Which transfers can we avoid: Multi-state analysis of factors associated with discharge home without procedure after ED to ED transfer for traumatic injury

Among injured patients transferred from one emergency department (ED) to another, we determined factors associated with being discharged from the second ED without procedures, or admission or observation. We analyzed all patients with injury diagnosis codes transferred between two EDs in the 2011 Healthcare Utilization Project State Emergency Department and State Inpatient Databases for 6 states. Multivariable hierarchical logistic regression evaluated the association between patient (demographics and clinical characteristics) and hospital factors, and discharge from the second ED without coded procedures. In 2011, there were a total of 48,160 ED-to-ED injury transfers, half of which (49%) were transferred to non-trauma centers, including 23% with major trauma. A total of 22,011 transfers went to a higher level of care, of which 36% were discharged from the ED without procedures. Relative to torso injuries, discharge without procedures was more likely for patients with soft tissue (OR 6.8, 95%CI 5.6–8.2), head (OR 3.7, 95%CI 3.1–4.6), facial (OR 3.8, 95%CI 3.1–4.7), or hand (OR 3.1, 95%CI 2.6–3.8) injuries. Other factors included Medicaid (OR 1.3, 95%CI 1.2–1.5) or uninsured (OR 1.3, 95%CI 1.2–1.5) status. Treatment at the receiving ED added an additional $2859 on average (95% CI $2750–$2968) per discharged patient to the total charges for injury care, not including the costs of ambulance transport between facilities. Over a third of patients transferred to another ED for traumatic injury are discharged from the second ED without admission, observation, or procedures. Telemedicine consultation with sub-specialists might reduce some of these transfers.