Accuracy of prehospital triage protocols in selecting severely injured patients: A systematic review

Accuracy of pre-hospital triage tools for major trauma: a systematic review with meta-analysis and net clinical benefit

BACKGROUND

We conducted a systematic review to evaluate and compare the accuracy of pre-hospital triage tools for major trauma in the context of the development of the Italian National Institute of Health guidelines on major trauma integrated management.

METHODS

PubMed, Embase, and CENTRAL were searched up to November 2019 for studies investigating pre-hospital triage tools. The ROC (receiver operating characteristics) curve and net clinical benefit for all selected triage tools were performed. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies-2. Certainty of the evidence was judged with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

We found 15 observational studies of 13 triage tools for adults and 11 for children. In adults, according to the ROC curve and the net clinical benefit, the most reliable tool was the Northern French Alps Trauma System (TRENAU), adopting injury severity score (ISS) > 15 as reference (sensitivity (Sn), 0.92; specificity (Sp), 0.41; 1 study; sample size, 2572; high certainty of the evidence). When mortality as reference was considered, the pre-hospital triage tool with the best net clinical benefit trajectory was the New Trauma Score (NTS) < 18 (Sn, 0.82; Sp, 0.86; 1 study; sample size, 1001; moderate certainty of the evidence). In children, high variability among all triage tools for sensitivity and specificity was found.

CONCLUSION

Sensitivity and specificity varied across all available pre-hospital trauma triage tools. TRENAU and NTS are the best accurate triage tools for adults, whereas in the pediatric area a large variability prevents any firm conclusion.

Field-Triage, Hospital-Triage and Triage-Assessment: A Literature Review of the Current Phases of Adult Trauma Triage

ABSTRACT

Despite major improvements in the United States trauma system over the past two decades, prehospital trauma triage is a significant challenge. Undertriage is associated with increased mortality, and overtriage results in significant resource overuse. The American College of Surgeons Committee on Trauma benchmarks for undertriage and overtriage are not being met. Many barriers to appropriate field triage exist, including lack of a formal definition for major trauma, absence of a simple and widely applicable triage mode, and emergency medical service adherence to triage protocols. Modern trauma triage systems should ideally be based on the need for intervention rather than injury severity. Future studies should focus on identifying the ideal definition for major trauma and creating triage models that can be easily deployed. This narrative review article presents challenges and potential solutions for prehospital trauma triage.

External validation of the Dutch prediction model for prehospital triage of trauma patients in South West region of England, United Kingdom

IMPORTANCE

This paper investigates the use of a major trauma prediction model in the UK setting. We demonstrate that application of this model could reduce the number of patients with major trauma being incorrectly sent to non-specialist hospitals. However, more research is needed to reduce over-triage and unnecessary transfer to Major Trauma Centres.

OBJECTIVE

To externally validate the Dutch prediction model for identifying major trauma in a large unselected prehospital population of injured patients in England.

DESIGN

External validation using a retrospective cohort of injured patients who ambulance crews transported to hospitals.

SETTING

South West region of England.

PARTICIPANTS

All patients ≥16 years with a suspected injury and transported by ambulance in the year from February 1, 2017.

EXCLUSION CRITERIA

1) Patients aged ≤15 years; 2) Non-ambulance attendance at hospital with injuries; 3) Death at the scene and; 4) Patients conveyed by helicopter. This study had a census sample of cases available to us over a one year period.

INTERVENTIONS OR EXPOSURES

Tested the accuracy of the prediction model in terms of discrimination, calibration, clinical usefulness, sensitivity and specificity and under- and over triage rates compared to usual triage practices in the South West region.

MAIN OUTCOME MEASURE

Major trauma defined as an Injury Severity Score>15.

RESULTS

A total of 68799 adult patients were included in the external validation cohort. The median age of patients was 72 (i.q.r. 46-84); 55.5% were female; and 524 (0.8%) had an Injury Severity Score>15. The model achieved good discrimination with a C-Statistic 0.75 (95% CI, 0.73 - 0.78). The maximal specificity of 50% and sensitivity of 83% suggests the model could improve undertriage rates at the expense of increased overtriage rates compared with routine trauma triage methods used in the South West, England.

CONCLUSIONS AND RELEVANCE

The Dutch prediction model for identifying major trauma could lower the undertriage rate to 17%, however it would increase the overtriage rate to 50% in this United Kingdom cohort. Further prospective research is needed to determine whether the model can be practically implemented by paramedics and is cost-effective.

Reducing patient surge: community based social networks as first responders

A major challenge for health services worldwide is in providing adequate medical care during mass disasters. The ongoing COVID-19 pandemic highlights this difficulty. Patient surge, a consequence of most types of disasters that contribute to trauma experiences, is a primary factor in disrupting such care as it is composed of worried well persons and those experiencing psychosocial trauma that can severely disrupt and overwhelm effective acute hospital based health care. We review the literature and propose a potential solution framework to reduce such a surge that relies on exploiting community social networks as first responders. We utilize and integrate literature based evidence on patient surge, community disaster behaviors and community based informal social networks to examine reasons for patient surge to hospitals. We then propose that leveraging community based social networks as a potent deterrent for non-critically injured, especially those who have experienced psychosocial trauma or the worried well, from seeking hospital care during ongoing disasters. By emphasizing the social capital inherent in community based social networks, this perspective posits an alternative cost-effective means of reducing patient surge.

The impact of regionalized trauma care on the distribution of severely injured patients in the Netherlands

Background

Twenty years ago, an inclusive trauma system was implemented in the Netherlands. The goal of this study was to evaluate the impact of structured trauma care on the concentration of severely injured patients over time.

