Secondary emergency department triage (supertriage) and trauma team activation: effects on resource utilization and patient care

In-House Attending Trauma Surgeon Does Not Reduce Mortality in Patients Presented to a Level 1 Trauma Center

BACKGROUND

Trauma is the leading cause of death in the Western world. Trauma systems have been paramount in opposing this problem. Commonly, Level 1 Trauma Centers are staffed by in-house (IH) attending trauma surgeons available 24/7, whereas other institutions function on an on-call (OC) basis with defined response times. There is on-going debate about the value of an IH attending trauma surgeon compared to OC trauma surgeons regarding clinical outcome.

METHODS

This study was performed at a tertiary care facility complying with all requirements to be a designated Level 1 Trauma Center as defined by the American College of Surgeons Committee on Trauma (ACSCOT). Inclusion occurred from January 1, 2012 through December 31, 2013. Patients were assigned an identifier for IH trauma surgeon attendance versus OC attendance. The primary outcome variable studied was overall mortality in relation to IH or OC attending trauma surgeons. Additionally, time to operating theater, hospital length-of-stay (HLOS), and intensive care unit (ICU) admittance were investigated.

RESULTS

A total of 1,287 unique trauma cases in 1,285 patients were presented to the trauma team. Of all cases, 712 (55.3%) occurred between 1700h and 0800h. These 712 cases were treated by an IH attending in 66.3% (n = 472) and an OC attending in 33.7% (n = 240). In the group of patients treated by an IH attending trauma surgeon, the overall mortality rate was 5.5% (n = 26); in the group treated by an OC attending, the overall mortality rate was 4.6% (n = 11; P = .599). Cause of death was traumatic brain injury (TBI) in 57.6%. No significant difference was found in the time between initial presentation at the trauma room and arrival in the operating theater.

CONCLUSION

In terms of trauma-related mortality during non-office hours, no benefit was demonstrated through IH trauma surgeons compared to OC trauma surgeons.

The performance of trauma team activation criteria at an Australian regional hospital

OBJECTIVE

It is common practice for hospitals to use a trauma team activation criteria (TTAC) to identify patients at risk of major trauma and to activate a multidisciplinary team to receive such patients on arrival to the ED. The aims of this study are to describe the frequency of individual criteria and the ability of one currently used system to predict major trauma, and to estimate the effect of simplified criteria on the prediction.

DESIGN AND SETTING

A retrospective observational study of the entire cohort of adult patients who a) received trauma team activation or b) were included in the trauma registry of Royal Darwin Hospital in 2015. From the original clinical record all components of the TTAC, and corresponding outcomes, were extracted for each case. The predictive effect of each criterion, adjusted for the presence of others, was assessed by logistic regression. The poorest predictors were sequentially "dropped" to develop a number of models of which the predictive value of the resulting hypothetical TTAC was calculated.

MAIN OUTCOME MEASURES

Major trauma (MT) was defined as a death in ED, immediate operative intervention or direct admission to ICU. Overtriage was defined as activation of the trauma team without major trauma. Undertriage was defined as major trauma without trauma team activation.

RESULTS

794 trauma presentations were reviewed, 428 of those presentations met TTAC. Major trauma was present in 135 (32%) of those with TTAC hence overtriage was 68%. Criteria based on mechanism of injury (MOI) were responsible for over half of the overtriage and were collectively present without other activation criteria in only 10 MTs (6%). Removal of the criteria with the worst predictive value decreased overtriage to 50% before a rise in undertriage to beyond 24%.

CONCLUSION

A number of criteria including those based on MOI decrease the accuracy of TTAC and lead to high rates of overtriage. Airway, respiratory and neurological compromise were the best predictors of MT. Any criteria simplification should be introduced in the context of a further audit of TTAC performance, as the estimates of the separate criteria in the current TTAC are not robustto bias or to undetected correlation.

Trauma resource designation: an innovative approach to improving trauma system overtriage

Background

Effective triage of injured patients is often a balancing act for trauma systems. As healthcare reimbursements continue to decline,¹ innovative programs to effectively use hospital resources are essential in maintaining a viable trauma system. The objective of this pilot intervention was to evaluate a new triage model using 'trauma resource' (TR) as a new category in our existing Tiered Trauma Team Activation (TA) approach with hopes of decreasing charges without adversely affecting patient outcome.

