Survival prediction algorithms miss significant opportunities for improvement if used for case selection in trauma quality improvement programs

BackgroundQuality improvement (QI) programs have shown to reduce preventable mortality in trauma care. Detailed review of all trauma deaths is a time and resource consuming process and calculated probability of survival (Ps) has been proposed as audit filter. Review is limited on deaths that were ‘expected to survive’. However no Ps-based algorithm has been validated and no study has examined elements of preventability associated with deaths classified as ‘expected’. The objective of this study was to examine whether trauma performance review can be streamlined using existing mortality prediction tools without missing important areas for improvement.MethodsWe conducted a retrospective study of all trauma deaths reviewed by our trauma QI program. Deaths were classified into non-preventable, possibly preventable, probably preventable or preventable. Opportunities for improvement (OPIs) involve failure in the process of care and were classified into clinical and system deviations from standards of care. TRISS and PS were used for calculation of probability of survival. Peer-review charts were reviewed by a single investigator.ResultsOver 8 years, 626 patients were included. One third showed elements of preventability and 4% were preventable. Preventability occurred across the entire range of the calculated Ps band. Limiting review to unexpected deaths would have missed over 50% of all preventability issues and a third of preventable deaths. 37% of patients showed opportunities for improvement (OPIs). Neither TRISS nor PS allowed for reliable identification of OPIs and limiting peer-review to patients with unexpected deaths would have missed close to 60% of all issues in care.ConclusionsTRISS and PS fail to identify a significant proportion of avoidable deaths and miss important opportunities for process and system improvement. Based on this, all trauma deaths should be subjected to expert panel review in order to aim at a maximal output of performance improvement programs.     

The identification of criteria to evaluate prehospital trauma care using the Delphi technique

OBJECTIVE: Current trauma system performance improvement emphasizes hospital- and patient-based outcome measures such as mortality and morbidity, with little focus upon the processes of prehospital trauma care. Little data exist to suggest which prehospital criteria should serve as potential filters. This study identifies the most important filters for auditing prehospital trauma care using a Delphi technique to achieve consensus of expert opinion. METHODS: Experts in trauma care from the United States (n = 81) were asked to generate filters of potential utility in monitoring the prehospital aspect of the trauma system, and were then required to rank these questions in order of importance to identify those of greatest importance. RESULTS: Twenty-eight filters ranking in the highest tertile are proposed. The majority (54%) pertains to aspects of emergency medical services, which comprise 7 of the top 10 (70%) filters. Triage filters follow in priority ranking, comprising 29% of the final list. Filters concerning interfacility transfers and transportation ranked lowest. CONCLUSION: This study identifies audit filters representing the most important aspects of prehospital trauma care that merit continued evaluation and monitoring. A subsequent trial addressing the utility of these filters could potentially enhance the sensitivity of identifying deviations in prehospital care, standardize the performance improvement process, and translate into an improvement in patient care and outcome.     

Trauma system in Hong Kong

The presence of a regionalized trauma system has been shown to improve outcome in trauma. Trauma care has undergone significant changes in Hong Kong in recent years. In 2003, five public hospitals were designated as trauma centres. Since then, there has been a progressive improvement in trauma patient outcome in Hong Kong. Trauma centre designation by itself, however, does not constitute a trauma system. The latter is an integration of prehospital care, interhospital transfer, trauma centres, rehabilitation, prevention, education and research. Under the primary trauma diversion policy, trauma patients in Hong Kong are no longer sent to the nearest hospitals, but transferred directly to trauma centres where definitive care can be implemented earlier. The present article describes some of these changes and addresses issues pertinent to the future development of trauma service in Hong Kong.     

