Evaluation and Comparison of Different Prehospital Triage Scores of Trauma Patients on In-Hospital Mortality

The association between regional guidelines compliance and mortality in severe trauma patients: an observational, retrospective study

BACKGROUND AND IMPORTANCE

Trauma is a major cause of mortality and morbidity. Regional trauma systems are the cornerstones of healthcare systems, helping to improve outcomes and avoid preventable deaths in severe trauma patients.

OBJECTIVES

The goal of this study was to evaluate the association between compliance with the guidelines of a regional trauma management system and survival at 28 days of severe trauma patients.

DESIGN, SETTINGS AND PARTICIPANTS

We conducted a retrospective observational study from 1 January 2019 to 31 December 2019. All adult patients admitted for trauma at the University Hospital of Marseille (France) and requiring a pre-hospital medical team were analysed. Compliance with a list of 30 items based on the regional guidelines for the trauma management was evaluated. Each item was classified as compliant, not compliant or not applicable. The global compliance was calculated for each patient as the ratio between the number of compliant items over the number of applicable items.

OUTCOME MEASURES AND ANALYSIS

The primary aim was to measure the association between compliance with the guidelines and survival at 28 days using a logistic regression. Secondary objectives were to measure the association between compliance with the guidelines and survival at 28 days and 6 months according to the severity of the patients, using a cut-off of the injury severity score at 24.

MAIN RESULTS

A total of 494 patients with a median age of 35.0 (25.0-50.0) years were analysed. Global compliance with guidelines was 63%. Mortality at 28 days and 6 months was assessed at 33 (6.7%) and 37 (7.5%) patients, respectively. The level of compliance was associated with reduced mortality at 28 days [odds ratio (OR) at 0.94 and 95% confidence interval (CI) at 0.89-0.98]. In the subgroup of 122 patients with an injury severity score above 23, the level of compliance was associated with reduced mortality at 28 days [OR: 0.93 (95% CI: 0.88-0.99)] and 6 months [OR: 0.93 (95% CI: 0.87-0.99)].

CONCLUSION

Increased levels of compliance with the guidelines in severe trauma patients were associated with an increase in survival, notably in the most severe patients.

Spanish vs USA cohort comparison of prehospital trauma scores to predict short-term mortality

BACKGROUND

This study aimed to evaluate three prehospital early warning scores (EWSs): RTS, MGAP and MREMS, to predict short-term mortality in acute life-threatening trauma and injury/illness by comparing United States (US) and Spanish cohorts.

METHODS

A total of 8,854 patients, 8,598/256 survivors/nonsurvivors, comprised the unified cohort. Datasets were randomly divided into training and test sets. Training sets were used to analyse the discriminative power of the scores in terms of the area under the curve (AUC), and the score performance was assessed in the test set in terms of sensitivity (SE), specificity (SP), accuracy (ACC) and balanced accuracy (BAC).

RESULTS

The three scores showed great discriminative power with AUCs>0.90, and no significant differences between cohorts were found. In the test set, RTS/MREMS/MGAP showed SE/SP/ACC/BAC values of 86.0/89.9/89.6/87.1%, 91.0/86.9/87.5/88.5%, and 87.7/82.9/83.4/85.2%, respectively.

CONCLUSIONS

All EWSs showed excellent ability to predict the risk of short-term mortality, independent of the country.

Older patients' perceptions of the Swedish ambulance service: A qualitative exploratory study

BACKGROUND

As worldwide life expectancy increases, the Swedish Ambulance Service is likely to be affected by the demographic shift towards a larger proportion of older persons. An older population tends to increase the demand for ambulances, indicating a need to illuminate older patients' perspective. Thus, the aim of this study was to explore older patients' perceptions of the Swedish Ambulance Service.

METHODS

This interview study employed a descriptive qualitative design with a phenomenographic approach in accordance with Dahlgren and Fallsberg.

RESULTS

Three main descriptive categories emerged to describe the underlying conceptions in the interviews; A double-edged encounter, Trust is created by perceived competence, and Safety through accessibility in vulnerable situations.

CONCLUSION

Older patients described trust in ambulance clinicians as a prerequisite for feeling safe enough to share their feelings and allow a bodily examination. However, they also criticized the care provided because they questioned the need for certain actions.

Development and Asian-wide validation of the Grade for Interpretable Field Triage (GIFT) for predicting mortality in pre-hospital patients using the Pan-Asian Trauma Outcomes Study (PATOS)

Background

Field triage is critical in injury patients as the appropriate transport of patients to trauma centers is directly associated with clinical outcomes. Several prehospital triage scores have been developed in Western and European cohorts; however, their validity and applicability in Asia remains unclear. Therefore, we aimed to develop and validate an interpretable field triage scoring systems based on a multinational trauma registry in Asia.