Methods

Patients at one Level II Trauma Center (TC) over seven months were studied. Patients not meeting American College of Surgeons criteria for TA were assigned as TR and transported to a designated TC for expedited emergency department (ED) evaluation. Such patients were immediately assessed by a trauma nurse, ED nurse, and board-certified ED physician. Diagnostic studies were ordered, and the trauma surgeon (TS) was consulted as needed. Demographics, injury mechanism, time to physician evaluation, time to CT scan, time to disposition, hospital length of stay (LOS), and in-hospital mortality were analyzed.

Results

Fifty-two of the 318 TR patients were admitted by the TS and were similar to TA patients (N=684) with regard to gender, mean Injury Severity Score, mean LOS and in-hospital mortality, but were older (60.4 vs 47.2 years, p<0.0001) and often involved in a fall injury (52% vs 35%, p=0.0170). TR patients had increased door to physician evaluation times (11.5 vs 0.4 minutes, p<0.0001) and increased door to CT times (76.2 vs 25.9 minutes, p<0.0001). Of the 313 TR patients, 52 incurred charges totaling US$253 708 compared with US$1 041 612 if patients had been classified as TA.

Conclusions

Designating patients as TR prehospital with expedited evaluation by an ED physician and early TS consultation resulted in reduced use of resources and lower hospital charges without increase in LOS, time to disposition or in-hospital mortality.

Level of evidence

Level II.

Triage

A review of the literature underpinning modern triage methodology is presented. The philosophy and history is described prior to a review of triage scoring methodology relevant to modern day practice. The importance of triage is most acute during major incidents and the triage process is highlighted within this framework. Triage has wide-ranging applications throughout medical practice and these are included as part of the discussion.

Trauma team activation varies across Dutch emergency departments: a national survey

Background

Tiered trauma team response may contribute to efficient in-hospital trauma triage by reducing the amount of resources required and by improving health outcomes. This study evaluates current practice of trauma team activation (TTA) in Dutch emergency departments (EDs).

Methods

A survey was conducted among managers of all 102 EDs in the Netherlands, using a semi-structured online questionnaire.

Results

Seventy-two questionnaires were analysed. Most EDs use a one-team system (68 %). EDs with a tiered-response receive more multi trauma patients (p < 0.01) and have more trauma team alerts per year (p < 0.05) than one-team EDs. The number of trauma team members varies from three to 16 professionals. The ED nurse usually receives the pre-notification (97 %), whereas the decision to activate a team is made by an ED nurse (46 %), ED physician (30 %), by multiple professionals (20 %) or other (4 %). Information in the pre-notification mostly used for trauma team activation are Airway-Breathing-Circulation (87 %), Glasgow Coma Score (90 %), and Revised Trauma Score (85 %) or Paediatric Trauma Score (86 %). However, this information is only available for 75 % of the patients or less. Only 56 % of the respondents were satisfied with their current in-hospital trauma triage system.

Conclusions

Trauma team activation varies across Dutch EDs and there is room for improvement in the trauma triage system used, size of the teams and the professionals involved. More direct communication and more uniform criteria could be used to efficiently and safely activate a specific trauma team. Therefore, the implementation of a revised national consensus guideline is recommended.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-015-0185-0) contains supplementary material, which is available to authorized users.

Efficacy of a two-tiered trauma team activation protocol in a Norwegian trauma centre

BACKGROUND

A registry-based analysis revealed imprecise informal one-tiered trauma team activation (TTA) in a primary trauma centre. A two-tiered TTA protocol was introduced and analysed to examine its impact on triage precision and resource utilization.

METHODS

Interhospital transfers and patients admitted by non-healthcare personnel were excluded. Undertriage was defined as the fraction of major trauma victims (New Injury Severity Score over 15) admitted without TTA. Overtriage was the fraction of TTA without major trauma.

