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Left behind: Association of prehospital field undertriage and outcomes after injury
Liling Lu1, Sebastian Boland2, Tamara Byrd2
1Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Pittsburgh Trauma and Transfusion Medicine Research Center Department of Surgery, University of Pittsburgh and UPMC, Pittsburgh, PA.
Background:
Despite the perception of the negative effects of field undertriage for injured patients, relatively little literature exists documenting worse outcomes, and trauma registry data are limited by missing patients who never arrive at a trauma center. Our objective is to evaluate the impact of undertriage on outcomes in a population-based data set.
Methods:
This was a retrospective cohort study of injured adult patients in the 2023 Pennsylvania state discharge database (Pennsylvania Health Care Cost Containment Council). Undertriage was defined as patients not being transported initially to a level I/II trauma center who met anatomic and mechanism of National Field Triage Criteria using the International Classification of Diseases, 10th Revision codes and external cause of injury codes. Our primary outcome was in-hospital mortality. Secondary outcomes were hospital length of stay and discharge disposition (home versus nonhome). The association between outcomes and undertriage was determined using doubly robust targeted maximum likelihood estimation, adjusting for age, sex, race, mechanism of injury, distance to hospital, major operative procedures, and injury severity.
Results:
A total of 59,095 trauma patients were included, with an undertriage rate of 53%. Targeted maximum likelihood estimation demonstrated a 19% increased relative risk of in-hospital mortality associated with undertriage (adjusted risk ratio, 1.19; 95% confidence interval, 1.07-1.33) but shorter length of stay (-0.29 days; 95% confidence interval, -0.42 to -0.15). For discharge disposition, a generalized additive model identified a significant change in the effect of undertriage at 60 years old. For patients older than 60 years, undertriage is associated with a lower risk of discharge home (adjusted risk ratio, 0.95; 95% confidence interval, 0.93-0.97).
Conclusion:
We demonstrate among injured adults transported to both trauma and nontrauma centers in Pennsylvania that prehospital field undertriage based on the National Field Triage Guidelines is associated with an increased risk of mortality and lower likelihood of discharge home among older adults.