Methods

This retrospective and multinational cohort study included all adult transferred injury patients from Korea, Malaysia, Vietnam, and Taiwan between 2016 and 2018. The outcome of interest was a death in the emergency department (ED) after the patients' ED visit. Using these results, we developed the interpretable field triage score with the Korea registry using an interpretable machine learning framework and validated the score externally. The performance of each country's score was assessed using the area under the receiver operating characteristic curve (AUROC). Furthermore, a website for real-world application was developed using R Shiny.

Findings

The study population included 26,294, 9404, 673 and 826 transferred injury patients between 2016 and 2018 from Korea, Malaysia, Vietnam, and Taiwan, respectively. The corresponding rates of a death in the ED were 0.30%, 0.60%, 4.0%, and 4.6% respectively. Age and vital sign were found to be the significant variables for predicting mortality. External validation showed the accuracy of the model with an AUROC of 0.756-0.850.

Interpretation

The Grade for Interpretable Field Triage (GIFT) score is an interpretable and practical tool to predict mortality in field triage for trauma.

Funding

This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (Grant Number: HI19C1328).

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.

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.

Accuracy and external validation of the modified rapid emergency medicine score in road traffic injuries in a Bangkok level I trauma center

Background

Trauma is a significant public health problem. Therefore, many injury scores have been created to predict mortality and triage patients. This study aims to validate the modified Rapid Emergency Medicine Score (mREMS) for in-hospital mortality prediction in road traffic injuries and compare the mREMS with the revised trauma score (RTS) and the mechanisms, Glasgow Coma Scale (GCS), age, and arterial pressure (MGAP) score.

Methods

Data were retrospectively collected from the Vajira Hospital (1,033 cases). The mREMS was calculated from six predictors: age, systolic blood pressure, heart rate, respiratory rate, pulse oxygen saturation, and GCS. The receiver operating characteristic curve was plotted, and the area under the curve (AUC) was calculated. The AUC and 95% confidence interval (CI) of the mREMS were compared with the AUCs of other scores. Model calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test.

Results

The mREMS was significantly better than the RTS at predicting death in road traffic injury patients [mREMS: AUCs, 0.909 (95% CI, 0.866-0.951); RTS: AUCs, 0.859 (95% CI, 0.791-0.927] (p = 0.023). However, the difference between the AUCs of the mREMS and MGAP score was not statistically significant (p = 0.150). The mREMS' calibration performance was also satisfactory in this dataset based on the Hosmer-Lemeshow goodness-of-fit test (p = 0.277).

Conclusion

In the road traffic injury population, the mREMS is an excellent predictor of in-hospital mortality. These results can be applied to improve triage. However, this score should be further validated in other trauma centers before nationwide implementation.

Interest of the MGAP score on in-hospital trauma patients: Comparison with TRISS, ISS and NISS scores

Trauma scoring systems were created to predict mortality and enhance triage capabilities. However, efficacy of scoring systems to predict mortality and accuracy of originally reported severity thresholds remains uncertain. A single-center, retrospective study was conducted at University of Virginia (UVA), an American College of Surgeons verified Level I trauma center. We compared four scoring systems: MGAP (Mechanism, Glasgow Coma Scale, Age, and arterial pressure), Injury Severity Score (ISS), New Injury Severity Score (NISS), and Trauma Related Injury Severity Score (TRISS) to predict in-hospital mortality and disposition from the emergency department to higher acuity level of care including mortality (i.e. operating room, intensive care unit, morgue) versus standard floor admission using area under the curve (AUC) for receiver operating characteristic analysis. Second, we examined sensitivity of these scores at standard thresholds to determine if adjustments were needed to minimize under-triage (sensitivity ≥95%). TRISS was the best predictor of mortality in a cohort of n = 16,265 with AUC of 0.920 (95% CI: 0.911-0.929, p<0.0001), followed by MGAP with AUC of 0.900 (95% CI: 0.889-0.911, p<0.0001), and finally ISS and NISS (0.830 (95% CI: 0.814-0.847) and 0.827 (95% CI: 0.809-0.844) respectively). NISS was the best predictor of high acuity disposition with an AUC of 0.729 (95% CI: 0.721-0.736, p<0.0001), followed by ISS with AUC of 0.714 (95% CI: 0.707-0.722, p<0.0001), and finally TRISS and MGAP (0.673 (95% CI: 0.665-0.682) and 0.613 (95% CI: 0.604-0.621) respectively (p<0.0001). At historic thresholds, no scoring system displayed adequate sensitivity to predict mortality, with values ranging from 73% for ISS to 80% for NISS. In conclusion, in the reported study cohort, TRISS was the best predictor of mortality while NISS was the best predictor of high acuity disposition. We also stress updating scoring system thresholds to achieve ideal sensitivity, and investigating how scoring systems derived to predict mortality perform when predicting indicators of morbidity such as disposition from the emergency department.