Trauma system development in a theater of war: Experiences from Operation Iraqi Freedom and Operation Enduring Freedom

BACKGROUND: Medical lessons learned from Vietnam and previous military conflicts led to the development of civilian trauma systems in the United States. Operation Iraqi Freedom represents the first protracted, large-scale, armed conflict since the advent of civilian trauma systems in which to evaluate a similar paradigm on the battlefield. METHODS: Collaborative efforts between the joint military forces of the United States initiated development of a theater trauma system in May 2004. Formal implementation of the system occurred in November 2004, the collaborative effort of the three Surgeons General of the U.S. military, the United States Army Institute of Surgical Research, and the American College of Surgeons Committee on Trauma. One trauma surgeon (Trauma System Director) and a team of six trauma nurse coordinators were deployed to theater to evaluate trauma system component issues. Demographic, mechanistic, physiologic, diagnostic, therapeutic, and outcome data were gathered for 4,700 injured patients using the Joint Theater Trauma Registry. Interview and survey methods were utilized to evaluate logistic aspects of the system. RESULTS: System implementation identified more than 30 systemic issues requiring policy development, research, education, evaluation of medical resource allocation, and alterations in clinical care. Among the issues were transfer of casualties from point of injury to the most appropriate level of care, trauma clinical practice guidelines, standard forms, prophylactic antibiotic regimens, morbidity/mortality reporting, on-line medical evacuation regulation, improved data capture for the trauma registry, and implementation of a performance improvement program. CONCLUSIONS: The implementation of a theater trauma system demonstrated numerous opportunities to improve the outcome of soldiers wounded on the battlefield.     

The association between trauma system and trauma center components and outcome in a mature regionalized trauma system

BACKGROUND: Regionalized trauma systems have been shown repeatedly to improve the outcome of seriously injured patients. However, we do not have data regarding which components of these systems have the most impact on outcome and to what degree. The objective of this study was to understand the association between various components that make up a trauma system and outcome. METHODS: Surveys were administered to trauma directors at 59 hospitals in the province of Quebec, Canada. Data from the surveys were then linked with specific outcome variables obtained from a regionalized trauma database. Specific outcomes were assigned to trauma system- and in-hospital-based components after controlling for injury severity. RESULTS: Over 4.8 years, 72,073 patients met inclusion criteria. Components found to affect survival after risk adjustment were prehospital notification (OR, 0.61; 95% CI, 0.39-0.94) and the presence of a performance improvement program in that hospital (OR, 0.44; 95% CI, 0.20-0.94). Increased patient volume was associated with a reduction in risk-adjusted mortality (OR, 0.98; 95% CI, 0.97-0.99). Tertiary trauma centers were also associated with a reduction in risk-adjusted mortality compared with both secondary and primary centers (OR, 0.68; 95% CI, 0.48-0.99). CONCLUSIONS: Improvements in outcome in a regionalized trauma system are secondary to a combination of elements, as well as to the interplay of these elements on each other. Prehospital notification protocols and performance improvement programs appear to be most associated with decreased risk-adjusted odds of death.     

Prehospital prediction of intensive care unit stay and mortality in blunt trauma patients

BACKGROUND: The success of a trauma system relies on transfer of patients from the field to the most appropriate hospital for definitive care. However, no consensus has been reached regarding the best criteria or triage tool for identifying patients injured seriously enough to warrant transfer to a trauma center. METHODS: Predictors of mortality and intensive care unit stay were identified and prediction models developed in a design data set. The performance of these models was evaluated in a test data set and compared with current trauma triage guidelines, derived from the American College of Surgeons model. RESULTS: The newly developed prediction models performed comparably with the current trauma triage guidelines. CONCLUSION: Although the performance of newly developed triage models was promising, their performance did not exceed that of the current trauma triage guidelines. In particular, the anatomic injury criteria appeared to be the key component of the current trauma triage guidelines.     

