A multisite assessment of the American College of Surgeons Committee on Trauma field triage decision scheme for identifying seriously injured children and adults

Effectiveness of a two-tiered trauma team activation system at a level I trauma center

PURPOSE

Many trauma patients who are transported to our level I trauma center have minor injuries that do not require full trauma team activation (FTTA). Thus, we implemented a two-tiered TTA system categorizing patients into red and yellow code alerts, indicating FTTA and Limited TTA (LTTA) requirements, respectively. This study aimed to assess the effectiveness of this triage tool by evaluating its diagnostic parameters (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), undertriage and overtriage) and comparing injury severity between the two groups.

METHODS

A retrospective cohort study of patients admitted to a Level I trauma center. Characteristics compared between the red and yellow code groups included demographics, injury severity, treatments, and hospital length of stay (LOS). Calculating the diagnostic parameters was based on Injury Severity Score (ISS) and the need for life-saving surgery or procedures.

RESULTS

Significant differences in injury severity indicators were observed between the two groups. Patients in the red code group had a higher ISS and New Injury Severity Score (NISS), a lower Glasgow Coma Score (GCS), Revised Trauma Score (RTS), and probability of survival. They had a longer hospital LOS, a higher Intensive Care Unit (ICU) admission rate and required more emergency operations. The Sensitivity of the triage tool was 85.2%, specificity was 55.6%, PPV was 74.2%, NPV was 71.5%, undertriage was 14.7%, and overtriage was 25.7%.

CONCLUSION

The two-tiered TTA system effectively distinguish between patients with major trauma who need FTTA and patients with minor trauma who can be managed by LTTA.

Review article: Pre-hospital trauma guidelines and access to lifesaving interventions in Australia and Aotearoa/New Zealand

The centralisation of trauma services in western countries has led to an improvement in patient outcomes. Effective trauma systems include a pre-hospital trauma system. Delivery of high-level pre-hospital trauma care must include identification of potential major trauma patients, access and correct application of lifesaving interventions (LSIs) and timely transport to definitive care. Globally, many nations endorse nationwide pre-hospital major trauma triage guidelines, to ensure a universal approach to patient care. This paper examined clinical guidelines from all 10 EMS in Australia and Aotearoa/New Zealand. All relevant trauma guidelines were included, and key information was extracted. Authors compared major trauma triage criteria, all LSI included in guidelines, and guidelines for transport to definitive care. The identification of major trauma patients varied between all 10 EMS, with no universal criteria. The most common approach to trauma triage included a three-step assessment process: physiological criteria, identified injuries and mechanism of injury. Disparity between physiological criteria, injuries and mechanism was found when comparing guidelines. All 10 EMS had fundamental LSI included in their trauma guidelines. Fundamental LSI included haemorrhage control (arterial tourniquets, pelvic binders), non-invasive airway management (face mask ventilation, supraglottic airway devices) and pleural wall needle decompression. Variation in more advanced LSI was evident between EMS. Optimising trauma triage guidelines is an important aspect of a robust and evidence driven trauma system. The lack of consensus in trauma triage identified in the present study makes benchmarking and comparison of trauma systems difficult.

Modified physiologic criteria for the field triage scheme: Efficacy of major trauma recognition in different age groups in Asia

BACKGROUND

Major trauma is a leading cause of unexpected death globally, with increasing age-adjusted death rates for unintentional injuries. Field triage schemes (FTSs) assist emergency medical technicians in identifying appropriate medical care facilities for patients. While full FTSs may improve sensitivity, step-by-step field triage is time-consuming. A simplified FTS (sFTS) that uses only physiological and anatomical criteria may offer a more rapid decision-making process. However, evidence for this approach is limited, and its performance in identifying all age groups requiring trauma center resources in Asia remains unclear.

METHODS

We conducted a multinational retrospective cohort study involving adult trauma patients admitted to emergency departments in the included countries from 2016 to 2020. Prehospital and hospital data were reviewed from the Pan-Asia Trauma Outcomes Study database. Patients aged ≥18 years transported by emergency medical services were included. Patients lacking data regarding age, sex, physiological criteria, or injury severity scores were excluded. We examined the performance of sFTS in all age groups and fine-tuned physiological criteria to improve sFTS performance in identifying high-risk trauma patients in different age groups.

RESULTS

The sensitivity and specificity of the physiological and anatomical criteria for identifying major trauma (injury severity score ≥ 16) were 80.6% and 58.8%, respectively. The modified sFTS showed increased sensitivity and decreased specificity, with more pronounced changes in the young age group. Adding the shock index further increased sensitivity in both age groups.

CONCLUSIONS

sFTS using only physiological and anatomical criteria is suboptimal for Asian adult patients with trauma of all age groups. Adjusting the physiological criteria and adding a shock index as a triage tool can improve the sensitivity of severely injured patients, particularly in young age groups. A swift field triage process can maintain acceptable sensitivity and specificity in severely injured patients.

Massive transfusion protocol reactivation as a novel marker of physician team under-triage after injury

BACKGROUND

Large trauma centers have protocols for the assessment of injury and triaging of care with attempts to over-triage to ensure adequate care for all patients. We noted that a significant number of patients undergo a second massive transfusion protocol (MTP) activation in the first 24 h of care and conducted a retrospective cohort study of patients involved over a 3-year period.

METHODS

Transfusion service records of MTP activations 2019-2021 were linked to Trauma Registry records and divided into cohorts receiving a single versus a reactivation of the MTP. Time of activation and amounts of blood products issued were linked to demographic, injury severity, and outcome data. Categorical and continuous data were compared between cohorts with chi-squared, Fisher's, and Wilcoxan tests as appropriate, and multivariable regression models were used to seek interactions (p < .05).

RESULTS

MTP activation was recorded for 1884 acute trauma patients over our 3-year study period, 142 of whom (7.5%) had reactivation. Factors associated with reactivation included older age (46 vs. 40 years), higher injury severity score (ISS, 27 vs. 22), leg injuries, and presentation during morning shift change (5-7 a.m., 3.3% vs. 7.7%). Patients undergoing MTP reactivation used more RBCs (5 U vs. 2 U) and had more ICU days (3 vs. 2).

CONCLUSIONS

Older patients and those presenting during shift change are at risk for failure to recognize their complex injury patterns and under-triage for trauma care. The fidelity and granularity of transfusion service records can provide unique opportunities for quality assessment and improvement in trauma care.

Modified Needleman-Wunsch algorithm for trauma management performance evaluation

BACKGROUND

Trauma injuries are one of the leading causes of death in the world, representing approximately 8 % of all deaths. Therefore, trauma management training is of great importance and new training courses have arisen during the last decades. However, actual training courses do not typically analyze compliance with the protocols and guidelines available in the literature. Considering general trauma management guidelines such as the Advanced Trauma Life Support (ATLS) manual and the expertise of trauma specialists, a trauma management automated evaluation system has been designed in this paper.

METHODS

A modification to the Needleman-Wunsch (NW) algorithm is developed, including all relevant aspects of trauma management to automatically evaluate how a trauma intervention has been implemented according to trauma protocols. This allows to consider more information with respect to the order of the actions taken and the type of actions performed than current evaluation methods, such as checklists or videos recorded in simulation. A web-based trauma simulator is used so that it can be used at any setting with internet connection. Final-year medical students and first- and second-year residents performed an experimental test, where a trauma score is obtained with the modified NW algorithm. This automatic score relates to how similar the actions are to trauma protocols.

RESULTS

The results show the best combination of the scores used for the modified NW variables. This combination has an error, for the different case scenarios created, below 0.07 which verifies the values obtained. Additionally, trauma experts verified the results obtained showing a median difference of 0 between the protocol adherence evaluation using the algorithm and the one provided by the trauma experts.

CONCLUSIONS

The best set of score values to apply to the modified NW algorithm show that the modified NW algorithm provides a successful objective measurement with respect to the protocol compliance.

