Variability in California triage from 2005 to 2009: a population-based longitudinal study of severely injured patients.

BackgroundTimely access to trauma care requires that severely injured patients are ultimately triaged to trauma centers. We sought to determine triage patterns for the injured population within the state of California to determine those factors associated with undertriage.MethodsWe conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database from January 1, 2005, and December 31, 2009. All visits associated with injury were linked longitudinally. Sixty-day and one-year mortality was determined using vital statistics data. Primary field triage was defined as field triage to a Level I/II trauma center; retriage was defined as initial triage to a non-Level I/II center followed by transfer to a Level I/II. Regions were organized by local emergency medical services agencies. The primary outcomes were triage patterns and mortality.ResultsThe undertriage rate was 35% (n = 20,988) but was variable across regions (12-87%). Primary field triage ranged from 7% to 77%. Retriage rates not only were overall low (6% of all severely injured patients) but also varied by region (1-38%). In adjusted analysis, factors associated with a lower odds ratio (OR) of primary field triage included the following: age of 55 years or greater (OR, 0.78; p = 0.001), female sex (OR, 0.88; p = 0.014), greater number of comorbidities (OR, 0.92; p < 0.001), and fall mechanism versus motor vehicle collision (OR, 0.54; p < 0.001). One-year mortality was higher for undertriaged patients (25% vs. 16% and 18% for primary field and retriage, respectively, p < 0.001).ConclusionThis is the first study to create a longitudinal database of all emergency department visits, hospitalizations, and long-term mortality for every severely injured patient within an entire state during a 5-year period. Undertriage varied substantially by region and was associated with multiple factors including access to care and patient factors.Level of evidenceEpidemiologic study, level III

Variability in California triage from 2005 to 2009: a population-based longitudinal study of severely injured patients.

BACKGROUND: Timely access to trauma care requires that severely injured patients are ultimately triaged to trauma centers. We sought to determine triage patterns for the injured population within the state of California to determine those factors associated with undertriage. METHODS: We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database from January 1, 2005, and December 31, 2009. All visits associated with injury were linked longitudinally. Sixty-day and one-year mortality was determined using vital statistics data. Primary field triage was defined as field triage to a Level I/II trauma center; retriage was defined as initial triage to a non-Level I/II center followed by transfer to a Level I/II. Regions were organized by local emergency medical services agencies. The primary outcomes were triage patterns and mortality. RESULTS: The undertriage rate was 35% (n = 20,988) but was variable across regions (12-87%). Primary field triage ranged from 7% to 77%. Retriage rates not only were overall low (6% of all severely injured patients) but also varied by region (1-38%). In adjusted analysis, factors associated with a lower odds ratio (OR) of primary field triage included the following: age of 55 years or greater (OR, 0.78; p = 0.001), female sex (OR, 0.88; p = 0.014), greater number of comorbidities (OR, 0.92; p < 0.001), and fall mechanism versus motor vehicle collision (OR, 0.54; p < 0.001). One-year mortality was higher for undertriaged patients (25% vs. 16% and 18% for primary field and retriage, respectively, p < 0.001). CONCLUSION: This is the first study to create a longitudinal database of all emergency department visits, hospitalizations, and long-term mortality for every severely injured patient within an entire state during a 5-year period. Undertriage varied substantially by region and was associated with multiple factors including access to care and patient factors. LEVEL OF EVIDENCE: Epidemiologic study, level III

Variability in California triage from 2005 to 2009: a population-based longitudinal study of severely injured patients.

BackgroundTimely access to trauma care requires that severely injured patients are ultimately triaged to trauma centers. We sought to determine triage patterns for the injured population within the state of California to determine those factors associated with undertriage.MethodsWe conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database from January 1, 2005, and December 31, 2009. All visits associated with injury were linked longitudinally. Sixty-day and one-year mortality was determined using vital statistics data. Primary field triage was defined as field triage to a Level I/II trauma center; retriage was defined as initial triage to a non-Level I/II center followed by transfer to a Level I/II. Regions were organized by local emergency medical services agencies. The primary outcomes were triage patterns and mortality.ResultsThe undertriage rate was 35% (n = 20,988) but was variable across regions (12-87%). Primary field triage ranged from 7% to 77%. Retriage rates not only were overall low (6% of all severely injured patients) but also varied by region (1-38%). In adjusted analysis, factors associated with a lower odds ratio (OR) of primary field triage included the following: age of 55 years or greater (OR, 0.78; p = 0.001), female sex (OR, 0.88; p = 0.014), greater number of comorbidities (OR, 0.92; p < 0.001), and fall mechanism versus motor vehicle collision (OR, 0.54; p < 0.001). One-year mortality was higher for undertriaged patients (25% vs. 16% and 18% for primary field and retriage, respectively, p < 0.001).ConclusionThis is the first study to create a longitudinal database of all emergency department visits, hospitalizations, and long-term mortality for every severely injured patient within an entire state during a 5-year period. Undertriage varied substantially by region and was associated with multiple factors including access to care and patient factors.Level of evidenceEpidemiologic study, level III

Describing the density of high-level trauma centers in the 15 largest US cities.