Development of a Nomogram Model to Predict in-Hospital Survival in Patients with Multiple Trauma

Background

Herein, we purposed to establish a nomogram model capable of assessing the probability of in-hospital survival in patients with multiple trauma.

Methods

Our retrospective study is associated with 286 multiple trauma patients with 21 variables from 2017 to 2021 in The Second Affiliated Hospital, Hengyang Medical School, University of South China. We performed the univariate and multivariate logistic regression analyses for investigating the risk factors of multiple trauma. Further, we constructed a novel nomogram model, and this nomogram was evaluated by a calibration plot. Based on the multivariate analysis or the nomogram prediction model, we calculated the risk score of each patient for multiple trauma. Moreover, we compared the survival probability between the high-risk score and low-risk score groups. Finally, we assessed the discrimination of the risk score by using the C-index and the time-dependent receiver operating characteristics (ROC) curve.

Results

Multivariate regression analysis revealed that the age and ISS scores were the independent risk factors, while the GCS score had protective effects on in-hospital survival. The high C-index and area under the curve (AUC) of the ROC curve confirmed reasonable discrimination for the multivariate analysis and the nomogram prediction model. Further, the calibration plot indicated reasonable accuracy of the nomogram predicting 30-day and 60-day survival probabilities.

Conclusion

The nomogram model established here has good predictive efficacy for in-hospital survival of patients with multiple injuries.

Epidemiology and outcomes of severe injury patients: Nationwide community-based study in Korea

INTRODUCTION

The aim of this study was to estimate the annual incidence of various severe injuries, case fatality rates, and case disability rates for patients in Korea.

MATERIALS AND METHODS

This community-based observational study involved all residents in Korea between Jan. 1, 2018, and Dec. 31, 2018. Nationwide data were retrieved from the patient care report of the National Fire Agency and hospital medical records review of the Korea Disease Control and Prevention Agency. Severe injury was defined as any injury that resulted in emergency medical service (EMS) use and any field-based physiologic abnormality: systolic blood pressure ≤90 mm Hg, respiratory rate <10 or >29 per min, or AVPU scale nonalert. Crude and adjusted incidence rates were calculated without any exclusion. Outcomes including the Glasgow Outcome Scale (GOS) at hospital discharge were assessed according to a medical review. Case-fatality and case-disability rates were calculated after excluding patients with unknown vital status.

RESULTS

During the one-year period, 36,363 severe injuries occurred, yielding a crude annual incidence rate of 70.9 per 100,000 population; 57.8% were traumatic injuries, and 42.2% were nontraumatic injuries. The adjusted annual incidence rates were 61.7/100,000 for all severe injuries, 35.3/100,000 for traumatic injuries, and 26.4/100,000 for nontraumatic injuries. The case-fatality rate was 24.3% for all severe injuries, 27.0% for traumatic injuries, and 21.0% for nontraumatic injuries. The case-disability rate of GOS 3,4 was 6.0%, and the case-disability rate of GOS 2-4 was 16.4% for all severe injury patients.

CONCLUSIONS

This nationwide community-based study revealed incidence rates and outcomes of severe injury patients in Korea.

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01019-z.

Assessment of earthquake casualties and comparison of accuracy of five injury triage methods: evidence from a retrospective study

OBJECTIVE

The use of an injury triage method among earthquake injury patients can facilitate the reasonable allocation of resources, but the various existing injury triage methods need further confirmation. This study aims to assess the accuracy of several injury triage methods, namely, the Simple Triage and Rapid Treatment (START) technique; CareFlight Injury Triage (CareFlight); Rapid Emergency Medicine Score (REMS); Triage Revised Trauma Score (T-RTS) and Triage Early Warning Score (TEWS), based on their effects on earthquake injury patients.

DESIGN

Data in the Huaxi Earthquake Casualty Database were analysed retrospectively.

SETTING

This study was conducted in China.

PARTICIPANTS

Data on 29 523 earthquake casualties were separately evaluated using the START technique, CareFlight, REMS, T-RTS and TEWS, with these being the five types of injury triage studied.