Tradeoffs in Triage of Motor Vehicle Trauma by Rural 911 Emergency Medical Services Practitioners

PURPOSE

Identification and triage of severely injured patients to trauma centers is paramount to survival. Many patients are undertriaged in rural areas and do not receive proper care. The decision-making processes involved in triage are not well understood and should be assessed to improve the triage process and outcomes.

METHODS

Triage decision-making processes were explored through emergency medical services (EMS) practitioner focus groups and a discrete choice experiment (DCE). Attributes of trauma determined from focus groups and the literature included patient demography, injury mechanism, and trauma center distance. DCE data were analyzed using mixed logit models.

RESULTS

High-risk mechanism, decreased age, multiple comorbidities, and pregnancy were found to increase the preference for triage. Greater trauma center distance was found to decrease preference for triage, but practitioners were willing to trade off up to 2 h of travel time to transport a third-trimester pregnancy and 48 min of travel time to transport a 25-y-old than they would a 50-y-old with the same comorbidities, injuries, and stability.

CONCLUSIONS

Our findings suggest that current forms of EMS protocols may not be appropriately tailored to support the mechanisms underlying practitioner decision making. Public health professionals and researchers should consider using DCEs to better understand EMS practitioner decision making and identify structures and incentives that may improve patient outcomes and optimally guide appropriate triage decisions.

HIGHLIGHTS

Discrete choice experiments are an effective method to elicit prehospital practitioners' preferences around transport of the traumatized patient.Practitioner biases observed in EMS transport data are recovered in stated preference models incorporating individual preference heterogeneity.There is a discrepancy between the triage priorities recommended by protocol and those measured from prehospital practitioners' decisions-this may have implications in over- and undertriage rates and prehospital protocol design.

Geographic Disparities in Re-triage Destinations Among Seriously Injured Californians

Objective

To quantify geographic disparities in sub-optimal re-triage of seriously injured patients in California.

Summary of Background Data

Re-triage is the emergent transfer of seriously injured patients from the emergency departments of non-trauma and low-level trauma centers to, ideally, high-level trauma centers. Some patients are re-triaged to a second non-trauma or low-level trauma center (sub-optimal) instead of a high-level trauma center (optimal).

Methods

This was a retrospective observational cohort study of seriously injured patients, defined by an Injury Severity Score > 15, re-triaged in California (2009-2018). Re-triages within one day of presentation to the sending center were considered. The sub-optimal re-triage rate was quantified at the state, regional trauma coordinating committees (RTCC), local emergency medical service agencies, and sending center level. A generalized linear mixed-effects regression quantified the association of sub-optimality with the RTCC of the sending center. Geospatial analyses demonstrated geographic variations in sub-optimal re-triage rates and calculated alternative re-triage destinations.

Results

There were 8,882 re-triages of seriously injured patients and 2,680 (30.2 %) were sub-optimal. Sub-optimally re-triaged patients had 1.5 higher odds of transfer to a third short-term acute care hospital and 1.25 increased odds of re-admission within 60 days from discharge. The sub-optimal re-triage rates increased from 29.3 % in 2009 to 38.6 % in 2018. 56.0 % of non-trauma and low-level trauma centers had at least one sub-optimal re-triage. The Southwest RTCC accounted for the largest proportion (39.8 %) of all sub-optimal re-triages in California.

Conclusion

High population density geographic areas experienced higher sub-optimal re-triage rates.

Under-Triage and Over-Triage Using the Field Triage Guidelines for Injured Patients: A Systematic Review

OBJECTIVES

The Field Triage Guidelines (FTG) are used across North America to identify seriously injured patients for transport to appropriate level trauma centers, with a goal of under-triaging no more than 5% and over-triaging between 25% and 35%. Our objective was to systematically review the literature on under-triage and over-triage rates of the FTG.

METHODS

We conducted a systematic review of the FTG performance. Ovid Medline, EMBASE, and the Cochrane databases were searched for studies published between January 2011 and February 2021. Two investigators dual-reviewed eligibility of abstracts and full-text. We included studies evaluating under- or over-triage of patients using the FTG in the prehospital setting. We excluded studies not reporting an outcome of under- or over-triage, studies evaluating other triage tools, or studies of triage not in the prehospital setting. Two investigators independently assessed the risk of bias for each included article. The primary accuracy measures to assess the FTG were under-triage, defined as seriously injured patients transported to non-trauma hospitals (1-sensitivity), and over-triage, defined as non-injured patients transported to trauma hospitals (1-specificity). Due to heterogeneity, results were synthesized qualitatively.

RESULTS

We screened 2,418 abstracts, reviewed 315 full-text publications, and identified 17 studies that evaluated the accuracy of the FTG. Among eight studies evaluating the entire FTG (steps 1-4), under-triage rates ranged from 1.6% to 72.0% and were higher for older (≥55 or ≥65 years) adults (20.1-72.0%) and pediatric (<15 years) patients (15.9-34.8%) compared to all ages (1.6-33.8%). Over-triage rates ranged from 9.9% to 87.4% and were higher for all ages (12.2-87.4%) compared to older (≥55 or ≥65 years) adults (9.9-48.2%) and pediatric (<15 years) patients (28.0-33.6%). Under-triage was lower in studies strictly applying the FTG retrospectively (1.6-34.8%) compared to as-practiced (10.5-72.0%), while over-triage was higher retrospectively (64.2-87.4%) compared to as-practiced (9.9-48.2%).

CONCLUSIONS

Evidence suggests that under-triage, while improved if the FTG is strictly applied, remains above targets, with higher rates of under-triage in both children and older adults.

Accuracy of Trauma on Scene Triage Screening Tool (Shock Index, Reverse Shock Index Glasgow Coma Scale and National Early Warning Score) to Predict the Severity of Emergency Department Triage: A Retrospective Cross-Sectional Study

Introduction

Prehospital trauma care includes on-scene assessments, essential treatment, and facilitating transfer to an appropriate trauma center to deliver optimal care for trauma patients. While the Simple Triage and Rapid Treatment (START), Revised Triage Sieve (rTS), and National Early Warning Score (NEWS) tools are user-friendly in a prehospital setting, there is currently no standardized on-scene triage protocol in Thailand Emergency Medical Service (EMS). Therefore, this study aims to evaluate the precision of these tools (SI, rSIG, and NEWS) in predicting the severity of trauma patients who are transferred to the emergency department (ED).

Methods

This study was a retrospective cross-sectional and diagnostic research conducted on trauma patients transferred by EMS to the ED of Ramathibodi Hospital, a university-affiliated super tertiary care hospital in Bangkok, Thailand, from January 2015 to September 2022. We compared the on-scene triage tool (SI, rSIG, and NEWS) and ED triage tool (Emergency Severity Index) parameters, massive transfusion protocol (MTP), and intensive care unit (ICU) admission with the area under ROC (univariable analysis) and diagnostic odds ratio (multivariable logistic regression analysis). The optimal cut-off threshold for the best parameter was determined by selecting the value that produced the highest area under the ROC curve.

Results

A total of 218 patients were traumatic patients transported by EMS to the ED, out of which 161 were classified as ESI levels 1-2, while the remaining 57 patients were categorized as levels 3-5 on the ESI triage scale. We found that NEWS was a more accurate triage tool to discriminate the severity of trauma patients than rSIG and SI. The area under the ROC was 0.74 (95% CI 0.70-0.79) (OR 18.98, 95% CI 1.06-337.25), 0.65 (95% CI 0.59-0.70) (OR 1.74, 95% CI 0.17-18.09) and 0.58 (95% CI 0.52-0.65) (OR 0.28, 95% CI 0.04-1.62), respectively (P-value <0.001). The cut point of NEWS to discriminate ESI levels 1-2 and levels 3-5 was >6 points.

Conclusion

NEWS is the best on-scene triage screening tool to predict the severity at the emergency department, massive transfusion protocol (MTP), and intensive care unit (ICU) admission compared with other triage tools SI and rSIG.

