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Factors associated with patients transferred from undesignated trauma centers to trauma centers
Sergey Tarima1, Allison Ertl, Jonathan I Groner
1From the Institute for Health and Society (S.T., A.E., L.D.C.), Medical College of Wisconsin, Milwaukee, Wisconsin; and Nationwide Children's Hospital (J.I.G.), Columbus, Ohio.
Insights
Younger children with severe injuries are at higher risk for mortality and transfer. Many pediatric trauma patients seen at nontrauma centers (NTCs) are transferred, even when not severely injured.
Area of Science:
- Pediatric Trauma Care
- Healthcare Access
- Injury Outcomes
Background:
- Optimizing outcomes for severely injured pediatric trauma patients requires timely access to appropriate care.
- Many pediatric patients lack adequate access to verified Level 1 trauma centers.
- This study is the first statewide analysis including pediatric patients initially seen at nontrauma centers (NTCs).
Purpose of the Study:
- Identify predictors of in-hospital mortality in pediatric trauma patients.
- Identify predictors of transfer to a higher level of care.
- Analyze outcomes for pediatric trauma patients initially managed at NTCs.
Main Methods:
- Analysis of mortality and interhospital transfers for the first hospital of care.
- Generalized estimating equations used to account for clustering.
- Epidemiologic/prognostic study, level III.
Main Results:
- Younger age associated with mortality and transfer for less severely injured children (Injury Severity Score < 15).
- NTCs had lower observed mortality, but most patients were transferred.
- Self-pay patients had significantly higher mortality odds; trauma type impacted outcomes.
Conclusions:
- Nontrauma centers transfer 98% of pediatric trauma patients, including those with low Injury Severity Score and high Glasgow Coma Scale.
- Further evaluation of transferred patients is needed.
- Findings may inform triage guidelines to potentially avoid unnecessary transfers from NTCs.
Background:
Timely access to the appropriate level of care, both in the prehospital and in the hospital setting, is necessary to optimize outcomes in severely injured pediatric trauma patients. However, a substantial portion of the pediatric population does not have adequate timely access to a verified Level 1 trauma center. This study aimed to identify significant predictors of in-hospital mortality and transfer to a higher level of care. This is the first statewide analysis that includes pediatric patients who are first seen at nontrauma centers (NTCs).
Methods:
Mortality interhospital transfers to a higher level of care were analyzed for the first hospital of care. Clustering was accounted for by generalized estimating equations. p < 0.01 was considered significant.
Results:
Younger age was significantly associated with mortality for all patients and with transfer for less severely injured children (Injury Severity Score [ISS] < 15). The odds of mortality in NTCs were lower than in Level 1 trauma centers; however, the majority of NTC patients were transferred, artificially decreasing NTC mortality. The type of trauma (blunt or penetrating) was significantly associated with both mortality and transfer for more severe cases. Although insurance was not significantly associated with transfer, self-pay patients had significantly higher mortality odds.
Conclusion:
The NTCs are transferring 98% of their patients, even those with very low ISS and high Glasgow Coma Scale (GCS). Further evaluation of the outcomes and characteristics of patients transferred from NTCs will provide important information to inform the triage guidelines to potentially safely avoid transfer of less severely injured patients from NTCs in their community.
Level Of Evidence:
Therapeutic study, level IV; epidemiologic/prognostic study, level III.
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