RESULTS

Of 1812 patients, 768 had major trauma. Overall undertriage was reduced from 28·4 to 19·1 per cent (P < 0·001) after system revision. Overall overtriage increased from 61·5 to 71·6 per cent, whereas the mean number of skilled hours spent per overtriaged patient was reduced from 6·5 to 3·5 (P < 0·001) and the number of skilled hours spent per major trauma victim was reduced from 7·4 to 7·1 (P < 0·001). Increasing age increased risk for undertriage and decreased risk for overtriage. Falls increased risk for undertriage and decreased risk for overtriage, whereas motor vehicle-related accidents showed the opposite effects. Patients triaged to a prehospital response involving an anaesthetist had less chance of both undertriage and overtriage.

CONCLUSION

A two-tiered TTA protocol was associated with reduced undertriage and increased overtriage, while trauma team resource consumption was reduced.

REGISTRATION NUMBER

NCT00876564 (http://www.clinicaltrials.gov).

Factors associated with trauma center use for elderly patients with trauma: a statewide analysis, 1999-2008

OBJECTIVES

To estimate the likelihood of trauma center admission for injured elderly patients with trauma, determine trends in trauma center admissions, and identify factors associated with trauma center use for elderly patients with trauma.

DESIGN

Retrospective analysis.

SETTING

Acute care hospitals in California.

PATIENTS

All patients hospitalized for acute traumatic injuries during the period from January 1, 1999, to December 31, 2008 (n = 430,081). Patients who had scheduled admissions for nonacute or minor trauma were excluded.

MAIN OUTCOME MEASURE

Likelihood of admission to level I or II trauma center was calculated according to age categories after adjusting for patient and system factors.

RESULTS

Of 430,081 patients admitted to California acute care hospitals for trauma-related diagnoses, 27% were older than 65 years. After adjusting for demographic, clinical, and system factors, compared with trauma patients aged 18-25 years, the odds of admission to a trauma center decreased with increasing age; patients aged 26-45 years had lower odds (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.71-0.80) of being admitted to a trauma center for their injuries than did patients 46-65 years of age (OR, 0.57; 95% CI, 0.54-0.60), patients 66-85 years of age (OR, 0.35; 95% CI, 0.30-0.41), and patients older than 85 years (OR, 0.30; 95% CI, 0.25-0.36). Similar patterns were found when stratifying the analysis by trauma type and severity. Living more than 50 miles away from a trauma center (OR, 0.03; 95% CI, 0.01-0.06) and lack of county trauma center (OR, 0.17; 95% CI, 0.09-0.35) were also predictors of not receiving trauma care.

CONCLUSION

Age and likelihood of admission to a trauma center for injured patients were observed to be inversely proportional after controlling for other factors. System-level factors play a major role in determining which injured patients receive trauma care.

Prospective evaluation of a two-tiered trauma activation protocol in an Australian major trauma referral hospital

OBJECTIVE

To evaluate a two-tiered trauma activation protocol in a major trauma referral hospital in Australia.

METHODS

A prospective study performed over a 12-month period of all consecutive trauma activations in a major trauma referral hospital. The triage tool assigned patients into two tiers of trauma activation. The full trauma activation was initiated where physiological or anatomical criteria were present. These patients were assessed by a multispecialty trauma team. A consult trauma activation was initiated where only mechanism of injury criteria was present. These patients were assessed by the Emergency Department Registrar and Surgical Registrar. The primary endpoint was major trauma outcome defined as either injury severity score (ISS) greater than 15, requirement for High Dependency Unit or Intensive Care Unit (HDU/ICU) admission, need for urgent operative intervention, or in hospital mortality.

RESULTS

Of 1144 trauma activations, 468 (41%) were full trauma and 676 (59%) were consult trauma activations. The full trauma activation group had a significantly higher proportion of the major trauma outcome (34% vs. 5%, p<0.01) and all 18 patients (2%) who died were in the full trauma activation group. Sensitivity of the triage tool for the major trauma outcome was 83%, specificity was 68%, undertriage was 3% and overtriage was 27%.

CONCLUSIONS

The two-tiered trauma activation protocol is effective in identifying patients with major trauma from those with minor trauma. There were no deaths in undertriaged patients.

