Prehospital triage of trauma patients before and after implementation of a regional triage guideline

IntroductionSeverely injured trauma patients have a considerable mortality rate. One way to reduce the mortality is to ensure optimal triage. The American College of Surgeons Committee on Trauma has since 1986 made guidelines for the triage of trauma patients. These guidelines formed the basis, when the capital region of Denmark implemented a regional trauma triage guideline on February 15th 2016. It is uncertain how the implementation of the regional trauma triage guideline has influenced the triage of trauma patients. The aim of this study was to investigate the changes in admission pattern of trauma patients in the entire region after the implementation of the regional trauma triage guideline. We hypothesized that there would be a reduction in the proportion of trauma patients admitted to the trauma center after the implementation of the regional trauma triage guideline.Patients and methodsIn this observational cohort study with one-year follow-up, we used a national patient registry in Denmark. We identified trauma patients three years before and three years after the implementation of a new regional trauma triage guideline. The primary outcome was the proportion of trauma patients triaged to the regional trauma center. Secondary outcomes were: 30-day and one-year mortality, overtriage, and undertriage.ResultsWe found a significant reduction in the proportion of trauma patients triaged to the trauma center from 2115/5951 (35.5%) to 1970/5857 (33.6%), after the implementation of the regional trauma triage guideline, the difference being 1.9% (95% CI: 0.19 to 3.6%); P = 0.03. Further, a significant reduction of overtriage from 15.4% to 9.5% (difference 5.9% with 95% CI of 3.8 to 7.9%) was found. No significant changes in undertriage, 30-day or one-year mortality were found (1.07% vs 0.97%, 4.3% vs 4.5%, and 15.7% vs 16.6% respectively).ConclusionA significant decrease in the proportion of trauma patients admitted to the trauma center was found after implementation of a new regional trauma triage guideline. A reduction was seen in overtriage, but no changes were found in undertriage and both short-term and long-term mortality remained unchanged.     

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 ). Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Avoiding Cribari gridlock 2: The standardized triage assessment tool outperforms the Cribari matrix method in 38 adult and pediatric trauma centers

ObjectivesThe Cribari Matrix Method (CMM) is the current standard to identify over/undertriage but requires manual trauma triage reviews to address its inadequacies. The Standardized Triage Assessment Tool (STAT) partially emulates triage review by combining CMM with the Need For Trauma Intervention, an indicator of major trauma. This study aimed to validate STAT in a multicenter sample.MethodsThirty-eight adult and pediatric US trauma centers submitted data for 97,282 encounters. Mixed models estimated the effects of overtriage and undertriage versus appropriate triage on the odds of complication, odds of discharge to a continuing care facility, and differences in length of stay for both CMM and STAT. Significance was assessed at p <0.005.ResultsOvertriage (53.49% vs. 30.79%) and undertriage (17.19% vs. 3.55%) rates were notably lower with STAT than with CMM. CMM and STAT had significant associations with all outcomes, with overtriages demonstrating lower injury burdens and undertriages showing higher injury burdens than appropriately triaged patients. STAT indicated significantly stronger associations with outcomes than CMM, except in odds of discharge to continuing care facility among patients who received a full trauma team activation where STAT and CMM were similar.ConclusionsThis multicenter study strongly indicates STAT safely and accurately flags fewer cases for triage reviews, thereby reducing the subjectivity introduced by manual triage determinations. This may enable better refinement of activation criteria and reduced workload.     

Accuracy of the field triage protocol in selecting severely injured patients after high energy trauma

Background

For optimal treatment of trauma patients it is of great importance to identify patients who are at risk for severe injuries. The Dutch field triage protocol for trauma patients, the LPA (National Protocol of Ambulance Services), is designed to get the right patient, in the right time, to the right hospital. Purpose of this study was to determine diagnostic accuracy and compliance of this triage protocol.

Study design

Triage criteria were categorised into physiological condition (P), mechanism of trauma (M) and injury type (I). A retrospective analysis of prospectively collected data of all high-energy trauma patients from 2008 to 2011 in the region Central Netherlands is performed. Diagnostic parameters (sensitivity, specificity, negative predictive value, positive predictive value) of the field triage protocol for selecting severely injured patients were calculated including rates of under- and overtriage. Undertriage was defined as the proportion of severely injured patients (Injury Severity Score (ISS) ≥ 16) who were transported to a level two or three trauma care centre. Overtriage was defined as the proportion of non-severely injured patients (ISS < 16) who were transported to a level one trauma care centre.

