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J Trauma Acute Care Surg. 2014 Apr;76(4):1041-7. doi: 10.1097/TA.0000000000000197.

Variability in California triage from 2005 to 2009: a population-based longitudinal study of severely injured patients.

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From the Department of Surgery (K.S., D.S.), Stanford University School of Medicine, Stanford; and Departments of Epidemiology and Biostatistics (F.L.), Surgery (R.M.), Emergency Medicine (R.H.), University of California, San Francisco, California.



Timely access to trauma care requires that severely injured patients are ultimately triaged to trauma centers. We sought to determine triage patterns for the injured population within the state of California to determine those factors associated with undertriage.


We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database from January 1, 2005, and December 31, 2009. All visits associated with injury were linked longitudinally. Sixty-day and one-year mortality was determined using vital statistics data. Primary field triage was defined as field triage to a Level I/II trauma center; retriage was defined as initial triage to a non-Level I/II center followed by transfer to a Level I/II. Regions were organized by local emergency medical services agencies. The primary outcomes were triage patterns and mortality.


The undertriage rate was 35% (n = 20,988) but was variable across regions (12-87%). Primary field triage ranged from 7% to 77%. Retriage rates not only were overall low (6% of all severely injured patients) but also varied by region (1-38%). In adjusted analysis, factors associated with a lower odds ratio (OR) of primary field triage included the following: age of 55 years or greater (OR, 0.78; p = 0.001), female sex (OR, 0.88; p = 0.014), greater number of comorbidities (OR, 0.92; p < 0.001), and fall mechanism versus motor vehicle collision (OR, 0.54; p < 0.001). One-year mortality was higher for undertriaged patients (25% vs. 16% and 18% for primary field and retriage, respectively, p < 0.001).


This is the first study to create a longitudinal database of all emergency department visits, hospitalizations, and long-term mortality for every severely injured patient within an entire state during a 5-year period. Undertriage varied substantially by region and was associated with multiple factors including access to care and patient factors.


Epidemiologic study, level III.

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