Exploring patient and system factors impacting undertriage of injured patients meeting national field triage guideline criteria

BACKGROUND Trauma systems save lives by coordinating timely and effective responses to injury. However, trauma system effectiveness varies geographically, with worse outcomes observed in rural settings. Prior data suggest that undertriage may play a role in this disparity. Our aim was to explore potential driving factors for decision making among clinicians for undertriaged trauma patients. METHODS We performed a retrospective analysis of the National Emergency Medical Services Information System database among patients who met physiologic or anatomic national field triage guideline criteria for transport to the highest level of trauma center. Undertriage was defined as transport to a non–level I/II trauma center. Multivariable logistic regression was used to determine demographic, injury, and system characteristics associated with undertriage. Undertriaged patients were then categorized into “recognized” and “unrecognized” groups using the documented reason for transport destination to identify underlying factors associated with undertriage. RESULTS A total of 36,094 patients were analyzed. Patients in urban areas were more likely to be transported to a destination based on protocol rather than the closest available facility. As expected, patients injured in urban regions were less likely to be undertriaged than their suburban (adjusted odds ratio aOR, 2.69; 95% confidence interval 95% CI, 2.21–3.31), rural (aOR, 2.71; 95% CI, 2.28–3.21), and wilderness counterparts (aOR, 3.99; 95% CI, 2.93–5.45). The strongest predictor of undertriage was patient/family choice (aOR, 6.29; 5.28–7.50), followed by closest facility (aOR, 5.49; 95% CI, 4.91–6.13) as the reason for hospital selection. Nonurban settings had over twice the odds of recognizing the presence of triage criteria among undertriaged patients ( p < 0.05). CONCLUSION Patients with injuries in nonurban settings and those with less apparent causes of severe injury are more likely to experience undertriage. By analyzing how prehospital clinicians choose transport destinations, we identified patient and system factors associated with undertriage. Targeting these at-risk demographics and contributing factors may help alleviate regional disparities in undertriage. LEVEL OF EVIDENCE Diagnostic; Level IV.