Category Archives: Trauma Systems

The January Trauma MedEd Newsletter Is Available!

The January issue of the Trauma MedEd newsletter is now available to everyone!

This issue is a primer on trauma systems. It includes:

  • What Is A Trauma System?
  • US Trauma Systems – The Origin Story
  • The Rise Of State Systems
  • The Feds Pay Attention
  • Where Are We Now And What Should We Do Next?

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Best of EAST #4: Futile Trauma Transfers

Level I and II trauma centers are regularly on the receiving end of what may be termed as “futile transfers.” These are patients who have sustained unsalvageable injuries and are initially seen at a lower level center. They are then transferred upstream where they succumb shortly (0-48 hours) after arrival.

As you might imagine, these patients can place a significant burden on resources at the Level I or II center. This is an even more acute situation given the large numbers of COVID patients who also require hospitalization and palliative care services these days.

The group at the University of Kansas sought to put some numbers on this phenomenon. They examined their own experience as one of two Level I trauma centers in the Kansas City metro area. They defined futile care as patients who died or were discharged to hospice care within 48 hours of arrival and who did not undergo operative, endoscopic, or interventional radiology procedures.

Here are the factoids:

  • A total of 1,241 patients were transferred in during the two year study period
  • Of these, 407 had stays of 48 hours or less, and 18 (1.5%) were deemed futile care according to their definition
  • The futile care patients tended to be much older (75 vs 61 years) and were much more severely injured (ISS 21 vs 8)
  • When transport and hospital charges were combined, the average total cost was $56,000
  • Total cost to this hospital was $1.7 million, and this was extrapolated to an annual cost of 27 million for the entire US

The authors concluded that these futile transfers are a small yet costly patient population. They suggested that accurately identifying these patients and providing resources to help referral hospitals figure out how to care for them would be helpful.

My comments: This is a very straightforward descriptive paper that details a problem that every high level trauma center sees on a regular basis. Older patients, typically those with critical head injuries that are beyond treatment, are transferred to the “big house.” The families are frequently told that there are no local resources to provide the care needed, and that the higher level center is their only chance. 

The families then have unrealistic expectations, and are inconvenienced by the travel involved. Wouldn’t it be better to just tell the family that the injury is a really bad one, and provide palliative / hospice care in the local community? Unfortunately, it’s not that simple. Many small hospitals do not have providers who are well-versed in this type of care. Thus, the suggestion to provide resources (people? training?) is a sound one.

This abstract highlights a problem we all face but seldom publicize. Hopefully this one will get us talking. And acting.

Here are my questions for the authors and presenter:

  1. What kind of resources do you think are needed to allow referral hospitals to care for these patients?
  2. How will these hospitals know when care is futile? Will there be an expectation to work with the receiving center to help determine this?

I enjoyed this paper and can’t wait to hear the details!

Reference: Futile trauma transfers: an infrequent but costly component of regionalized trauma care. EAST 2021, paper 9.

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Trauma Center Density In Urban Areas

The focus of this post is going to be a little different. I’ll be coming up out of the trenches of clinical care, and focusing on trauma systems for a bit. Specifically, I’m going to look at the density of high-level trauma centers in bigger cities. For my non-US readers, this paper is based on data from the States, but is most likely applicable in your countries as well.

Why look at trauma center distribution? More than 80% of the population lives in an urban area of the US. And over the next thirty years, that number will approach 90%. As more people move to the big cities, there are concentrations of homelessness, poverty, mental illness, and violence. This last factor is one of the reasons for trauma center existence, and their distribution is ostensibly one of the reasons to have a trauma system in the first place.

In theory, there should be an optimal number of trauma centers for a given population base. The American College of Surgeons (ACS) created a needs-based assessment tool to predict the optimal number of centers given the population size, trauma volume, EMS transport times, and more. If you are interested, you can download it here.

But has it been followed? Trauma leaders from some of the most established Level I centers in the country performed an analysis of the density of Level I and II centers in 15 of the largest cities in the US. They tried to test what social and economic conditions in an area determined the number of centers available in it, if any.

The cities were determined using information from 2015 census information. The trauma centers in each were identified from ACS or state system information.

Here are the factoids:

  • 14 of 15 cities had multiple Level I or II centers
  • There was a large variation of centers per geographic area covered, ranging from 1 per 150 km sq (Philadelphia) to 1 per 596 km sq (San Antonio)
  • Population density (the population divided by the number of trauma centers) varied from 1:285,000 people in Columbus to 1:870,000 in San Francisco
  • The median minimum distance between centers was 8 km, and varied from 1 km in Houston to 43 km in San Antonio
  • Poverty and unemployment rates were highly correlated to violence rates
  • There was no correlation with trauma center density and social determinants of health or violence rates

Bottom line: What does all this mean? It appears that the number and geographic distribution of trauma centers in larger cities has nothing to do with need as measured by the social and economic conditions of the area. More likely, it is related to financial considerations. Trauma center closures in urban areas have disproportionately occurred in the lowest income areas. And it is less likely that new centers will open in these areas.

Obviously, hospitals need to make money to survive. Insurance coverage has become more available to people with lower incomes over the past 10 years. Unfortunately, the reimbursement rates for hospital stays continue to decline slowly. This combination makes it more difficult for a hospital to eke out an existence in one of these areas.

What can be done? Unfortunately, this is one of those many-headed hydra type issues. There are so many competing interests, and the people affected have little representation in the process. Our trauma systems should play a larger part in this, as they are supposed to have some say over the structure and distribution of their centers. Unfortunately, many of them do not have the financial support or the political wherewithal to do this.

