Patient Choice in the Selection of Hospitals by 9-1-1 Emergency Medical Services Providers in Trauma Systems

Reasons for undertriage (transporting seriously injured patients to nontrauma centers) and the apparent lack of benefit of trauma centers among older adults remain unclear; understanding emergency medical services (EMS) provider reasons for selecting certain hospitals in trauma systems may provide insight to these issues. In this study, the authors evaluated reasons cited by EMS providers for selecting specific hospital destinations for injured patients, stratified by age, injury severity, field triage status, and prognosis. This was a retrospective cohort study of injured children and adults transported by 61 EMS agencies to 93 hospitals (trauma and nontrauma centers) in five regions of the western United States from 2006 through 2008. Hospital records were probabilistically linked to EMS records using trauma registries, state discharge data, and emergency department data. The seven standardized reasons cited by EMS providers for selecting hospital destinations included closest facility, ambulance diversion, physician choice, law enforcement choice, patient or family choice, specialty resource center, and other. “Serious injury” was defined as an Injury Severity Score (ISS) ≥ 16, and unadjusted in-hospital mortality was considered as a marker of prognosis. All analyses were stratified by age in 10-year increments, and descriptive statistics were used to characterize the findings. A total of 176,981 injured patients were evaluated and transported by EMS over the 3-year period, of whom 5,752 (3.3%) had ISS ≥ 16 and 2,773 (1.6%) died. Patient or family choice (50.6%), closest facility (20.7%), and specialty resource center (15.2%) were the most common reasons indicated by EMS providers for selecting destination hospitals; these frequencies varied substantially by patient age. The frequency of patient or family choice increased with increasing age, from 36.4% among 21- to 30-year-olds to 75.8% among those older than 90 years. This trend paralleled undertriage rates and persisted when restricted to patients with serious injuries. Older patients with the worst prognoses were preferentially transported to major trauma centers, a finding that was not explained by field triage protocols. Emergency medical services transport patterns among injured patients are not random, even after accounting for field triage protocols. The selection of hospitals appears to be heavily influenced by patient or family choice, which increases with patient age and involves inherent differences in patient prognosis. Las razones para el infratriaje (el transporte de pacientes gravemente lesionados a centros no traumatológicos) y la aparente falta de beneficios de los centros traumatológicos en los pacientes ancianos permanecen no aclaradas. El conocimiento de las razones por las que los sistemas de emergencias médicas (SEM) seleccionan ciertos hospitales entre todos los que atienden pacientes con traumatismos (centros traumatológicos) puede proporcionar reflexiones acerca de estos problemas. En este estudio, se evaluaron las razones citadas por los proveedores de SEM para la selección de determinados destinos hospitalarios para los pacientes lesionados, estratificados por edad, gravedad de la lesión, estados del triaje de campo y pronóstico. Estudio de cohorte retrospectivo de niños y adultos lesionados transportados por 61 SEM a 93 hospitales (centros traumatológicos y no traumatológicos) en cinco regiones del Oeste de Estados Unidos desde 2006 a 2008. Las historias clínicas hospitalarias se vincularon probabilísticamente a las historias clínicas del SEM mediante registros de traumatología, datos del estado al alta y datos de los servicios de urgencias (SU). Las siete razones estandarizadas citadas por los proveedores del SEM para la selección de los destinos hospitalarios incluyeron: el centro más cercano, la derivación de la ambulancia, la elección del médico, la elección de los cuerpos de seguridad, la elección del paciente o la familia, los recursos de especialistas del centro y otras. Lesión grave se definió como una puntuación del Injury Severity Score (ISS) ≥ 16, y se consideró la mortalidad intrahospitalaria no ajustada como un marcador pronóstico. Todos los análisis se estratificaron por la edad en intervalos de 10 años, y se utilizó la estadística descriptiva para caracterizar los resultados. Un total de 176.981 pacientes lesionados se evaluaron y transportaron por los SEM en los 3 años del periodo, de los cuales 5.752 (3,3%) tuvieron un ISS ≥ 16 y 2.773 (1,6%) fallecieron. Las razones más comunes aducidas por los proveedores del SEM para la selección de los hospitale de destino fueron la elección del paciente o la familia (50,6%), la cercanía del centro (20,7%) y los recursos de especialistas del centro (15,2%). Estas frecuencias variaron sustancialmente según la edad del paciente. La frecuencia de elección del paciente o la familia se incrementó con el aumento de la edad, de un 36,4% entre los pacientes de 21 a 30 años a un 75,8% entre los mayores de 90 años. Esta tendencia igualó los porcentajes de infratriaje, y persistió cuando se restringió a los pacientes con lesiones graves. Los pacientes mayores con los peor pronóstico fueron trasportados preferentemente a los centros traumatológicos mayores, un resultado que no se explica por los protocolos de triaje de campo. Los patrones de transporte de los SEM