Defining obstacles to emergency transfer of trauma patients: An evaluation of retriage processes from nontrauma and lower-level Illinois trauma centers

BACKGROUND

Retriage is the emergency transfer of severely injured patients from nontrauma and lower-level trauma centers to higher-level trauma centers. We identified the barriers to retriage at sending centers in a single health system.

METHODS

We conducted a failure modes effects and criticality analysis at 4 nontrauma centers and 5 lower-level trauma centers in a single health system. Clinicians from each center described the steps in the trauma assessment and retriage process to create a process map. We used standardized scoring to characterize each failure based on frequency, impact on retriage, and prevention safeguards. We ranked each failure using the scores to calculate a risk priority number.

RESULTS

We identified 26 steps and 93 failures. The highest-risk failure was refusal by higher-level trauma centers (receiving hospitals) to accept a patient. The most critical failures in the retriage process based on total risk, frequency, and safeguard scores were (1) refusal from a receiving higher-level trauma center to accept a patient (risk priority number = 191), (2) delay in a sending center's consultant examination of a patient in the emergency department (risk priority number = 177), and (3) delay in receiving hospital's consultant calling back (risk priority number = 177).

CONCLUSION

We identified (1) addressing obstacles to determining clinical indications for retriage and (2) identifying receiving level I trauma centers who would accept the patient as opportunities to increase timely retriage. Establishing clear clinical indications for retriage that sending and receiving hospitals agree on represents an opportunity for intervention that could improve the retriage of injured patients.

Advanced Automatic Crash Notification Algorithm for Children

BACKGROUND

Advanced automatic crash notification (AACN) can improve triage decision-making by using vehicle telemetry to alert first responders of a motor vehicle crash and estimate an occupant's likelihood of injury. The objective was to develop an AACN algorithm to predict the risk that a pediatric occupant is seriously injured and requires treatment at a Level I or II trauma center.

METHODS

Based on 3 injury facets (severity; time sensitivity; predictability), a list of Target Injuries associated with a child's need for Level I/II trauma center treatment was determined. Multivariable logistic regression of motor vehicle crash occupants was performed creating the pediatric-specific AACN algorithm to predict risk of sustaining a Target Injury. Algorithm inputs included: delta-v, rollover quarter-turns, belt status, multiple impacts, airbag deployment, and age. The algorithm was optimized to achieve under-triage ≤5% and over-triage ≤50%. Societal benefits were assessed by comparing correctly triaged motor vehicle crash occupants using the AACN algorithm against real-world decisions.

RESULTS

The pediatric AACN algorithm achieved 25% to 49% over-triage across crash modes, and under-triage rates of 2% for far-side, 3% for frontal and near-side, 8% for rear, and 14% for rollover crashes. Applied to real-world motor vehicle crashes, improvements of 59% in under-triage and 45% in over-triage are estimated: more appropriate triage of 32,320 pediatric occupants annually.

CONCLUSIONS

This AACN algorithm accounts for pediatric developmental stage and will aid emergency personnel in correctly triaging pediatric occupants after a motor vehicle crash. Once incorporated into the trauma triage network, it will increase triage efficiency and improve patient outcomes.

National guideline for the field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2021

This work details the process of developing the updated field triage guideline, the supporting evidence, and the final version of the 2021 National Guideline for the Field Triage of Injured Patients.

Evaluation of mechanism of injury criteria for field triage of occupants involved in motor vehicle collisions

OBJECTIVE

The mechanism of injury (MOI) criteria assist in determining which patients are at high risk of severe injury and would benefit from direct transport to a trauma center. The goal of this study was to determine whether the prognostic performance of the Centers for Disease Control's (CDC) MOI criteria for motor vehicle collisions (MVCs) has changed during the decade since the guidelines were approved. Secondary objectives were to evaluate the performance of these criteria for different age groups and evaluate potential criteria that are not currently in the guidelines.

METHODS

Data were obtained from NASS and Crash Investigation Sampling System (CISS) for 2000-2009 and 2010-2019. Cases missing injury severity were excluded, and all other missing data were imputed. The outcome of interest was Injury Severity Score (ISS) ≥16. The area under the receiver operator characteristic (AUROC) and 95% confidence intervals (CIs) were obtained from 1,000 bootstrapped samples using national case weights. The AUROC for the existing CDC MOI criteria were compared between the 2 decades. The performance of the criteria was also assessed for different age groups based on accuracy, sensitivity, and specificity. Potential new criteria were then evaluated when added to the current CDC MOI criteria.

RESULTS

There were 150,683 (weighted 73,423,189) cases identified for analysis. There was a small but statistically significant improvement in the AUROC of the MOI criteria in the later decade (2010-2019; AUROC = 0.77, 95% CI [0.76-0.78]) compared to the earlier decade (2000-2009; AUROC = 0.75, 95% CI [0.74-0.76]). The accuracy and specificity did not vary with age, but the sensitivity dropped significantly for older adults (0-18 years: 0.62, 19-54 years: 0.59, ≥55 years: 0.37, and ≥65 years: 0.36). The addition of entrapment improved the sensitivity of the existing criteria and was the only potential new criterion to maintain a sensitivity above 0.95.

CONCLUSIONS

The MOI criteria for MVCs in the current CDC guidelines still perform well even as vehicle design has changed. However, the sensitivity of these criteria for older adults is much lower than for younger occupants. The addition of entrapment improved sensitivity while maintaining high specificity and could be considered as a potential modification to current MOI criteria.

Disparity in Transport of Critically Injured Patients to Trauma Centers: Analysis of the National Emergency Medical Services Information System (NEMSIS)

BACKGROUND

Patient morbidity and mortality decrease when injured patients meeting CDC Field Triage Criteria (FTC) are transported by emergency medical services (EMS) directly to designated trauma centers (TCs). This study aimed to identify potential disparities in the transport of critically injured patients to TCs by EMS.

STUDY DESIGN

We identified all patients in the National EMS Information System (NEMSIS) database in the National Association of EMS State Officials East region from January 1, 2018, to December 31, 2019, with a final prehospital acuity of critical or emergent by EMS. The cohort was stratified into patients transported to TCs or non-TCs. Analyses consisted of descriptive epidemiology, comparisons, and multivariable logistic regression analysis to measure the association of demographic features, vital signs, and CDC FTC designation by EMS with transport to a TC.

RESULTS

A total of 670,264 patients were identified as sustaining an injury, of which 94,250 (14%) were critically injured. Of those 94,250 critically injured, 56.0% (52,747) were transported to TCs. Among all critically injured women (n = 41,522), 50.4% were transported to TCs compared with 60.4% of critically injured men (n = 52,728, p < 0.001). In a multivariable logistic regression model, critically injured women were 19% less likely to be taken to a TC compared with critically injured men (OR 0.81, 95% CI 0.71-0.93, p = 0.003).

CONCLUSIONS

Critically injured female patients are less likely to be transported to TCs when compared with their male counterparts. Performance improvement processes that assess EMS compliance with field triage guidelines should explicitly evaluate for sex-based disparities. Further studies are warranted.

Accuracy and influencing factors of the Field Triage Decision Scheme for adult trauma patients at a level-1 trauma center in Korea

BACKGROUND

We evaluated the accuracy of the prehospital Field Triage Decision Scheme, which has recently been applied in the Korean trauma system, and the factors associated with severe injury and prognosis at a regional trauma center in Korea.

METHODS

From 2016 to 2018, prehospital data of injured patients were obtained from the emergency medical services of the national fire agency and matched with trauma outcomes at our institution. Severe injury (Injury Severity Score > 15), overtriage/undertriage rate, positive predictive value, negative predictive value, and accuracy were reviewed according to the triage protocol steps. A multivariate logistic regression analysis was performed to identify influencing factors in the field triage.