Key Performance Indicators in British Military Trauma

BACKGROUND: Key performance indicators (KPI) are tools for assessing process and outcome in systems of health care provision and are an essential component in performance improvement. Although KPI have been used in British military trauma for 10 years, they remain poorly defined and are derived from civilian metrics that do not adjust for the realities of field trauma care. Our aim was to modify current trauma KPI to ensure they more faithfully reflect both the military setting and contemporary evidence in order to both aid accurate calibration of the performance of the British Defence Medical Services and act as a driver for performance improvement. METHOD: A workshop was convened that was attended by senior, experienced doctors and nurses from all disciplines of trauma care in the British military. "Speciality-specific" KPI were developed by interest groups using evidence-based data where available and collective experience where this was lacking. In a final discussion these were streamlined into 60 KPI covering each phase of trauma management. CONCLUSION: The introduction of these KPI sets a number of important benchmarks by which British military trauma can be measured. As part of a performance improvement programme, these will allow closer monitoring of our performance and assist efforts to develop, train, and resource British military trauma providers.     

Physiologic trauma triage criteria in adult trauma patients: are they effective in saving lives by transporting patients to trauma centers?

BACKGROUND: Trauma triage criteria have been in place for many years and were updated in 1999 by the American College of Surgeons. We are unaware of any studies that have directly examined the ability of these criteria to reduce short-term mortality by transporting patients to trauma centers rather than to noncenters. STUDY DESIGN: Retrospective observational cohort study of adult patients meeting physiologic triage criteria who were transported to 9 regional (Level I) trauma centers, 21 area (Level II) trauma centers, and 119 noncenters in New York in 1996 to 1998. For each triage criterion and for one or more of the criteria, odds ratios and their confidence intervals for mortality in regional and area trauma centers versus noncenters and odds ratios and their confidence intervals for mortality in regional centers versus area centers and noncenters were used to measure performance. RESULTS: Patients in regional trauma centers had considerably lower mortality than patients in area trauma centers and noncenters for two individual triage criteria and for patients with one or more triage criteria (odds ratio, 0.75; 95% CI, 0.63-0.90 for one or more criteria). Also, patients with head injuries who were treated in regional centers had notably lower mortality than patients in other hospitals (odds ratio, 0.67; 95% CI, 0.53-0.85). CONCLUSIONS: In New York, regional trauma centers exhibit considerably lower mortality than area trauma centers or noncenters for adult patients meeting specific physiologic triage criteria. It is important that population-based trauma systems with data from centers and noncenters be developed for the purpose of evaluating and redesigning trauma systems.     

The American College of Surgeons Trauma Quality Improvement Program

The American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) is a recent addition to the many quality improvement collaboratives that have been established in surgery. On the background of a well-established trauma center and its performance improvement activities, ACS TQIP offers the potential to advance trauma care and offers participating centers the opportunity to better understand their strengths and areas for improvement. The rationale for ACS TQIP's development, implementation challenges, and potential for advancing the quality of trauma care are described.     

Evaluation of the Victorian state adult pre-hospital trauma triage criteria

BackgroundPre-hospital trauma triage criteria are used to expedite the transport of severely injured patients to major trauma services. The current Victorian adult pre-hospital trauma triage criteria consist of physiological, anatomical and mechanistic elements. The purpose of this study was to evaluate the performance of the current triage criteria and, if necessary propose refined criteria to improve the under and over-triage rates.MethodsThe study was conducted in Melbourne, Victoria, which has a fully integrated State Trauma System. Trauma data was sourced from the pre-hospital Victorian Ambulance Clinical Information System and the Victorian State Trauma Registry. Confirmed major trauma was defined at hospital discharge as one or more of death, ISS > 15, ICU ventilation or urgent surgery. Data was matched through probabilistic linkage. The triage criteria were evaluated using multivariate logistic regression and classification tree modelling. Diagnostic statistics, including sensitivity and specificity were calculated to assess triage performance.ResultsOver 12-months there were 1166 ‘confirmed major trauma’ patients and 44,166 ‘non-major trauma’ patients. Evaluation showed the current triage criteria needed refinement, and multiple revised pre-hospital trauma triage models were constructed. Based on the best overall combination of diagnostic statistics, a revised model was chosen with a sensitivity of 97.8% (vs. 95.3% in the current model), a specificity of 82.7% (vs. 62.7%) and an accuracy of 83.0% (vs. 63.4%). The over-triage rate was 17.3% (vs. 37.3%) and the under-triage rate was 2.2% (vs. 4.7%).ConclusionsEvaluation showed that the specificity and sensitivity of the current trauma triage criteria could be improved. The implementation of a revised triage model should identify more confirmed major trauma patients. Likewise, over-triage of non-major trauma patients to major trauma services would be significantly reduced. The refined criteria should also decrease discretionary decision-making by paramedics in the field.     

