title: Undertriage of Trauma-Related Deaths in U.S. Emergency Departments.
abstract: BACKGROUND
  Accurate field triage of critically injured patients to trauma centers is vital for improving survival. We sought to estimate the national degree of undertriage of trauma patients who die in emergency departments (EDs) by evaluating the frequency and characteristics associated with triage to non-trauma centers.
  
  
  METHODS
  This was a retrospective cross-sectional analysis of adult ED trauma deaths in the 2010 National Emergency Department Sample (NEDS). The primary outcome was appropriate triage to a trauma center (Level I, II or III) or undertriage to a non-trauma center. We subsequently focused on urban areas given improved access to trauma centers. We evaluated the associations of patient demographics, hospital region and mechanism of injury with triage to a trauma versus non-trauma center using multivariable logistic regression.
  
  
  RESULTS
  We analyzed 3,971 included visits, representing 18,464 adult ED trauma-related deaths nationally. Of all trauma deaths, nearly half (44.5%, 95% CI [43.0-46.0]) of patients were triaged to non-trauma centers. In a subgroup analysis, over a third of urban ED visits (35.6%, 95% CI [34.1-37.1]) and most rural ED visits (86.4%, 95% CI [81.5-90.1]) were triaged to non-trauma centers. In urban EDs, female patients were less likely to be triaged to trauma centers versus non-trauma centers (adjusted odds ratio [OR] 0.83, 95% CI [0.70-0.99]). Highest median household income zip codes (≥$67,000) were less likely to be triaged to trauma centers than lowest median income ($1-40,999) (OR 0.54, 95% CI [0.43-0.69]). Compared to motor vehicle trauma, firearm trauma had similar odds of being triaged to a trauma center (OR 0.90, 95% CI [0.71-1.14]); however, falls were less likely to be triaged to a trauma center (OR 0.50, 95 %CI [0.38-0.66]).
  
  
  CONCLUSIONS
  We found that nearly half of all trauma patients nationally and one-third of urban trauma patients, who died in the ED, were triaged to non-trauma centers, and thus undertriaged. Sex and other demographic disparities associated with this triage decision represent targeted opportunities to improve our trauma systems and reduce undertriage.
authors.affiliation: University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado; Denver Health Medical Center, Department of Emergency Medicine, Denver, Colorado.
authors.forename: Jenelle A
authors.initials: JA
authors.lastname: Holst
authors.affiliation: University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado.
authors.forename: Sarah M
authors.initials: SM
authors.lastname: Perman
authors.affiliation: University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado.
authors.forename: Roberta
authors.initials: R
authors.lastname: Capp
authors.affiliation: University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado; Denver Health Medical Center, Department of Emergency Medicine, Denver, Colorado.
authors.forename: Jason S
authors.initials: JS
authors.lastname: Haukoos
authors.affiliation: University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado.
authors.forename: Adit A
authors.initials: AA
authors.lastname: Ginde
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D003430:Cross-Sectional Studies; D004636:Emergency Service, Hospital; D005260:Female; D006302:Health Services Research; D006801:Humans; D015601:Injury Severity Score; D019458:Insurance Coverage / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000401:mortality*; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D012737:Sex Factors; D014218:Triage / Q000592:standards / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology; D014947:Wounds and Injuries / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D055815:Young Adult