RESULTS

Of the 2438 patients reviewed, 853 (35.0%) were severely injured. The protocol accuracy was as follows: step 1, 72.3%; step 2, 65.0%; step 3, 66.2%; step 1 or 2, 70.2%; and step 1, 2, or 3, 66.4%. Odds ratios (OR) (95% confidence interval [CIfor systolic blood pressure < 90 mmHg (3.535 [1.920-6.509]; p < 0.001), altered mental status (17.924 [8.980-35.777]; p < 0.001), and pedestrian injuries (2.473 [1.339-4.570], p = 0.04) were significantly associated with 24-h mortality. Penetrating torso injuries (7.108 [4.108-12.300]; p < 0.001); two or more proximal long bone fractures (4.134 [2.316-7.377]); p < 0.001); crushed, degloved, and mangled extremities (8.477 [4.068-17.663]; p < 0.001); amputation proximal to the wrist or ankle (42.964 [5.764-320.278]; p < 0.001); and fall from height (2.141 [1.497-3.062]; p < 0.001) were associated with 24-h surgical intervention.

CONCLUSION

The Korean field triage protocol is not yet accurate, with only some factors reflecting injury severity, making reevaluation necessary.

Prehospital triage tools across the world: a scoping review of the published literature

BACKGROUND

Accurate triage of the undifferentiated patient is a critical task in prehospital emergency care. However, there is a paucity of literature synthesizing currently available prehospital triage tools. This scoping review aims to identify published tools used for prehospital triage globally and describe their performance characteristics.

METHODS

A comprehensive search was performed of primary literature in English-language journals from 2009 to 2019. Papers included focused on emergency medical services (EMS) triage of single patients. Two blinded reviewers and a third adjudicator performed independent title and abstract screening and subsequent full-text reviews.

RESULTS

Of 1521 unique articles, 55 (3.6%) were included in the final synthesis. The majority of prehospital triage tools focused on stroke (n = 19; 35%), trauma (19; 35%), and general undifferentiated patients (15; 27%). All studies were performed in high income countries, with the majority in North America (23, 42%) and Europe (22, 40%). 4 (7%) articles focused on the pediatric population. General triage tools aggregate prehospital vital signs, mental status assessments, history, exam, and anticipated resource need, to categorize patients by level of acuity. Studies assessed the tools' ability to accurately predict emergency department triage assignment, hospitalization and short-term mortality. Stroke triage tools promote rapid identification of patients with acute large vessel occlusion ischemic stroke to trigger timely transport to diagnostically- and therapeutically-capable hospitals. Studies evaluated tools' diagnostic performance, impact on tissue plasminogen activator administration rates, and correlation with in-hospital stroke scales. Trauma triage tools identify patients that require immediate transport to trauma centers with emergency surgery capability. Studies evaluated tools' prediction of trauma center need, under-triage and over-triage rates for major trauma, and survival to discharge.

CONCLUSIONS

The published literature on prehospital triage tools predominantly derive from high-income health systems and mostly focus on adult stroke and trauma populations. Most studies sought to further simplify existing triage tools without sacrificing triage accuracy, or assessed the predictive capability of the triage tool. There was no clear 'gold-standard' singular prehospital triage tool for acute undifferentiated patients.

TRIAL REGISTRATION

Not applicable.

Emergency general surgery: impact of distance and rurality on mortality

BACKGROUND

There is debate about whether the distance from hospital, or rurality, impacts outcomes in patients admitted under emergency general surgery (EGS). The aim of this study was to determine whether distance from hospital, or rurality, affects the mortality of emergency surgical patients admitted in Scotland.

METHODS

This was a retrospective population-level cohort study, including all EGS patients in Scotland aged 16 years or older admitted between 1998 and 2018. A multiple logistic regression model was created with inpatient mortality as the dependent variable, and distance from hospital (in quartiles) as the independent variable of interest, adjusting for age, sex, co-morbidity, deprivation, admission origin, diagnosis category, operative category, and year of admission. A second multiple logistic regression model was created with a six-fold Scottish Urban Rural Classification (SURC) as the independent variable of interest. Subgroup analyses evaluated patients who required operations, emergency laparotomy, and inter-hospital transfer.

RESULTS

Data included 1 572 196 EGS admissions. Those living in the farthest distance quartile from hospital had lower odds of mortality than those in the closest quartile (OR 0.829, 95 per cent c.i. 0.798 to 0.861). Patients from the most rural areas (SURC 6) had higher odds of survival than those from the most urban (SURC 1) areas (OR 0.800, 95 per cent c.i. 0.755 to 0.848). Subgroup analysis showed that these effects were not observed for patients who required emergency laparotomy or transfer.

CONCLUSION

EGS patients who live some distance from a hospital, or in rural areas, have lower odds of mortality, after adjusting for multiple covariates. Rural and distant patients undergoing emergency laparotomy have no survival advantage, and transferred patients have higher mortality.

Field Trauma Triage among Older Adults: A Cost-Effectiveness Analysis

BACKGROUND

National guidelines for prehospital trauma triage aim to identify seriously injured patients who may benefit from transport to trauma centers. These guidelines have poor sensitivity for serious injury among older adults. We evaluated the cost-effectiveness of a high-sensitivity triage strategy for older adults.

STUDY DESIGN

We developed a Markov chain Monte Carlo microsimulation model to estimate the cost-effectiveness of high-sensitivity field triage criteria among older adults compared with current practice. The model used a retrospective cohort of 3621 community-dwelling Medicare beneficiaries who were transported by emergency medical services after an acute injury in 7 counties in the northwestern US during January to December 2011. These data informed model estimates of emergency medical services triage assessment, hospital transport patterns, and outcomes from index hospitalization up to 1 year after discharge. Outcomes beyond 1 year were modeled using published literature. Differences in cost and quality-adjusted life years (QALYs) were calculated for both strategies using a lifetime analytical horizon. We calculated the incremental cost-effectiveness ratio (cost per QALY gained) to assess cost-effectiveness, which we defined using a threshold of less than $100,000 per QALY.

RESULTS

High-sensitivity trauma field triage for older adults would produce a small incremental benefit in average trauma system effectiveness (0.0003 QALY) per patient at a cost of $1,236,295 per QALY. Sensitivity analysis indicates that the cost of initial hospitalization and emergency medical services adherence to triage status (ie transporting triage-positive patients to a trauma center) had the largest influence on overall cost-effectiveness.

CONCLUSIONS

High-sensitivity trauma field triage is not cost-effective among older adults.

CDC field triage criteria accurately predicts outcomes in high impact trauma

BACKGROUND

The precision of emergency medical services (EMS) triage criteria dictates whether an injured patient receives appropriate care. The trauma triage protocol is a decision scheme that groups patients into triage categories of major, moderate and minor. We hypothesized that there is a difference between trauma triage category and injury severity score (ISS).

METHODS

This retrospective, observational study was conducted to investigate a difference between trauma triage category and ISS. Bivariate analysis was used to test for differences between the subgroup means. The differences between the group means on each measure were analyzed for direction and statistical significance using ANOVA for continuous variables and chi square tests for categorical variables. Logistic and linear regressions were performed to evaluate factors predicting mortality, ICU length of stay.

RESULTS

With respect to trauma triage category, our findings indicate that minor and moderate triage categories are similar with respect to ISS, GCS, ICU LOS, hospital LOS, and mortality. However, after excluding for low impact injuries (falls), differences between the minor and moderate categories were evident when comparing to ISS, GCS, ICU LOS, and hospital LOS. Additionally, after excluding for low impact injures, ISS, ICU LOS, and hospital stay were found to correlate well with trauma triage category.

CONCLUSIONS

In this retrospective, observational study significant differences were not seen when comparing ISS with the trauma triage categories of moderate and minor during our initial analysis. However, a difference was found after excluding for low impact injuries. These findings suggest that CDC criteria accurately predicts outcomes in high impact trauma.

