A Third of Patients Transferred to Level 1 Trauma Center Didn't Belong There

BOSTON  – A third of patients transferred to a level 1 regional trauma center were sent there unnecessarily and at substantial cost to the center, and most of this “secondary overtriage” could be attributed to nonmedical reasons such as time of day or the patient’s insurance status rather than severity of injury.

Of 2,486 patients transferred, 374 who were admitted to the trauma center had injuries that could have been safely handled by the referring institutions, and 582 were seen and released from the emergency department, Dr. Eric A. Toschlog said at the American Association for the Surgery of Trauma Annual Meeting.

From 2007 through 2009, secondary overtriage resulted in an estimated $570,000 loss for the center, whereas appropriate transfers, after adjustment for Medicaid payments, resulted in an estimated $1.5 million gain.

“Overtriage is a costly entity to our trauma center,” said Dr. Toschlog, of the Brody School of Medicine at East Carolina University in Greenville, N.C.

The study results, he said, are in agreement with the American College of Surgeons’ Resources for Optimal Care of the Injured Patient (Green Book), which states that overtriage has no or at most minimal consequences for patients, but results in “excessive costs and burden for higher level trauma centers in the routine care of injured patients.”

Despite that assertion, overtriage rates as high as 50% have been deemed acceptable as a means of preventing undertriage, Dr. Toschlog said.

The term “secondary overtriage” was coined by investigators from the Washington Hospital Center in Washington as overtriage originating from outlying hospitals (J. Am. Coll. Surg. 2008;206:131-7).

To determine the secondary overtriage rate, identify risk factors associated with transfer, and evaluate its financial impact, Dr. Toschlog and colleagues retrospectively reviewed data from their trauma registry on consecutive trauma transfer admissions over 24 months from 2007 to 2009.

They used Green Book criteria to define appropriate triage as death at the trauma center, admission to an intensive care unit, urgent surgery, or trauma center length of stay greater than 48 hours.

The secondary overtriage rate was calculated as the difference between the total number of transfer admissions and appropriately triaged cases, divided by the total number of transfer admissions.

The appropriate and overtriage groups were compared by demographics (including insurance status), injury severity, time of transfer, and day of week. Financial variables included total, direct, and indirect hospital costs, as well as total payments before and after Medicaid year-end lump-sum adjustments to the hospital for the percentage of Medicaid and Medicare patients treated.

Of the 3,661 total admissions, 2,486, or just under 68%, were transfers from 1 of 36 facilities; 88% of the transfers came from 1 of 13 hospitals.

A total of 374 patients met the secondary overtriage definition, and 2,112 were determined to be secondary appropriate transfers. An additional 582 patients transferred from outlying hospitals were seen in the emergency department and released. The total secondary overtriage rate, therefore, was 31.2% (956 of 3,068) patients, Dr. Toschlog said.

The transfer population had a mean age of 40.7 years, 71% were male, and 56% were white. About half of the patients (52%) arrived on a weekend. The mean Injury Severity Score (ISS) was 13.9 (moderate).

Univariate analysis indicated that the overtriaged patients were more likely to be younger, to be uninsured, to arrive at night, and to be less severely injured across all measures of severity, compared with appropriately triaged patients. The overtriaged group had a mean hospital length of stay of 1 day, compared with 8.4 days for the appropriately triaged patients. Gender, ethnicity, weekend transfer, and substance abuse were not significantly associated with overtriage.

In a multivariate analysis, factors that were significantly associated with overtriage were age (odds ratio, 0.71), self-pay (OR, 1.88), night-time transfer (OR, 1.32), nonblunt trauma (OR, 0.56), ISS, and Revised Trauma Score less than 7.

As expected based on length of stay, total per-patient charges and costs for the appropriately triaged/transferred patients were higher.

Before adjustment for state Medicaid reimbursements, all transferred patients resulted in a financial loss for the trauma center. The loss for overtriaged patients averaged $1,520, and for appropriate transfers was $2,196. But after Medicaid payments were added, overtriage resulted in a $1,356 loss, whereas appropriate triage resulted in a $692 gain.

“Of particular concern is that the appropriately transferred cohort would have lost $4.6 million without government support,” Dr. Toschlog commented.

The study was limited by the retrospective design and by the possibility that the data may be unique to their institution and to their regional system, which defaults to the referring provider for acceptance of trauma transfer without input from the trauma surgeon. Overtriage criteria may have been unfairly applied, because some of the referring hospitals are not well equipped for evaluating trauma patients, he acknowledged.

“Our hope is that our study will contribute to the movement of the national trauma agenda toward further and better trauma system development. We can certainly maintain our commitment to caring for the injured while also working to ensure that the right patient is cared for in the right place at the right time,” he said.

Dr. C. William Schwab of the University of Pennsylvania, Philadelphia, the invited discussant, said that the focus of the study was too narrow, because it looked only at patient characteristics as a predictor of transfer and did not consider local hospital resources, provider level and skill complement, or distance from the local hospital to the level 1 center.

The study’s funding source was not disclosed. Dr. Toschlog and Dr. Schwab disclosed no conflicts of interest.