Ultimately, I believe that we are working for something that should be considered a common good. Which means that it is up to state and ultimately the federal government to work with all the stakeholders to better control the distribution of this valuable resource. Which means that it is up to the trauma center administrators and trauma leaders to make sure the call is heard by their government leaders who can make things happen.

This is likely to remain a sticky problem during the age of COVID. Resources are needed for more pressing matters right now. But when the time comes, all trauma professionals need to speak up and help work this problem. Get involved with your regional trauma advisory committee. Make sure your state trauma advisory council makes it a priority. And don’t shy away from letting your legislators know about the problem. Otherwise, they will remain blithely unaware and our patients may continue to suffer.

Reference: Describing the density of high-level trauma centers in
the 15 largest US cities. Trauma Surgery & Acute Care Open 2020;5:e000562.

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Secondary Overtriage: What Is It, And Why Is It Bad?

Simply put, secondary overtriage (SO) is the unnecessary transfer of a patient to another hospital. How can you, as the referring trauma professional, know that it is unnecessary? Almost by definition, you can’t, unless you have some kind of precognition. If you knew it wasn’t necessary, you wouldn’t do it in the first place, right?

But using the retrospectoscope, it’s much easier. The classic definition describes a patient who is discharged from the hospital shortly after arrival there. What is “shortly?” Typically, it occurs within 48 hours in a patient with low injury severity (ISS < 16) and without operative intervention. Definitions may vary slightly.

And why is it bad?

Several states with rural trauma systems have scrutinized this issue. The first study is from West Virginia, where six years of state registry data were analyzed. Over 19,000 adults were discharged home from a non-Level I center within 48 hours after an injury. Of those, about 1,900 (10%) had been transferred to a “higher level of care” and discharged from that center (secondary overtriage, could be any higher-level trauma center).

The factoids:

  • Patients with ISS > 15 and requiring blood transfusion were more likely to be SO. (I would argue that this is appropriate triage in most cases!)
  • Neurosurgical, spine and facial injuries were also associated with SO. (This one is a little more interesting, see below).
  • SO was more likely for transfers during the night shift, when resources are often more scarce

The problem is that this study is descriptive only. It doesn’t really help us figure out which patients could/should be kept based on any of the variables they collected.

The next study is from Dartmouth in New Hampshire and examines transfers into that single Level I center from 72 other hospitals. Registry data were examined over 5 years, identifying transfer patients with ISS < 15 who were discharged within 48 hours without an operation.

Yet more factoids:

  • 62% of the nearly 8,000 patients received by this center were transfers
  • Overall SO rate was 26%
  • A quarter of adult patients and one half of pediatric patients were considered SO, and about 15% of them were actually discharged from the ED (!)
  • Head and neck, and soft tissue injuries were most common among SO patients

The real bottom line: Here are my thoughts on what you can do to try to decrease the number of your patients with SO and optimize the transfer process:

  • Work with your upstream trauma center to determine how much imaging you really need to perform
  • Develop a reliable method of getting those images to them
  • Ask them to help you develop practice guidelines and educate your hospital/ED staff to help manage common diagnoses that often result in SO from your center
  • If you are located in a rural area, inquire about RTTD courses you might attend


  • Secondary overtriage in a statewide rural trauma system. J Surg Research 198:462-467, 2015.
  • Secondary overtriage: the burden of unnecessary interfacility transfers in a rural trauma system. JAMA Surg 48(8):763-768, 2013.
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Radiographic Image Sharing Systems

There are generally three ways to share radiographic images with your upstream trauma center:

  • Hard copy. These days, that usually means a CD. Nearly all PACS systems (picture archiving and communications systems) can write CDs that can accompany your patient. Advantage: super cheap. Possible downsides: the CD may be corrupted and not openable, the software on the disk cannot be installed or will not run at the receiving hospital, and finally it can just be forgotten in the rush to get the patient out of the ED.
  • PACS system connections. These are software links that enable one hospital’s PACS software to communicate with another’s. They must be established in advance, and generally require some expertise from the hospitals’ IT departments. Images can be pushed from one system to another. Advantages: once set up, it is very inexpensive to maintain, and images can be viewed prior to patient arrival at the receiving hospital. Possible downside: Al-though the interchange format is standardized, every once in a while the systems just can’t communicate.
  • Web-based image sharing system. This consists of a web server-based software application available via the internet that allows subscribing hospitals to sign on and share images. Referring hospitals can upload images from their PACS systems for free, and the receiving hospital can view the images and/or download into their own system. Advantage: these products are simple to set up, and easy to use after just a little training. Compatibility is very high, and the services are continually working to ensure it. Downside: expensive. Depending on specifics, the annual subscription may be up to $100K per year, and is generally footed by the receiving trauma center.

Is a web-based solution worth it? MetroHealth in Cleveland looked at this over five years ago, and published their results in 2015. They looked at their experience pre- and post-implementation and found the following:

  • Three years of transfer data prior to the web system implementation was compared to one year of experience after
  • CT imaging decreased at both referring and receiving hospitals across the study period
  • Repeat scan rate decreased from 38% to 28%. Repeat head scans were the major driver at 21%.
  • Cost of reimaging dropped from about $1000 per patient to $600

Bottom line: As a referring hospital, it is your responsibility to ensure that the (hopefully) few images you obtain make it to the upstream trauma center. Although hard copy (CD) is the cheapest, it is also the least reliable. Work with your radiology and IT departments to determine which electronic solution is best for you. Some states and regional trauma systems help subsidize or provide a web-based solution for their member hospitals.

Reference: Implementation of an image sharing system significantly reduced repeat computed tomographic imaging in a regional trauma system. J Trauma 80(1):51-56, 2016.

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