Systematic review of screening instruments for adults at risk of PTSD

The development of effective methods of screening for posttraumatic stress disorder (PTSD) is important in the context of mass trauma, the geographical dispersion of victims, and the restricted availability of specialists in psychological trauma. The review focused on published English-language screening instruments for civilian PTSD consisting of 30 items or fewer and validated against structured clinical interviews. Thirteen instruments were identified meeting these criteria, all consisting of symptoms of traumatic stress. The review concluded that the performance of some currently available instruments is near to their maximal potential effectiveness, and that instruments with fewer items, simpler response scales, and simpler scoring methods perform as well as if not better than longer and more complex measures.     

Reorganization of neuronal connections following CNS trauma: principles and experimental paradigms

The present review summarizes how the nervous system responds to trauma. The goal is to provide an introduction to the problems, techniques, experimental paradigms, current issues, and future promise. The review is especially designed for basic scientists and clinicians who are not currently involved in research on CNS reorganization, and for students just entering the field. The review characterizes the secondary degenerative events that occur after trauma, and the types of growth that commonly occur. A standard terminology is set forth with criteria for differentiating between related phenomena. Experimental methods are described that can be used documenting reorganization of circuitry. The principles that determine whether a given process will or will not occur are summarized, and some of the factors that may regulate the nature and extent of growth are considered. Research strategies are outlined that have been used to evaluate whether reorganization of circuitry is functionally significant. Finally, future directions in research and clinical application are discussed, focusing especially on the efforts to facilitate regeneration, and the work on transplants of CNS tissue to facilitate growth of surviving connections, and to replace tissue destroyed by trauma.     

Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria

Background

There is a paucity of literature comparing trauma patients who meet pre-hospital trauma triage guidelines (‘potential major trauma’) with trauma patients who are identified as ‘confirmed major trauma patients’ at hospital discharge. This type of epidemiological surveillance is critical to continuous performance monitoring of mature trauma care systems. The current study aimed to determine if the current trauma triage criteria resulted in under/over-triage and whether the triage criteria were being adhered to.

Methods

For a 12-month time period there were 45,332 adult (≥16 years of age) trauma patients transported by ambulance to hospitals in metropolitan Melbourne. This retrospective study analysed data from 1166 patients identified at hospital discharge as ‘confirmed major trauma patients’ and 16,479 patients captured by the current pre-hospital trauma triage criteria, who did not go on to meet the definition of confirmed major trauma. These patients comprise the ‘potential major trauma’ group. Non-major trauma patients (N = 27,687) were excluded from the study. Pre-hospital data was sourced from the Victorian Ambulance Clinical Information System (VACIS) and hospital data was sourced from the Victorian State Trauma Registry (VSTR). Statistical analyses compared the characteristics of confirmed major trauma and potential major trauma patients according to the current trauma triage criteria.

