Over a third of trauma patients are over-triaged

State trauma systems try to put scarce resources to the best use. Yet, over-triage of minor injuries is costly and inefficient.

With estimated costs as high as $163 billion, trauma care represents close to 10% of US health care expenditures. Studies have proven the worth of trauma centers by showing improved survival among seriously injured patients compared to care at non-trauma hospitals. On the other hand, numerous studies have shown that the overall costs of providing care to seriously injured patients is higher at major trauma centers than non-trauma hospitals.

Unfortunately, there is a paucity of data on the cost-effectiveness of trauma centers for less seriously injured patients. A recent study compared the costs of providing care at major trauma centers to non-trauma hospitals for patients without serious injuries. Considering costs per patient from EMS transport all the way to hospital discharge, the concept of over-triage (i.e. transporting patients without serious injuries to major trauma centers) took center stage. Of note, the majority of injured patients are not seriously injured.

By comparing the total cost of trauma care (EMS transport, emergency department evaluation, and hospital admission), the authors hoped to highlight the importance of eliminating over-triage and its associated potential cost savings. The patient population included adults and children seen by 94 different EMS agencies and transported to 122 hospitals in 8 major cities in the Western US. Over 300,000 patients were included in the sample from January 2006 to December 2008; hospital care costs were more than $1 billion.

The average cost of care was $5,590 higher in major trauma centers when compared to non-trauma hospitals. The study found that 34.3% of patients were over-triaged. These patients were all identified as low risk by EMS algorithms, however, due to patient choice or hospital proximity, EMS still transported these patients to major trauma centers. Redirecting over-triaged patients to non-trauma hospitals could bear cost savings as high as 40.6%. Stricter adherence by EMS personnel to field guidelines therefore has large cost implications.

Commentary

Trauma care is the second leading cause of health care costs in the United States. Regionalized trauma centers reduce mortality for seriously injured patients and ultimately reduce preventable deaths. But trauma care mandates a comprehensive evaluation of patients often including multiple specialists and expensive services. In this age of cost containment, and with such a large disparity in costs per patient at trauma centers and non-trauma centers, society must accurately define which patients best benefit from these scarce resources.

Triage decisions by EMS personnel have large cost implications. Substantial savings can be attained by reducing over-triage. But the dilemma for emergency systems is two fold: (1) What criteria should be used to determine “serious injury”? (2) Are current EMS protocols robust enough to reduce both over- and under-triage?

The limitations of non-trauma hospitals play a factor in EMS decision-making. From a policy perspective, the Affordable Care Act provides important funding for states to revamp their trauma systems and trauma centers to compensate losses from uninsured patients. The ACA also provides for pilot programs to find innovative ways to further regionalize emergency care.

Newgard, CD, et al. Health Affairs. 2013; 32 (9) 1591-1599.

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