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Evaluating the effect of driving distance to the nearest higher level trauma centre on undertriage: a cohort study
  1. Job F Waalwijk1,2,3,
  2. Robin D Lokerman1,
  3. Rogier van der Sluijs4,
  4. Audrey A A Fiddelers3,
  5. Luke P H Leenen1,
  6. Martijn Poeze2,3,
  7. Mark van Heijl1,5
  8. Pre-hospital Trauma Triage Research Collaborative (PTTRC)
    1. 1Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
    2. 2Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
    3. 3Network Acute Care Limburg, Maastricht University Medical Centre, Maastricht, The Netherlands
    4. 4Center for Artificial Intelligence in Medicine & Imaging, Stanford University, Stanford, California, USA
    5. 5Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, The Netherlands
    1. Correspondence to Job F Waalwijk, Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands; j.f.waalwijk{at}umcutrecht.nl

    Abstract

    Background It is of great importance that emergency medical services professionals transport trauma patients in need of specialised care to higher level trauma centres to achieve optimal patient outcomes. Possibly, undertriage is more likely to occur in patients with a longer distance to the nearest higher level trauma centre. This study aims to determine the association between driving distance and undertriage.

    Method This prospective cohort study was conducted from January 2015 to December 2017. All trauma patients in need of specialised care that were transported to a trauma centre by emergency medical services professionals from eight ambulance regions in the Netherlands were included. Patients with critical resource use or an Injury Severity Score ≥16 were defined as in need of specialised care. Driving distance was calculated between the scene of injury and the nearest higher level trauma centre. Undertriage was defined as transporting a patient in need of specialised care to a lower level trauma centre. Generalised linear models adjusting for confounders were constructed to determine the association between driving distance to the nearest higher level trauma centre per 1 and 10 km and undertriage. A sensitivity analysis was conducted with a generalised linear model including inverse probability weights.

    Results 6101 patients, of which 4404 patients with critical resource use and 3760 patients with an Injury Severity Score ≥16, were included. The adjusted generalised linear model demonstrated a significant association between a 1 km (OR 1.04; 95% CI 1.04 to 1.05) and 10 kilometre (OR 1.50; 95% CI 1.42 to 1.58) increase in driving distance and undertriage in patients with critical resource use. Also in patients with an Injury Severity Score ≥16, a significant association between driving distance (1 km (OR 1.06; 95% CI 1.06 to 1.07), 10 km (OR 1.83; 95% CI 1.71 to 1.95)) and undertriage was observed.

    Conclusion Patients in need of specialised care are less likely to be transported to the appropriate trauma centre with increasing driving distance. Our results suggest that emergency medical services professionals incorporate driving distance into their decision making regarding transport destinations, although distance is not included in the triage protocol.

    • emergency ambulance systems
    • triage
    • trauma
    • prehospital care

    Data availability statement

    Data are available upon reasonable request, approval of the participating emergency medical services and trauma regions, provided that appropriate ethical approval is sought and approved.

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    Data availability statement

    Data are available upon reasonable request, approval of the participating emergency medical services and trauma regions, provided that appropriate ethical approval is sought and approved.

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    Footnotes

    • Handling editor Katie Walker

    • Collaborators Members of the Pre-hospital Trauma Triage Research Collaborative (PTTRC) are: Koen W W Lansink (ETZ Hospital Tilburg), Mariska A C de Jongh (Netwerk Acute Zorg Brabant), Dennis den Hartog (Erasmus University Medical Centre), Jens A Halm, Georgios F Giannakópoulos (Amsterdam University Medical Centre), Michael J R Edwards (Radboud University Medical Centre), Pierre M van Grunsven (Veiligheidsregio Gelderland-Zuid), Wim Breeman (Regionale Ambulance Voorziening Rotterdam-Rijnmond), Laura Esteve Cuevas (Regionale Ambulance Voorziening Zuid-Holland Zuid), Arjen Siegers (Regionale Ambulance Voorziening Ambulance Amsterdam-Amstelland, Regionale Ambulance Voorziening Zaanstreek-Waterland), Risco van Vliet (Regionale Ambulance Voorziening Brabant Midden-West, Regionale Ambulance Voorziening Brabant-Noord) and Rinske M Tuinema (Regionale Ambulance Voorziening Utrecht).

    • Contributors JFW, LPHL, MvH and MP conceived and designed the study. JFW, RDL, RvdS and MvH obtained data for this study. All authors contributed to the data collection, statistical analysis and interpretation of the results. JFW drafted the manuscript, and all authors contributed substantially to its revision.

    • Funding This study was partly funded by grants from the Netherlands Organisation for Health Research and Development (ZonMw; 80-84300-98-18555) and the Innovation Fund Health Insurers (3383).

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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