Results

Overall sensitivity and specificity of the field triage protocol was 89.1% (95% confidence interval (CI) 84.4–92.6) and 60.5% (95% CI 57.9–63.1), respectively. The overall rate of undertriage was 10.9% (95%CI 7.4–15.7) and the overall rate of overtriage was 39.5% (95%CI 36.9–42.1). These rates were 16.5% and 37.7%, respectively for patients with M+I−P−. Compliance to the triage protocol for patients with M+I−P− was 78.7%. Furthermore, compliance in patients with either a positive I+ or positive P+ was 91.2%.

Conclusion

The overall rate of undertriage (10.8%) was mainly influenced by a high rate of undertriage in the group of patients with only a positive mechanism criterion, therefore showing low diagnostic accuracy in selecting severely injured patients. As a consequence these patients with severe injury are undetected using the current triage protocol. As it has been shown that severely injured patients have better outcome in level one trauma care centres further optimisation of this protocol aiming at lowering undertriage is therefore essential, preferably without incrementing overtriage too much.     

Effectiveness of posterior structures in the development of proximal junctional kyphosis following posterior instrumentation: A biomechanical study in a sheep spine model

IntroductionProximal junctional kyphosis – PJK has been defined by a 10 or greater increase in kyphosis at the proximal junction as measured by the Cobb angle from the caudal endplate of the uppermost instrumented vertebrae (UIV) to the cephalad endplate of the vertebrae 1 segments cranial to the UIV. In this biomechanical study, it is aimed to evaluate effects of interspinosus ligament complex distruption and facet joint degeneration on PJK development.Materials and methodsPosterior instrumentation applied between T2 – T7 vertebrae using pedicle screws to randomly selected 21 sheeps, divided into 3 groups. First group selected as control group (CG), of which posterior soft tissue and facet joints are protected. In second group (spinosus group, SG) interspinosus ligament complex which 1 segment cranial to UIV has been transected, and third group (faset group-FG) was applied facet joint excision. 25 N, 50 N, 100 N, 150 N and 200 N forces applied at frequency of 5 Hertz as 100 cycles axial to the samples. Then, 250 N, 275 N and 300 N forces applied static axially. Interspinosus distance, kyphosis angle and discus heights was measured in radiological evaluation. Abnormal PJK was defined by a proximal junctional angle greater than 10⁰ and at least 10⁰ greater than the corresponding preoperative measurement.ResultsIn CG group, average interspinosus distance was 6,6 $\pm$ 1.54 mm and kyphosis angle was 2,2 $\pm$ 0.46° before biomechanical testing, and they were measured as 9,4 $\pm$ 1.21 mm and 3,3 $\pm$0.44° respectively after forces applied to samples. In SG group, average interspinosus distance was 6,2 $\pm$ 1.72 mm and kyphosis angle was 2,7 $\pm$ 1.01° before experiment, and they were measured as 20,8 $\pm$ 5.66 mm and 15,1 $\pm$ 2.34° respectively after forces applied to samples. In FG group, average interspinosus distance was 4,8 $\pm$ 1.15 mm and kyphosis angle was ?1 $\pm$ 4.14° before experiment, and they were measured as 11,1 $\pm 1.96$mm and 11 $\pm$ 2.87° respectively after forces applied to samples. In comparison to group CG, statistically significant junctional kyphosis was seen on both FG and SG group after statistical analysis. (p < 0.05). PJK was seen statistically significant more on SG group than FG group. (p < 0.05). Not any statistically significant difference was seen on measurement of disk distances among three groups. (p > 0.05)ConclusionsProtecting interspinosus ligament complex and facet joint unity during posterior surgical treatment for spine deformation is vital to prevent PJK development. Based on our literature review, this is the first biomechanical study that reveals interspinosus ligament complex are more effective on preventing PJK development than facet joints.     

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.