The efficacy of a two-tiered trauma activation system at a level I trauma center

BACKGROUND

By using current American College of Surgeons trauma center triage criteria, 52% of patients transported to our level I trauma center are discharged home from the emergency department (ED). Because the majority of our trauma transports were based solely on mechanism of injury, we instituted, in 1990, a two-tiered trauma team activation system. Patients are triaged into major and minor trauma alert categories based on prehospital provider information. For minor trauma patients, respiratory therapy, operating room staff, and blood bank do not respond. The current study evaluated this triage system.

METHODS

Trauma registry data on all trauma activations from 1998 to 2007 were analyzed.

RESULTS

There were 20,332 trauma activations: 5,881 were major trauma, 14,451 minor trauma. The mean Injury Severity Score in major versus minor patients was significantly different (11.7 vs. 3.6, p < 0.0001). Significant differences (p < 0.0001) were also noted for all other markers of serious injury: Injury Severity Score >16, ED blood pressure <90, Glasgow Coma Score <or=12, ED intubation, disposition directly to the operating room or the intensive care unit, and death. There were 19 deaths (0.13%) in the minor trauma group, all occurring after hospital admission. All these patients were seen in the ED by the attending trauma surgeon. Two patients were mistriaged. The remaining 17 deaths were due to progression of brain injury in 10 patients, preexisting medical conditions in 4, delayed diagnosis of blunt intestinal injury in 1, delayed aortic rupture in 1, and papillary muscle rupture in 1.

CONCLUSION

A two-tiered trauma activation system identifies patients who require a full trauma team response and may result in a more effective use of trauma center resources.

The role of emergency medicine physicians in trauma care in North America: evolution of a specialty

The role of Emergency Medicine Physicians (EMP) in the care of trauma patients in North America has evolved since the advent of the specialty in the late 1980's. The evolution of this role in the context of the overall demands of the specialty and accreditation requirements of North American trauma centers will be discussed. Limited available data published in the literature examining the role of EMP's in trauma care will be reviewed with respect to its implications for an expanded role for EMPs in trauma care. Two training models currently in the early stages of development have been proposed to address needs for increased manpower in trauma and the critical care of trauma patients. The available information regarding these models will be reviewed along with the implications for improving the care of trauma patients in both Europe and North America.

Let the surgeon sleep: trauma team activation for severe hypotension

BACKGROUND

Trauma centers must balance the need to bring the full resources of the trauma center to the sickest patients emphasizing a need for personnel resource allocation. Our level I academic trauma center changed the systolic blood pressure (SBP) requirement for trauma team activation (TTA) from 90 mm Hg to 80 mm Hg. This investigation was undertaken to determine the effects of such change.

METHODS

The hospital's trauma registry identified patients for two 18-month periods, pre and post the change in TTA criteria. Data elements included team activation level, emergency department length of stay, emergency department to operating room (OR) times, delay to OR, and Injury Severity Score.

RESULTS

Full TTA decreased as did the percentage of cases with TTA. Eleven patients were identified in the SBP <80 mm Hg group who would have had TTA before the change. All 11 had timely trauma surgery consults. No delays to OR were related to TTA. The percentage of cases with laparotomy occurring >2 hours after arrival was unchanged. One hundred ninety fewer TTA were called in an 18-month period. Inpatient mortality between the two groups was not significantly changed.

CONCLUSIONS

Changing criteria for TTA from SBP 90 mm Hg to <80 mm Hg preserves personnel without patient harm. Lowering the SBP for TTA is one method of preserving trauma surgery manpower.

Asistencia al paciente politraumatizado. Realidad actual desde la perspectiva de las unidades de cuidados intensivos

OBJECTIVE

To study the epidemiology and management of pediatric trauma patients as well as the organizational, human and technical resources dedicated to these children from the perspective of the pediatric intensive care unit (PICU).

MATERIAL AND METHODS

A standardized data collection form was sent to 43 PICUs in Spain. Items inquired about the existence of training courses, trauma clinical practice guidelines and trauma registers, and which physician was in charge of trauma patients. Data on casuistics, the age of trauma patients, and the availability of human and technical resources, were also recorded.

