The Dilemma of Undertriaged Trauma Cases

The Dilemma of Undertriaged Trauma Cases 150 150 Katie Brind'Amour, PhD, MS, CHES

Nationally, at least one in three children ages 5 and under with major trauma receive their definitive care at a level III trauma center or non-trauma center, according to arecent study in the American Journal of Emergency Medicine. Among children ages 6 to 17, the frequency of undertriage decreases to one in every four major trauma cases, but the problem remains the same: a significant portion of childhood trauma patients obtain their definitive care at a center that may not be fully equipped to handle the severity of their cases. Although this is problematic, the authors of the study also suggest the solutions to widespread undertriage would be difficult to implement.

Undertriage occurs when patients with major trauma receive definitive care at non-trauma centers or level III trauma centers. This issue affects individuals of all ages but is particularly prevalent among children and older adults. Research shows that individuals with severe injuries have better outcomes when treated at level I and II centers.

That’s why researchers at Nationwide Children’s Hospital decided to investigate the prevalence of undertriage among major trauma cases in the United States. Their study provided the first national ED undertriage estimate as well as the first simulation of the increase in capacity that level I and II trauma centers would need in order to accommodate such cases.

“A worrisome number of children and adults don’t receive the level of care they need for their injuries,” says Huiyun Xiang, MD, PhD, MPH, lead author of the study and director of the Center for Pediatric Trauma Research at Nationwide Children’s. “This is concerning because previous research reported that the risk of death is 25 percent lower when treatment is provided by a level I center when compared with care at non-trauma centers.”

The research team used the 2010 Nationwide Emergency Department Sample to estimate undertriage rates, classifying over 18,000 major trauma visits (patients with injury severity score ≥ 16) to level III or non-trauma centers by the location of definitive care. Forty percent of the undertriaged trauma cases involved traumatic brain injuries, including intracranial hemorrhages. According to Dr. Xiang and his team, these injuries could particularly benefit from care at level I or II trauma centers.

After determining the number of cases that appeared to be undertriaged, the team ran a simulation to estimate the increase in capacity that existing level I and II trauma centers would need to accommodate such cases. The team found that level I and II trauma centers in the United States would have to increase their capacity by 51.5 percent to take all of these undertriaged cases, each with an injury severity score of 16 or greater. If the injury severity score cut-off for major trauma cases were increased to include only the most severe cases (ISS≥ 25), the centers would still have to increase their capacity by up to 6.2 percent.

“Many factors affect where major trauma patients are treated in the United States. In some rural areas, no level I or II trauma center exists within an hour’s travel,” says Dr. Xiang, who also is a principal investigator in the Center for Injury Research and Policy in The Research Institute at Nationwide Children’s and a professor of pediatrics at The Ohio State University College of Medicine. “Given the current practice model, it’s almost impossible for level I and II trauma centers to implement such a significant capacity increase to provide care to all major trauma patients.”

“Level III and non-trauma centers are important players in a regionalized trauma care system. In many areas, there is not enough major trauma patient volume to warrant a level I or II trauma center,” Dr. Xiang says. “Our ultimate goal is to get the right resources to the right patient at the right time. But how to achieve this goal has no easy answer.”



Xiang H, Wheeler KK, Groner JI, Shi J, Haley KJ. Undertriage of major trauma patients in the US emergency departmentsThe American Journal of Emergency Medicine. 2014 Sep, 32(9):997-1004.

About the author

Katherine (Katie) Brind’Amour is a freelance medical and health science writer based in Pennsylvania. She has written about nearly every therapeutic area for patients, doctors and the general public. Dr. Brind’Amour specializes in health literacy and patient education. She completed her BS and MS degrees in Biology at Arizona State University and her PhD in Health Services Management and Policy at The Ohio State University. She is a Certified Health Education Specialist and is interested in health promotion via health programs and the communication of medical information.