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Trauma triage in the emergency departments of nontrauma centers: An analysis of individual physician caseload on triage patterns

Mohan, Deepika MPH, MD; Barnato, Amber E. MD, MPH, MS; Rosengart, Matthew R. MD, MPH; Farris, Coreen PhD; Yealy, Donald M. MD; Switzer, Galen E. PhD; Fischhoff, Baruch PhD; Saul, Melissa MS; Angus, Derek C. MD, MPH

Journal of Trauma and Acute Care Surgery: June 2013 - Volume 74 - Issue 6 - p 1541–1547
doi: 10.1097/TA.0b013e31828c3f75
Original Articles
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BACKGROUND Treatment at Level I/II trauma centers improves outcomes for patients with severe injuries. Little is known about the role of physicians’ clinical judgment in triage at outlying hospitals. We assessed the association between physician caseload, case mix, and the triage of trauma patients presenting to nontrauma centers.

METHODS A retrospective cohort analysis of patients evaluated between January 1, 2007, and December 31, 2010, by emergency physicians working in eight community hospitals in western Pennsylvania. We linked billing records to hospital charts, summarized physicians’ caseloads, and calculated rates of undertriage (proportion of patients with moderate-to-severe injuries not transferred to a trauma center), and overtriage (proportion of patients transferred with a minor injury). We measured the correlation between physician characteristics, caseload, and rates of triage.

RESULTS Of 50 eligible physicians, 29 (58%) participated in the study. Physicians had a mean (SD) of 16.8 (10.1) years of postresidency clinical experience; 21 (72%) were board certified in emergency medicine. They evaluated a median of 2,423 patients per year, of whom 148 (6%) were trauma patients and 3 (0.1%) had moderate-to-severe injuries. The median undertriage rate was 80%; the median overtriage rate was 91%. Physicians’ caseload of patients with moderate-to-severe injuries was inversely associated with rates of undertriage (correlation coefficient, −0.42; p = 0.03). Compared with physicians in the lowest quartile, those in the highest quartile undertriaged 31% fewer patients.

CONCLUSION Emergency physicians working in nontrauma centers rarely encounter patients with moderate-to-severe injuries. Caseload was strongly associated with compliance with American College of Surgeons’ Committee on Trauma guidelines.

LEVEL OF EVIDENCE Therapeutic/care management, level IV.

From the Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.

Submitted: November 8, 2012, Revised: January 11, 2013, Accepted: January 11, 2013.

Address for reprints: Deepika Mohan, MD, MPH, University of Pittsburgh, 3550 Terrace Street, PA 15261; email: mohand@upmc.edu.

© 2013 Lippincott Williams & Wilkins, Inc.