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Rapid Discharge After Transfer: Risk Factors, Incidence, and Implications for Trauma Systems

Osen, Hayley B. BA; Bass, Robert R. MD; Abdullah, Fizan MD; Chang, David C. PhD, MPH, MBA

Journal of Trauma and Acute Care Surgery: September 2010 - Volume 69 - Issue 3 - p 602-606
doi: 10.1097/TA.0b013e3181e7db37
Original Article

Background: The occurrence of discharge to home shortly after transfer from another hospital, also termed “secondary overtriage,” needs to be analyzed in trauma patients because it helps to assess the efficiency of triage and transfer criteria. The extent of secondary overtriage and factors associated with it remain largely undescribed.

Methods: A retrospective analysis of the Nationwide Inpatient Sample from 2000 to 2004. Inclusion criteria were trauma patients (as identified by ICD-9 diagnosis codes of 800–959 in the primary position, excluding codes representing late effects of injury, foreign body, burn, or early complications) who were admitted as transfers from another hospital. Rapid discharge after transfer (secondary overtriage) was defined as patients who were discharged alive within 1 day after transfer and did not receive any surgical procedure.

Results: The overall rate of secondary overtriage was 6.9% (3,291 of 51,278), with an increasing trend over the years. This rate was significantly higher among patients younger than 18 years (19.5% vs. 4.2%). Patients meeting the definition were more likely to be male (68.3% vs. 50.65%), more likely to be black or Hispanic (25.16% vs. 16.8%), more likely to come from ZIP codes with above-median household incomes (43.4% vs. 38.1%), and more likely to be treated at teaching hospitals (77.3% vs. 61.3%). The majority of these patients (98.7%) were insured, although the proportion of uninsured patients was significantly higher among secondary overtriage (1.3% vs. 0.54%). On multivariate analysis, younger age, uninsured status, and being transferred to a teaching hospital were associated with higher likelihood of rapid discharge after transfer. No association was found with gender, race, and urbanicity.

Conclusion: Secondary overtriage is more common in pediatric patients than in adults. The underlying causes of this occurrence need to be further investigated (e.g., fear of litigation and uneven distribution of resources). There are significant direct and indirect costs associated with these occurrences that must be considered as we identify areas of potential cost savings in our nation's health care.

From the Department of Surgery (H.B.O., F.A., D.C.C.), Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Health Policy and Management (D.C.C.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Surgery (D.C.C.), Howard University College of Medicine, Washington, District of Columbia; Department of Surgery (H.B.O., D.C.C.), Center for Surgical Systems and Public Health, University of California, San Diego, California; and Maryland Institute for Emergency Medical Services Systems (R.R.B.), Baltimore, Maryland.

Submitted for publication April 5, 2010.

Accepted for publication May 13, 2010.

Presented as a poster at the 68th Annual Meeting of the American Association for the Surgery of Trauma, October 1–3, 2009, Pittsburgh, Pennsylvania.

Address for reprints: David Chang, PhD, MPH, MBA, 200 W Arbor Drive, San Diego, CA 92103; email:

© 2010 Lippincott Williams & Wilkins, Inc.