Impact of triage guidelines on prehospital triage: comparison of guidelines with a statistical model

Substantial heterogeneity in trauma triage tool characteristic operationalization for identification of major trauma: a hybrid systematic review

PURPOSE

Trauma Triage Tools (TTTs) support pre-hospital staff to identify major trauma patients based on prehospital characteristics and bring them to appropriate trauma centres. However, while triaging trauma has been examined extensively, there appears to be little consensus on how variables within TTTs are applied. We therefore aimed to examine the prehospital characteristics and their operationalization applied in the international literature in TTTs.

METHODS

We applied a hybrid systematic review approach. Searches were conducted in multiple databases. We initially searched for systematic reviews that analyse prehospital characteristics applied in TTTs, then supplemented this with an updated search of original TTT papers from November 2019.

RESULTS

We identified 92 papers which identified 52 adult general population TTTs. Results indicate considerable heterogeneity in prehospital characteristics included in TTTs internationally. There was similarity in the higher-level categories included in the tools: tools often included measurements of a patient's physiological characteristics, injury characteristics, mechanism of injury and any modifiers for high-risk groups. However, the prehospital characteristics that made up those groups, how they were applied and interpreted were found to vary considerably.

CONCLUSION

While there is agreement in the higher-level categories used in TTTs, the thresholds adopted in specific variables vary widely, which may reflect statistical rather than clinical considerations. This may contribute to considerable variation in standards of major trauma triaging internationally. An agreed taxonomy of operationalization of prehospital characteristics used in TTTs is required to prevent sub-optimal clinical decision-making in major trauma triaging.

REGISTRATION

PROSPERO CRD42023393094.

The Oregon District Shooting: Reviewing the Pre-Hospital Protocols and the Role of the Resident During a Multiple Casualty Event

Background: Review of multiple casualty events (MCEs) protocols in an academic trauma center and more importantly role of residents in management of MCEs has not been discussed. Also, no real-world examples have been described. This study reviews utilization of multiple casualty protocols by the area hospitals and EMS along with role of residents in one such real-world MCEMethods: A mass shooting event in the Oregon District in Dayton, Ohio from 2019 was reviewed. MCE protocols from a Level I trauma center were reviewed as well as patient outcomes and role of residents.Results: A total of 10 casualties were observed and 38 patients presented to hospitals throughout the city. There were 25 patients presented to the Level I trauma center, 1 to the Level II trauma center, and 12 to the Level III trauma centers in the community. Surgical and Emergency residents performed initial triage upon arrival to the ED, managed resuscitation, and performed various procedures under supervision of attending staff. A total of 5 patients required emergent surgery and 4 patients required tourniquets. All patients that were presented to the hospitals survived.Conclusion: MCEs are going to continue, and healthcare systems should have protocols in place. Residents are a valuable resource to hospital systems that provide trauma services. Creation of a protocol with the assistance of EMS will allow first responders to utilize resources available. We recommend testing of this protocol, as an MCE in your area may not be a matter of if, but when.

Field Measures Are All You Need: Predicting Need for Surgery in Elderly Ground-Level Fall Patients via Machine Learning

BACKGROUND

As ground-level falls (GLFs) are a significant cause of mortality in elderly patients, field triage plays an essential role in patient outcomes. This research investigates how machine learning algorithms can supplement traditional t-tests to recognize statistically significant patterns in medical data and to aid clinical guidelines.

METHODS

This is a retrospective study using data from 715 GLF patients over 75 years old. We first calculated P-values for each recorded factor to determine the factor's significance in contributing to a need for surgery (P < .05 is significant). We then utilized the XGBoost machine learning method to rank contributing factors. We applied SHapley Additive exPlanations (SHAP) values to interpret the feature importance and provide clinical guidance via decision trees.

RESULTS

The three most significant P-values when comparing patients with and without surgery are as follows: Glasgow Coma Scale (GCS) (P < .001), no comorbidities (P < .001), and transfer-in (P = .019). The XGBoost algorithm determined that GCS and systolic blood pressure contribute most strongly. The prediction accuracy of these XGBoost results based on the test/train split was 90.3%.