"Low initial pre-hospital end-tidal carbon dioxide predicts inferior clinical outcomes in trauma patients"

INTRODUCTION

Current guidelines continue to lead to under- and over-triage of injured patients in the pre-hospital setting. End-tidal carbon dioxide (ETCO2) has been correlated with mortality and hemorrhagic shock in trauma patients. This study examines the correlation between ETCO2 and in-hospital outcomes among non-intubated patients in the pre-hospital setting.

METHODS

We retrospectively studied a cohort of non-intubated adult trauma patients with initial pre-hospital side-stream capnography-obtained ETCO2 presenting via ground transport from a single North Carolina EMS agency to a level one trauma center from January 2018 to December 2018. Using the Liu method, the optimal threshold for low ETCO2 was ≤ 28.5 mmHg.

RESULTS

Initial pre-hospital ETCO2 was recorded for 324 (22.0%) of 1473 patients with EMS data. Patients with low ETCO2 (N = 98, 30.3% of cohort) were older (median 58y vs 45y), but mechanisms of injury and scene vital signs were similar (p>0.05) between low and normal/high ETCO2 cohorts. Median injury severity score (ISS) did not differ significantly between the low and normal/high ETCO2 groups (5 vs 8, p=0.48). Compared to normal/high ETCO2, low ETCO2 correlated with increased unadjusted odds of mortality (OR 5.06), in-hospital complications (OR 2.06), and blood transfusion requirement (OR 3.05), p<0.05. Low ETCO2 was associated with 7.25 odds of mortality (95% CI 2.19,23.97, p=0.001) and 3.94 odds of blood transfusion (95% CI 1.32-11.78) after adjusting for age, ISS, and scene GCS. All but one of the massive transfusion patients (N = 8/9) had a low pre-hospital ETCO2.

CONCLUSIONS

Low initial pre-hospital ETCO2 associates with poor clinical outcomes despite similar ISS and mechanisms of injury. ETCO2 is a potentially useful pre-hospital point-of-care tool to aid triage of trauma patients as it may identify hemorrhaging patients and predict mortality.

The advanced machine learner XGBoost did not reduce prehospital trauma mistriage compared with logistic regression: a simulation study

Background

Accurate prehospital trauma triage is crucial for identifying critically injured patients and determining the level of care. In the prehospital setting, time and data are often scarce, limiting the complexity of triage models. The aim of this study was to assess whether, compared with logistic regression, the advanced machine learner XGBoost (eXtreme Gradient Boosting) is associated with reduced prehospital trauma mistriage.

Methods

We conducted a simulation study based on data from the US National Trauma Data Bank (NTDB) and the Swedish Trauma Registry (SweTrau). We used categorized systolic blood pressure, respiratory rate, Glasgow Coma Scale and age as our predictors. The outcome was the difference in under- and overtriage rates between the models for different training dataset sizes.

Results

We used data from 813,567 patients in the NTDB and 30,577 patients in SweTrau. In SweTrau, the smallest training set of 10 events per free parameter was sufficient for model development. XGBoost achieved undertriage rates in the range of 0.314–0.324 with corresponding overtriage rates of 0.319–0.322. Logistic regression achieved undertriage rates ranging from 0.312 to 0.321 with associated overtriage rates ranging from 0.321 to 0.323. In NTDB, XGBoost required the largest training set size of 1000 events per free parameter to achieve robust results, whereas logistic regression achieved stable performance from a training set size of 25 events per free parameter. For the training set size of 1000 events per free parameter, XGBoost obtained an undertriage rate of 0.406 with an overtriage of 0.463. For logistic regression, the corresponding undertriage was 0.395 with an overtriage of 0.468.

Conclusion

The under- and overtriage rates associated with the advanced machine learner XGBoost were similar to the rates associated with logistic regression regardless of sample size, but XGBoost required larger training sets to obtain robust results. We do not recommend using XGBoost over logistic regression in this context when predictors are few and categorical.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01558-y.

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.

Evaluation der Aufnahmekriterien von Patienten nach Verkehrsunfall in den Schockraum

Hintergrund

Die aktuelle S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung der Deutschen Gesellschaft für Unfallchirurgie (DGU) empfiehlt bei einem Pkw-Unfall mit einer Geschwindigkeitsveränderung von delta >30 km/h die Versorgung in einem Schockraum ohne Berücksichtigung der Verletzungen des Patienten. Ziel dieser Studie war es zu untersuchen, ob Patienten, die ausschließlich aufgrund dieses Kriteriums über einen Schockraum aufgenommen wurden, relevante Verletzungen aufwiesen, die intensivmedizinische Behandlungen oder (Not‑)Operationen benötigten.

Methode

Nach einem Pkw-Unfall wurden Patienten ohne spezifische Verletzung, bei denen ausschließlich eine Geschwindigkeitsveränderung von delta >30 km/h vorlag (Empfehlungsgrad B der S3-Leitlinie), der Studiengruppe, Patienten mit Verletzungen gem. Empfehlungsgrad A der Leitlinie der Vergleichsgruppe zugeordnet. Ein schockraumrelevantes Trauma wurde als Injury Severity Score (ISS) ≥16, operative Versorgung innerhalb 24 h, intensivmedizinische Überwachung >24 h, Versterben während des Krankenhausaufenthalts sowie DGU-Basiskollektiv (MAIS3+ oder MAIS2 mit Intensivverweildauer >24 h bzw. Versterben während des Krankenhausaufenthalts) definiert.

Ergebnisse

Der Vergleich zeigte einen hochsignifikanten Unterschied in Bezug auf den mittleren ISS (p ≤ 0,001), ein schockraumrelevantes Trauma (ISS ≥16; p ≤ 0,001), eine intensivmedizinische Versorgung >24 h (p ≤ 0,001), Operation innerhalb von 24 h nach Krankenhausaufnahme (p ≤ 0,001), Letalität (p ≤ 0,001) sowie DGU-Basiskollektiv (p ≤ 0,001). Anhand dieser Ergebnisse konnte gezeigt werden, dass innerhalb der Studiengruppe (Geschwindigkeitsveränderung von delta >30 km/h; Empfehlungsgrad B der S3-Leitlinie) lediglich ein Patient eine Traumafolge aufwies, die eine intensivmedizinische Behandlung >24 h oder eine Operation nötig machte. Studien- und Vergleichsgruppen waren in Bezug auf das mittlere Alter (p = 1,778), das männliche Geschlecht (p = 0,1728) sowie die durchschnittliche Unfallgeschwindigkeit (p = 0,4606) vergleichbar.

Diskussion

Ein alleiniges Vorliegen eines Pkw-Unfalls mit einer Geschwindigkeitsveränderung von delta >30 km/h kann nicht als adäquater Prädiktor für ein schockraumrelevantes Trauma gesehen werden. Weitere Studien könnten durch eine Leitlinienanpassung eine weiterhin sichere und hochwertige Patientenversorgung bei Reduktion von personellen und finanziellen Belastungen ermöglichen.

Effect of Field Triage Training on Emergency Medical Technicians in Taipei City

Injury is a leading cause of death among young adults. An accurately implemented fi led triage scheme (FTS) by emergency medical technicians (EMTs) is the first step for delivering right patients to the right hospital. However, the training effect of FTS on EMTs with different levels and backgrounds has scarcely been reported. We evaluated training effects of FTS among EMTs in Taipei. Standard FTS contains physiologic status, anatomical sites of injury, and mechanism of injury criteria. The intervention was a 30-minute lecture and pre-and-post tests, each containing five questions about trauma severity judgment (i.e., mechanism of injury [2 questions], anatomic sites of injury [2 questions], and physiological status [1 question]). The change in EMT accuracy was measured before and after training. Subgroup analyses were performed across EMTs with different levels and seniorities. From September 1, 2015 to March 31, 2016, 821 EMTs were enrolled, including 740 EMT-intermediates and 81 paramedics. Overall, EMT accuracy improved after the intervention in the intermediate (73.2% vs. 85.5%, p < 0.05) and paramedic (76.0% vs. 85.7%, p <0.01) groups. All trainees showed improvements in physiology and mechanism criteria, but paramedics showed decreased accuracy in anatomic criteria. The subgroup analysis showed that accuracy positively associated with prehospital care experience for major trauma cases 1 year before the training course, and the anatomical criterion accuracy was adversely associated with paramedic seniority. Field triage training can improve EMT accuracy for FTS. The anatomical aspect is more diffi cult to improve and should be emphasized in FTS training courses.

