Introduction: Over 500,000 burn injuries and up to 10,000 burn related deaths occur annually in the United States, according to the CDC. However, the number of dedicated burn centers across the country has reduced dramatically over the past 20-30 years, thereby reducing the ability to treat all burn patients. Given this background, it is essential that critical patients have access to these dedicated units. Nevertheless, recent research shows a significant proportion of patients transferred to these burn centers may have been overtriaged – they were discharged rapidly and could probably have been treated at the referring facility itself. Apart from the needless transportation and related costs, overtriage can also increase the risk of complications to patients such as insufficient cooling of acute burns and hypothermia. Perhaps more importantly, overtriaged patients can place an undue strain on the limited resources of burn centers, thereby depriving access and/or diminishing the quality of care for more needy and critical patients. Previous research studies have shown that almost 30% of patients transferred to Burn Centers may be overtriaged. Other researchers have found that the incidence of overtriage among burn patients transferred by air may be as high as 20%, representing substantial, unwarranted healthcare costs. More recent studies – albeit on a smaller patient population – have indicated that overtriage rates of air transferred patients may be much higher, thus necessitating a detailed analysis of the current trends of overtriage. In this study, we analyze overtriage at a regional burn center using recent five-year data to find current prevalence and associated injury characteristics of overtriaged patients. We calculate overtriage for all transferred patients as well as air transported patients separately. Unlike previous research, we include direct discharges from the emergency room and differentiate between ICU and non-ICU admissions when calculating overtriage. In addition, based on burn specialists’ domain knowledge we utilize two overtriage definitions – discharges within 24 hours and 48 hours of admission. Overtriaged patients arriving from distant locations usually tend to stay an extra day after treatment, and such cases may not be captured by strictly considering a 24-hour discharge period. We compare the mode of injury, degree of burn, burn percentages, and time duration from injury to admission of overtriaged patients with correctly triaged patients. Our findings show that burn patient overtriage is a highly prevalent problem and may be more significant than estimated earlier. The analysis of injuries of overtriaged patients provide interesting insights that could help design focused methods to mitigate it.

Methods: The study cohort consisted of patients admitted within a five-year period between January 2015 to March 2020 to an ABA-verified regional burn center serving a largely rural community with a catchment area radius of approximately 300 miles. Details of injuries including, mechanism of injury, degree of burn etc., as well as administrative/clinical/demographic data including age, date/time of injury, admission date/time, etc., were obtained from the institution’s burn registry. The individual medical records were referenced to verify and correct inconsistent data. Overtriage was defined in two ways – patients who were transferred to the Burn Center from a referring facility and discharged within 24 hours and within 48 hours. This is sometimes referred to as “secondary overtriage”. Statistical tests including ANOVA, Student’s t-test, c2 analysis and Pareto analysis was used to compare overtriaged patients with properly triaged patients and to determine the main types of overtriage.

Results: Data for 1871 burn-related patients transferred to the burn center from referring facilities between January 2015 and March 2020 was used in the analysis. Of these 1871 patients, 33.1% were discharged within 24 hours of admission, while 48.9% were discharged within 48 hours, indicating the overtriage cohort of transferred patients. For air-transported patients, the overtriage percentage was 26.1% considering a discharge period of 24 hours, and 38.5% considering a discharge period of 48 hours. Considering only non-ICU admissions, the overtriage percentages were still high, specifically 29.3% and 21.3% using the 24-hour criterion, and 41.9% and 29.2% using the 48-hour criterion for transfer patients and air transported patients, respectively. A closer look at injuries of the overtriaged cohorts showed that most patients suffered thermal injuries. More than 80% of the overtriaged patients had only second degree burns with a percentage burn surface area of less than 5%. Comparisons with correctly triaged patients showed that the overtriaged cohort had significantly fewer patients with third degree burns and a lower percentage total burn surface area.

Conclusions: Overtriage of burn patients transferred to burn centers may be more prevalent than previously estimated, especially when including direct discharge from the ER and more realistic definitions of overtriage. This study showed that burn patient overtriage was close to 50% in the worst case, using most recent data from a regional burn center. Although a certain degree of overtriage may be necessary to avoid under-triage, the current overtriage rates indicate that there may be significant unnecessary healthcare costs and risks to patients. A majority of overtriaged patients had only second degree burns of less than 5% total burn surface area, indicating that inaccurate determination of percentage burn surface area at the referring facility may have led to the unnecessary transfer. Unnecessary admissions can be extremely detrimental to the daily functioning of a dedicated burn center, especially at times of high utilization, and may also delay the treatment of critical patients. This study further exemplified the need for burn patient overtriage to be properly defined and monitored. However, only improved communication between referring facilities and burn centers, a review of transfer criteria and the continued education and training of referring facility staff in the management of small burns would provide a sustainable solution to the overtriage problem.

References and Resources

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