en los pacientes con lesiones no son aleatorios, incluso tras tener en cuenta los protocolos de triaje de campo. La selección de hospitales parece estar más fuertemente influida por la elección del paciente o la familia, hecho que se acentúa con la edad del paciente, y conlleva diferencias inherentes en el pronóstico de paciente. A key aspect of regionalized trauma care is concentrating seriously injured patients in major trauma centers to maximize health outcomes. Because most seriously injured patients access acute trauma care through 9-1-1 emergency medical services (EMS), optimizing field triage has been a crucial aspect of concentrating high-need patients in the hospitals most capable of caring for them. Since 1987, the process of field triage has been guided by the Field Triage Decision Scheme, an algorithmic national guideline for identifying seriously injured patients in the prehospital setting.1-3 Patients not meeting the triage guidelines for transport to major trauma centers are assumed to be transported to nontrauma hospitals. However, factors affecting the actual distribution of injured patients among hospitals in trauma systems remain poorly understood. Because trauma systems serve as the model for regionalized health care, understanding factors driving the distribution of injured patients transported by EMS has important implications for improving the efficiency of other regionalized care systems. Two key issues in trauma systems relate to the distribution of injured patients and remain poorly understood: 1) the high rate of undertriage (seriously injured patients transported to nontrauma hospitals) among older adults4-9 and 2) the lack of demonstrated outcome benefit of care in major trauma centers among seriously injured older adults.10 Whether these issues are interrelated remains unknown, although it is plausible they are tied to other out-of-hospital factors affecting the selection of hospitals. With an aging U.S. population, understanding these issues and determining the ideal location of care for injured older adults are critically important. If factors other than field triage protocols are important in directing the regional distribution of injured patients in trauma systems (especially older adults), such findings may help explain undertriage and the role of trauma centers in caring for an aging population. We hypothesized that older patients have strong preferences in directing EMS transport to specific hospitals following injury, even in the setting of prehospital field triage protocols. To test this hypothesis and further assess EMS transport patterns, we evaluated reasons cited by EMS providers for selecting specific hospital destinations among injured patients transported by 61 EMS agencies to 93 hospitals. We stratified the analysis by age, injury severity, field triage status, and prognosis. This study expands on a previous single-site study that evaluated EMS provider cognitive processing during field triage and the selection of hospital destinations for injured patients.11 This was a multiregion, population-based, retrospective cohort study. Eleven institutional review boards at five sites approved this protocol and waived the requirement for informed consent. The study included injured children and adults evaluated and transported by 61 EMS agencies to 93 hospitals, including 10 Level I, 6 Level II, and 77 community/private/federal hospitals in five regions across the western United States between January 1, 2006, and December 31, 2008. The regions included: 1) Portland, Oregon, and Vancouver, Washington (four counties); 2) Sacramento, California (two counties); 3) San Francisco, California; 4) Santa Clara, California (two counties); and 5) Salt Lake City, Utah (four counties). These sites are part of the Western Emergency Services Translational Research Network (WESTRN), a consortium of geographic regions, EMS agencies, and hospitals linked through Clinical and Translational Science Award centers. Regions were selected for this study based on standardized EMS documentation of reasons for hospital selection in their patient care reports. Each site represents a predefined geographic “footprint” consisting of a central metropolitan area and surrounding region (urban, suburban, and some rural areas), defined by EMS agency service areas. All sites have mature trauma systems and use a variety of EMS system structures and response types (e.g., dual advanced life support response, tiered basic-advanced life support response). For injured patients evaluated by EMS providers at these sites, there is an initial decision of whether an injured patient meets field trauma triage criteria (a field “trauma activation”) using standardized triage protocols based on the Field Triage Decision Scheme.2, 3 A field trauma activation generally triggers transport to a major trauma center (Level I or II hospital). The study sample included all injured patients for whom the 9-1-1 EMS system was activated within the five predefined geographic regions with transport to an acute care hospital (trauma centers and nontrauma centers). Injured patients were identified based on an EMS provider primary impression of “injury” or “trauma” recorded in the prehospital patient report. Specifying the sample in this manner allowed for a broad, population-based, out-of-hospital injury cohort served by EMS providers in multiple trauma systems. We excluded patients transferred between hospitals without initial