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.

Medicine in the Sport of Horse Racing

Horseracing is among the most popular and increasingly lucrative industry sports in the nation. The average jockey must control a thoroughbred horse 10 times their weight that may act unpredictably whether at rest or full gallop resulting in falls, kicks, or even biting injuries. Despite the risks, jockeys do not have access to the same quality of medical care that is standard in similarly profitable sports organizations. Beyond the mental and physical demands of training and performance endured by any professional athlete, jockeys are confronted with health challenges unique to their sport. In this review of the literature, we aim to educate sports medicine physicians regarding the underlying causes of injuries, describe injury management, and make recommendations for appropriate preventive strategies. Overall, there is a void of literature, and so our authors offer expert opinion and encourage others to get involved in making this a safer sport.

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.

The "Golden Hour" and field triage pattern for road trauma patients

INTRODUCTION

Although the term "golden hour" is a well-known concept among trauma system and emergency medical service providers, the relationship between time and trauma patient outcome and the process of prehospital care for road trauma patients in rural settings are poorly understood. As the underlying basis for triage decision-making, the estimated transport interval to trauma center is usually absent in the existing studies.

METHOD

In this study, the crash data between 2013 and 2017 were obtained from the Fatality Analysis Reporting System, and the estimated intervals were calculated by using a Geographic Information System software. By comparing the estimated intervals with actual emergency medical services records, the field triage patterns for road patients were investigated at the state and county levels.

RESULTS AND CONCLUSIONS

With the help of the interval prediction maps, the different triage patterns among counties were identified. Further, the average fatalities per 100,000 population by county from the National Highway Traffic Safety Administration were adopted to clarify the associated outcomes. The linear regression analysis results revealed that, for most states, all intervals except the notification interval had a significant correlation with the mortality. The estimated interval had a more significant relationship with the mortality than the actual transport interval. Practical applications: These findings indicated that adhering to the "golden hour" without regarding the destination may not be helpful for the survival of road trauma patients. The regression analyses and the interval maps can be used to identify patterns of inappropriate destination selection so that prospective decision-making can be improved.

Prehospital end-tidal CO2 as an early marker for transfusion requirement in trauma patients

OBJECTIVE

Below normal end-tidal carbon dioxide measurement (ETCO2) is associated with worse outcomes in sepsis and trauma patients as compared to patients with normal ETCO2. We sought to determine if ETCO2 can be used in the prehospital setting to predict transfusion requirement, operative hemorrhage control, or mortality in the first 24 h after admission for trauma.

METHODS

This is a retrospective cohort study at a suburban, academic Level 1 Trauma Center. Patients were sequentially identified as prehospital trauma alerts from a single EMS system which requires, per policy, ETCO2 for all traumas. One year of prehospital data was collected and paired with hospital trauma registry data. Comparisons were made between ETCO2 values for patients who required transfusion, operative blood loss control, or who died, and those who did not.

RESULTS

Two hundred thirty-five trauma patients were transported via the study EMS system, of which 105 (44.7%) had documented ETCO2 values. Patient mean age was 60 (SD24) years with 59 (56.2%) male. Three patients were intubated prehospital and seven were intubated in the trauma bay. Mean prehospital ETCO2 for those who needed transfusion, surgery, or died (n = 11) was 25.7 (9.1) compared to 30.6 (7.8) for those who did not (p = 0.049). Optimal cutoff for our population was EtCO2 ≤ 27 with a sensitivity of 72.7% (95% CI 32-93) and specificity of 72.2% (62-81).

CONCLUSION

Below normal ETCO2 values were associated with increase need for transfusion, operative intervention, and death. Further study is warranted to determine if ETCO2 outperforms other predictors of severe trauma.

Mortality of trauma patients treated at trauma centers compared to non-trauma centers in Sweden: a retrospective study

Objective

The main objective was to compare the 30-day mortality rate of trauma patients treated at trauma centers as compared to non-trauma centers in Sweden. The secondary objective was to evaluate how injury severity influences the potential survival benefit of specialized care.

Methods

This retrospective study included 29,864 patients from the national Swedish Trauma Registry (SweTrau) during the period 2013–2017. Three sampling exclusion criteria were applied: (1) Injury Severity Score (ISS) of zero; (2) missing data in any variable of interest; (3) data falling outside realistic values and duplicate registrations. University hospitals were classified as trauma centers; other hospitals as non-trauma centers. Logistic regression was used to analyze the effect of trauma center care on mortality rate, while adjusting for other factors potentially affecting the risk of death.

Results

Treatment at a trauma center in Sweden was associated with a 41% lower adjusted 30-day mortality (odds ratio 0.59 [0.50–0.70], p < 0.0001) compared to non-trauma center care, considering all injured patients (ISS ≥ 1). The potential survival benefit increased substantially with higher injury severity, with up to > 70% mortality decrease for the most critically injured group (ISS ≥ 50).

Conclusions

There exists a potentially substantial survival benefit for trauma patients treated at trauma centers in Sweden, especially for the most severely injured. This study motivates a critical review and possible reorganization of the national trauma system, and further research to identify the characteristics of patients in most need of specialized care.

Comorbidities, anticoagulants, and geriatric-specific physiology for the field triage of injured older adults

BACKGROUND

Comorbid conditions and anticoagulants have been considered as field triage criteria to raise the sensitivity for identifying seriously injured older adults, but research is sparse. We evaluated the utility of comorbidities, anticoagulant use, and geriatric-specific physiologic measures to improve the sensitivity of the field triage guidelines for high-risk older adults in the out-of-hospital setting.

METHODS

This was a cohort study of injured adults 65 years or older transported by 44 emergency medical services agencies to 51 trauma and nontrauma hospitals in seven Oregon and Washington counties from January 1, 2011, to December 31, 2011. Out-of-hospital predictors included current field triage criteria, 13 comorbidities, preinjury anticoagulant use, and previously developed geriatric specific physiologic measures. The primary outcome (high-risk patients) was Injury Severity Score of 16 or greater or need for major nonorthopedic surgical intervention. We used binary recursive partitioning to develop a clinical decision rule with a target sensitivity of 95% or greater.

RESULTS

There were 5,021 older adults, of which 320 (6.4%) had Injury Severity Score of 16 or greater or required major nonorthopedic surgery. Of the 2,639 patients with preinjury medication history available, 400 (15.2%) were taking an anticoagulant. Current field triage practices were 36.6% sensitive (95% confidence interval [CI], 31.2%-42.0%) and 90.1% specific (95% CI, 89.2%-91.0%) for high-risk patients. Recursive partitioning identified (in order): any current field triage criteria, Glasgow Coma Scale score of 14 or less, geriatric-specific vital signs, and comorbidity count of 2 or more. Anticoagulant use was not identified as a predictor variable. The new criteria were 90.3% sensitive (95% CI, 86.8%-93.7%) and 17.0% specific (95% CI, 15.8%-18.1%).

CONCLUSIONS

The current field triage guidelines have poor sensitivity for high-risk older adults. Adding comorbidity information and geriatric-specific physiologic measures improved sensitivity, with a decrement in specificity.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic, level II.

Does Mechanism of Injury Predict Trauma Center Need for Children?

OBJECTIVE

To determine if the Mechanism of Injury Criteria of the Field Triage Decision Scheme (FTDS) are accurate for identifying children who need the resources of a trauma center.

