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Original Investigation
April 2017

Factors Associated With Nontransfer in Trauma Patients Meeting American College of Surgeons’ Criteria for Transfer at Nontertiary Centers

Author Affiliations
  • 1Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
  • 2Department of Anesthesiology, Shanghai Sixth People’s Hospital, Shanghai, China
JAMA Surg. 2017;152(4):369-376. doi:10.1001/jamasurg.2016.4976
Key Points

Question  What are factors associated with nontransfer among trauma patients taken to nontertiary centers who meet guideline criteria to consider transfer to facilities providing higher-level care?

Findings  In this cohort study of 96 528 patients, few meeting guideline criteria to consider transfer to higher-level care were transferred from nontertiary centers. Patient-level factors associated with nontransfer included older age, chest injury, and commercial insurance, accounting for approximately one-third of the transfer variation; center-level factors included greater center resources and university affiliation, accounting for approximately half of transfer variation.

Meaning  These factors associated with nontransfer may be useful for trauma system stakeholders to target education and outreach to guide development of more inclusive trauma systems.

Abstract

Importance  Secondary triage from nontertiary centers is vital to trauma system success. It remains unclear what factors are associated with nontransfer among patients who should be considered for transfer to facilities providing higher-level care.

Objective  To identify factors associated with nontransfer among patients meeting American College of Surgeons (ACS) guideline criteria for transfer from nontertiary centers.

Design, Setting, and Participants  A retrospective cohort study was performed using multilevel logistic regression to ascertain factors associated with nontransfer from nontertiary centers, including demographics, injury characteristics, and center resources. With information obtained from the National Trauma Data Bank (January 1, 2007, to December 31, 2012), relative proportion of variance in outcome across centers was determined for patient-level and center-level attributes. In all, 96 528 patients taken to nontertiary centers (levels III, IV, V, and nontrauma centers) that met ACS guideline transfer criteria were eligible for inclusion. Data analysis was performed from March 17, 2016, to May 20, 2016.

Main Outcomes and Measures  The primary outcome was nontransfer from a nontertiary center.

Results  Among 96 528 patients meeting ACS guideline criteria for transfer taken initially to nontertiary centers, 55 611 (57.6%) were male and the median age was 52 years (interquartile range, 28-77 years). Only 19 396 patients (20.1%) underwent transfer. Patient-level factors associated with nontransfer included age older than 65 years (adjusted odds ratio [AOR], 1.70; 95% CI, 1.46-1.98; P < .001), severe chest injury (AOR, 1.63; 95% CI, 1.42-1.89; P < .001), and commercial insurance (vs self-pay: AOR, 1.39; 95% CI, 1.15-1.67; P < .001). Center-level factors associated with nontransfer included larger bed size (>600 vs <200 beds: AOR, 9.22; 95% CI, 7.70-11.05; P < .001), nontrauma center (vs level III centers: AOR, 2.71; 95% CI, 2.44-3.01; P < .001), university affiliation (vs community: AOR, 9.68; 95% CI, 8.03-11.66; P < .001), more trauma surgeons (per surgeon: AOR, 1.08; 95% CI, 1.06-1.09; P < .001), and more neurosurgeons (per surgeon: AOR, 1.25; 95% CI, 1.23-1.28; P < .001). For-profit status was associated with nontransfer at nontrauma centers (AOR, 1.55; 95% CI, 1.39-1.74; P < .001), but not at level III, IV, and V trauma centers. Overall, patient-level factors accounted for 36% and center-level factors accounted for 58% of the variation in transfer practices. Patient-level factors accounted for more variation at level III, IV, and V trauma centers (44%), but less variation at nontrauma centers (13%).

Conclusions and Relevance  Only 1 in 5 patients meeting ACS transfer criteria underwent transfer. Factors associated with nontransfer may be useful for trauma system stakeholders to target education and outreach to guide development of more inclusive trauma systems. Further study is necessary to critically evaluate whether these ACS criteria identify patients who require transfer.

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