presentations involving EMS, EMS runs without patient contact (e.g., “canceled,” “no patient found,” “stand-by”), and patients who were not transported (e.g., deaths in the field, refusals of transport). The primary variables of interest were EMS provider-cited reasons for selecting specific hospital destinations and patient age. Reasons for selecting hospital destinations were systematically captured in the participating sites using categories specified in the National EMS Information System.12 Reasons included closest facility, ambulance diversion, physician choice (e.g., patient's physician choice, direct medical oversight), law enforcement choice, patient or family choice, specialty resource center, and other (e.g., health maintenance organization, protocol). While some EMS agencies separated “patient choice” and “family choice,” other agencies did not, so they were combined for purposes of this analysis. Similarly, the categories for direct medical oversight and patient's physician choice were combined because many agencies considered these reasons a single “physician choice” category. We also captured field trauma activation status, a dichotomous measure of patients meeting field trauma triage criteria as determined by EMS providers. Because relying exclusively on EMS charts to ascertain field triage status can underestimate the proportion of field trauma activations (e.g., due to missing data and differing terminology between systems), we triangulated multiple data sources to minimize misclassification bias. We identified field trauma activations by the presence of any of the following: field trauma triage criteria specified in the EMS chart: EMS provider documented “trauma activation” (or similar charting, depending on local terminology), EMS-recorded trauma identification number (used at some sites as a mechanism for tracking injured patients entered into the trauma system), a matched record from the local trauma registry specifying “scene” origin (i.e., EMS-identified trauma patient), and matched trauma communication telephone records from local base hospitals (a requirement in some sites specifying that EMS providers call ahead to the Level I hospital before transporting a trauma activation patient). All other patients were considered trauma triage-negative. The presence of triage criteria was considered independent of transport destination. We also captured hospital destinations, with categorization of acute care hospitals as tertiary trauma centers (Level I or II trauma hospitals) based on their American College of Surgeons accreditation status and state-level designations. We tracked transport mode (air vs. ground), Injury Severity Score (ISS), and in-hospital mortality. We defined “serious injury” as an ISS ≥ 16 based on the American College of Surgeons Committee on Trauma (ACS-COT) definition for trauma systems2 and the definition most consistently used to demonstrate the benefit of trauma center care.10, 13-17 We defined undertriage using the ACS-COT definition of patients with ISS ≥ 16 transported to nontrauma centers.2 We considered unadjusted in-hospital mortality as a measure of prognosis, rather than a primary patient outcome. While adjusted mortality is commonly used as an outcome measure in observational trauma research, unadjusted mortality reflects a combination of prognostic factors (e.g., injury severity, comorbidities, age, physiologic compromise, and overall clinical acuity). In this study, we used crude mortality as a global measure of acuity and prognosis for patients transported to different types of hospitals. We matched hospital records (required for calculating injury severity and mortality) to EMS records using probabilistic linkage (LinkSolv v8.2, Strategic Matching, Inc., Morrisonville, NY). Record linkage methodology has been used to link EMS data to hospital records in previous studies,18 has been validated for matching ambulance records to trauma registry data,19 and was rigorously evaluated in this database.20 Sources of electronic hospital records included local trauma registries, state hospital discharge databases, and state emergency department databases. To calculate ISS, we used a College that to ISS The use of to to injury has been validated in previous and we have validated ISS ISS in this We used descriptive statistics to characterize the sample and EMS reasons for selecting different hospitals. We stratified all analyses by patient age in 10-year included field trauma activation status and serious injury ≥ To the and minimize in the we used multiple to missing We have demonstrated the of multiple for missing out-of-hospital and trauma data a variety of and have evaluated the use and benefit of multiple in this We used for multiple Research for of with of 10 data and combined using to for within and between data In the of multiple to the use of (e.g., to missing for rather than a of to missing data (e.g., We the and descriptive analyses using were 176,981 injured patients evaluated and transported by EMS to acute care hospitals over the 3-year period, of whom were field trauma 5,752 (3.3%) were seriously and 2,773 (1.6%) during their hospital A total of patients with ISS ≥ 16 were to nontrauma centers. The most common reasons cited by EMS providers for selecting specific hospitals were patient or family choice (50.6%), closest facility (20.7%), and specialty resource center of the study sample and reasons for selecting transport destinations are