RESULTS

Twenty-four PICUs completed the questionnaire. The PICU physician was responsible for trauma patient care in 66% of the hospitals. No training courses were available in 59% of the hospitals. No trauma register was available in 62% of the hospitals. Trauma patients represented 11% of PICU admissions, and most patients were aged up to 14 years old. An anesthetist was always at the hospital in 100% of the hospitals. A radiologist and traumatologist were always at the hospital in 91%, a neurosurgeon in 66% and a pediatric surgeon in 50%. The remaining surgical and medical specialties were on call. Continuous intracranial pressure monitoring was available in 87% of the PICUs, jugular venous saturation monitoring in 54% and continuous electroencephalogram and transcranial Doppler ultrasound in 50%. Computed tomography and ultrasound were available at all times in all hospitals. Magnetic nuclear resonance and echocardiography were available at all times in 44% of the hospitals, and arteriography in 42%.

CONCLUSION

In Spain, the organization of pediatric trauma management is based on pediatric teams under the supervision of a PICU physician. Some hospitals show a lack of technical and human resources. Therefore, the minimum criteria required to consider a hospital as a pediatric trauma center should be established. Trauma training courses are required.

Is There Evidence to Support the Need for Routine Surgeon Presence on Trauma Patient Arrival?

The trauma center certification requirements of the American College of Surgeons include the expectation that, whenever possible, general surgeons be routinely present at the emergency department arrival of seriously injured patients. The 2 historical factors that originally prompted this requirement, frequent exploratory laparotomies and emergency physicians without trauma training, no longer exist in most modern trauma centers. Research from multiple centers and in multiple varying formats has not identified improvement in patient-oriented outcomes from early surgeon involvement. Surgeons are not routinely present during the resuscitative phase of Canadian and European trauma care, with no demonstrated or perceived decrease in the quality of care. American trauma surgeons themselves do not consistently believe that their use in this capacity is either necessary or an efficient distribution of resources. There is not compelling evidence to support the assumption that trauma outcomes are improved by the routine presence of surgeons on patient arrival. Research is necessary to clarify which trauma patients require either emergency or urgent unique expertise of a general surgeon during the initial phase of trauma management. Individual trauma centers should be permitted the flexibility necessary to perform such research and to use such findings to refine and focus their secondary triage criteria.

Clinical decision rules for secondary trauma triage: predictors of emergency operative management

STUDY OBJECTIVE

Most injured patients taken by ambulance to hospital emergency departments do not require emergency surgery, yet most US trauma centers require a surgeon to be present on their arrival. If a clinical decision rule could be developed to accurately identify which injured patients require emergency operative intervention, then such "secondary triage" criteria could permit a trauma center to more efficiently use their surgeons' time.

METHODS

We analyzed 7.5 years of data (8,289 consecutive trauma activations) in our prospectively maintained Level I trauma center registry. We used classification and regression tree analyses to generate clinical decision rules using standard out-of-hospital variables to identify emergency operative intervention (within 1 hour) by a general surgeon (for adults) or a pediatric surgeon (if < or =14 years).

RESULTS

Emergency operative intervention occurred in 3.0% of adults and 0.35% of children. For adults, summoning a surgeon for any one of 3 criteria (penetrating mechanism, systolic blood pressure <96 mm Hg, pulse rate >104 beats/min) could reduce surgeon calls by 51.2% while failing to identify emergency operative intervention in only 0.08% (rule sensitivity 97.2% and specificity 48.6%). For children, no rule at all (ie, never automatically summoning a surgeon) would fail to identify emergency operative intervention in only 0.35% of patients, and use of a single criterion (penetrating mechanism) would reduce surgeon calls by 96.2% while failing to identify emergency operative intervention in only 0.09% (rule sensitivity 75.0% and specificity 96.5%).

CONCLUSION

We have derived simple decision rules for trauma centers that, if validated, could substantially reduce the need for routine surgeon presence on trauma patient arrival. These rules demonstrate low false-negative rates.

Difference in trauma team activation criteria between hospitals within the same region

OBJECTIVES

The present study was conducted to establish the current criteria for trauma team activation (TTA) in hospitals in the Metropolitan Sydney area, and examine the rationale behind their use.

METHODS

A cross-sectional survey was undertaken of the seven hospitals in the Metropolitan Sydney area designated to receive adult major trauma in March 2004. Trauma coordinators in each hospital provided the criteria used for adult TTA within their hospital.