BOSTON  – A third of patients transferred to a level 1 regional trauma center were sent there unnecessarily and at substantial cost to the center, and most of this “secondary overtriage” could be attributed to nonmedical reasons such as time of day or the patient’s insurance status rather than severity of injury.

Of 2,486 patients transferred, 374 who were admitted to the trauma center had injuries that could have been safely handled by the referring institutions, and 582 were seen and released from the emergency department, Dr. Eric A. Toschlog said at the American Association for the Surgery of Trauma Annual Meeting.

From 2007 through 2009, secondary overtriage resulted in an estimated $570,000 loss for the center, whereas appropriate transfers, after adjustment for Medicaid payments, resulted in an estimated $1.5 million gain.

“Overtriage is a costly entity to our trauma center,” said Dr. Toschlog, of the Brody School of Medicine at East Carolina University in Greenville, N.C.

The study results, he said, are in agreement with the American College of Surgeons’ Resources for Optimal Care of the Injured Patient (Green Book), which states that overtriage has no or at most minimal consequences for patients, but results in “excessive costs and burden for higher level trauma centers in the routine care of injured patients.”

Despite that assertion, overtriage rates as high as 50% have been deemed acceptable as a means of preventing undertriage, Dr. Toschlog said.

The term “secondary overtriage” was coined by investigators from the Washington Hospital Center in Washington as overtriage originating from outlying hospitals (J. Am. Coll. Surg. 2008;206:131-7).

To determine the secondary overtriage rate, identify risk factors associated with transfer, and evaluate its financial impact, Dr. Toschlog and colleagues retrospectively reviewed data from their trauma registry on consecutive trauma transfer admissions over 24 months from 2007 to 2009.

They used Green Book criteria to define appropriate triage as death at the trauma center, admission to an intensive care unit, urgent surgery, or trauma center length of stay greater than 48 hours.

The secondary overtriage rate was calculated as the difference between the total number of transfer admissions and appropriately triaged cases, divided by the total number of transfer admissions.

The appropriate and overtriage groups were compared by demographics (including insurance status), injury severity, time of transfer, and day of week. Financial variables included total, direct, and indirect hospital costs, as well as total payments before and after Medicaid year-end lump-sum adjustments to the hospital for the percentage of Medicaid and Medicare patients treated.

Of the 3,661 total admissions, 2,486, or just under 68%, were transfers from 1 of 36 facilities; 88% of the transfers came from 1 of 13 hospitals.

A total of 374 patients met the secondary overtriage definition, and 2,112 were determined to be secondary appropriate transfers. An additional 582 patients transferred from outlying hospitals were seen in the emergency department and released. The total secondary overtriage rate, therefore, was 31.2% (956 of 3,068) patients, Dr. Toschlog said.

The transfer population had a mean age of 40.7 years, 71% were male, and 56% were white. About half of the patients (52%) arrived on a weekend. The mean Injury Severity Score (ISS) was 13.9 (moderate).

Univariate analysis indicated that the overtriaged patients were more likely to be younger, to be uninsured, to arrive at night, and to be less severely injured across all measures of severity, compared with appropriately triaged patients. The overtriaged group had a mean hospital length of stay of 1 day, compared with 8.4 days for the appropriately triaged patients. Gender, ethnicity, weekend transfer, and substance abuse were not significantly associated with overtriage.

In a multivariate analysis, factors that were significantly associated with overtriage were age (odds ratio, 0.71), self-pay (OR, 1.88), night-time transfer (OR, 1.32), nonblunt trauma (OR, 0.56), ISS, and Revised Trauma Score less than 7.

As expected based on length of stay, total per-patient charges and costs for the appropriately triaged/transferred patients were higher.

Before adjustment for state Medicaid reimbursements, all transferred patients resulted in a financial loss for the trauma center. The loss for overtriaged patients averaged $1,520, and for appropriate transfers was $2,196. But after Medicaid payments were added, overtriage resulted in a $1,356 loss, whereas appropriate triage resulted in a $692 gain.

“Of particular concern is that the appropriately transferred cohort would have lost $4.6 million without government support,” Dr. Toschlog commented.

The study was limited by the retrospective design and by the possibility that the data may be unique to their institution and to their regional system, which defaults to the referring provider for acceptance of trauma transfer without input from the trauma surgeon. Overtriage criteria may have been unfairly applied, because some of the referring hospitals are not well equipped for evaluating trauma patients, he acknowledged.

“Our hope is that our study will contribute to the movement of the national trauma agenda toward further and better trauma system development. We can certainly maintain our commitment to caring for the injured while also working to ensure that the right patient is cared for in the right place at the right time,” he said.

Dr. C. William Schwab of the University of Pennsylvania, Philadelphia, the invited discussant, said that the focus of the study was too narrow, because it looked only at patient characteristics as a predictor of transfer and did not consider local hospital resources, provider level and skill complement, or distance from the local hospital to the level 1 center.

The study’s funding source was not disclosed. Dr. Toschlog and Dr. Schwab disclosed no conflicts of interest.

