Geographic Disparities in Re-triage Destinations Among Seriously Injured Californians

OBJECTIVE: The objective of this study is to quantify geographic disparities in suboptimal re-triage of seriously injured patients in California. SUMMARY OF BACKGROUND DATA: Re-triage is the emergent transfer of seriously injured patients from the emergency departments of nontrauma and low-level trauma centers to, ideally, high-level trauma centers. Some patients are re-triaged to a second nontrauma or low-level trauma center (suboptimal) instead of a high-level trauma center (optimal). METHODS: This was a retrospective observational cohort study of seriously injured patients, defined by an Injury Severity Score >15, re-triaged in California (2009–2018). Re-triages within 1 day of presentation to the sending center were considered. The suboptimal re-triage rate was quantified at the state, regional trauma coordinating committees (RTCC), local emergency medical service agencies, and sending center level. A generalized linear mixed-effects regression quantified the association of suboptimality with the RTCC of the sending center. Geospatial analyses demonstrated geographic variations in suboptimal re-triage rates and calculated alternative re-triage destinations. RESULTS: There were 8,882 re-triages of seriously injured patients and 2,680 (30.2%) were suboptimal. Suboptimally re-triaged patients had 1.5 higher odds of transfer to a third short-term acute care hospital and 1.25 increased odds of re-admission within 60 days from discharge. The suboptimal re-triage rates increased from 29.3% in 2009 to 38.6% in 2018. However, 56.0% of nontrauma and low-level trauma centers had at least one suboptimal re-triage. The Southwest RTCC accounted for the largest proportion (39.8 %) of all suboptimal re-triages in California. CONCLUSION: High population density geographic areas experienced higher suboptimal re-triage rates.