in The reasons cited by EMS providers for selecting different hospitals varied substantially by patient age The proportion of cited as patient or family choice by EMS providers increased with increasing patient age older than 30 75.8% for injured patients older than 90 The of patients paralleled the proportion of patient or family choice as the for selecting a hospital destination. were similar when the sample was restricted to seriously injured patients ≥ seriously injured patients to nontrauma centers patient or family choice was commonly increasing from a of among 21- to 30-year-olds to among patients over 90 mortality rates by transport destination trauma center vs. nontrauma rates with increasing age, among patients older than rates were consistently among patients transported to major trauma centers. This finding was when the sample was restricted to seriously injured patients and was most among older than The proportion of patients transported to major trauma centers after this was for the sample and among seriously injured mortality rates based on field trauma activation status than by transport the based on destination hospital and were for not we the of seriously injured older adults over with ISS ≥ transported to a hospital destination based on patient or family choice vs. other reasons injured older adults a specific hospital were commonly injured from vs. and with physiologic in the The patient or family choice also to be transported to nontrauma centers vs. have ≥ vs. and unadjusted mortality vs. Hospital also between these with the choice a proportion of vs. and proportion of other major vs. In this study, we demonstrate that the process of selecting hospitals by EMS providers in trauma systems is by factors other than field triage protocols. 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The finding that injured patients with prognoses are transported to major trauma centers The use of field triage protocols is a of trauma systems to the most seriously injured patients in major trauma centers. However, because undertriage is among older the prognostic between trauma and nontrauma hospitals to in this age (i.e., of older patients with the worst prognoses in trauma centers). that this with increasing age, even after accounting for injury This finding that factors other than field triage (e.g., patient are to prognosis and hospital key when outcomes. Because seriously injured ≥ older patients as choice” for destination to have physiologic compromise, and transport to major trauma centers, the was nontrauma hospitals seriously injured patients with prognosis. demonstrated similar with patients to specific hospitals for their selection combined with the of commonly variables to for these prognostic differences may help explain the lack of benefit of major trauma centers for older adults that for are implications from this study. patient choice and hospital preferences be considered in the of regionalized care systems. the lack of outcome benefit among seriously injured older adults in major trauma centers not be as that care is for all such patients in nontrauma hospitals. the most hospitals to care for older adults may on many including medical and clinical patients with to the of care However, there may be a of injured older adults who have at nontrauma hospitals. the definition of ≥ used to trauma systems may be for older some older adults with ISS may the of major trauma centers, with ISS may in nontrauma hospitals. National field triage guidelines and trauma system benefit from which older patients are most to benefit from care in major trauma centers. With the retrospective study it is there were other reasons that EMS providers selected certain hospitals was recorded in the for destination because the for selecting a hospital was by EMS it is whether cited reasons be the by is also that different EMS providers selected these reasons data not of misclassification (e.g., patient a certain tertiary care is by the EMS provider as resource The of findings be in with other EMS systems and including patients with For some patients, data were missing EMS provider for selecting a hospital and hospital severity and than such patients, we used multiple to missing has been to to and has been validated in using EMS and trauma However, it is that the have been different there were no missing data. This study was not to the benefit of trauma center care among older provide insight into some of the of the benefit of trauma center care across all age to measure the on among older adults accounting for patient choice in selecting specific hospitals. findings provide insight into undertriage and the apparent lack of trauma center benefit among older of these are and are by many are and to further Emergency medical service transport patterns for injured patients are heavily influenced by patient choice, among older a finding that even after accounting for injury patient prognosis based on the of hospital to which they were transported and the for selecting a most among older These findings insight into the factors affecting the distribution of patients in trauma in the benefit of trauma centers among older and the increased rate of undertriage in this population. The authors and all the participating EMS agencies, EMS medical trauma and state that and provide data for this The is not for the or of any by the than missing be to the for the

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