METHODS

EMS providers transporting any injured child ≤15 years, regardless of severity, to a pediatric trauma center in 3 midsized communities over 3 years were interviewed. Data collected through the interview included EMS observed physiologic condition, suspected anatomic injuries, and mechanism. Patients were then followed to determine if they needed the resources of a trauma center by reviewing their medical record after hospital discharge. Patients were considered to need a trauma center if they received an intervention included in a previously published consensus definition. Data were analyzed with descriptive statistics including positive likelihood ratios (+LR) and 95% confidence intervals (95%CI).

RESULTS

9,483 provider interviews were conducted and linked to hospital outcome data. Of those, 230 (2.4%) met the consensus definition for needing a trauma center. 1,572 enrolled patients were excluded from further analysis because they met the Physiologic or Anatomic Criteria of the FTDS. Of the remaining 7,911 cases, 62 met the consensus definition for needing a trauma center (TC). Taken as a whole, the Mechanism of Injury Criteria of the FTDS identified 14 of the remaining 62 children who needed the resources of a trauma center for a 77% under-triage rate. The mechanisms sustained were 36% fall (16 needed TC), 28% motor vehicle crash (MVC) (20 needed TC), 7% struck by a vehicle (10 needed TC), <1% motorcycle crash (none needed TC), and 29% had a mechanism not included in the FTDS (16 needed TC). Of those who sustained a mechanisms not listed in the FTDS, the most common mechanisms were sport related injuries not including falls (24% of 2,283 cases with a mechanism not included) and assault (13%). Among those who fell from a height greater than 10 feet, 4 needed a TC (+LR 5.9; 95%CI 2.8-12.6). Among those in a MVC, 41 were reported to have been ejected and none needed a TC, while 31 had reported meeting the intrusion criteria and 0 needed a TC. There were 32 reported as having a death in the same vehicle, and 2 needed a TC (+LR 7.42; 95%CI: 1.90-29.0).

CONCLUSION

Over a quarter of the children who needed the resources of a trauma center were not identified using the Physiologic or Anatomic Criteria of the Field Triage Decision Scheme. The Mechanism of Injury Criteria did not apply to over a quarter of the mechanisms experienced by children transported by EMS for injury. Use of the Mechanism Criteria did not greatly enhance identification of children who need a trauma center. More work is needed to improve the tool used to assist EMS providers in the identification of children who need the resources of a trauma center.

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 pre-hospital trauma triage and field triage decision rules in children (P2-T2 study): an observational study

BACKGROUND

Adequate pre-hospital trauma triage is crucial to enable optimal care in inclusive trauma systems. Transport of children in need of specialised trauma care to lower-level trauma centres is associated with adverse patient outcomes. We aimed to evaluate the diagnostic accuracy of paediatric field triage based on patient destination and triage tools.

METHODS

We did a multisite observational study (P2-T2) of all children (aged <16 years) transported with high priority by ambulance from the scene of injury to any emergency department in seven of 11 inclusive trauma regions in the Netherlands. Diagnostic accuracy based on the initial transport destination was evaluated in terms of undertriage rate (ie, the proportion of patients in need of specialised trauma care who were initially transported to a lower-level paediatric or adult trauma centre) and overtriage rate (ie, the proportion of patients not requiring specialised trauma care who were transported to a level-I [highest level] paediatric trauma centre). The Dutch National Protocol of Ambulance Services and Field Triage Decision Scheme triage protocols were externally validated using data from this cohort against an anatomical (Injury Severity Score [ISS] ≥16) and a resource-based reference standard.

FINDINGS

Between Jan 1, 2015, and Dec 31, 2017, 12 915 children (median age 10·3 years, IQR 4·2-13·6) were transported to the emergency department with injuries. 4091 (31·7%) patients were admitted to hospital, of whom 129 (3·2%) patients had an ISS of 16 or greater and 227 (5·5%) patients used critical resources within a limited timeframe. Ten patients died within 24 h of arrival at the emergency department. Based on the primary reference standard (ISS ≥16), the undertriage rate was 16·3% (95% CI 10·8-23·7) and the overtriage rate was 21·2% (20·5-22·0). The National Protocol of Ambulance Services had a sensitivity of 53·5% (95% CI 43·9-62·9) and a specificity of 94·0% (93·4-94·6), and the Field Triage Decision Scheme had a sensitivity of 64·5% (54·1-74·1) and a specificity of 84·3% (83·1-85·5).

INTERPRETATION

Too many children in need of specialised care were transported to lower-level paediatric or adult trauma centres, which is associated with increased mortality and morbidity. Current protocols cannot accurately discriminate between patients at low and high risk, and highly sensitive and child-specific triage tools need to be developed to ensure the right patient is transported to the right hospital.

FUNDING

The Netherlands Organisation for Health Research and Development, Innovation Fund Health Insurers.

Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients

Importance

A major component of trauma care is adequate prehospital triage. To optimize the prehospital triage system, it is essential to gain insight in the quality of prehospital triage of the entire trauma system.

Objective

To prospectively evaluate the quality of the field triage system to identify severely injured adult trauma patients.

Design, Setting, and Participants

Prehospital and hospital data of all adult trauma patients during 2012 to 2014 transported with the highest priority by emergency medical services professionals to 10 hospitals in Central Netherlands were prospectively collected. Prehospital data collected by the emergency medical services professionals were matched to hospital data collected in the trauma registry. An Injury Severity Score of 16 or more was used to determine severe injury.

Main Outcomes and Measures

The quality and diagnostic accuracy of the field triage protocol and compliance of emergency medical services professionals to the protocol.

Results

A total of 4950 trauma patients were evaluated of which 436 (8.8%) patients were severely injured. The undertriage rate based on actual destination facility was 21.6% (95% CI, 18.0-25.7) with an overtriage rate of 30.6% (95% CI, 29.3-32.0). Analysis of the protocol itself, regardless of destination facility, resulted in an undertriage of 63.8% (95% CI, 59.2-68.1) and overtriage of 7.4% (95% CI, 6.7-8.2). The compliance to the field triage trauma protocol was 73% for patients with a level 1 indication.

Conclusions and Relevance

More than 20% of the patients with severe injuries were not transported to a level I trauma center. These patients are at risk for preventable morbidity and mortality. This finding indicates the need for improvement of the prehospital triage protocol.

Using G-FAST to recognize emergent large vessel occlusion: a training program for a prehospital bypass strategy

INTRODUCTION

The shorter the time between the onset of symptoms and reperfusion using endovascular thrombectomy, the better the functional outcome of patients. A training program was designed for emergency medical technicians (EMTs) to learn the gaze-face-arm-speech-time test (G-FAST) score for initiating a prehospital bypass strategy in an urban city. This study aimed to evaluate the effect of the training program on EMTs.

METHODS

All EMTs in the city were invited to join the training program. The program consisted of a 30 min lecture and a 20 min video which demonstrated the G-FAST evaluation. The participants underwent tests before and after the program. The tests included (1) a questionnaire of knowledge, attitudes, confidence, and behaviors towards stroke care; and (2) watching 10 different scenarios in a video and answering questions, including eight sub-questions of G-FAST parameters, and choosing a suitable receiving hospital.

RESULTS

In total, 1058 EMTs completed the training program. After the program, significant improvement was noted in knowledge, attitudes, and confidence, as well as scenario judgement. The performance of the EMTs in evaluating G-FAST criteria in comatose patients was relatively poor in the pre-test and improved significantly after the training course. Although the participants answered the G-FAST items correctly, they tended to overtriage the patients and refer them to higher-level hospitals.

CONCLUSIONS

A short training program can improve the ability to identify stroke patients and choose a suitable receiving hospital. A future training program could put further emphasis on how to evaluate comatose patients and choose a suitable receiving hospital.

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.

Identifying Predictors of Undertriage in Injured Older Adults After Implementation of Statewide Geriatric Trauma Triage Criteria

OBJECTIVES

The objective was to identify factors associated with transport of injured older adults meeting statewide geriatric trauma triage criteria to a trauma center.