Methods

All severely injured patients (Injury Severity Score [ISS] ≥ 16) documented in the Dutch Trauma Registry (DTR) in the calendar period 2008–2018 were included for analysis. We compared severely injured patients, with and without severe neurotrauma, directly brought to trauma centers (TC) and non-trauma centers (NTC). The proportion of patients being directly transported to a trauma center was determined, as was the total Abbreviated Injury Score (AIS), and ISS.

Results

The documented number of severely injured patients increased from 2350 in 2008 to 4694 in 2018. During this period, on average, 70% of these patients were directly admitted to a TC (range 63–74%). Patients without severe neurotrauma had a lower chance of being brought to a TC compared to those with severe neurotrauma. Patients directly presented to a TC were more severely injured, reflected by a higher total AIS and ISS, than those directly transported to a NTC.

Conclusion

Since the introduction of a well-organized trauma system in the Netherlands, trauma care has become progressively centralized, with more severely injured patients being directly presented to a TC. However, still 30% of these patients is initially brought to a NTC. Future research should focus on improving pre-hospital triage to facilitate swift transfer of the right patient to the right hospital.

Real-time breath recognition by movies from a small drone landing on victim's bodies

In local and global disaster scenes, rapid recognition of victims' breathing is vital. It is unclear whether the footage transmitted from small drones can enable medical providers to detect breathing. This study investigated the ability of small drones to evaluate breathing correctly after landing on victims' bodies and hovering over them. We enrolled 46 medical workers in this prospective, randomized, crossover study. The participants were provided with envelopes, from which they were asked to pull four notes sequentially and follow the written instructions ("breathing" and "no breathing"). After they lied on the ground in the supine position, a drone was landed on their abdomen, subsequently hovering over them. Two evaluators were asked to determine whether the participant had followed the "breathing" or "no breathing" instruction based on the real-time footage transmitted from the drone camera. The same experiment was performed while the participant was in the prone position. If both evaluators were able to determine the participant's breathing status correctly, the results were tagged as "correct." All experiments were successfully performed. Breathing was correctly determined in all 46 participants (100%) when the drone was landed on the abdomen and in 19 participants when the drone hovered over them while they were in the supine position (p < 0.01). In the prone position, breathing was correctly determined in 44 participants when the drone was landed on the abdomen and in 10 participants when it was kept hovering over them (p < 0.01). Notably, breathing status was misinterpreted as "no breathing" in 8 out of 27 (29.6%) participants lying in the supine position and 13 out of 36 (36.1%) participants lying in the prone position when the drone was kept hovering over them. The landing points seemed wider laterally when the participants were in the supine position than when they were in the prone position. Breathing status was more reliably determined when a small drone was landed on an individual's body than when it hovered over them.

Diagnostic accuracy of prehospital triage tools for identifying major trauma in elderly injured patients: A systematic review

BACKGROUND

Older adults with major trauma are frequently undertriaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to evaluate the diagnostic performance of prehospital triage tools to identify suspected elderly trauma patients in need of specialized trauma care.

METHODS

Several electronic databases (including MEDLINE, EMBASE, and the Cochrane Library) were searched from inception to February 2019. Prospective or retrospective diagnostic studies were eligible if they examined prehospital triage tools as index tests (either scored theoretically using observed patient variables or evaluated according to actual paramedic transport decisions) compared with a reference standard for major trauma in elderly adults who require transport by paramedics following injury. Selection of studies, data extraction, and risk of bias assessments using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarize the findings.

RESULTS

Fifteen studies met the inclusion criteria, with 11 studies examining theoretical accuracy, three evaluating real-life transport decisions, and one assessing both (of 21 individual index tests). Estimates for sensitivity and specificity were highly variable with sensitivity estimates ranging from 19.8% to 95.5% and 57.7% to 83.3% for theoretical accuracy and real life triage performance, respectively. Specificity results were similarly diverse ranging from 17.0% to 93.1% for theoretical accuracy and 46.3% to 78.9% for actual paramedic decisions. Most studies had unclear or high risk of bias and applicability concerns. There were no obvious differences between different triage tools, and findings did not appear to vary systematically with major trauma prevalence, age, alternative reference standards, study designs, or setting.

CONCLUSION

Existing prehospital triage tools may not accurately identify elderly patients with serious injury. Future work should focus on more relevant reference standards, establishing the best trade-off between undertriage and overtriage, optimizing the role prehospital clinician judgment, and further developing geriatric specific triage variables and thresholds.

LEVEL OF EVIDENCE

Systematic review, level III.

The impact of age and receipt antihypertensives to systolic blood pressure and shock index at injury scene and in the emergency department to predict massive transfusion in trauma patients

Background

Systolic blood pressure (SBP) and shock index (SI) are accurate indicators of hemodynamic instability and the need for transfusion in trauma patients. We aimed to determine whether the utility and cutoff point for SBP and SI are affected by age and antihypertensives.

Methods

This was a retrospective observational study of a level 1 trauma center between January 2017 and December 2018. We analyzed the utility and cutoff points of SBP and SI for predicting massive transfusion (MT) and 30-day mortality according to patients’ age and whether they were taking antihypertensives. A multivariable logistic regression analysis was conducted to estimate the association of age and antihypertensives on primary and secondary outcomes.