Secondary overtriage: a consequence of an immature trauma system

BACKGROUND: Trauma systems are designed to bring the injured patient to definitive care in the shortest practical time. This depends on prehospital destination criteria (primary triage) and interfacility transfer guidelines (secondary triage). Although primary undertriage is associated with increased costs and worse outcomes for selected injuries, secondary overtriage can overwhelm system resources and delay definitive care. The purpose of this study was to determine the incidence of secondary overtriage in a region without a formal trauma system. STUDY DESIGN: Retrospective cohort study of trauma registry data at an American College of Surgeons Committee on Trauma-verified Level I trauma center and regional referral center. Secondary overtriage was defined as patients transferred from another hospital emergency department to our trauma receiving unit who had an injury severity score < 10, did not require an operation, and who were discharged to home within 48 hours of admission. RESULTS: Data on 9,064 patients were reviewed; 6,875 (76%) arrived directly from the scene and 2,189 (24%) were transferred. Although the transferred group was more severely injured, the majority (64%) had minor injuries and 824 (39%) met secondary overtriage criteria. The degree of secondary overtriage and injury pattern varied with respect to referring facility. Peak admission day and times for overtriage patients coincided with scene admissions trauma receiving unit closure events. Patient payor mix and facility cost and reimbursement profiles did not differ between scene and transfer overtriage patients. CONCLUSIONS: A substantial proportion of transferred trauma patients require only brief diagnostic or observational care. Excessive overtriage calls for development of a regional inclusive trauma system with established primary and secondary triage guidelines to improve access to care and trauma system efficiency.     

Efficiency of activation of the trauma team in a Norwegian trauma referral centre.

OBJECTIVE: To evaluate the efficiency (sensitivity, specificity, positive predictive value, overtriage, and undertriage) of activation of the trauma team in a Norwegian trauma referral centre. DESIGN: A cohort study with univariate and multivariate analysis. SETTING: A primary trauma hospital and trauma referral centre, Norway. SUBJECTS: 3391 injured patients admitted during a 12 months period, starting January 15th, 1996. MAIN OUTCOME MEASURES: Activation of the trauma team for severely injured patients and factors associated with correct activation. RESULTS: Of the 3383 injured patients admitted, 283 (8%) were classified as severely injured. Of 507 activations of the trauma team, 240 (47%) were for severely injured patients (sensitivity 85%, undertriage 15%, specificity 91%, overtriage 9%, positive predictive value 0.47). The system of activation was significantly more efficient for patients admitted by anaesthetist-manned ambulances than by ordinary ground ambulances (sensitivity 94% compared with 83%, corresponding positive predictive value 0.55 and 0.33, p < 0.05). Female sex and age over 70 years were independent factors associated with significantly less use of the trauma team in severely injured patients (p < 0.05). CONCLUSION: The undertriage rate of 15% and a positive predictive value of only 0.47 indicates a need for improvement of our activation system. Female sex and age over 70 years were significantly associated with undertriage in severely injured patients. Our protocol for triage and the initial treatment of severely injured patients has been revised in the light of these findings, and we have established a trauma registry.     

In-hospital downgrading of the trauma team: Validation of the Academic Medical Center downgrading criteria

BACKGROUND: To reduce overtriage of trauma patients while at the same time minimising undertriage, an in-hospital triage tool was developed with the purpose of reducing the initial full trauma team (downgrading) in a structured and evidence-based manner. This study evaluated the effect on overtriage rates by the AMC downgrading protocol (AMCDP) consisting of 24 criteria scored during the primary survey. PATIENTS AND METHODS: We prospectively investigated if any of the patients treated by the downgraded trauma team (DTT) were undertriaged by the protocol. All patients fulfilling the definition of severely injured (SI) patients but treated by the DTT were deemed undertriaged patients. Overtriage was measured by the percentage of patients treated by a full trauma team (FTT) while not classified as an SI patient. RESULTS: A total of 220 patients were eligible and triaged by the AMCDP. After triage, 95 patients (43%) were treated by the DTT while 125 patients (57%) were treated by the FTT. A total of 66 patients (30%) met one or more of the criteria for an SI patient. None of these patients were treated by the DTT. Of the 125 patients treated by the FTT, 59 patients were not defined as SI. CONCLUSION: For the entire study population no undertriage was found, while implementation of the AMCDP reduced overtriage in the entire study population from 70% to 26.8%. Similar trauma centres can benefit from implementing the AMC downgrading protocol.