following admission. POT was defined as patients transferred to a PTC with an early discharge. Multilevel mixed-effects logistic regression model controlling for demographic and injury severity covariates were utilized to determine the adjusted impact of injury patterns on early discharge. ResultsA total of 37,653 patients met inclusion criteria. For transfers, POT compromised 18,752 (49.8%) patients. Compared to POT, non-POT were more severely injured (ISS: 10 versus 6;P < 0.001) and spent less time in the ED (Min: 181 versus 207;P < 0.001). In adjusted analysis, concussion, closed skull vault fractures, supracondylar humerus fractures, and consults to neurosurgery were associated with increased odds of POT. Overall, femur fracture, child abuse evaluation, and consults to plastic surgery, orthopedics, and ophthalmology were all associated with a decreased risk of being POT. ConclusionsPOT comprises 49.8% of PTC transfer admissions in Pennsylvania's trauma system. Improving community resources for management of pediatric concussion and mild TBI could result in decreased rates of POT to PTCs. Developing better inter-facility transfer guidelines and increased education of adult TC and nontrauma center hospitals is needed to decrease POT.Level of Evidence: Epidemiologic study, level III.

Reply: Unnecessary Interfacility Transfers for Craniomaxillofacial Trauma

Sir: We appreciate the auhors’ review of our recent study.1 The question of whether a referring provider is able to diagnose a patient’s traumatic injuries is an important one. We did not address this because it was not the goal of this study. The goal of this study was to identify the problem of secondary overtriage of facial trauma patients. The second phase of our study has been designed to evaluate national perceptions of this problem and whether the craniomaxillofacial surgical community felt there was a need for transfer guidelines. Indeed, the results of this multidisciplinary survey demonstrated that roughly 50 percent of facial trauma surgeons agreed that most emergency transfers for isolated facial trauma at their institutions were unnecessary. Eighty-seven percent of respondents thought that transfer guidelines could help decrease unnecessary transfers, and data regarding which specific injury patterns should be transferred were also collected.2 With regard to the availability of on-call facial traumatologists, the data presented by the authors’ team appear to be regional. Unfortunately, studies have shown that a large percentage of referral centers implicated in secondary overtriage of facial trauma patients have full-time facial trauma coverage.3 This was also the case in our cohort. The long-term goal of our project is not to leave the diagnosis of facial injuries to the nontrauma practitioner; in fact, it is the opposite. Our goal is to educate those practitioners and provide them with tools to diagnose injuries of lesser acuity that may not require emergency systems activation. Education is essential in this effort. The first phase is to define the problem; the second, to quantify the need; and the third, to provide a solution. The third phase of our project, which is underway, uses an assembled panel of expert craniomaxillofacial traumatologists in the fields of ear, nose, and throat; oromaxillofacial; and plastic surgery. We aim to construct transfer guidelines similar to those put forth by the American Burn Association for referral to a regional burn center. The guidelines will be written for use by all providers, including those with little facial trauma experience. Using data collected from our second study2 and consensus collected in our third stage (using the modified Delphi method), our guidelines will define exactly which facial skeletal and soft-tissue injuries should be transferred. We agree that a patient with an unclear diagnosis should be transferred to a higher level of care. It is well documented that isolated facial trauma is implicated in secondary overtriage,2–6 and we, alongside facial trauma providers from different specialties across the nation, believe that there is room to improve the management of these patients. Our goal remains to refine the transfer process for facial trauma patients while minimizing the potential untoward consequence of secondary undertriage. Unfortunately, a small percentage of secondary undertriage is a necessary tradeoff for a reduction in substantial secondary overtriage, and a proper balance of undertriage and overtriage is paramount. Such a large percentage of unnecessary transfers carry far worse ramifications to the patient and the health care system than does the rare undertriage event. We thank the authors for their thoughtful commentary. DISCLOSURE The authors have no relevant financial disclosures related to the content of this communication.

242 The Impact of Hospital Resources on Secondary Overtriage: A Population-Based Analysis

242 The Impact of Hospital Resources on Secondary Overtriage: A Population-Based Analysis

Interfacility Transfers for Isolated Craniomaxillofacial Trauma: Perspectives of the Facial Trauma Surgeon.

Secondary overtriage is a burden to the medical system. Unnecessary transfers overload trauma centers, occupy emergency transfer resources, and delay definitive patient care. Craniomaxillofacial (CMF) trauma, especially in isolation, is a frequent culprit. The aim of this study is to assess the perspectives of facial trauma surgeons regarding the interfacility transfer of patients with isolated CMF trauma. A 31-item survey was developed using Likert-type scale and open-ended response systems. Internal consistency testing among facial trauma surgeons yielded a Cronbach's α calculation of .75. The survey was distributed anonymously to the American Society of Maxillofacial Surgeons, the North American Division of AO Craniomaxillofacial, and the American Academy of Facial Plastic and Reconstructive Surgery. Statistical significance in response plurality was determined by nonoverlapping 99.9% confidence intervals (P < .001). Sum totals were reported as means with standard deviations and z scores with P values of less than .05 considered significant. The survey yielded 196 responses. Seventy-seven percent of respondents did not believe that most isolated CMF transfers required emergency surgery and roughly half (49%) thought that most emergency transfers were unnecessary. Fifty-four percent of respondents agreed that most patients transferred could have been referred for outpatient management and 87% thought that transfer guidelines could help decrease unnecessary transfers. Twenty-seven percent of respondents had no pre-transfer communication with the referring facility. Perspectives on the transfer of specific fracture patterns and their presentations were also collected. Most facial trauma surgeons in this study believe that emergent transfer for isolated CMF trauma is frequently unnecessary. Such injuries rarely require emergent surgery and can frequently be managed in the outpatient setting without activating emergency transfer services. The fracture-specific data collected are a representation of the national, multidisciplinary opinion of facial trauma surgeons and correlate with previously published data on which specific types of facial fractures are most often transferred unnecessarily. The results of this study can serve as the foundation for interfacility transfer guidelines, which may provide a valuable resource in triaging transfers and decreasing associated health-care costs.

Secondary Overtriage of Trauma Patients: Analysis of Clinical and Geographic Patterns

BackgroundThe purpose of a trauma system is to match patients’ needs with hospitals' ability to care for them, recognizing that the highest levels of care cannot be provided in all locations. This means that some patients will need to be transferred from a local facility to a higher level of care. Unnecessary transfers are expensive and inconvenient to patients and families. The aim of this study is to analyze the pattern of secondary transfers in a regional trauma system. MethodsThis is a retrospective analysis. We included patients aged 16 y and older who were transferred to University of Alabama at Birmingham Hospital between 2014 and 2018. We conducted bivariate and multivariate logistic regression analysis to identify clinical and organizational predictors of requiring a critical intervention, early discharge, intensive care unit admission, and mortality. Rather than treating each injury as isolated, we analyzed injury patterns. ResultsA total of3824 patients met the inclusion criteria. Of them, 664 patients (17.4%) required a critical intervention, 635 (16.6%) were discharged within 24 h, 1356 (35.5%) were admitted to the intensive care unit, and 172 (4.0%) patients died. Univariate and multivariate analyses revealed many positive associations, with regard to injury pattern, originating center, and insurance status. ConclusionsThere are patterns in the data, and further study is required to understand drivers of secondary overtriage, and how we might be able to address this problem. Reducing the number of unnecessary transfers is a difficult task, which will require engagement at all levels of the trauma system.