METHODS

An observational retrospective cohort study using the 2009 to 2011 Ohio Trauma Registry. Subjects were adults ≥ 70 years old who met Ohio's geriatric triage criteria for trauma center transport by emergency medical services. We created multivariable logistic regression models to identify predictors of initial and ultimate (e.g., interfacility transfer) transport to a Level I or II trauma center and to a Level I, II, or III center.

RESULTS

Of 10,411 subjects, 47% were initially and 59% were ultimately transported to a Level I or II trauma center with rates of 66 and 74%, respectively, for transport to a Level I, II, or III center. For initial transport to a Level I or II center, age 80 to 89 (odds ratio [OR] = 0.89), age ≥ 90 (OR = 0.76), and either only a Level 3 (OR = 0.3) or no trauma center (OR = 0.11) in county of residence had decreased odds of transport, while male sex (OR = 1.38), black race (OR = 2.07), Injury Severity Score (ISS) 10-15 (OR = 1.99), ISS > 15 (OR = 2.85), and Glasgow Coma Scale score < 9 (OR = 2.11) had increased odds. Results were similar for ultimate transport to a Level I or II center. Analyzing transport to a Level I, II, or III center demonstrated similar results except a Level III trauma center in county of residence was associated with increased odds (OR = 2.00 for initial and 2.21 for ultimate) of transport to a Level I, II, or III center.

CONCLUSIONS

We identified factors independently associated with failure to transport injured older adults to trauma centers in statewide data collected after adoption of geriatric triage criteria. Lack of a trauma center in the county of residence remained a factor even in analyses that included ultimate transport.

Evaluation of Trauma Triage Criteria Performance in a Regional Trauma System

Objective: We evaluated the performance of individual trauma triage criteria using data from a regional trauma registry. Methods: Los Angeles County (LAC) paramedics use triage criteria adapted from the 2011 Center for Disease Control (CDC) guidelines to triage injured patients to Trauma Centers (TCs). TCs report outcomes to a LAC EMS registry. We abstracted data for patients 15 years or older from 2013 to 2015 and identified all trauma triage criteria that were met for each encounter. Study outcomes were: (1) "clear need" for a TC, defined as receiving a non-orthopedic operative intervention within 6 hours of arrival, injury severity score (ISS) > 15, or surgical ICU admission; or (2) "no need" for a TC, defined as discharge home from the emergency department (ED). We also defined "possible need" as those patients not discharged home from the ED, inclusive of "clear need" and all other admitted patients. For each individual triage criteria, we calculated the positive likelihood ratios and positive predictive values for TC need. Results: There were 71,536 adult patients in the registry transported by EMS to a LAC TC during the study. Median age was 38 years (IQR 25-55) with 73% male. There were 23,628 (33%) who met "no need" criteria for a TC, leaving 47,908 (67%) patients with "possible need" for a TC, of whom 13,343 patients (19% of total) met "clear need" for a TC. No individual trauma criterion met the a priori likelihood ratio threshold of 10 for predicting "clear need" for a TC. Cardiopulmonary arrest with penetrating torso trauma and flail chest met this threshold for "possible need." Conclusion: In this retrospective analysis, no individual triage criterion definitively identified patients who benefit from transport to a TC. Yet, the majority of patients demonstrated potential benefit for nearly all criteria, supporting CDC recommendations that trauma triage criteria be considered in their entirety, not as individual criterion.

Maximizing geographical efficiency: An analysis of the configuration of Colorado's trauma system

BACKGROUND

Trauma center designation in excess of need risks dilution of experience, reduction in research and training opportunities, and increased costs. The objective of this study was to evaluate the use of a novel data-driven approach (whole-system mathematical modeling of patient flow) to compare the configuration of an existing trauma system with a mathematically optimized design, using the State of Colorado as a case study.

METHODS

Geographical network analysis and multiobjective optimization, 105,448 patients injured in the State of Colorado between 2009 and 2013, who met the criteria for inclusion in the state-mandated trauma registry maintained by the Colorado Department of Public Health and Environment were included. We used the Nondominant Sorting Genetic Algorithm II to conduct a multiobjective optimization of possible trauma system configurations, with the objectives of minimizing total system access time, and the number of casualties who could not reach the desired level of care.

RESULTS

Modeling suggested that system configurations with high-volume Level I trauma centers could be mathematically optimized with two centers rather than the current three (with an estimated annual volume of 970-1,020 and 715-722 severely injured patients per year), four to five Level II centers, and 12 to 13 Level III centers. Configurations with moderate volume Level I centers could be optimized with three such centers (with estimated institutional volumes of 439-502, 699-947, and 520-726 severely injured patients per year), two to five Level II centers, and eight to ten Level III centers.

CONCLUSION

The modeling suggested that the configuration of Colorado's trauma system could be mathematically optimized with fewer trauma centers than currently designated. Consideration should be given to the role of optimization modeling to inform decisions about the ongoing efficiency of trauma systems. However, modeling on its own cannot guarantee improved patient outcome; thus, the use of model results for decision making should take into account wider contextual information.

LEVEL OF EVIDENCE

Epidemiological, Level IV.

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.

Undertriage of major trauma patients at a university hospital: a retrospective cohort study

Background

Studies show increased mortality among severely injured patients not met by trauma team. Proper triage is important to ensure that all severely injured patients receive vital trauma care. In 2017 a new national trauma plan was implemented in Norway, which recommended the use of a modified version of “Guidelines for Field Triage of Injured Patients” to identify severely injured patients.

Methods

A retrospective study of 30,444 patients admitted to Haukeland University Hospital in 2013, with ICD-10 injury codes upon discharge. The exclusion criteria were department affiliation considered irrelevant when identifying trauma, patients with injuries that resulted in Injury Severity Score < 15, patients that did receive trauma team, and patients admitted > 24 h after time of injury. Information from patient records of every severely injured patient admitted in 2013 was obtained in order to investigate the sensitivity of the new guidelines.

Results

Trauma team activation was performed in 369 admissions and 85 patients were identified as major trauma. Ten severely injured patients did not receive trauma team resuscitation, resulting in an undertriage of 10.5%. Nine out of ten patients were men, median age 54 years. Five patients were 60 years or older. All of the undertriaged patients experienced fall from low height (< 4 m). Traumatic brain injury was seen in six patients. Six patients had a Glasgow Coma Scale score ≤ 13. The new trauma activation guidelines had a sensitivity of 95.0% in our 2013 trauma population. The degree of undertriage could have been reduced to 4.0% had the guidelines been implemented and correctly applied.

Conclusions

The rate of undertriage at Haukeland University Hospital in 2013 was above the recommendations of less than 5%. Use of the new trauma guidelines showed increased triage precision in the present trauma population.

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.

Anticoagulated Trauma Patients: A Level I Trauma Center's Response to a Growing Geriatric Population

BACKGROUND

Injured older adults often receive delayed care in the emergency department (ED) because they do not meet criteria for trauma team activation (TTA). This is particularly dangerous for the increasing number of patients taking anticoagulant or antiplatelet (AC/AP) medication at the time of injury.

OBJECTIVES

The present study examined improvements in processes of care and triage accuracy when TTA criteria include an escalated response for older anticoagulated patients.

METHODS

A retrospective study was performed at a Level I trauma center. The study population (referred to as A55) included patients aged 55 years or older who were taking an AC/AP medication at the time of injury. Study periods included 11 months prior to the criteria change (Phase 1: July 2013-May 2014; n = 107) and 11 months after the change (Phase 2: July 2014-May 2015; n = 211). Differences were assessed with Kruskal-Wallis and chi-squared tests.

RESULTS

More A55 patients received a full or limited TTA after criteria were revised (70% vs. 26%, p < 0.001). Undertriage was reduced from 13% to 2% (p < 0.001). The trauma center significantly decreased time to first laboratory result, time to first computed tomography scan, and total time in ED prior to admission for A55 patients arriving from the scene of injury or by private vehicle.

CONCLUSION

Criteria that escalated the trauma response for A55 patients led to reductions in undertriage for anticoagulated older adults, as well as more timely mobilization of important clinical resources.