Secondary overtriage is defined as a trauma patient transfer to a higher-level trauma center where the patient ultimately does not require any major intervention. Frequently, these patients are discharged directly from the receiving hospital’s ED or soon thereafter. The downside of secondary overtriage is that it may unnecessarily use considerable resources at the tertiary center.  This creates a clear drain on the receiving center and contributes to the congestion issues that have been prevalent since the COVID-19 pandemic.

A recent paper examined the impact of trauma center designation for the referring center on patterns of secondary overtriage. Specifically, it examined whether the referring hospital was a designated level three state trauma center or a non-level three center. It was written by the HCA Health Care Center for Trauma and Acute Care Surgery Research in Nashville. The paper focused on resource consumption at the upstream Level I trauma center, including hospital length of stay, intensive care unit length of stay, and average ventilator days.

Here are the factoids:

• A total of 2,309 inter-facility transfers to a single level one center were analyzed.
• Transfers from 20 referring non-tertiary facilities over two years were reviewed. Only centers that referred more than 30 patients per year were included (see my comments below). All were part of the same regional trauma system.
• Five of the referring centers were Level III trauma centers (4 ACS verified in the receiving Level I center’s hospital system, and one center designated by the State of Tennessee).
• The other 15 were non-Level III centers (Level IV or non-trauma centers).
• Secondary over triage was formally defined as patients who had no major surgical intervention under anesthesia and 1) were either discharged home directly from the ED within two days or 2) were admitted and discharged alive from the hospital without transfer to hospice within two days.
• Secondary overtriage occurred in 24% of transfers from a Level III versus 28% of non-Level III transfers. This is statistically significant and indicates that transfer from a non-Level III center is associated with a 31% higher likelihood of secondary overtriage.
• Mortality rates were similar between the groups,  but transfers from non-Level III centers had shorter hospital, ICU, and ventilator days, which suggested they were lower acuity transfers.

The authors concluded that there is value in the trauma designation requirements and process, which may allow those centers to retain patients who might otherwise be unnecessarily transferred to a higher-level center.

Bottom line: This is an important and well-written paper that addresses the significant issue of secondary overtriage, which occurs frequently every day across this country. It had enough statistical power to identify differences between transfers from trauma and non-trauma centers. 

It does have a few weaknesses, however. As always, a single-center retrospective study raises a few flags, but the statistical power remains significant here. The authors excluded non-trauma centers that referred fewer than 30 patients per year. This could bias the sample toward hospitals that have active referral relationships. I can’t predict the actual impact on their data. Finally, there is no realistic way to capture the actual reason for transfer using registry data. This factor is really unknown in most papers on trauma transfers and hints at the very complex reasons that centers decide to transfer. 

Every state has a verification or designation process for trauma centers. The system exists. The individual hospitals typically decide whether to participate. This paper suggests that all hospitals should participate in a system to the best of their capabilities, so they can optimize patient care and relieve as much strain on the overall system as possible. The next step in research on this topic is to focus on the individual patient impact (and their families) of these potentially unnecessary transfers. 

Reference: Secondary overtriage: impact of trauma center designation and trauma system integration. Trauma Surg Acute Care Open. 2026 Feb 23;11(1):e002027. doi: 10.1136/tsaco-2025-002027. PMID: 41743404; PMCID: PMC12931552.