Tag Archives: trauma centers

Trauma Center

Secondary Overtriage: Level III vs Nontrauma centers

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.

Abstracts, Trauma Center

Best of AAST 2022 #8: Financial Vulnerability Of Trauma Centers

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Here’s another abstract on trauma center / system finance. Trauma centers are part of the safety net in the healthcare systems of many countries. The way they are funded varies tremendously. In the US, health insurance pays most of the bill for patient care. Unfortunately, not all patients are covered, so there is financial risk to the center based on how many underpaying patients present for care.

The group at Scripps Mercy in San Diego performed a financial health analysis of all ACS-verified trauma centers in the US. They applied a Financial Vulnerability Score metric (FVS), although I could not locate anything on this via an internet search. They analyzed the RAND Hospital Financial Database, which is based on information obtained from the CMS Healthcare Cost Report Information System. Using this data they calculated the FVS for each center. They sub-grouped the hospitals into high, medium, and low vulnerability and compared them.

Here are the factoids:

  • A total of 617 trauma centers were identified and analyzed: 194 Level I, 278 Level II, and 145 Level III
  • Level III trauma centers made up 59% of the high financial risk centers
  • The majority of Level I and II centers were in the middle or low risk categories
  • Characteristics of high risk centers were lower number of beds, negative operating margin, and less cash on hand
  • Low risk centers had greater asset to liability ratios, lower outpatient shares, and 3x less uncompensated care
  • The largest proportion of HFR hospitals were in New England and East North Central regions
  • Non-teaching centers had significantly higher financial risk than teaching hospitals (46% vs 29%)

The authors concluded that about 25% of Level I and II trauma centers are at high financial risk and that factors such as payor mix and outpatient status should be targeted to reduce this risk.

Bottom line: This is a fascinating abstract but leaves a lot to the imagination. The databases used have not been used in previous papers, and the information contained in them is proprietary. The FVS is also new and I have not been able to obtain any details.

Nevertheless, if the data and analysis are sound it may provide some new information to trauma centers and perhaps some insight on what factors to address to lessen their financial vulnerability. This is a lot of ifs. Hopefully the authors will enlighten us during the presentation so we can appreciate the real world value of the analysis.

Here are my questions and comments for the authors/presenter:

  • Please explain both the dataset used and the new FVS metric. Most readers and listeners are unfamiliar. We need to see how the data and analysis apply to trauma center financials and how the FVS has been validated.
  • How can the vulnerability factors be addressed? Payor mix is based on patient coverage and their socioeconomic status. It would seem to be difficult to manipulate by the trauma center. Outpatient vs inpatient status is also difficult to change and not fall afoul of CMS rules. What were other factors that were identified that could help centers reduce their financial vulnerability?

This could be an interesting abstract, but there was not enough room in the abstract to reveal all the details. Hopefully all will become obvious during the presentation.

Reference: FINANCIAL VULNERABILITY OF TRAUMA CENTERS: A NATIONAL ANALYSIS, Plenary paper #41, AAST 2022.

Trauma Center

Best of AAST #3: Level I vs Level II Trauma Centers

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There is an ongoing debate over the differences between Level I vs Level II trauma centers in the US. On paper, the major differences include resident rotations in trauma, research, and the available of certain specialty surgeons and services. There have been several papers that look at survival differences between the two levels.

One podium paper at AAST 2018 re-examines this debate. It is a medium-sized pooled series that looks at a particular type of injury, pelvic ring fractures. These injuries can be complex, and many times require specialized orthopedic expertise. ACS Level I centers are required to have at least one Orthopedic Trauma Association fellowship-trained surgeon among their orthopedists. This is not required for Level II centers, but many do have them.

The group at the University of Michigan examined patients with partially stable or unstable pelvic ring injuries in a trauma collaborative database including 29 Level I and Level II centers over a 7-year period. They used propensity matching to compare 610 patients admitted to Level I and 610 patients admitted to Level II centers with these injuries:

Here are the factoids:

  • Mortality was significantly increased at Level II centers ( 12%) vs Level I centers (8%)
  • Angiography was used significantly less at Level II centers (6% vs 11%)
  • Complex repairs were used significantly less frequently at Level II centers (32% vs 42%)
  • Patients were significantly less likely to be admitted to an ICU at Level II centers, and were more often admitted to stepdown units (45% vs 52%)
  • Failure to rescue rate was lower (better) in ICU patients

Bottom line: Obviously, there are some limitations to using this pooled data, but it does provide larger numbers than many similar papers have. It cannot distinguish Level II centers that have OTA-trained orthopedic surgeons from those that do not. But the results are rather striking. It’s not clear exactly which of the institutional differences might be responsible for the improved mortality, and they all probably contribute to some degree. But the abstract appears to show that Level II centers are not just non-academic Level Is. This work suggests that certain injury patterns really should be transferred to a center with the specialized resources to treat it well.