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Consequences of Pediatric Undertriage and Overtriage in a Statewide Trauma System
Hilary A. Hewes MD1, Stephen J. Fenton MD2, Mathew Christensen PhD3, Kammy K. Jacobsen BS1, Peter P. Taillac MD4. 1Division of Pediatric Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA, 2Division of Pediatric Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA, 3Bureau of Emergency Medical Services and Preparedness, Utah Department of Health, Salt Lake City, UT, USA, 4Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.

Background: With increasing attention to cost and quality of health care delivery, evaluating trauma triage decisions in a large system of emergency care can increase accountability and help decision-makers reduce mortality, morbidity and unnecessary healthcare costs. To quantify the magnitude of pediatric traumatic injury undertriage (mortality risk) and overtriage (early trauma center discharge after transfer) in a statewide trauma system.

Methods: A statewide population-based evaluation of pediatric trauma outcomes and secondary triage (interfacility transfers) patterns from 2001-2013 among 45 hospitals in a large statewide trauma system.

Results: The odds of pediatric transfer were 13x lower (OR=13.15, P<.0001, 95% CI: 11.0-15.7) in acute care hospitals meeting undertriage criteria than hospitals meeting overtriage criteria. Hospital triage practice was a stronger predictor of pediatric transfer than injury severity, injury diagnoses, age, and geographic distance. Pediatric trauma mortality likelihood was more than 2x higher in undertriage hospitals than overtriage hospitals (OR=2.44, P<.0001, 95% CI: 1.5-3.8). Among pediatric patients that survived the injury to transfer, 61% were discharged from the pediatric center in less than 24 hours; these patients represent 42% of the total number of in-state pediatric trauma patients receiving definitive care at a Level I pediatric trauma center.

Conclusions: Substantial opportunity exists in the state trauma system to improve pediatric trauma patient transfer practices to reduce pediatric trauma mortality, morbidity, and healthcare costs associated with unnecessary transfers. The pediatric emergency medical system in Utah shares similar patient flow challenges seen in other trauma systems across the United States.

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