Results

We analyzed 4681 trauma cases. There were 1949 patients aged 65 years or older (41.6%), and 1375 hypertensive patients (29.4%). MT was given to 137 patients (2.9%). The 30-day mortality rate was 6.3% (n = 294). In geriatric trauma patients taking antihypertensives, a prehospital SBP less than 110 mmHg was the cutoff value for predicting MT in multivariate logistic regression analyses; packed red blood cell transfusion volume decreased abruptly based on prehospital SBP of 110 mmHg. Emergency Department SI greater than 1.0 was the cutoff value for predicting MT in patients who were older than 65 years and were not taking antihypertensives.

Conclusions

The triage of trauma patients is based on the identification of clinical features readily identifiable by first responders. However, age and medications may also affect the accurate evaluation. In initial trauma management, we must apply SBP and SI differently depending on age, whether a patient is taking antihypertensives, and the time at which the indicators are measured.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00840-2.

Effect of under triage on early mortality after major pediatric trauma: a registry-based propensity score matching analysis

Background

Little is known about the effect of under triage on early mortality in trauma in a pediatric population. Our objective is to describe the effect of under triage on 24-h mortality after major pediatric trauma in a regional trauma system.

Methods

This cohort study was conducted from January 2009 to December 2017. Data were obtained from the registry of the Northern French Alps Trauma System. The network guidelines triage pediatric trauma patients according to an algorithm shared with adult patients. Under triage was defined by the number of pediatric trauma patients that required specialized trauma care transported to a non-level I pediatric trauma center on the total number of injured patients with critical resource use. The effect of under triage on 24-h mortality was assessed with inverse probability treatment weighting (IPTW) and a propensity score (Ps) matching analysis.

Results

A total of 1143 pediatric patients were included (mean [SD], age 10 [5] years), mainly after a blunt trauma (1130 [99%]). Of the children, 402 (35%) had an ISS higher than 15 and 547 (48%) required specialized trauma care. Nineteen (1.7%) patients died within 24 h. Under triage rate was 33% based on the need of specialized trauma care. Under triage of children requiring specialized trauma care increased the risk of death in IPTW (risk difference 6.0 [95% CI 1.3–10.7]) and Ps matching analyses (risk difference 3.1 [95% CI 0.8–5.4]).

Conclusions

In a regional inclusive trauma system, under triage increased the risk of early death after pediatric major trauma.

Association of Prehospital Step 1 Vital Sign Criteria and Vital Sign Decline with Increased Emergency Department and Hospital Death

BACKGROUND

This study analyzed data from the 2017 American College of Surgeons National Trauma Data Bank to examine the effects of pre-hospital Field Triage Decision Scheme Step 1 vital sign criteria (S1C) and vital sign decline on subsequent emergency department (ED) and hospital death in emergency medical services (EMS) transported trauma victims.

STUDY DESIGN

Patient and injury characteristics, transport time, and ED and hospital disposition were collected. S1C (respiratory rate [RR]<10, RR>29 breaths/min, systolic blood pressure [SBP]<90 mmHg, Glasgow Coma Scale [GCS]<14) were recorded at the injury scene and hospital arrival. Decline was defined as a change ≥ 1 standard deviation (SD) into or within an S1C range. S1C and decline were analyzed relative to ED and hospital death using logistic regression.

RESULTS

Of 333,213 included patients, 54,849 (16.5%) met Step 1 criteria at the scene, and 21,566 (6.9%) declined en route. The ED death rate was 0.4% (n = 1,188), and the hospital death/hospice rate was 4.0% (11,624 of 287,675). Patients who met S1C at the scene or who declined were more likely to require longer hospital lengths of stay, ICU admission, and surgical intervention. S1C and decline patients had higher odds of death in both the ED (S1C odds ratio [OR] 15.1, decline OR 2.4, p values < 0.001) and hospital (S1C OR 4.8, decline OR 2.0, p values < 0.001) after adjusting for patient demographics, transport time and mode, injury severity, and injury mechanism. Each S1C and decline measure was independently predictive of death.

CONCLUSIONS

This study quantifies the mortality risks associated with individual S1C and validates their use as an indicator for injury severity and pre-hospital triage tool.

Trauma-team-activation in Germany: how do emergency service professionals use the activation due to trauma mechanism? Results from a nationwide survey

BACKGROUND

Trauma team activation (TTA) requires significant human and financial resources. The implemented German guidelines reduced the mortality of severe injured patients significantly over the last decade. Up to now there is no two-tier trauma team activation protocol in Germany. A two-tier TTA [often activated due to trauma mechanism (TM)] is thought to be a reasonable way to maintain patient safety while increasing cost efficiency.

METHODS

We created an online survey addressed at the Emergency Medical Service in Germany to conduct a cross-sectional study. Both physicians and rescue service professionals (RSPs) were included. A minimum of 1550 participants answered questions in 4 different categories concerning the aspects of limited-TTA (L-TTA). Case studies were presented to evaluate the usage of TTA due to TM in the daily routine.

RESULTS

Eighty percent (n:1233) of the respondents wish for a possibility to activate a limited trauma team. Seventy-two percent (n: 1109) of the participants consider a L-TTA due to TM to be adequate. There were significant differences (p < 0.05) in the assessment and opinion on L-TTA among physicians and RSPs as well as different medical professions. The evaluated case studies showed diverse answers: depending on the profession, the same patient was ranked as severely injured by 54% and as minorly injured by 46% of the 1550 participants.

CONCLUSIONS

Members of the German Emergency Medical Service call for a two-tier TTA-protocol. Up to now we cannot fully recommend an automatic reduction of the trauma team when activated due to TM in Germany with the guidelines implemented. The profession might affect the L-TTA-behavior. Criteria for a L-TTA in Germany have to be defined and evaluated.

