title: Nationwide secondary overtriage in level 3 and level 4 trauma centers: are these transfers necessary?
abstract: Secondary overtriage (SO) refers to the interfacility transfer of trauma patients who are rapidly discharged home without surgical intervention by the receiving institution. SO imposes a financial hardship on patients and strains trauma center resources. Most studies on SO have been conducted from the perspective of the receiving hospital, which is usually a level 1 trauma center. Having previously studied SO from the referring rural hospital's perspective, we sought to identify variables contributing to SO at the national level.
  
  
  
  Using data from the 2008-2012 National Trauma Data Bank, we isolated patients transferred to level 1 trauma centers who were: (1) discharged home within 48 h and (2) did not undergo any surgical procedure. This population was subsequently compared with similar patients treated at and discharged directly from level 3 and 4 centers. Multivariate logistic regression analysis was used to isolate variables that independently influenced a patient's risk of undergoing SO. Injury patterns were characterized by use of subspecialty consultants.
  
  
  
  A total of 99,114 patients met inclusion criteria, of which 13.2% were discharged directly from level 3 or 4 trauma centers, and 86.8% of them were transferred to a level 1 trauma center before discharge. The mean Injury Severity Score of the nontransfer and transfer groups was 5.4 ± 4.5 and 7.3 ± 5.7, respectively. Multivariate regression analysis showed that Injury Severity Score > 15, alcoholism, smoking, drug use, and certain injury patterns involving the head, vertebra, and face were associated with being transferred. In this minimally injured population, factors protective against transfers were: age > 65 y, female gender, systolic blood pressure <80, a head computed tomography scan and orthopedic injuries.
  
  
  
  SO results from the complex interplay of variables including patient demographics, facility characteristics, and injury type. The inability to exclude a potentially devastating neurologic injury seems to drive SO.
authors: School of Medicine, West Virginia University, Morgantown, West Virginia.
authors: Kevin T
authors: KT
authors: Lynch
authors: School of Medicine, West Virginia University, Morgantown, West Virginia.
authors: Rachael M
authors: RM
authors: Essig
authors: Department of Biostatistics, West Virginia University, Morgantown, West Virginia.
authors: Dustin M
authors: DM
authors: Long
authors: Department of Surgery, West Virginia University, Morgantown, West Virginia.
authors: Alison
authors: A
authors: Wilson
authors: Department of Surgery, West Virginia University, Morgantown, West Virginia. Electronic address: jocon@hsc.wvu.edu.
authors: Jorge
authors: J
authors: Con
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D000069342:Medical Overuse; D008875:Middle Aged; D010360:Patient Transfer / Q000706:statistics & numerical data*; D062606:Tertiary Care Centers / Q000706:statistics & numerical data*; D014193:Trauma Centers / Q000706:statistics & numerical data*
keywords: CT scan; Rural; Secondary overtriage; Transfers; Trauma system; Triage