DISCUSSION

When compared to P-values, XGBoost provides more robust, detailed results regarding the factors that suggest a need for surgery. This demonstrates the clinical applicability of machine learning algorithms. Paramedics can use resulting decision trees to inform medical decision-making in real time. XGBoost's generalizability power increases with more data and can be tuned to prospectively assist individual hospitals.

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.

Mechanism of injury and special considerations as predictive of serious injury: A systematic review

OBJECTIVES

The Centers for Disease Control and Prevention's field triage guidelines (FTG) are routinely used by emergency medical services personnel for triaging injured patients. The most recent (2011) FTG contains physiologic, anatomic, mechanism, and special consideration steps. Our objective was to systematically review the criteria in the mechanism and special consideration steps that might be predictive of serious injury or need for a trauma center.

METHODS

We conducted a systematic review of the predictive utility of mechanism and special consideration criteria for predicting serious injury. A research librarian searched in Ovid Medline, EMBASE, and the Cochrane databases for studies published between January 2011 and February 2021. Eligible studies were identified using a priori inclusion and exclusion criteria. Studies were excluded if they lacked an outcome for serious injury, such as measures of resource use, injury severity scores, mortality, or composite measures using a combination of outcomes. Given the heterogeneity in populations, measures, and outcomes, results were synthesized qualitatively focusing on positive likelihood ratios (LR+) whenever these could be calculated from presented data or adjusted odds ratios (aOR).

RESULTS

We reviewed 2418 abstracts and 315 full-text publications and identified 42 relevant studies. The factors most predictive of serious injury across multiple studies were death in the same vehicle (LR+ 2.2-7.4), ejection (aOR 3.2-266.2), extrication (LR+ 1.1-6.6), lack of seat belt use (aOR 4.4-11.3), high speeds (aOR 2.0-2.9), concerning crash variables identified by vehicle telemetry systems (LR+ 4.7-22.2), falls from height (LR+ 2.4-5.9), and axial load or diving (aOR 2.5-17.6). Minor or inconsistent predictors of serious injury were vehicle intrusion (LR+ 0.8-7.2), cardiopulmonary or neurologic comorbidities (LR+ 0.8-3.1), older age (LR+ 0.6-6.8), or anticoagulant use (LR+ 1.1-1.8).

CONCLUSIONS

Select mechanism and special consideration criteria contribute positively to appropriate field triage of potentially injured patients.

Trauma-Specific Performance Improvement Activities for Emergency Medical Services Providers: A Statewide Perspective

INTRODUCTION

Trauma-specific performance improvement (PI) activities are highly variable among Emergency Medical Services (EMS) providers. This study assesses the perception of the trauma PI activities of EMS providers in the state of Ohio and identifies potential barriers to conducting a successful program.

METHODS

An institutional review board-approved, voluntary, and anonymous Qualtrics survey was disseminated to all EMS agencies registered under the Ohio Department of Public Safety throughout the 88 counties of Ohio. It included questions regarding what agencies considered trauma-specific PI activities, how frequently they completed those activities, and barriers related to conducting such PI activities. There were both open-ended and closed-ended questions in the survey, along with a follow-up interview. The data were descriptively and thematically analyzed.

RESULTS

From the recorded responses (341), most the respondents (98.5%) either agreed or strongly agreed that trauma-specific PI activities improve performance of EMS providers, while only 63.8% (218) of the agencies performed them. Some activities considered as trauma PI and conducted at least once a month included (1) record keeping (74.6%), (2) confirmation on the use of correct triage protocols (66.9%), (3) measuring response time on trauma calls (60.0%), (4) PI reviews of trauma cases (56.9%), and (5) obtaining feedback from the receiving facility and or authorizing physicians (48.5%). Primary barriers to performing trauma PI activities included a lack of interest and financial resources, followed by system-level reasons such as unavailability of training centers and a lack of regional/state support. Thematic analysis of the data suggested that improved communication and awareness of trauma PI, sharing statewide data on trauma PI, better synchronization among EMS agencies and trauma centers, and enhanced EMS funding could potentially improve trauma-specific PI programs at the EMS level.