Results

The leading causes of confirmed major trauma and potential major trauma were motor vehicle collisions (30.1% vs. 19.2%) and falls (30.0% vs. 48.7%). More than 80% of confirmed major trauma and 24.4% of potential major trauma patients were directly transported to a major trauma service. Overall, similar numbers of confirmed major trauma patients and potential major trauma patients had one or more aberrant vital signs (67.0% vs. 66.4%). Specific injuries meeting triage criteria were sustained by 69.2% of confirmed major trauma patients and 51.4% of potential major trauma patients, while 11.7% of confirmed major trauma patients and 4.6% of potential major trauma patients met the combined mechanism of injury criteria.

Conclusions

While the sensitivity of the current pre-hospital trauma triage criteria is high, if paramedics strictly followed the criteria there would be significant over-triage. Triage models using different mechanistic and physiologic criteria should be evaluated.     

Evaluation of trauma team performance using an advanced human patient simulator for resuscitation training

BACKGROUND: Human patient simulation (HPS) has been used since 1969 for teaching purposes. Only recently has technology advanced to allow application to the complex field of trauma resuscitation. The purpose of our study was to validate an advanced HPS as an evaluation tool of trauma team resuscitation skills. METHODS: The pilot study evaluated 10 three-person military resuscitation teams from community hospitals that participated in a 28-day rotation at a civilian trauma center. Each team consisted of physicians, nurses, and medics. Using the HPS, teams were evaluated on arrival and again on completion of the rotation. In addition, the 10 trauma teams were compared with 5 expert teams composed of experienced trauma surgeons and nurses. Two standardized trauma scenarios were used, representing a severely injured patient with multiple injuries and with an Injury Severity Score of 41 (probability of survival, 50%). Performance was measured using a unique human performance assessment tool that included five scored and eight timed tasks generally accepted as critical to the initial assessment and treatment of a trauma patient. Scored tasks included airway, breathing, circulation, and disability assessments as well as overall organizational skills and a total score. The nonparametric Wilcoxon test was used to compare the military teams' scores for scenarios 1 and 2, and the comparison of the military teams' final scores with the expert teams. A value of p < 0.05 was considered significant. RESULTS: The 10 military teams demonstrated significant improvement in four of the five scored (p < or = 0.05) and six of the eight timed (p < or = 0.05) tasks during the final scenario. This improvement reflects the teams' cumulative didactic and clinical experience during the 28-day trauma refresher course as well as some degree of simulator familiarization. Improved final scores reflected efficient and coordinated team efforts. The military teams' initial scores were worse than the expert group in all categories, but their final scores were only lower than the expert groups in 2 of 13 measurements (p < or = 0.05). CONCLUSION: No studies have validated the use of the HPS as an effective teaching or evaluation tool in the complex field of trauma resuscitation. These pilot data demonstrate the ability to evaluate trauma team performance in a reproducible fashion. In addition, we were able to document a significant improvement in team performance after a 28-day trauma refresher course, with scores approaching those of the expert teams.     

Identifying areas for improvement in paediatric trauma care in NSW Australia using a clinical,system and human factors peer-review tool

BackgroundThere is known variability in the quality of care delivered to injured children. Identifying where care improvement can be made is critical. This study aimed to review paediatric trauma cases across the most populous Australian State to identify factors contributing to clinical incidents.MethodsMedical records from three New South Wales Paediatric Trauma Centres were reviewed for children <16 years requiring intensive care; with an injury severity score of ≥9, or who died following injury between July 2015 and September 2016. Records were peer-reviewed by nurse surveyors who identified cases that might not meet the expected standard of care or where the child died following the injury. A multidisciplinary panel conducted the peer-review using a major trauma peer-review tool. Records were reviewed independently, then discussed to establish consensus.ResultsA total 535 records were reviewed and 41 cases were peer-reviewed. The median (IQR) age was 7 (2–12) years, the median ISS was 25 (IQR 16–30). The peer-review identified a combination of clinical (85%), systems (51%) and communication (12%) problems that contributed to difficulties in care delivery. In 85% of records, staff actions were identified to contribute to events; with medical task failure the most frequently identified cause (89%).ConclusionThe peer-review of paediatric trauma cases assisted in the identification of contributing factors to clinical incidents in trauma care resulting in 26 recommendations for change. The prioritisation and implementation of these recommendations, alongside a uniform State-wide trauma case review process with consistent criteria (definitions), performance indicators, monitoring and reporting would facilitate improvement in health service delivery to children sustaining severe injury.     