BackgroundThere has been a proliferation of urban high-level trauma centers. The aim of this study was to describe the density of high-level adult trauma centers in the 15 largest cities in the USA and determine whether density was correlated with urban social determinants of health and violence rates.MethodsThe largest 15 US cities by population were identified. The American College of Surgeons' (ACS) and states' department of health websites were cross-referenced for designated high-level (levels 1 and 2) trauma centers in each city. Trauma centers and associated 20 min drive radius were mapped. High-level trauma centers per square mile and per population were calculated. The distance between high-level trauma centers was calculated. Publicly reported social determinants of health and violence data were tested for correlation with trauma center density.ResultsAmong the 15 largest cities, 14 cities had multiple high-level adult trauma centers. There was a median of one high-level trauma center per every 150 square kilometers with a range of one center per every 39 square kilometers in Philadelphia to one center per596 square kilometers in San Antonio. There was a median of one high-level trauma center per 285 034 people with a range of one center per 175 058 people in Columbus to one center per 870 044 people in San Francisco. The median minimum distance between high-level trauma centers in the 14 cities with multiple centers was 8 kilometers and ranged from 1 kilometer in Houston to 43 kilometers in San Antonio. Social determinants of health, specifically poverty rate and unemployment rate, were highly correlated with violence rates. However, there was no correlation between trauma center density and social determinants of health or violence rates.DiscussionHigh-level trauma centers density is not correlated with social determinants of health or violence rates.Level of evidenceVI.Study typeEconomic/decision

The Triage of Injured Patients: Mechanism of Injury, Regardless of Injury Severity, Determines Hospital Destination

The target rate for trauma undertriage is <5 per cent, but rates are as high as 30 to 40 per cent in many trauma systems. We hypothesized that high undertriage rates were due to the tendency to undertriage injured elderly patients and a growing elderly population. We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database over a 5-year period. All hospital admissions and emergency department visits associated with injury were longitudinally linked. The primary outcome was triage pattern. Triage patterns were stratified across three dimensions: age, mechanism of injury, and access to care. A total of 60,182 severely injured patients were included in the analysis. Fall-related injuries were frequently undertriaged compared with injuries from motor vehicle collisions (MVCs) and penetrating trauma (52% vs 12% and 10%, respectively). This pattern was true for all age groups. Conversely, MVCs and penetrating traumas were associated with high rates of overtriage (>70% for both). In conclusion, in contrast to our hypothesis, we found that triage is largely determined by mechanism of injury regardless of injury severity. High rates of undertriage are largely due to the undertriage of fall-related injuries, which occurs in both younger and older adults. Patients injured after MVCs and penetrating trauma victims are brought to trauma centers regardless of injury severity, resulting in high rates of overtriage. These findings suggest an opportunity to improve trauma system performance

Emergency general surgery utilization and disparities during COVID-19: an interrupted time-series analysis

Objective We aimed to compare general surgery emergency (GSE) volume, demographics and disease severity before and during COVID-19.Background Presentations to the emergency department (ED) for GSEs fell during the early COVID-19 pandemic. Barriers to accessing care may be heightened, especially for vulnerable populations, and patients delaying care raises public health concerns.Methods We included adult patients with ED presentations for potential GSEs at a single quaternary-care hospital from January 2018 to August 2020. To compare GSE volumes in total and by subgroup, an interrupted time-series analysis was performed using the March shelter-in-place order as the start of the COVID-19 period. Bivariate analysis was used to compare demographics and disease severity.Results 3255 patients (28/week) presented with potential GSEs before COVID-19, while 546 (23/week) presented during COVID-19. When shelter-in-place started, presentations fell by 8.7/week (31%) from the previous week (p<0.001), driven by decreases in peritonitis (β=−2.76, p=0.017) and gallbladder disease (β=−2.91, p=0.016). During COVID-19, patients were younger (54 vs 57, p=0.001), more often privately insured (44% vs 38%, p=0.044), and fewer required interpreters (12% vs 15%, p<0.001). Fewer patients presented with sepsis during the pandemic (15% vs 20%, p=0.009) and the average severity of illness decreased (p<0.001). Length of stay was shorter during the COVID-19 period (3.91 vs 5.50 days, p<0.001).Conclusions GSE volumes and severity fell during the pandemic. Patients presenting during the pandemic were less likely to be elderly, publicly insured and have limited English proficiency, potentially exacerbating underlying health disparities and highlighting the need to improve care access for these patients.Level of evidence III

Characterizing re-triage guidelines: A scoping review of states\u27 rules and regulations

Background:State guidelines for re-triage, or emergency inter-facility transfer, have never been characterized across the United States. Methods: All 50 states\u27 Department of Health and/or Trauma System websites were reviewed for publicly available re-triage guidelines within their rules and regulations. Communication was made via phone or email to state agencies or trauma advisory committees to obtain or confirm the absence of guidelines where public data was unavailable. Guideline criteria were abstracted and grouped into domains of Center for Disease Control Field Triage Criteria: pattern/anatomy of injury, vital signs, special populations, and mechanisms of injury. Re-triage criteria were summarized across states using median and interquartile ranges for continuous data and frequencies for categorical data. Demographic data of states with and without re-triage guidelines were compared using the Wilcoxon rank sum test. Results: Re-triage guidelines were identified for 22 of 50 states (44%). Common anatomy of injury criteria included head trauma (91% of states with guidelines), spinal cord injury (82%), chest injury (77%), and pelvic injury (73%). Common vital signs criteria included Glasgow Coma Score (91% of states) ranging from 8 to 14, systolic blood pressure (36%) ranging from 90 to 100 mm Hg, and respiratory rate (23%) with all using 10 respirations/minute. Common special populations criteria included mechanical ventilation (73% of states), age (68%) ranging from60 years, cardiac disease (59%), and pregnancy (55%). No significant demographic differences were found between states with versus without re-triage guidelines. Conclusion: A minority of US states have re-triage guidelines. Characterizing existing criteria can inform future guideline development