LEVEL OF EVIDENCE

IV, cross-sectional study.

The impact of the Trauma Triage App on pre-hospital trauma triage: design and protocol of the stepped-wedge, cluster-randomized TESLA trial

BACKGROUND

Field triage of trauma patients is crucial to get the right patient to the right hospital within a particular time frame. Minimization of undertriage, overtriage, and interhospital transfer rates could substantially reduce mortality rates, life-long disabilities, and costs. Identification of patients in need of specialized trauma care is predominantly based on the judgment of Emergency Medical Services professionals and a pre-hospital triage protocol. The Trauma Triage App is a smartphone application that includes a prediction model to aid Emergency Medical Services professionals in the identification of patients in need of specialized trauma care. The aim of this trial is to assess the impact of this new digital approach to field triage on the primary endpoint undertriage.

METHODS

The Trauma triage using Supervised Learning Algorithms (TESLA) trial is a stepped-wedge cluster-randomized controlled trial with eight clusters defined as Emergency Medical Services regions. These clusters are an integral part of five inclusive trauma regions. Injured patients, evaluated on-scene by an Emergency Medical Services professional, suspected of moderate to severe injuries, will be assessed for eligibility. This unidirectional crossover trial will start with a baseline period in which the default pre-hospital triage protocol is used, after which all clusters gradually implement the Trauma Triage App as an add-on to the existing triage protocol. The primary endpoint is undertriage on patient and cluster level and is defined as the transportation of a severely injured patient (Injury Severity Score ≥ 16) to a lower-level trauma center. Secondary endpoints include overtriage, hospital resource use, and a cost-utility analysis.

DISCUSSION

The TESLA trial will assess the impact of the Trauma Triage App in clinical practice. This novel approach to field triage will give new and previously undiscovered insights into several isolated components of the diagnostic strategy to get the right trauma patient to the right hospital. The stepped-wedge design allows for within and between cluster comparisons.

TRIAL REGISTRATION

Netherlands Trial Register, NTR7243. Registered 30 May 2018, https://www.trialregister.nl/trial/7038.

Undertriage in trauma: an ignored quality indicator?

BACKGROUND

Early identification of life-threatening injuries is essential to reduce morbidity and mortality in trauma patients. Failure to detect severe injury may cause delayed diagnosis and therapeutic interventions and is associated with increased morbidity. A national trauma system will contribute to ensure the optimal care for seriously injured patients throughout the treatment chain by, among other things, defining a sensitive triage tool for identifying severe injury and contribute to correct treatment destination. In 2017, a National trauma plan was implemented in Norway and several quality indicators were recommended to ensure an evaluation of potential gaps between achieved and desired quality, and thereby highlighting areas with potential for quality improvement. With this commentary, we want to draw attention to, what we believe is, an ignoring of an important quality indicator: undertriage in trauma.

MAIN BODY

Severely injured patients not met by a trauma team is commonly referred to as undertriage. An undertriage rate below 5 % is an internationally recognized quality indicator in trauma care and is emphasized in the Norwegian national trauma plan. However, whether hospitals measure and report data about undertriage, have received little attention. Therefore, a national survey was performed among Norwegian hospitals, where thirty-seven of forty trauma receiving hospitals contributed. The results of the survey showed that only half of Norwegian trauma hospitals were capable of providing these data. The results of this survey show that currently the national trauma system is not equipped to obtain important data on an important and specific quality indicator. An ongoing discussion at a national level is how to define severe injury, which may alter future definitions on undertriage.

CONCLUSIONS

Knowledge of undertriage in trauma is important to enhance patient safety, increase the precision of the triage tool and provide valuable learning information to individual hospitals and prehospital services. Currently only half of Norwegian hospitals who receive trauma patients report undertriage rates and unfortunately, only few hospital administrators request these data.

Development and Validation of a Prediction Model for Prehospital Triage of Trauma Patients

Importance

Prehospital trauma triage protocols are used worldwide to get the right patient to the right hospital and thereby improve the chance of survival and avert lifelong disabilities. The American College of Surgeons Committee on Trauma set target levels for undertriage rates of less than 5%. None of the existing triage protocols has been able to achieve this target in isolation.

Objective

To develop and validate a new prehospital trauma triage protocol to improve current triage rates.

Design, Setting, and Participants

In this multicenter cohort study, all patients with trauma who were 16 years and older and transported to a trauma center in 2 different regions of the Netherlands were included in the analysis. Data were collected from January 1, 2012, through June 30, 2014, in the Central Netherlands region for the design data cohort and from January 1 through December 31, 2015, in the Brabant region for the validation cohort. Data were analyzed from May 3, 2017, through July 19, 2018.

Main Outcomes and Measures

A new prediction model was developed in the Central Netherlands region based on prehospital predictors associated with severe injury. Severe injury was defined as an Injury Severity Score greater than 15. A full-model strategy with penalized maximum likelihood estimation was used to construct a model with 8 predictors that were chosen based on clinical reasoning. Accuracy of the developed prediction model was assessed in terms of discrimination and calibration. The model was externally validated in the Brabant region.