Fractures in access to and assessment of trauma systems

BACKGROUND: Trauma is a major public health problem and organized systems of trauma care have been shown to substantially reduce trauma-related mortality. Currently California and many other states have incompletely developed systems of trauma care delivery. This study was undertaken to determine how frequently patients incurring serious trauma in California receive treatment at a trauma center. STUDY DESIGN: Hospital discharge records for 360,743 acute trauma patients for 1995 to 1997 were analyzed. Abbreviated Injury Scale scores were calculated from discharge diagnosis codes. Severity of trauma and the need for trauma center treatment was defined by eight Abbreviated Injury Scale criteria combined with patient age and type of injury. RESULTS: According to study criteria, 67,718 patients needed trauma center care and 56% were treated at a trauma center. Among patients less than 55 years of age, 62% were treated at a trauma center compared with 40% of those aged 55 years or more (p < 0.0001). For patients less than 55 years old with brain injuries, 66% were treated at a trauma center compared with 44% for patients aged 55 years or more (p < 0.0001). Of the 29,849 patients who met Abbreviated Injury Scale criteria but were not treated at trauma centers, 59% were in counties with designated trauma centers and 41% were in counties without trauma centers. CONCLUSIONS: Only 56% of seriously injured patients in California were treated at trauma centers, despite most of the injuries occurring in the catchment areas of designated trauma care systems. Substantial undertriage of serious trauma patients to trauma centers appears to be occurring, especially in older persons and in persons with brain injuries. Efforts to understand why undertriage is occurring so frequently are hampered by fragmentation of the systems of care, inadequate data management systems, and lack of trauma care performance reporting by non-trauma center hospitals.     

Assuring optimal trauma care: the role of trauma centre accreditation.

Optimal care of the injured patient requires the delivery of appropriate, definitive care shortly after injury. Over the last 30 to 40 years, civilian trauma systems and trauma centres have been developed in the United States based on experience gained in military conflicts, particularly in Korea and Vietnam. A similar process is evolving in Canada. National trauma committees in the US and Canada have defined optimal resources to meet the goal of rapid, appropriate care in trauma centres. They have introduced programs (verification or accreditation) to externally audit trauma centre performance based on these guidelines. It is generally accepted that implementing trauma systems results in decreased preventable death and improved survival after trauma. What is less clear is the degree to which each facet of trauma system development contributes to this improvement. The relative importance of national performance guidelines and trauma centre audit as integral steps toward improved outcomes following injury are reviewed. Current Trauma Association of Canada guidelines for trauma centres are presented and the process of trauma centre accreditation is discussed.     

Preventable Deaths in Multiple Trauma Patients: The Importance of Auditing and Continuous Quality Improvement

Background

Management errors during pre-hospital care, triage process and resuscitation have been widely reported as the major source of preventable and potentially preventable deaths in multiple trauma patients. Common tools for defining whether it is a preventable, potentially preventable or non-preventable death include the Advanced Trauma Life Support (ATLS^®) clinical guideline, the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS). Therefore, these surrogated scores were utilized in reviewing the study’s trauma services.

Methods

Trauma data were prospectively collected and retrospectively reviewed from January 1, 2018, to December 31, 2018. All cases of trauma death were discussed and audited by the Hospital Trauma Committee on a regular basis. Standardized form was used to document the patient’s management flow and details in every case during the meeting, and the final verdict (whether death was preventable or not) was agreed and signed by every member of the team. The reasons for the death of the patients were further classified into severe injuries, inappropriate/delayed examination, inappropriate/delayed treatment, wrong decision, insufficient supervision/guidance or lack of appropriate guidance.