CONCLUSIONS

Our results showed variability in the perception, execution, and availability of trauma-specific PI activities among EMS agencies in the state. Common barriers could potentially be mitigated by collaboration between agencies, trauma centers, and state-led initiatives. With the increased frequency of mass shootings and other large-scale trauma disasters, it is imperative from a state and regional level to address these inconsistencies and further elucidate effective measures of trauma PI for the EMS community.

Locating trauma centers considering patient safety

Trauma continues to be the leading cause of death and disability in the U.S. for those under the age of 44, making it a prominent public health problem. Recent literature suggests that geographical maldistribution of Trauma Centers (TCs), and the resultant increase of the access time to the nearest TC, could impact patient safety and increase disability or mortality. To address this issue, we introduce the Trauma Center Location Problem (TCLP) that determines the optimal number and location of TCs in order to improve patient safety. We model patient safety through a surrogate measure of mistriages, which refers to a mismatch in the injury severity of a trauma patient and the destination hospital. Our proposed bi-objective optimization model directly accounts for the two types of mistriages, system-related under-triage (srUT) and over-triage (srOT), both of which are estimated using a notional tasking algorithm. We propose a heuristic based on the Particle Swarm Optimization framework to efficiently derive a near-optimal solution to the TCLP for realistic problem sizes. Based on 2012 data from the state of Ohio, we observe that the solutions are sensitive to the choice of weights for srUT and srOT, volume requirements at a TC, and the two thresholds used to mimic EMS decisions. Using our approach to optimize that network resulted in over 31.5% reduction in the objective with only 1 additional TC; redistribution of the existing 21 TCs led to 30.4% reduction.

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).

Factors associated with the occurrence of prehospital medical interventions provided by physicians among non-trauma patients: a single-centre retrospective observational study in Japan

OBJECTIVES

Physician-staffed prehospital units are widely used in many countries. The criteria for predicting fatal injury are well recognised for trauma victims, but there are no criteria for predicting critical condition for non-trauma patients. This study aimed to identify the factors associated with non-trauma cases receiving prehospital interventions by physicians.

DESIGN

Retrospective observational study.

SETTING

Physician-staffed prehospital unit (car) at a single-base hospital in a suburban city in Japan.

PARTICIPANTS

Participants were 1058 non-trauma patients who received prehospital medical examinations from April 2014 to December 2017.

OUTCOME MEASURES

The outcome was the occurrence of physician-only interventions (POIs) exceeding paramedics' competencies. Univariate analysis and multiple logistic regression analysis were performed. Patient's age and gender, presumed disease category, type of location of the emergency, time of alarm, activation time, activator's occupation, time to arrival, transportation time and the destination facility were included as covariates.

RESULTS

POIs were provided to 380 (36%) patients. Patient's age, presumed disease category, type of location of the emergency, activator's occupation, time to arrival, transportation time and the destination facility were identified as potential independent factors. Multiple logistic regression analysis found that patient's age, presumed disease category, type of location of the emergency, transportation time and destination facility were the significant independent factors. Transportation times of more than 15 min (adjusted ORs (AORs)=4.17, 95% CI 2.59 to 6.72, p<0.01) or 10 to 14 min (AOR=3.66, 95% CI 2.32 to 5.79, p<0.01) and patient age of 40-59 years (AOR=3.16, 95% CI 1.66 to 6.01, p<0.01) were the strongest independent factors.

CONCLUSIONS

This study identified the factors associated with non-trauma cases receiving prehospital POIs. Patient's age, presumed disease category, type of location of the emergency and transportation time are independent factors associated with requiring POIs.

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.