Results

Using data from 4950 patients with trauma from the Central Netherlands region for the design data set (58.3% male; mean [SD] age, 47 [21] years) and 6859 patients for the validation Brabant region (52.2% male; mean [SD] age, 51 [22] years), the following 8 significant predictors were selected for the prediction model: age; systolic blood pressure; Glasgow Coma Scale score; mechanism criteria; penetrating injury to the head, thorax, or abdomen; signs and/or symptoms of head or neck injury; expected injury in the Abbreviated Injury Scale thorax region; and expected injury in 2 or more Abbreviated Injury Scale regions. The prediction model showed a C statistic of 0.823 (95% CI, 0.813-0.832) and good calibration. The cutoff point with a minimum specificity of 50.0% (95% CI, 49.3%-50.7%) led to a sensitivity of 88.8% (95% CI, 87.5%-90.0%). External validation showed a C statistic of 0.831 (95% CI, 0.814-0.848) and adequate calibration.

Conclusions and Relevance

The new prehospital trauma triage prediction model may lower undertriage rates to approximately 10% with an overtriage rate of 50%. The next step should be to implement this prediction model with the use of a mobile app for emergency medical services professionals.

Accuracy of National Early Warning Score 2 (NEWS2) in Prehospital Triage on In-Hospital Early Mortality: A Multi-Center Observational Prospective Cohort Study

INTRODUCTION

In cases of mass-casualty incidents (MCIs), triage represents a fundamental tool for the management of and assistance to the wounded, which helps discriminate not only the priority of attention, but also the priority of referral to the most suitable center.

HYPOTHESIS/PROBLEM

The objective of this study was to evaluate the capacity of different prehospital triage systems based on physiological parameters (Shock Index [SI], Glasgow-Age-Pressure Score [GAP], Revised Trauma Score [RTS], and National Early Warning Score 2 [NEWS2]) to predict early mortality (within 48 hours) from the index event for use in MCIs.

METHODS

This was a longitudinal prospective observational multi-center study on patients who were attended by Advanced Life Support (ALS) units and transferred to the emergency department (ED) of their reference hospital. Collected were: demographic, physiological, and clinical variables; main diagnosis; and data on early mortality. The main outcome variable was mortality from any cause within 48 hours.

RESULTS

From April 1, 2018 through February 28, 2019, a total of 1,288 patients were included in this study. Of these, 262 (20.3%) participants required assistance for trauma and injuries by external agents. Early mortality within the first 48 hours due to any cause affected 69 patients (5.4%). The system with the best predictive capacity was the NEWS2 with an area under the curve (AUC) of 0.891 (95% CI, 0.84-0.94); a sensitivity of 79.7% (95% CI, 68.8-87.5); and a specificity of 84.5% (95% CI, 82.4-86.4) for a cut-off point of nine points, with a positive likelihood ratio of 5.14 (95% CI, 4.31-6.14) and a negative predictive value of 98.7% (95% CI, 97.8-99.2).

CONCLUSION

Prehospital scores of the NEWS2 are easy to obtain and represent a reliable test, which make it an ideal system to help in the initial assessment of high-risk patients, and to determine their level of triage effectively and efficiently. The Prehospital Emergency Medical System (PhEMS) should evaluate the inclusion of the NEWS2 as a triage system, which is especially useful for the second triage (evacuation priority).

Torso computed tomography in blunt trauma patients with normal vital signs can be avoided using non-invasive tests and close clinical evaluation

PURPOSE

To determine whether torso CT can be avoided in patients who experience high-energy blunt trauma but have normal vital signs.

METHODS

High-energy blunt trauma patients with normal vital signs were retrieved retrospectively from our registry. We reviewed 1317 patients (1027 men and 290 women) and 761 (57.8%) fulfilled the inclusion criteria. All patients were initially evaluated at the emergency room (ER), with a set of tests, part of a specific protocol. Patients with at least one altered exam at initial examination or after six-hour observation received a torso CECT. Sensitivity, specificity, accuracy, positive (PPV) and negative predictive values (NPV), and likelihood ratio (LH) of the protocol were evaluated.

RESULTS

Of 761 patients, 354 (46.5%) received torso CECT because of the positive ER test, with 330 being true positive and 24 being false positive. The remaining 407 patients were negative at ER tests and did not receive torso CECT, showing a significantly (P < 0.001) lower Injury Severity Score (ISS). The positive and negative LH of the protocol to detect torso injuries were respectively 16.5 and 0.01 (overall accuracy of 0.96).

CONCLUSIONS

Torso CT can be avoided without adverse clinical outcomes in patients who experience high-energy blunt trauma, are hemodynamically stable, and have normal initial laboratory and imaging tests.

Crash Telemetry-Based Injury Severity Prediction is Equivalent to or Out-Performs Field Protocols in Triage of Planar Vehicle Collisions

INTRODUCTION

With the increasing availability of vehicle telemetry technology, there is great potential for Advanced Automatic Collision Notification (AACN) systems to improve trauma outcomes by detecting patients at-risk for severe injury and facilitating early transport to trauma centers.

METHODS

National Automotive Sampling System Crashworthiness Data System (NASS-CDS) data from 1999-2013 were used to construct a logistic regression model (injury severity prediction [ISP] model) predicting the probability that one or more occupants in planar, non-rollover motor vehicle collisions (MVCs) would have Injury Severity Score (ISS) 15+ injuries. Variables included principal direction of force (PDOF), change in velocity (Delta-V), multiple impacts, presence of any older occupant (≥55 years old), presence of any female occupant, presence of right-sided passenger, belt use, and vehicle type. The model was validated using medical records and 2008-2011 crash data from AACN-enabled Michigan (USA) vehicles identified from OnStar (OnStar Corporation; General Motors; Detroit, Michigan USA) records. To compare the ISP to previously established protocols, a literature search was performed to determine the sensitivity and specificity of first responder identification of ISS 15+ for MVC occupants.