RESULTS

All seven hospitals replied with their TTA criteria and completed the survey. The results show a wide variation in those criteria used by hospitals to activate their trauma team. Universally used criteria included penetrating injury to the head, neck or torso, limb amputation, spinal cord injury and systolic blood pressure <90 mmHg. Physiological limits for TTA varied between hospitals, with different limits for pulse rate and GCS used in different hospitals. All hospitals used mechanism of injury criteria alone as an activation prompt.

CONCLUSIONS

The criteria for TTA differ between hospitals within the same region. The criteria currently used will result in over-triage of trauma patients, but this might be of benefit in training the trauma team in centres that do not see a large volume of trauma patients. There are several advantages in standardization of criteria including optimization of patient care, training, research and audit. Further work is needed to validate existing criteria for use throughout the region.

Trauma teams in Australia: a national survey

BACKGROUND

Trauma teams have been associated with improved trauma patient outcomes. The present study seeks to estimate the use of trauma teams in Australian hospitals and describe their medical composition, leadership and criteria for activation.

METHODS

Australian public hospitals with more than 100 beds, an emergency department and offering surgical services were identified. A survey assessing the presence, composition and means of activation of a trauma team was mailed to the 'Director, Emergency Department' of all identified hospitals. Three months later, all hospitals were contacted by telephone to complete and verify data collection.

RESULTS

Questionnaires were distributed to 130 hospitals. After exclusion of hospitals that did not receive patients with traumatic injuries, and dedicated paediatric tertiary referral centres, 111 hospitals remained for analysis. Of these, 56% had an established trauma team, while 71% of hospitals without a trauma team claimed to have insufficient doctors to form one team. Ninety-five per cent of trauma teams were potentially activated by prehospital paramedic data (field triage). For 92% of trauma teams a combination of anatomical, physiological and mechanistic criteria were required for activation. The most common methods of mobilizing a trauma team were by dispatching a common call onto individual pagers (31%) or by paging trauma team members individually (31%). Fifty-eight per cent of trauma team leaders were emergency medicine specialists/registrars, while 8% of trauma teams were led by surgeons/registrars. Consultant surgeons were members of 23% of trauma teams and 74% of trauma teams consisted of more junior members after hours. Some form of trauma audit was engaged in by 64% of hospitals.

CONCLUSIONS

Trauma teams are yet to be utilized by many Australian hospitals that provide trauma care. Australian surgeons presently have limited leadership roles and membership in trauma teams. Trauma audit can be more widely adopted in Australian hospitals.

All patients with truncal gunshot wounds deserve trauma team activation

BACKGROUND

Traditional criteria for trauma team activation (TTA) include hypotension, tachycardia, tachypnea, and unresponsiveness. In a recent revision of the Resources for Optimal Care of the Trauma Patient, gunshot wound to the trunk (GSWT) was recommended as an independent criterion for major resuscitation and TTA. To validate this suggestion, we reviewed records of patients with GSWT to see if patients not meeting standard TTA criteria had serious injuries that would benefit from TTA.

METHODS

This study was a retrospective trauma registry study at a large Level I trauma center. Records of all patients over an 8.5-year period with GSW to chest, back, or abdomen/pelvis were included in the study. Patients who died in hospital, required ICU admission within 24 hours, had non-orthopedic operation within 24 hours, or had ISS > 15 were considered severely injured, and were assumed to benefit from TTA.

RESULTS

Between January 1993 and June 2000, 4,198 patients were admitted with GSWT, 94% of whom met traditional TTA criteria. Sixty-one percent of patients meeting traditional TTA criteria had severe injury, compared with 45.7% for those without TTA criteria. Of the 234 patients who did not meet traditional TTA criteria, 9.4% required early ICU admission, 29.5% required non-orthopedic operation within 24 hours, and 1.3% died.

CONCLUSION

Patients with GSWT often require high-level care, even when physiologic TTA criteria are absent on admission. Gunshot wound to the trunk should be an independent criterion for TTA.

Trauma teams

Although the value of a team approach in the resuscitation of the trauma patient has been recognized for more than 30 years, the integration of teams into United Kingdom (UK) hospitals has been slow. The multidisciplinary trauma team needs to be horizontally organized and the members require precise role allocation and practice so that they work together efficiently. To ensure that the trauma team is activated appropriately, criteria need to be defined. The role of the team leader is paramount in effective team-based resuscitation.

