The statewide trauma system in Pennsylvania has been in existence since 1985, and thus is a mature system with years of data and performance improvement initiatives based on these data. However, statewide, the overall UTR of pediatric trauma patients is 45.8%. It is quite shocking that in a system as mature as this, the pediatric UTR would be as high as it is. This is markedly higher than the 21.7% rate previously calculated from Nationwide Emergency Department Sample (NEDS).25
Additional factors, which may potentially lead to hot spot zones, are the influence of major health care systems and prehospital triage. Some systems expect that patients admitted to their facilities only be transferred within their network, which can influence the UTR. Unfortunately, this study was not able to calculate the impact of hospital systems on the transfer practices of pediatric patients. Competition between hospitals, which may influence UTR, remains understudied. Despite proximity, there may be a tendency to not transfer patients out of network to an unaffiliated TC. The education and training of health care professionals also influence UTR. The importance of prehospital triage is undeniable, and the true cost of undertriage has potentially been underappreciated and subject to survivor bias.26 France's trauma system, TRENAU (Trauma Réseau Nord Alpin des Urgences), where an emergency medicine physician makes an on-scene assessment and refers each patient to the appropriate trauma center, successfully optimizes prehospital triage.27 While others have studied the accuracy of prehospital trauma notification calls and found that emergency medical services (EMS) crews often provide inaccurate information or sometimes no information at all.28 In reality, it may not be feasible to send a physician on every EMS call. However, training and educating EMS providers on appropriate prehospital triage and using a standardized approach to reporting this assessment is a reasonable objective.
The authors previously investigated the adult UTR in the Commonwealth of Pennsylvania during the same time period and determined the UTR to be 32.2%. The geospatial representation of undertriage in that population is pointedly different. The clustering of undertriage in the adult population was around NTCs where there are no trauma centers in nearby, while that of pediatric patients is the opposite. As Figures 2 and 4 illustrate, there is significant undertriage in the densely populated eastern region of the state, where access to trauma centers is far from limited. This strongly suggests that NTCs are essentially acting as de facto trauma centers, without undergoing the rigorous accreditation process to ensure appropriate management of the pediatric trauma patient.
It must be noted that the existence of a TC does not always eliminate UTR. The presence of pediatric TCs seems to have a slight influence on UTR in the most proximal zip codes; but as evident in Figures 1 and 2, there is a clustering effect that is not always associated with a TC. This clustering effect is why geospatial representation of the data is so critical to get a more thorough understanding of the still undetermined influences on UTR.
This study is not without its limitations. The trauma criteria are imposed retrospectively on both data sets and may have resulted in some trauma cases being unintentionally excluded. The nature of the data sets, both containing deidentified data void of any patient identifying information, made it impossible to concatenate a patient's record. As the study was of a single state and completed retrospectively in nature, there are inherent threats to generalizability. Alongside the forenamed restrictions, only pediatric patients were evaluated. It should be noted that all pediatric patients were included from the PTSF database, but only those meeting trauma criteria were included from PHC4 using billing codes. As a result, errors in billing coding may also have unintentionally influenced the outcomes of this study. Although the main objective of this study was to evaluate UTR in Pennsylvania, trauma care is an organic process; thus, patients may have been treated at or transferred to TCs beyond the state boundaries and may have influenced the results of our study. Given the limited data available in PHC4, it was not possible to complete a risk adjusted analysis of the population, making it difficult to suggest any correlation between UTR and mortality. Furthermore, the authors acknowledge the importance of highlighting the consequences and effects that UTR have, but given the nature of the data set, they could not be analyzed. Subsequent research should explore the influence that health systems and cultural differences have on UTR across the Commonwealth.
The study used a trauma prediction model (TMPM) as the reporting method because of the significant disadvantage that ISS, which is calculated at discharge, poses.29 The TMPM estimates a patient's probability of death due to their five worst anatomic injuries exclusively. It has been compared to ISS and found to be a superior measure of injury.30–32
ATR interpreted the data and wrote the manuscript. MAH designed the study; collected, analyzed, and interpreted the data; and wrote the manuscript. TMV interpreted the data and wrote the manuscript and provided editorial oversight. BAG designed the study, interpreted data, and wrote the manuscript. EHB interpreted the data. ADC interpreted data. SJ designed the study and collected the data. FBR designed the study, interpreted the data, and provided editorial oversight.
The authors declare no conflicts of interest. This work received no funding. This study was accepted for a Quick Shot presentation at the 5th Annual Meeting for the Pediatric Trauma Society on November 8–10, 2018 in Houston, Texas.
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