RESULTS

The study population included 924 occupants in 836 crash events. The ISP model had a sensitivity of 72.7% (95% Confidence Interval [CI] 41%-91%) and specificity of 93% (95% CI 92%-95%) for identifying ISS 15+ occupants injured in planar MVCs. The current standard 2006 Field Triage Decision Scheme (FTDS) was 56%-66% sensitive and 75%-88% specific in identifying ISS 15+ patients.

CONCLUSIONS

The ISP algorithm comparably is more sensitive and more specific than current field triage in identifying MVC patients at-risk for ISS 15+ injuries. This real-world field study shows telemetry data transmitted before dispatch of emergency medical systems can be helpful to quickly identify patients who require urgent transfer to trauma centers.

Agreement between arterial and venous blood gases in trauma resuscitation in emergency department (AGREE)

INTRODUCTION

Arterial blood gas (ABG) sampling is routinely performed in major trauma patients to assess the severity of hemorrhagic shock. Compared to venous blood gas (VBG), ABG is an additional procedure with risks of hematoma and pain. We aim to determine if pH, base deficit (BD), and lactate from VBG and ABG in trauma patients are clinically equivalent. If proven, the need for ABG and its associated risks can be eliminated.

METHODS

This prospective observational study was conducted in the Emergency Department of National University Hospital, Singapore, between February and October 2016. We correlated paired ABG and VBG results in adult trauma patients. VBG and ABG were obtained within 10 min and processed within 5 min using a point-of-care blood gas analyzer. Bland-Altman plot analysis was used to evaluate the agreement between peripheral VBG and ABG in terms of pH, base deficit and lactate.

RESULTS

There were 102 patients included, with a median age of 34 (interquartile range 28-46) years and male predominance (90.2%). Majority of patients sustained blunt trauma (96.1%), and had injuries of Tier 1 and Tier 2 severity (60/102, 58.8%). Bland-Altman plot analyses demonstrated that only 72.6% of venous pH and 76.5% of venous BD lie within the pre-defined clinically acceptable limits of agreement, whereas 96.0% of venous lactate was within these limits.

CONCLUSION

Venous and arterial pH and BD are not within clinically acceptable limits of agreement, and ABG should be obtained for accurate acid-base status. However, venous lactate may be an acceptable substitute for arterial lactate.

Development of Trauma Level Prediction Models Using Emergency Medical Service Vital Signs to Reduce Over- and Undertriage Rates in Penetrating Wounds and Falls of the Elderly

Determining triage activation levels in geriatric patients who fall (GF), and patients with penetrating wounds can be difficult and inaccurate, resulting in excessive overtriage (OT) and undertriage (UT) rates. We developed trauma activation prediction models using field data to predict with greater accuracy trauma activation level and triage rates consistent with the ACS recommendations. Using data from the 2014 National Trauma Data Bank, we created binary regression equations for each type of injury (GF and penetrating wounds). The 2014 data were randomized and divided into two halves. The first half for each injury type was used to generate prediction models, whereas the second half of the 2014 data were combined with 2013 and 2015 National Trauma Data Bank data for model verification. Binary regression equations were generated from vital signs collected by EMS. A Cribari grid with ISS ≥ 15 was used to determine the appropriateness of activation level. Chi-square analysis was used to determine significant differences between OT, UT, and accuracy predictions. Using our triage models, we were able to obtain UTrates of less than 4 per cent for GF with OT rates of less than 40 per cent, UT rates less than 4.1 per cent and OT of less than 50 per cent for patients with gunshot wounds, and UTrates less than 4 per cent and OT rates less than 25 per cent for patients who had stab wounds. Our developed trauma level prediction models enable health providers to predict trauma activation levels that can result in OT and UT rates in the recommended ranges by the ACS.

Sensitivity and specificity of trauma team activation protocol criteria in an Italian trauma center: A retrospective observational study

BACKGROUND

The trauma team (TT) model could reduce mortality, morbidity, and duration of hospital stay, costs, and complications. To avoid over- or undertriage for trauma team activation, robust criteria have to be chosen.

OBJECTIVE

This study aimed to evaluate the sensitivity and specificity of a TT activation protocol for major trauma patients to predict the need for emergency treatment.

METHODS

A retrospective observational study was carried out in the Emergency Department (ED) of a major Italian trauma center. Patients with trauma or burns who accessed the ED in 2015 with a triage red or yellow priority treatment code were included, while pediatric patients were excluded. Sensitivity, specificity and positive predictive values were calculated for each TT activation criteria and the aggregated criteria.

RESULTS

Data from 240 patients were collected: 40.42% of patients had a congruent triage while 50% were overtriaged and 9.58% undertriaged. A correct triage led to a lower hospital stay (p < 0.01), while undertriage was not associated with patients' death (p = 0.16). All criteria had a specificity higher than 95%, a total sensitivity of 80.83% and a total positive predictive value of 43.49%.

CONCLUSION

This study highlighted that the TT activation criteria had high specificity and sensitivity, while the positive predictive value of the criteria was lower. Mechanisms of injury criteria were less specific and sensitive in detecting the TT activation correctly. As nurses play a pivotal role in the triage of traumatized patients and the TT, reduction of under- and overtriage is essential to improve the patients' health outcome.

Development and validation of a novel prediction model to identify patients in need of specialized trauma care during field triage: design and rationale of the GOAT study

BACKGROUND

Adequate field triage of trauma patients is crucial to transport patients to the right hospital. Mistriage and subsequent interhospital transfers should be minimized to reduce avoidable mortality, life-long disabilities, and costs. Availability of a prehospital triage tool may help to identify patients in need of specialized trauma care and to determine the optimal transportation destination.