Results

A total of 1913 trauma patients were admitted during the study period, 82 of whom were identified as major trauma (either ISS > 15 or trauma team was activated). Among the 82 patients with major trauma, eight were trauma-related deaths, one of which was considered a preventable death and the other 7 were considered unpreventable. The decision from the hospital’s performance improvement and patient safety program indicates that for every trauma patient, basic life support principles must be followed in the course of primary investigations for bedside trauma series X-ray (chest and pelvis) and FAST scan in the resuscitation room by a person who meets the criteria for trauma team activation recommended by ATLS^®.

Conclusion

Mechanisms to rectify errors in the management of multiple trauma patients are essential for improving the quality of trauma care. Regular auditing in the trauma service is one of the most important parts of performance improvement and patient safety program, and it should be well established by every major trauma center in Mainland China. It can enhance the trauma management processes, decision-making skills and practical skills, thereby continuously improving quality and reducing mortality of this group of patients.

     

Situation analysis of trauma based on Arizona trauma center standards in university hospitals of Tehran, Iran

Objective: Injuries are common and important problem in Tehran, capital of Iran. Although therapeutic centers are not essentially established following the constructional principles of developed countries, the present opportunities and equipments have to be used properly. We should recognize and reduce the deficits based on the global standards.This study deliberates the trauma resources and capacities in university hospitals of Tehran based on Arizona trauma center standards, which are suitable for the assessment of trauma centers.Methods: Forty-one university hospitals in Tehran were evaluated for their conformity with "Arizona trauma center standards" in 2008. A structured interview was arranged with the "Educational Supervisor" of all hospitals regarding their institutional organization, departments, clini-cal capabilities, clinical qualifications, facilities and resources, rehabilitation services, performance improvement, continuing education, prevention, research and additional requirements for pediatric trauma patients. Relative frequencies and percentages were calculated and Student's t test was used to compare the mean values.Results: Forty-one hospitals had the average of 77.7 (50.7%) standards from 153 Arizona trauma center standards and these standards were present in 97.5 out of 153 (63.7%) in 17 general hospitals. Based on the subgroups of the standards, 64.8% items of hospital resources and capabilities were considered as a subgroup with the maximum criteria, and 17.7% items of research section as another subgroup with the minimum standards.Conclusions: On the basis of our findings, no hospital meet all the Arizona trauma center standards completely. The hospitals as trauma centers at different levels must be promoted to manage trauma patients desirably.     

Overtriage in trauma – what are the causes?

BACKGROUND: Different criteria are employed to activate trauma teams. Because of a growing concern about overtriage, the objective of this study was to investigate the performance of our trauma team's activation protocol. METHODS: Injured patients with trauma team activation (TTA), admission to an intensive care unit or surgical intermediate care unit with a trauma diagnosis, or trauma-related death in the emergency department were investigated retrospectively from 1 January 2004 to 31 December 2005. Different TTA criteria were analysed with respect to sensitivity, positive predictive value (PPV) and overtriage (1 - PPV). RESULTS: Eight hundred and nine patients were included, 185 (23%) of whom had an Injury Severity Score (ISS) of more than 15. The performance of our protocol showed a sensitivity of 87%, PPV of 22% and overtriage of 78%. The mechanism of injury as a TTA criterion had a sensitivity of 14%, PPV of 7% and overtriage of 93%. Physiological/anatomical criteria and interfacility transfer showed higher PPV and less overtriage. Undertriage (no TTA despite ISS > 15) was identified in 23 patients (13%), 18 of whom were hospital transfers. CONCLUSION: A TTA protocol based on physiological, anatomical and interfacility transfer criteria seems to yield a higher precision than, in particular, that based on mechanism of injury criteria. Because of substantial overtriage in our hospital, the TTA protocol needs to be re-evaluated.