Old age as a criterion for trauma team activation

BACKGROUND

Elderly trauma patients have been shown to have a worse prognosis than young patients. Age alone is not a criterion for trauma team activation (TTA). In the present study, we evaluated the role of age > or = 70 years as a criterion for TTA.

METHODS

The present study was a trauma registry study that included injured patients 70 years of age or older. Patients who died in hospital, were admitted to the intensive care unit (ICU) within 24 hours, or had a non-orthopedic operation were assumed to benefit from TTA.

RESULTS

During a 7.5-year period, 883 elderly (> or = 70 years) trauma patients meeting trauma center criteria were admitted to our center. Overall, 223 patients (25%) met at least one of the standard TTA criteria. The mortality in this group was 50%, the ICU admission rate was 39%, and a non-orthopedic operation was required in 35%. The remaining 660 patients (75%) did not meet standard TTA criteria. The mortality was 16%, the need for ICU admission was 24%, and non-orthopedic operations were required in 19%. Sixty-three percent of patients with severe injuries (Injury Severity Score > 15) and 25% of patients with critical injuries (Injury Severity Score > 30) did not have any of the standard hemodynamic criteria for TTA.

CONCLUSION

Elderly trauma patients have a high mortality, even with fairly minor or moderately severe injuries. A significant number of elderly patients with severe injuries do not meet the standard criteria for TTA. It is suggested that age > or = 70 years alone should be a criterion for TTA.

Prehospital hypotension as a valid indicator of trauma team activation

BACKGROUND

Criteria for trauma team activation are continually being evaluated to ensure proper utilization of resources. We examined the impact of prehospital (PH) hypotension (systolic blood pressure < or = 90) on outcome (operative intervention and mortality) and its usefulness as an indicator for trauma team activation.

METHODS

A database was created by using the trauma registry for all nonburned, injured patients from July of 1993 through October of 1998 at our Level I trauma center.

RESULTS

Of 6,976 patients (83% blunt injury) in the database, 4,437 had a PH blood pressure recorded. Documented PH hypotension was present in 791 patients. Hypotension persisted in the emergency department (ED) in 299 patients, but 193 of them showed minimal or no signs of life on arrival. Four hundred ninety-two patients had PH hypotension but normal ED systolic blood pressure, and 130 patients developed ED hypotension after normal PH systolic blood pressure. Nearly half of the patients with hypotension were taken from the ED directly to the operating room primarily for hemorrhage control procedures. The early and late mortality rates of patients with PH and ED hypotension were 12% and 32%, respectively. Other PH interventions had minimal effect on mortality in the hypotensive patient.

CONCLUSION

Prehospital hypotension remains a valid indicator for trauma team activation. Even though most of the non-DOA patients (492 of 598) were stable on arrival to the ED, nearly 50% required operative intervention, and an additional 25% required intensive care unit admission. The trauma team should be activated and involved with these patients early.

Implementation of a two-tier trauma response

OBJECTIVE

To apply a triage tool to patients on their arrival in the emergency department and determine the efficacy and safety of a two-tier trauma response.

DESIGN

Descriptive prospective audit.

SETTING

Principal urban referral hospital that provides a major trauma service.

MATERIALS AND METHODS

The triage tool designated a major trauma or stable trauma response. A major trauma designation mobilised a multidisciplinary team and a stable trauma designation an expedited evaluation by emergency department staff. Chi-square test and Mann-Whitney U test were used to compare major and stable trauma designations. Triage accuracy was evaluated using outcome variables.

MAIN RESULTS

78% of 58 major trauma responses and 30% of 180 stable trauma responses were admitted. The median injury severity score (and interquartile range) of admitted patients was 9.0 (5.0-19.5) for major responses and 5.0 (2.0-9.0) for stable responses. The triage tool had a sensitivity of 65%, specificity of 87%, accuracy (appropriate triage rate) of 82%, undertriage rate of 8% and overtriage rate of 10%.

CONCLUSION

The triage tool adequately distinguished between patients with and without major trauma. Undertriaged patients had timely and appropriate referral for definitive surgical care and had no adverse outcomes.