BOSTON  – A third of patients transferred to a level 1 regional trauma center were sent there unnecessarily and at substantial cost to the center, and most of this “secondary overtriage” could be attributed to nonmedical reasons such as time of day or the patient’s insurance status rather than severity of injury.

Of 2,486 patients transferred, 374 who were admitted to the trauma center had injuries that could have been safely handled by the referring institutions, and 582 were seen and released from the emergency department, Dr. Eric A. Toschlog said at the American Association for the Surgery of Trauma Annual Meeting.

From 2007 through 2009, secondary overtriage resulted in an estimated $570,000 loss for the center, whereas appropriate transfers, after adjustment for Medicaid payments, resulted in an estimated $1.5 million gain.

“Overtriage is a costly entity to our trauma center,” said Dr. Toschlog, of the Brody School of Medicine at East Carolina University in Greenville, N.C.

The study results, he said, are in agreement with the American College of Surgeons’ Resources for Optimal Care of the Injured Patient (Green Book), which states that overtriage has no or at most minimal consequences for patients, but results in “excessive costs and burden for higher level trauma centers in the routine care of injured patients.”

Despite that assertion, overtriage rates as high as 50% have been deemed acceptable as a means of preventing undertriage, Dr. Toschlog said.

The term “secondary overtriage” was coined by investigators from the Washington Hospital Center in Washington as overtriage originating from outlying hospitals (J. Am. Coll. Surg. 2008;206:131-7).

To determine the secondary overtriage rate, identify risk factors associated with transfer, and evaluate its financial impact, Dr. Toschlog and colleagues retrospectively reviewed data from their trauma registry on consecutive trauma transfer admissions over 24 months from 2007 to 2009.

They used Green Book criteria to define appropriate triage as death at the trauma center, admission to an intensive care unit, urgent surgery, or trauma center length of stay greater than 48 hours.

The secondary overtriage rate was calculated as the difference between the total number of transfer admissions and appropriately triaged cases, divided by the total number of transfer admissions.

The appropriate and overtriage groups were compared by demographics (including insurance status), injury severity, time of transfer, and day of week. Financial variables included total, direct, and indirect hospital costs, as well as total payments before and after Medicaid year-end lump-sum adjustments to the hospital for the percentage of Medicaid and Medicare patients treated.

Of the 3,661 total admissions, 2,486, or just under 68%, were transfers from 1 of 36 facilities; 88% of the transfers came from 1 of 13 hospitals.

A total of 374 patients met the secondary overtriage definition, and 2,112 were determined to be secondary appropriate transfers. An additional 582 patients transferred from outlying hospitals were seen in the emergency department and released. The total secondary overtriage rate, therefore, was 31.2% (956 of 3,068) patients, Dr. Toschlog said.

The transfer population had a mean age of 40.7 years, 71% were male, and 56% were white. About half of the patients (52%) arrived on a weekend. The mean Injury Severity Score (ISS) was 13.9 (moderate).

Univariate analysis indicated that the overtriaged patients were more likely to be younger, to be uninsured, to arrive at night, and to be less severely injured across all measures of severity, compared with appropriately triaged patients. The overtriaged group had a mean hospital length of stay of 1 day, compared with 8.4 days for the appropriately triaged patients. Gender, ethnicity, weekend transfer, and substance abuse were not significantly associated with overtriage.

In a multivariate analysis, factors that were significantly associated with overtriage were age (odds ratio, 0.71), self-pay (OR, 1.88), night-time transfer (OR, 1.32), nonblunt trauma (OR, 0.56), ISS, and Revised Trauma Score less than 7.

As expected based on length of stay, total per-patient charges and costs for the appropriately triaged/transferred patients were higher.

Before adjustment for state Medicaid reimbursements, all transferred patients resulted in a financial loss for the trauma center. The loss for overtriaged patients averaged $1,520, and for appropriate transfers was $2,196. But after Medicaid payments were added, overtriage resulted in a $1,356 loss, whereas appropriate triage resulted in a $692 gain.

“Of particular concern is that the appropriately transferred cohort would have lost $4.6 million without government support,” Dr. Toschlog commented.

The study was limited by the retrospective design and by the possibility that the data may be unique to their institution and to their regional system, which defaults to the referring provider for acceptance of trauma transfer without input from the trauma surgeon. Overtriage criteria may have been unfairly applied, because some of the referring hospitals are not well equipped for evaluating trauma patients, he acknowledged.

“Our hope is that our study will contribute to the movement of the national trauma agenda toward further and better trauma system development. We can certainly maintain our commitment to caring for the injured while also working to ensure that the right patient is cared for in the right place at the right time,” he said.

Dr. C. William Schwab of the University of Pennsylvania, Philadelphia, the invited discussant, said that the focus of the study was too narrow, because it looked only at patient characteristics as a predictor of transfer and did not consider local hospital resources, provider level and skill complement, or distance from the local hospital to the level 1 center.

The study’s funding source was not disclosed. Dr. Toschlog and Dr. Schwab disclosed no conflicts of interest.