METHODS

The GOAT (Gradient Boosted Trauma Triage) study is a prospective, multi-site, cross-sectional diagnostic study. Patients transported by at least five ground Emergency Medical Services to any receiving hospital within the Netherlands are eligible for inclusion. The reference standards for the need of specialized trauma care are an Injury Severity Score ≥ 16 and early critical resource use, which will both be assessed by trauma registrars after the final diagnosis is made. Variable selection will be based on ease of use in practice and clinical expertise. A gradient boosting decision tree algorithm will be used to develop the prediction model. Model accuracy will be assessed in terms of discrimination (c-statistic) and calibration (intercept, slope, and plot) on individual participant's data from each participating cluster (i.e., Emergency Medical Service) through internal-external cross-validation. A reference model will be externally validated on each cluster as well. The resulting model statistics will be investigated, compared, and summarized through an individual participant's data meta-analysis.

DISCUSSION

The GOAT study protocol describes the development of a new prediction model for identifying patients in need of specialized trauma care. The aim is to attain acceptable undertriage rates and to minimize mortality rates and life-long disabilities.

Initial assessment, level of care and outcome among children who were seen by emergency medical services: a prospective observational study

Background

The assessment of children in the Emergency Medical Service (EMS) is infrequent representing 5.4% of the patients in an urban area in the western part of Sweden. In Sweden, patients are assessed on scene by an EMS nurse whom independently decides on interventions and level of care. To aid the EMS nurse in the assessment a triage instrument, Rapid Emergency Triage and Treatment System-paediatrics (RETTS-p) developed for Emergency Department (ED) purpose has been in use the last 5 years. The aim of this study was to evaluate the EMS nurse assessment, management, the utilisation of RETTS-p and patient outcome.

Methods

A prospective, observational study was performed on 651 children aged < 16 years from January to December 2016. Statistical tests used in the study were Mann-Whitney U test, Fisher’s exact test and Spearman’s rank statistics.

Results

The dispatch centre indexed life-threatening priority in 69% of the missions but, of all children, only 6.1% were given a life threatening RETTS-p red colour by the EMS nurse. A total of 69.7% of the children were transported to the ED and, of these, 31.7% were discharged without any interventions. Among the non-conveyed patients, 16 of 197 (8.1%) visited the ED within 72 h but only two were hospitalised. Full triage, including five out of five vital signs measurements and an emergency severity index, was conducted in 37.6% of all children. A triage colour was not present in 146 children (22.4%), of which the majority were non-conveyed. The overall 30-day mortality rate was 0.8% (n = 5) in children 0–15 years.

Conclusions

Despite the incomplete use of all vital signs according to the RETTS-p, the EMS nurse assessment of children appears to be adapted to the clinical situation in most cases and the patients appear to be assessed to the appropriate level of care but indicating an over triage. It seems that the RETTS-p with full triage is used selectively in the pre-hospital assessment of children with a risk of death during the first 30 days of less than 1%.

Comment appréhender une tuerie de masse pour les équipes Smur primo-intervenantes ?

Le risque terroriste présent sur l’ensemble de notre territoire depuis plusieurs années conduit les équipes de Samu–Smur à intervenir sur les lieux d’une tuerie de masse aux côtés de forces de sécurité, voire en tant que primointervenants. De telles circonstances exposent les équipes à un environnement de travail inhabituel et hostile. Cette mise au point, proposée en complément de la recommandation formalisée d’experts sur la prise en charge de tuerie de masse, répond aux interrogations qui naissent sur le terrain en pareilles circonstances. Elle facilite une juste appréciation des événements, aide à réguler ses émotions, dans le but d’augmenter la capacité des soignants à agir, tout en réduisant la phase de sidération initiale, elle-même responsable d’une inertie à même d’impacter le pronostic des blessés en choc hémorragique. Des procédures anticipées, sous forme de check-lists, guident les actions à mener de manière sereine. Les équipes médicales préhospitalières doivent apporter sur le terrain non seulement une compétence médicale, mais également une compétence tactique et décisionnelle pour accélérer les flux d’évacuation. Le premier médecin engagé doit aider à la décision aux côtés du commandant des opérations de secours, du commandant des opérations de police et de gendarmerie et des médecins intégrés aux forces de sécurité intérieure en attendant le directeur des secours médicaux. Il doit donc également faire preuve d’une compétence de chef d’équipe.

The role of emergency medical service providers in the decision-making process of prehospital trauma triage

PURPOSE

Severely injured patients should be treated at higher-level trauma centres, to improve chances of survival and avert life-long disabilities. Emergency medical service (EMS) providers must try to determine injury severity on-scene, using a prehospital trauma triage protocol, and decide the most appropriate type of trauma centre. The objective of this study is to investigate the role of EMS provider judgment in the prehospital triage process of trauma patients, by analysing the compliance rate to the protocol and administering a questionnaire among EMS providers.

METHODS

All trauma patients transported to a trauma centre in two different regions of the Netherlands were analysed. Compliance rate was based on the number of patients meeting the triage criteria and transported to the corresponding level trauma centre. The questionnaire was administered among EMS providers. Descriptive statistics were used to analyse the data.

RESULTS

For adult patients, the compliance rate to the level I criteria of the triage protocol was 72% in Central Netherlands and 42% in Brabant. For paediatric patients, this was 63% and 38% in Central Netherlands and Brabant, respectively. The judgment on injury severity was mostly based on the injury-type criteria. Additionally, the distance to a level I trauma centre influenced the decision for destination facility in the Brabant region.