PRIMARY OUTCOME MEASURE

The receiver operating characteristic (ROC) curves for the five injury triages were calculated based on hospital deaths, injury severity scores greater than 15 points, and whether casualties stayed in the intensive care unit.

RESULTS

The ROC curve areas of the START technique, CareFlight, REMS, T-RTS and TEWS were 0.750, 0.737, 0.835, 0.736 and 0.797, respectively. Among the five injury triages, the most accurate in predicting hospital deaths was REMS, with an average area under the curve (AUC) of 0.835, with this due to the inclusion of more evaluation indicators.

CONCLUSION

All methods had an effect on the triage of earthquake mass casualties. Among them, the REMS injury triage method had the largest AUC of the five triage methods. Except for REMS, no obvious difference was found in the effect of the other four injury triage methods.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

ISS is not an appropriate tool to estimate overtriage

PURPOSE

The aim of this work is to study a cohort of patients of ISS < 15 admitted to a TC, and to determine the number of patients that ultimately benefited from the skills and resources specific of a level 1 trauma center.

METHODS

Retrospective study from a prospective cohort of patients admitted to TC (Beaujon Hospital, APHP) for suspected severe trauma from January 2011 to December 2017. The main outcome criterion was the use of surgery or interventional radiology within the first 24 h after admission of patients with ISS < 15. The secondary outcomes were stratified into severe (mortality, resuscitation care, length of stay in intensive care units) and non-severe criteria (mild head injury, hospital discharge or transfer within 24 h).

RESULTS

Of 3035 patients admitted during the study period, 1409 with an ISS < 15 were included, corresponding to a theoretical overtriage rate of 46.4%. Among these, 611 patients (43.4%) underwent emergency intervention within the first 24 h (586 surgical interventions, 19 direct transfers to the operating theater and 6 acts of interventional radiology), 238 (16.9%) of patients presented with severe and 531 (38%) with non-severe outcome criteria.

CONCLUSION

This work demonstrates that in a cohort of patients classified as ISS < 15 admitted to a TC, a considerable amount of TC-specific resources are required, and patients present with severe outcome criteria despite being classified as overtriaged. These results suggest that triage of trauma patients should be based on resource use and clinical outcome rather than anatomic criteria.

Initial Prehospital Rapid Emergency Medicine Score (REMS) as a Predictor of Patient Outcomes

Background: A standardized objective measure of prehospital patient risk of hospitalization or death is needed. The Rapid Emergency Medicine Score (REMS), a validated risk-stratification tool, has not been widely tested for prehospital use. This study's objective was to assess predictive characteristics of initial prehospital REMS for ED disposition and overall patient mortality. Methods: This retrospective analysis used linked prehospital and hospital data from the national ESO Data Collaborative. All 911 responses from 1/1/2019-12/31/2019 were included. REMS (0-26) was calculated using age and first prehospital values for: pulse rate, mean arterial pressure, respiratory rate, oxygen saturation, and Glasgow Coma Scale. Non-transports, patients <18 and cardiac arrests prior to EMS arrival were excluded. The primary outcome was ED disposition, dichotomized to discharge versus admission, transfer, or death. The secondary outcome was overall survival to discharge (ED or inpatient). Transfers and records without inpatient disposition were excluded from the secondary analysis. Predictive ability was assessed using area under the receiver operating curve (AUROC). Optimal REMS cut points were determined using test characteristic curves. Univariable logistic regression modeling was used to quantify the association between initial prehospital REMS and each outcome. Results: Of 579,505 eligible records, 94,640 (16%) were excluded due to missing data needed to calculate REMS. Overall, 62% (n = 298,223) of patients were discharged from the ED, 36% (n = 175,212) were admitted, 2% (n = 10,499) were transferred, and 0.2% (n = 931) died in the ED. A REMS of 5 or lower demonstrated optimal statistical prediction for ED discharge versus not discharged (admission/transfer/death) (AUROC: 0.68). Patients with initial prehospital REMS of 5 or lower showed a three-fold increase in odds of ED discharge (OR: 3.28, 95%CI: 3.24-3.32). Of the 457,226 patients included in overall mortality analysis, >98% (n = 450,112) survived. AUROC of initial prehospital REMS for overall mortality was 0.79. A score 7 or lower was statistically optimal for predicting survival. Initial prehospital REMS of 7 or lower was associated with a five-fold increase in odds of overall survival (OR:5.41, 95%CI:5.15-5.69). Conclusion: Initial prehospital REMS was predictive of ED disposition and overall patient mortality, suggesting value as a risk-stratification measure for EMS agencies, systems and researchers.

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).