Newgard CD, Staudenmayer K, Hsia RY, et al. The cost of overtriage: More than one-third of low-risk injured patients were taken to major trauma centers. Health Aff. 2013;32(9)1591–1599.
Research abstract: In this study we estimated hospital level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in seven regions, overall and by injury severity.
Among 301,214 patients, the average adjusted per episode cost of care was $5,590 higher in a Level 1 trauma center than in a non-trauma hospital.
We found hospital-level differences in cost among patients with minor, moderate and serious injuries. Of the 248,342 low-risk patients—those who did not meet field triage guidelines for transport to trauma centers—85,155 (34.3%) were still transported to major trauma centers, accounting for up to 40% of acute injury costs.
Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions we studied.
Doc Keith Wesley Comments
The primary goal of EMS is to get the right resources to the right place at the right time.
Improved use of 9-1-1 priority dispatch, ALS intercepts, mutual aids and expanded BLS education have significantly reduced the likelihood that the severely injured patient goes unnoticed and increases the chance of being cared for quickly and efficiently. Once at the scene, the patient is rapidly triaged, treated and transported.
But to where? … Well? A trauma center of course.
For the past 30 years, states have been provided federal support to create regionalized trauma systems; the vast majority of EMS agencies operate within such a system. Integral to these systems has been the adoption of trauma triage criteria designed to identify patients with the greatest potential for serious injury.
However, studies show EMS providers frequently don’t apply the criteria correctly or often simply default to gut instinct and transport all trauma patients to the nearest Level 1 or 2 trauma center. This results in overtriage of as many as 30–50% of trauma patients, who are minimally injured but still being transported to a trauma center.
So what’s the harm in that? Trauma patients get the best care at trauma centers. Right?
Yes and no.
Level 1 and 2 trauma centers clearly benefit those with moderate to severe injuries, but at what cost to those patients with minimal injuries? This study found that minimally injured patients could expect a hospital bill from the trauma center that’s $5,000 more than what they would’ve paid at a non-trauma center.
Many of you will think $5,000 isn’t much, but, according to this study, proper triage criteria use and transportation of the minimally injured to non-trauma centers could’ve saved more than $136 million annually. Extrapolating this to the entire nation, which is served by more than 200 Level 1 and 300 Level 2 trauma centers, the additional savings would exceed $1 billion a year.
If we as a society are truly concerned about healthcare cost I propose we seriously examine why trauma triage criteria are so poorly utilized and develop processes to ensure patients are transported to the most appropriate facility to care for their injuries in a fiscally responsible manner.
Medic Karen Wesley Comments
Your points are all valid, Doc. The paper does state that 34% of patients transported to Level 1 and 2 trauma centers were over-triaged. However, let’s look at the rest of the story: The authors go on to state there were 12,382 seriously injured patients and that 52,872 field trauma activations identified only 58%. That results in a 38% under-triage rate from field activations. What’s the personal cost to those patients having to be transferred to a higher level of care because they wound up at facilities ill-equipped to care for them?
The variables of why patients get transported to specific facilities go beyond the triage guidelines.
Certainly a significant amount of healthcare dollars could be saved if all trauma patients were triaged correctly, agreed to go to a different hospital, or other less-specialized hospitals were available to take these patients. But these ideal situations don’t always exist. And the “gut feeling” of more than one EMT or paramedic has saved the lives of many.
I hope there’s at least a little concern over the under-triaged patients. I mean, 38% deserves a little outrage.
If we want better results, we have to continually educate and train all parties. We can’t exclude anyone in this—even the patients. With healthcare reform, we need to examine the a la carte mentality of patients: convenience or desire vs. need.
Lastly, we all have to make a conscientious effort to improve our skills at getting patients to the right place in a timely manner.