CONCLUSION

The compliance rate varied between regions. Improvement of prehospital trauma triage depends on the accuracy of the protocol and compliance rate. A new protocol, including EMS provider judgment, might be the key to improvement in the prehospital trauma triage quality.

Evaluating the ability of a trauma team activation tool to identify severe injury: a multicentre cohort study

Background

Sensitive decision making tools should assist prehospital personnel in the triage of injured patients, identifying those who require immediate lifesaving interventions and safely reducing unnecessary under- and overtriage. In 2014 a new trauma team activation (TTA) tool was implemented in Central Norway. The overall objective of this study was to evaluate the ability of the new TTA tool to identify severe injury.

Methods

This was a multi-center observational cohort study with retrospective data analysis. All patients received by trauma teams at seven hospitals in Central Norway between 01.01.2015 to 31.12.2015 were included. Severe injury was defined as Injury Severity Score (ISS) > 15. Overtriage was defined as the rate of patients with TTA and ISS < 15, whilst patients with TTA and ISS > 15 were defined as correctly triaged.

Results

A total of 1141 patients were identified, of which 998 were eligible for triage criteria analysis. Median age was 35 years (IQR 20–58) and the male proportion was 67%. Mechanism of injury was predominantly blunt trauma (96%) with transport related accidents (62%) followed by falls (22%) the most common. Overall, median injury severity score (ISS) was low and severely injured patients (ISS > 15) comprised 13% of the cohort. Utility of specific TTA criteria were: physiology 20%, anatomical injury 21%, mechanism of injury (MOI) 53% and special causes 6%. Overtriage among all patients was 87%, and for those with physiologic criteria 66%, anatomical injury 82%, mechanism of injury 97% and special causes criteria 92%, respectively.

Conclusions

Severe injury was infrequent and there was a substantial rate of overtriage. The ability of the TTA tool was relatively insensitive in identifying severe injury, but showed increased performance when utilizing physiologic and anatomical injury criteria. Many of the TTA mechanism of injury criteria might be considered for removal from the triage tool due to substantial rates of overtriage. This has relevance for the proposed development of national Norwegian TTA criteria.

Compliance to prehospital trauma triage protocols worldwide: A systematic review

BACKGROUND

Emergency medical services (EMS) providers must determine the injury severity on-scene, using a prehospital trauma triage protocol, and decide on the most appropriate hospital destination for the patient. Many severely injured patients are not transported to higher-level trauma centres. An accurate triage protocol is the base of prehospital trauma triage; however, ultimately the quality is dependent on the destination decision by the EMS provider. The aim of this systematic review is to describe compliance to triage protocols and evaluate compliance to the different categories of triage protocols.

METHODS

An extensive search of MEDLINE/Pubmed, Embase, CINAHL and Cochrane library was performed to identify all studies, published before May 2018, describing compliance to triage protocols in a trauma system. The search terms were a combination of synonyms for 'compliance,' 'trauma,' and 'triage'.

RESULTS

After selection, 11 articles were included. The studies showed a variety in compliance rates, ranging from 21% to 93% for triage protocols, and 41% to 94% for the different categories. The compliance rate was highest for the criterion: penetrating injury. The category of the protocol with the lowest compliance rate was: vital signs. Compliance rates were lower for elderly patients, compared to adults under the age of 55. The methodological quality of most studies was poor. One study with good methodological quality showed that the triage protocol identified only a minority of severely injured patients, but many of whom were transported to higher-level trauma centres.

CONCLUSIONS

The compliance rate ranged from 21% to 94%. Prehospital trauma triage effectiveness could be increased with an accurate triage protocol and improved compliance rates. EMS provider judgment could lower the undertriage rate, especially for severely injured patients meeting none of the criteria. Future research should focus on the improvement of triage protocols and the compliance rate.

Injury severity in polytrauma patients is underestimated using the injury severity score: a single-center correlation study in air rescue

PURPOSE

Prehospital estimation of injury severity is essential for prehospital therapy, deciding on the destination hospital and the associated emergency room care. The aim of this study was to compare prehospital estimates of the abbreviated injury scale (AIS) and the Injury Severity Score (ISS) by emergency physicians with the values of AIS and ISS of injury severity determined at the conclusion of diagnostics.

METHODS

In this prospective study, the ISS was determined prehospital by emergency physicians. The validated AIS and ISS were analyzed based on final diagnoses. A Bland-Altman plot was used in analyzing the agreement between two different assays as well as sensitivity and specificity were determined. Confidence intervals were calculated for a Wilson score. Significance level was set at p ≤ 0.05.

RESULTS

The prehospital ISS was estimated at 26.0 ± 13.0 and was 34.7 ± 16.3 (p < 0.001) after in-hospital validation. In addition, most of the AIS subgroups were significantly higher in the final calculation than preclinically estimated (p < 0.05). When analyzing subgroups of trauma patients (ISS < 16 vs. ISS ≥ 16), we were able to demonstrate a sensitivity of > 90% to identify a multiple-trauma patient. Diagnosing a higher injury severity group (ISS ≥ 25), sensitivity dropped to 61.1%. The Bland-Altman plot demonstrates that injury severity is underestimated in higher injury levels.

CONCLUSION

Multiple-trauma patients can be identified using the ISS. Anatomic scores might be used for transport decisions; however, an accurate estimation of the injury severity should also be based on other criteria such as patient status, mechanism of injury, and other triage criteria.