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Should they stay or should they go? Who benefits from interfacility transfer to a higher-level trauma center following initial presentation at a lower-level trauma center

Adzemovic, Tessa; Murray, Thomas PhD; Jenkins, Peter MD; Ottosen, Julie MD; Iyegha, Uroghupatei MD; Raghavendran, Krishnan MD; Napolitano, Lena M. MD; Hemmila, Mark R. MD; Gipson, Jonathan MD; Park, Pauline MD; Tignanelli, Christopher J. MD

Journal of Trauma and Acute Care Surgery: June 2019 - Volume 86 - Issue 6 - p 952–960
doi: 10.1097/TA.0000000000002248

BACKGROUND Interfacility transfer of patients from Level III/IV to Level I/II (tertiary) trauma centers has been associated with improved outcomes. However, little data are available classifying the specific subsets of patients that derive maximal benefit from transfer to a tertiary trauma center. Drawbacks to transfer include increased secondary overtriage. Here, we ask which injury patterns are associated with improved survival following interfacility transfer.

METHODS Data from the National Trauma Data Bank was utilized. Inclusion criteria were adults (≥16 years). Patients with Injury Severity Score of 10 or less or those who arrived with no signs of life were excluded. Patients were divided into two cohorts: those admitted to a Level III/IV trauma center versus those transferred into a tertiary trauma center. Multiple imputation was performed for missing values, and propensity scores were generated based on demographics, injury patterns, and disease severity. Using propensity score–stratified Cox proportional hazards regression, the hazard ratio for time to death was estimated.

RESULTS Twelve thousand five hundred thirty-four (5.2%) were admitted to Level III/IV trauma centers, and 227,315 (94.8%) were transferred to a tertiary trauma center. Patients transferred to a tertiary trauma center had reduced mortality (hazard ratio, 0.69; p < 0.001). We identified that patients with traumatic brain injury with Glasgow Coma Scale score less than 13, pelvic fracture, penetrating mechanism, solid organ injury, great vessel injury, respiratory distress, and tachycardia benefited from interfacility transfer to a tertiary trauma center. In this sample, 56.8% of the patients benefitted from transfer. Among those not transferred, 49.5% would have benefited from being transferred.

CONCLUSION Interfacility transfer is associated with a survival benefit for specific patients. These data support implementation of minimum evidence-based criteria for interfacility transfer.

LEVEL OF EVIDENCE Therapeutic/Care Management, Level IV.

From the University of Michigan Medical School (T.A.), Ann Arbor, Michigan; Division of Biostatistics (T.M.), University of Minnesota, Minneapolis, Minnesota; Department of Surgery (P.J.), Indiana University, Indianapolis, Indiana; Department of Surgery (J.O., C.J.T.), University of Minnesota, Minneapolis, Minnesota; Department of Surgery (J.O., J.G.P., C.J.T.), North Memorial Health Hospital, Robbinsdale, Minnesota, Department of Surgery (U.I.), Regions Hospital, St. Paul, Minnesota; Department of Surgery (K.R., L.M.N., M.R.H., P.P.), University of Michigan, Ann Arbor, Michigan; and Institute for Health Informatics (C.J.T.), University of Minnesota, Minneapolis, Minnesota.

Submitted: September 7, 2018, Revised: December 19, 2018, Accepted: January 2, 2019, Published online: March 1, 2019.

This study was presented as a plenary presentation at the 77th annual meeting of American Association for the Surgery of Trauma Meeting, September 26–29, 2018, in San Diego, California.

Address for reprints: Christopher J. Tignanelli, MD, Department of Surgery, University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN 55455; email:

© 2019 Lippincott Williams & Wilkins, Inc.