title: Triage patterns for medicare patients presenting to nontrauma hospitals with moderate or severe injuries.
abstract: OBJECTIVE
  To understand hospital-level variation in triage practices for patients with moderate-to-severe injuries presenting initially to nontrauma centers.
  
  
  BACKGROUND
  Many patients with moderate-to-severe traumatic injuries receive care at nontrauma hospitals, despite evidence of a survival benefit from treatment at trauma centers.
  
  
  METHODS
  We used claims from the Centers for Medicare and Medicaid Services to identify patients with moderate-to-severe injuries who presented initially to nontrauma centers. We determined whether or not they were transferred to a level I or II trauma center within 24 hours of presentation, and used multivariate regression to assess the influence of hospital-level factors on triage practices, after adjusting for differences in case mix.
  
  
  RESULTS
  Transfer of patients with moderate-to-severe injuries to trauma centers occurred infrequently, with significant variation among hospitals (median 2%; interquartile range 1%-6%). Greater resource availability at nontrauma centers was associated with lower rates of successful triage, including the presence of neurosurgeons (relative reduction in transfer rate: 76%, P < 0.01), more than 20 intensive care unit beds (relative reduction 30%, P < 0.01) and a high resident-to-bed ratio (relative reduction 23%, P < 0.01). However, patients were more likely to survive if they presented to hospitals with higher triage rates (odds of death for patients cared for at hospitals with the highest tercile of triage rates, compared with lowest tercile: 0.92; 95% confidence interval: 0.85-0.99, P = 0.02).
  
  
  CONCLUSIONS
  Injured Medicare beneficiaries presenting to nontrauma centers experience high rates of undertriage, determined in part by increasing availability of resources. Care at hospitals with low rates of successful triage is associated with worse outcomes.
authors.affiliation: *The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine †Department of Surgery ‡Department of Medicine; and §Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
authors.forename: Deepika
authors.initials: D
authors.lastname: Mohan
authors.forename: Amber E
authors.initials: AE
authors.lastname: Barnato
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Rosengart
authors.forename: Derek C
authors.initials: DC
authors.lastname: Angus
authors.forename: David J
authors.initials: DJ
authors.lastname: Wallace
authors.forename: Jeremy M
authors.initials: JM
authors.lastname: Kahn
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D016015:Logistic Models; D008297:Male; D006278:Medicare; D015999:Multivariate Analysis; D010360:Patient Transfer / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D014193:Trauma Centers / Q000458:organization & administration / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014218:Triage / Q000706:statistics & numerical data*; D014481:United States; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy*