Injured Older Adults Transported by Emergency Medical Services: One Year Outcomes by POLST Status

Background: Advance care planning documents, including Physician Orders for Life-Sustaining Treatment (POLST), are intended to guide care near end of life, particularly in emergency situations. Yet, research on POLST during emergency care is sparse. Methods: A total of 7,055 injured patients age ≥ 65 years were transported by 8 emergency medical services (EMS) agencies to 23 hospitals in Oregon. We linked multiple data sources to EMS records, including: the Oregon POLST Registry, Medicare claims data, Oregon Trauma Registry, Oregon statewide inpatient data, and Oregon vital statistics records. We describe patient and event characteristics by POLST status at time of 9-1-1 contact, subsequent changes in POLST forms, and mortality to 12 months. Results: Of 7,055 injured older adults, 1,412 (20.0%) had a registered POLST form at the time of 911 contact. Among the 1,412 POLST forms, 390 (27.6%) specified full orders, 585 (41.4%) limited interventions, and 437 (30.9%) comfort measures only. By one year, 2,471 (35%) patients had completed POLST forms. Among the 4 groups (no POLST, POLST-full orders, POLST-limited intervention, POLST-comfort measures), Injury Severity Scores were similar. Mortality differences were present by 30 days (5.0%, 4.6%, 8.0%, and 13.3%, p < 0.01) and were greater by one year (19.5%, 23.9%, 35.4%, and 46.2%, p < 0.01). Conclusions: Among injured older adults transported by ambulance in Oregon, one in 5 had an active POLST form at the time of 9-1-1 contact, the prevalence of which increased over the following year. Mortality differences by POLST status were evident at 30 days and large by one year. This information could help emergency, trauma, surgical, inpatient, and outpatient clinicians understand how to guide patients through acute injury episodes of care and post-injury follow up.

Building A Longitudinal Cohort From 9-1-1 to 1-Year Using Existing Data Sources, Probabilistic Linkage, and Multiple Imputation: A Validation Study

OBJECTIVE

The objective was to describe and validate construction of a population-based, longitudinal cohort of injured older adults from 9-1-1 call to 1-year follow-up using existing data sources, probabilistic linkage, and multiple imputation.

METHODS

This was a descriptive cohort study conducted in seven counties in Oregon and Washington from January 1, 2011, through December 31, 2011, with follow-up through December 31, 2012. The primary cohort included all injured adults ≥ 65 years served by 44 emergency medical services (EMS) agencies. We used nine existing databases to assemble the cohort, including EMS data, two state trauma registries, two state discharge databases, two state vital statistics databases, the Oregon Physician Order for Life-Sustaining Treatment registry, and Medicare claims data. We matched data files using probabilistic linkage and handled missing values with multiple imputation. We independently validated data processes using 1,350 randomly sampled records for probabilistic linkage and 3,140 randomly sampled records for variables created from existing data sources.

RESULTS

There were 15,649 injured older adults in the primary cohort, with 13,661 (87.3%) total matched records and 9,337 (59.7%) matches to the index ED/hospital visit. The sensitivity of linkage was 99.9% (95% confidence interval [CI] = 99.3%-100%) for any match and 98.3% (95% CI = 96.2%-99.4%) for index event matches. The specificity of linkage was 95.7% (95% CI = 93.7%-97.2%) for any match and 100% (95% CI = 99.2%-100%) for index event matches. Name, date of birth, home zip code, age, and hospital had the highest yield for linkage. Patients with matched records tended to be higher acuity than unmatched patients, suggesting selection bias if unmatched patients were excluded. Compared to hand-abstracted values, the sensitivity of electronically derived variables ranged from 18.2% (abdominal-pelvic Abbreviated Injury Scale score ≥ 3) to 97.4% (in-hospital mortality), with specificity of 88.0% to 99.8%.

CONCLUSIONS

A population-based emergency care cohort with long-term outcomes can be constructed from existing data sources with high accuracy and reasonable validity of resulting variables.

The First National Institutes of Health Institutional Training Program in Emergency Care Research: Productivity and Outcomes

STUDY OBJECTIVE

We assess the productivity, outcomes, and experiences of participants in the National Institutes of Health/National Heart, Lung, and Blood Institute-funded K12 institutional research training programs in emergency care research.

METHODS

We used a mixed-methods study design to evaluate the 6 K12 programs, including 2 surveys, participant interviews, scholar publications, grant submissions, and funded grants. The training program lasted from July 1, 2011, through June 30, 2017. We tracked scholars for a minimum of 3 years and up to 5 years, beginning with date of entry into the program. We interviewed program participants by telephone using open-ended prompts.

RESULTS

There were 94 participants, including 43 faculty scholars, 13 principal investigators, 30 non-principal investigator primary mentors, and 8 program administrators. The survey had a 74% overall response rate, including 95% of scholars. On entry to the program, scholars were aged a median of 37 years (interquartile range [IQR] 34 to 40 years), with 16 women (37%), and represented 11 disciplines. Of the 43 scholars, 40 (93%) submitted a career development award or research project grant during or after the program; 26 (60%) have secured independent funding as of August 1, 2017. Starting with date of entry into the program, the median time to grant submission was 19 months (IQR 11 to 27 months) and time to funding was 33 months (IQR 27 to 39 months). Cumulative median publications per scholar increased from 7 (IQR 4 to 15.5) at program entry to 21 (IQR 11 to 33.5) in the first post-K12 year. We conducted 57 semistructured interviews and identified 7 primary themes.

CONCLUSION

This training program produced 43 interdisciplinary investigators in emergency care research, with demonstrated productivity in grant funding and publications.

Time to Epinephrine Administration and Survival From Nonshockable Out-of-Hospital Cardiac Arrest Among Children and Adults

BACKGROUND

Previous studies have demonstrated that earlier epinephrine administration is associated with improved survival from out-of-hospital cardiac arrest (OHCA) with shockable initial rhythms. However, the effect of epinephrine timing on patients with nonshockable initial rhythms is unclear. The objective of this study was to measure the association between time to epinephrine administration and survival in adults and children with emergency medical services (EMS)-treated OHCA with nonshockable initial rhythms.

METHODS

We performed a secondary analysis of OHCAs prospectively identified by the Resuscitation Outcomes Consortium network from June 4, 2011, to June 30, 2015. We included patients of all ages with an EMS-treated OHCA and an initial nonshockable rhythm. We excluded those with return of spontaneous circulation in <10 minutes. We conducted a subgroup analysis involving patients <18 years of age. The primary exposure was time (minutes) from arrival of the first EMS agency to the first dose of epinephrine. Secondary exposure was time to epinephrine dichotomized as early (<10 minutes) or late (≥10 minutes). The primary outcome was survival to hospital discharge. We adjusted for Utstein covariates and Resuscitation Outcomes Consortium study site.

RESULTS

From 55 568 EMS-treated OHCAs, 32 101 patients with initial nonshockable rhythms were included. There were 12 238 in the early group, 14 517 in the late group, and 5346 not treated with epinephrine. After adjusting for potential confounders, each minute from EMS arrival to epinephrine administration was associated with a 4% decrease in odds of survival for adults, odds ratio=0.96 (95% confidence interval, 0.95-0.98). A subgroup analysis (n=13 290) examining neurological outcomes showed a similar association (adjusted odds ratio, 0.94 per minute; 95% confidence interval, 0.89-0.98). When epinephrine was given late in comparison with early, odds of survival were 18% lower (odds ratio, 0.82; 95% confidence interval, 0.68-0.98). In a pediatric analysis (n=595), odds of survival were 9% lower (odds ratio, 0.91; 95% confidence interval, 0.81-1.01) for each minute delay in epinephrine.

CONCLUSIONS

Among OHCAs with nonshockable initial rhythms, the majority of patients were administered epinephrine >10 minutes after EMS arrival. Each minute delay in epinephrine administration was associated with decreased survival and unfavorable neurological outcomes. EMS agencies should consider strategies to reduce epinephrine administration times in patients with initial nonshockable rhythms.

Out-of-hospital and Inter-hospital Under-triage to Designated Tertiary Trauma Centers among Injured Older Adults: A 10-year Statewide Geospatial-Adjusted Analysis

OBJECTIVE

While out-of-hospital under-triage of seriously injured older adults to tertiary trauma centers has long been acknowledged, no study has adjusted for place of injury or evaluated the extent of inter-facility under-triage. We sought to determine distance and confounder adjusted odds of treatment at a tertiary trauma center (TTC) for older adult trauma patients compared to younger trauma patients, for patients transported from the scene of injury and those transferred from a non-tertiary trauma (NTTC) center.

METHODS

This was a retrospective cohort study utilizing data from a statewide trauma registry reported over a 10-year period (2005-14). The outcome of interest was treatment at an American College of Surgeons or state-designated Level I/II trauma center (TTC). The predictor variable of interest was age group (> = 55 years vs. < 55 years). Covariates of interest included patient demographics, clinical characteristics and various distance measures calculated based on the patient's injury location.

RESULTS

84 930 patients met study criteria. Of these 42% (35659) were 55 years and older with an average age of 74 years (SD, 11.6). Older adult patients were on average, injured slightly farther away from a TTC (median distance, 34 vs. 29 miles, p < 0.001). Among patients initially presenting to NTTCs, older adults were significantly more likely to be transferred to another NTTC (53% vs. 34%). After adjusting for confounders and distance measures, older adults were less likely to be treated at TTCs overall (OR = 0.54, 95% CI: 0.52-0.56), whether transported by EMS from the scene of injury (OR = 0.47, 95% CI: 0.44-0.50) or via inter-facility transfer (OR = 0.63, 95%CI: 0.59-0.68).

CONCLUSIONS

Injured older adults face significant under-triage to TTCs whether by EMS from the scene of injury or via transfer from NTTCs. Adjusting for proximity of injury to a TTC does not alter these findings.

Using Press Ganey Provider Feedback to Improve Patient Satisfaction: A Pilot Randomized Controlled Trial

OBJECTIVE

The objective was to conduct a pilot randomized controlled trial to assess the feasibility, logistics, and potential effect of monthly provider funnel plot feedback reports from Press Ganey data and semiannual face-to-face coaching sessions to improve patient satisfaction scores.

METHODS

This was a pilot randomized controlled trial of 25 emergency medicine faculty providers in one urban academic emergency department. We enrolled full-time clinical faculty with at least 12 months of baseline Press Ganey data, who anticipated working in the ED for at least 12 additional months. Providers were randomized into intervention or control groups in a 1:1 ratio. The intervention group had an initial 20-minute meeting to introduce the funnel plot feedback tool and standardized feedback based on their baseline Press Ganey scores and then received a monthly e-mail with their individualized funnel plot depicting cumulative Press Ganey scores (compared to their baseline score and the mean score of all providers) for 12 months. The primary outcome was the difference in Press Ganey "doctor-overall" scores between treatment groups at 12 months. We used a weighted analysis of covariance model to analyze the study groups, accounting for variation in the number of surveys by provider and baseline scores.

RESULTS

Of 36 eligible faculty, we enrolled 25 providers, 13 of whom were randomized to the intervention group and 12 to the control group. During the study period, there were 815 Press Ganey surveys returned, ranging from four to 71 surveys per provider. For the standardized overall doctor score over 12 months (primary outcome), there was no difference between the intervention and control groups (difference = 1.3 points, 95% confidence interval = -2.4 to 5.9, p = 0.47). Similarly, there was no difference between groups when evaluating the four categories of doctor-specific patient satisfaction scores from the Press Ganey survey (all p > 0.05).

CONCLUSIONS

In this pilot trial of monthly provider funnel plot Press Ganey feedback reports, there was no difference in patient satisfaction scores between the intervention and control groups after 12 months. While this study was not powered to detect outcome differences, we demonstrate the feasibility, logistics, and effect sizes that could be used to inform future definitive trials.

The Academic RVU: Ten Years Developing a Metric for and Financially Incenting Academic Productivity at Oregon Health & Science University

PURPOSE

Established metrics reward academic faculty for clinical productivity. Few data have analyzed a bonus model to measure and reward academic productivity. This study's objective was to describe development and use of a departmental academic bonus system for incenting faculty scholarly and educational productivity.

METHOD

This cross-sectional study analyzed a departmental bonus system among emergency medicine academic faculty at Oregon Health & Science University, including growth from 2005 to 2015. All faculty members with a primary appointment were eligible for participation. Each activity was awarded points based on a predetermined education or scholarly point scale. Faculty members accumulated points based on their activity (numerator), and the cumulative points of all faculty were the denominator. Variables were individual faculty member (deidentified), academic year, bonus system points, bonus amounts awarded, and measures of academic productivity. Data were analyzed using descriptive statistics, including measures of variance.

RESULTS

The total annual financial bonus pool ranged from $211,622 to $274,706. The median annual per faculty academic bonus remained fairly constant over time ($3,980 in 2005-2006 vs. $4,293 in 2014-2015), with most change at the upper quartile of academic bonus (max bonus $16,920 in 2005-2006 vs. $39,207 in 2014-2015). Bonuses rose linearly among faculty in the bottom three quartiles of academic productivity, but increased exponentially in the 75th to 100th percentile.

CONCLUSIONS

Faculty academic productivity can be measured and financially rewarded according to an objective academic bonus system. The "academic point" used to measure productivity functions as an "academic relative value unit."

Evaluation of Rural vs Urban Trauma Patients Served by 9-1-1 Emergency Medical Services

Importance

Despite a large rural US population, there are potential differences between rural and urban regions in the processes and outcomes following trauma.

Objectives

To describe and evaluate rural vs urban processes of care, injury severity, and mortality among injured patients served by 9-1-1 emergency medical services (EMS).

Design, Setting, and Participants

This was a preplanned secondary analysis of a prospective cohort enrolled from January 1 through December 31, 2011, and followed up through hospitalization. The study included 44 EMS agencies transporting to 28 hospitals in 2 rural and 5 urban counties in Oregon and Washington. A population-based, consecutive sample of 67 047 injured children and adults served by EMS (1971 rural and 65 076 urban) was enrolled. Among the 53 487 patients transported by EMS, a stratified probability sample of 17 633 patients (1438 rural and 16 195 urban) was created to track hospital outcomes (78.9% with in-hospital follow-up). Data analysis was performed from June 12, 2015, to May 20, 2016.

Exposures

Rural was defined at the county level by 60 minutes or more driving proximity to the nearest level I or II trauma center and/or rural designation in the Centers for Medicare & Medicaid Services ambulance fee schedule by zip code.

Main Outcomes and Measures

Mortality (out-of-hospital and in-hospital), need for early critical resources, and transfer rates.

Results

Of the 53 487 injured patients transported by EMS (17 633 patients in the probability sample), 27 535 were women (51.5%); mean (SD) age was 51.6 (26.1) years. Rural vs urban sensitivity of field triage for identifying patients requiring early critical resources was 65.2% vs 80.5%, and only 29.4% of rural patients needing critical resources were initially transported to major trauma centers vs 88.7% of urban patients. After accounting for transfers, 39.8% of rural patients requiring critical resources were cared for in major trauma centers vs 88.7% of urban patients. Overall mortality did not differ between rural and urban regions (1.44% vs 0.89%; P = .09); however, 89.6% of rural deaths occurred within 24 hours compared with 64% of urban deaths. Rural regions had higher transfer rates (3.2% vs 2.7%) and longer transfer distances (median, 97.4 km; interquartile range [IQR], 51.7-394.5 km; range, 47.8-398.6 km vs 22.5 km; IQR, 11.6-24.6 km; range, 3.5-97.4 km).

Conclusions and Relevance

Most high-risk trauma patients injured in rural areas were cared for outside of major trauma centers and most rural trauma deaths occurred early, although overall mortality did not differ between regions. There are opportunities for improved timeliness and access to major trauma care among patients injured in rural regions.

The Association Between Hospital Capacity Strain and Inpatient Outcomes in Highly Developed Countries: A Systematic Review

BACKGROUND

Increases in patient needs can strain hospital resources, which may worsen care quality and outcomes. This systematic literature review sought to understand whether hospital capacity strain is associated with worse health outcomes for hospitalized patients and to evaluate benefits and harms of health system interventions to improve care quality during times of hospital capacity strain.

METHODS

Parallel searches were conducted in MEDLINE, CINAHL, the Cochrane Library, and reference lists from 1999-2015. Two reviewers assessed study eligibility. We included English-language studies describing the association between capacity strain (high census, acuity, turnover, or an indirect measure of strain such as delayed admission) and health outcomes or intermediate outcomes for children and adults hospitalized in highly developed countries. We also included studies of health system interventions to improve care during times of capacity strain. Two reviewers extracted data and assessed risk of bias using the Newcastle-Ottawa Score for observational studies and the Cochrane Collaboration Risk of Bias Assessment Tool for experimental studies.

RESULTS

Of 5,702 potentially relevant studies, we included 44 observational and 8 experimental studies. There was marked heterogeneity in the metrics used to define capacity strain, hospital settings, and overall study quality. Mortality increased during times of capacity strain in 18 of 30 studies and in 9 of 12 studies in intensive care unit settings. No experimental studies were randomized, and none demonstrated an improvement in health outcomes after implementing the intervention. The pediatric literature is very limited; only six observational studies included children. There was insufficient study homogeneity to perform meta-analyses.

DISCUSSION

In highly developed countries, hospital capacity strain is associated with increased mortality and worsened health outcomes. Evidence-based solutions to improve outcomes during times of capacity strain are needed.

Role of Guideline Adherence in Improving Field Triage

OBJECTIVE

To compare the sensitivity of current field triage practices for identifying high-risk trauma patients to strict guideline adherence, including changes in triage specificity, ambulance transport patterns, and trauma center volumes.

METHODS

This was a pre-planned secondary analysis of an out-of-hospital prospective cohort of injured children and adults transported by 44 EMS agencies to 28 trauma and non-trauma hospitals in 7 Northwest U.S. counties from January 1, 2011 through December 31, 2011. Outcomes included Injury Severity Score (ISS) ≥16 (primary) and early critical resource use. Strict adherence of the triage guidelines was based on evidence in the EMS chart for patients meeting any current field triage criteria, calculated with and without strict interpretation of the age criterion (<15 or >55 years). Due to the probability sampling nature of the cohort, strata and weights were included in all analyses.

RESULTS

17,633 injured patients were transported by EMS (weighted to represent 53,487 transported patients), including 3.1% with ISS ≥16 and 1.7% requiring early critical resources. Field triage sensitivity for identifying patients with ISS ≥16 increased from the current 66.2% (95% CI 60.2-71.7%) to 87.3% (95% CI 81.9-91.2%) for strict adherence without age and to 91.0% (95% CI 86.4-94.2%) for strict adherence with age. Specificity decreased with increasing adherence, from 87.8% (current) to 47.6% (strict adherence without age) and 35.8% (strict adherence with age). Areas under the curve (AUC) were 0.78, 0.73, and 0.72, respectively. Results were similar for patients requiring early critical resources. We estimate the number of triage-positive patients transported each year by EMS to an individual major trauma center (on average) to increase from 1,331 (current) to 5,139 (strict adherence without age) and to 6,256 (strict adherence with age).

CONCLUSIONS

The low sensitivity of current triage practices would be expected to improve with strict adherence to current triage guidelines, with a commensurate decrease in triage specificity and an increase in the number of triage-positive patients transported to major trauma centers.

QuickBrain MRI for the detection of acute pediatric traumatic brain injury

OBJECTIVE The current gold-standard imaging modality for pediatric traumatic brain injury (TBI) is CT, but it confers risks associated with ionizing radiation. QuickBrain MRI (qbMRI) is a rapid brain MRI protocol that has been studied in the setting of hydrocephalus, but its ability to detect traumatic injuries is unknown. METHODS The authors performed a retrospective cohort study of pediatric patients with TBI who were undergoing evaluation at a single Level I trauma center between February 2010 and December 2013. Patients who underwent CT imaging of the head and qbMRI during their acute hospitalization were included. Images were reviewed independently by 2 neuroradiology fellows blinded to patient identifiers. Image review consisted of identifying traumatic mass lesions and their intracranial compartment and the presence or absence of midline shift. CT imaging was used as the reference against which qbMRI was measured. RESULTS A total of 54 patients met the inclusion criteria; the median patient age was 3.24 years, 65% were male, and 74% were noted to have a Glasgow Coma Scale score of 14 or greater. The sensitivity and specificity of qbMRI to detect any lesion were 85% (95% CI 73%-93%) and 100% (95% CI 61%-100%), respectively; the sensitivity increased to 100% (95% CI 89%-100%) for clinically important TBIs as previously defined. The mean interval between CT and qbMRI was 27.5 hours, and approximately half of the images were obtained within 12 hours. CONCLUSIONS In this retrospective pilot study, qbMRI demonstrated reasonable sensitivity and specificity for detecting a lesion or injury seen with neuroimaging (radiographic TBI) and clinically important acute pediatric TBI.

Emergency Medicine Resources Within the Clinical Translational Science Institutes: A Cross-sectional Study

BACKGROUND

The Clinical and Translational Science Award (CTSA) program aims to strengthen and support translational research by accelerating the process of translating laboratory discoveries into treatments for patients, training a new generation of clinical and translational researchers, and engaging communities in clinical research efforts. Yet, little is known about how emergency care researchers have interacted with and utilized the resources of academic institutions with CTSAs.

OBJECTIVES

The purpose of this survey was to describe how emergency care researchers use local CTSA resources, to ascertain what proportion of CTSA consortium members have active emergency care research (ECR) programs, and to solicit participation in a national CTSA-associated emergency care translational research network.

METHODS

This study was a survey of all emergency departments affiliated with a CTSA.

RESULTS

Of the 65 CTSA consortium members, three had no ECR program and we obtained responses from 46 of the remaining 62 (74% response rate). The interactions with and resources used by emergency care researchers varied widely. Methodology and biostatistics support was most frequently accessed (77%), followed closely by education and training programs (60%). Several ECR programs (76%) had submitted for funding through CTSAs, with 71% receiving awards. Most CTSA consortium members had an active ECR infrastructure: 21 (46%) had 24/7 availability to recruit and screen for research, and 21 (46%) had less than 24/7 research recruitment. A number of emergency care research programs participated in National Institutes of Health research networks with the Neurological Emergencies Treatment Trials network most highly represented with 23 (59%) sites. Most ECR programs (96%) were interested in participating in a CTSA-based emergency care translational research network.

CONCLUSIONS

Despite little initial involvement in development of the CTSA program, there has been moderate interaction between CTSAs and emergency care. There is considerable interest in participating in a CTSA consortium-based emergency care translational research network.

A Geospatial Analysis of Severe Firearm Injuries Compared to Other Injury Mechanisms: Event Characteristics, Location, Timing, and Outcomes

OBJECTIVES

Relatively little is known about the context and location of firearm injury events. Using a prospective cohort of trauma patients, we describe and compare severe firearm injury events to other violent and nonviolent injury mechanisms regarding incident location, proximity to home, time of day, spatial clustering, and outcomes.

METHODS

This was a secondary analysis of a prospective cohort of injured children and adults with hypotension or Glasgow Coma Scale score ≤ 8, injured by one of four primary injury mechanisms (firearm, stabbing, assault, and motor vehicle collision [MVC]) who were transported by emergency medical services to a Level I or II trauma center in 10 regions of the United States and Canada from January 1, 2010, through June 30, 2011. We used descriptive statistics and geospatial analyses to compare the injury groups, distance from home, outcomes, and spatial clustering.

RESULTS

There were 2,079 persons available for analysis, including 506 (24.3%) firearm injuries, 297 (14.3%) stabbings, 339 (16.3%) assaults, and 950 (45.7%) MVCs. Firearm injuries resulted in the highest proportion of serious injuries (66.3%), early critical resources (75.3%), and in-hospital mortality (53.5%). Injury events occurring within 1 mile of a patient's home included 53.9% of stabbings, 49.2% of firearm events, 41.3% of assaults, and 20.0% of MVCs; the non-MVC events frequently occurred at home. While there was geospatial clustering, 94.4% of firearm events occurred outside of geographic clusters.

CONCLUSIONS

Severe firearm events tend to occur within a patient's own neighborhood, often at home, and generally outside of geospatial clusters. Public health efforts should focus on the home in all types of neighborhoods to reduce firearm violence.

Cost-Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services

BACKGROUND

The American College of Surgeons Committee on Trauma sets national targets for the accuracy of field trauma triage at ≥95% sensitivity and ≥65% specificity, yet the cost-effectiveness of realizing these goals is unknown. We evaluated the cost-effectiveness of current field trauma triage practices compared with triage strategies consistent with the national targets.

STUDY DESIGN

This was a cost-effectiveness analysis using data from 79,937 injured adults transported by 48 emergency medical services agencies to 105 trauma and nontrauma hospitals in 6 regions of the western United States from 2006 through 2008. Incremental differences in survival, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio (costs per QALY gained) were estimated for each triage strategy during a 1-year and lifetime horizon using a decision analytic Markov model. We considered an incremental cost-effectiveness ratio threshold of <$100,000 to be cost-effective.

RESULTS

For these 6 regions, a high-sensitivity triage strategy consistent with national trauma policy (sensitivity 98.6%, specificity 17.1%) would cost $1,317,333 per QALY gained, and current triage practices (sensitivity 87.2%, specificity 64.0%) cost $88,000 per QALY gained, compared with a moderate sensitivity strategy (sensitivity 71.2%, specificity 66.5%). Refining emergency medical services transport patterns by triage status improved cost-effectiveness. At the trauma-system level, a high-sensitivity triage strategy would save 3.7 additional lives per year at a 1-year cost of $8.78 million, and a moderate sensitivity approach would cost 5.2 additional lives and save $781,616 each year.

CONCLUSIONS

A high-sensitivity approach to field triage consistent with national trauma policy is not cost-effective. The most cost-effective approach to field triage appears closely tied to triage specificity and adherence to triage-based emergency medical services transport practices.

Improving early identification of the high-risk elderly trauma patient by emergency medical services

STUDY OBJECTIVE

We sought to (1) define the high-risk elderly trauma patient based on prognostic differences associated with different injury patterns and (2) derive alternative field trauma triage guidelines that mesh with national field triage guidelines to improve identification of high-risk elderly patients.

METHODS

This was a retrospective cohort study of injured adults ≥65 years transported by 94 EMS agencies to 122 hospitals in 7 regions from 1/1/2006 through 12/31/2008. We tracked current field triage practices by EMS, patient demographics, out-of-hospital physiology, procedures and mechanism of injury. Outcomes included Injury Severity Score≥16 and specific anatomic patterns of serious injury using abbreviated injury scale score ≥3 and surgical interventions. In-hospital mortality was used as a measure of prognosis for different injury patterns.

RESULTS

33,298 injured elderly patients were transported by EMS, including 4.5% with ISS≥16, 4.8% with serious brain injury, 3.4% with serious chest injury, 1.6% with serious abdominal-pelvic injury and 29.2% with serious extremity injury. In-hospital mortality ranged from 18.7% (95% CI 16.7-20.7) for ISS≥16 to 2.9% (95% CI 2.6-3.3) for serious extremity injury. The alternative triage guidelines (any positive criterion from the current guidelines, GCS≤14 or abnormal vital signs) outperformed current field triage practices for identifying patients with ISS≥16: sensitivity (92.1% [95% CI 89.6-94.1%] vs. 75.9% [95% CI 72.3-79.2%]), specificity (41.5% [95% CI 40.6-42.4%] vs. 77.8% [95% CI 77.1-78.5%]). Sensitivity decreased for individual injury patterns, but was higher than current triage practices.

CONCLUSIONS

High-risk elderly trauma patients can be defined by ISS≥16 or specific non-extremity injury patterns. The field triage guidelines could be improved to better identify high-risk elderly trauma patients by EMS, with a reduction in triage specificity.

Validation of the Denver Emergency Department Trauma Organ Failure Score to Predict Post-Injury Multiple Organ Failure

BACKGROUND

Early recognition of trauma patients at risk for multiple organ failure (MOF) is important to reduce the morbidity and mortality associated with MOF. The objective of the study was to externally validate the Denver Emergency Department (ED) Trauma Organ Failure (TOF) Score, a 6-item instrument that includes age, intubation, hematocrit, systolic blood pressure, blood urea nitrogen, and white blood cell count, which was designed to predict the development of MOF within 7 days of hospitalization.

STUDY DESIGN

We performed a prospective multicenter study of adult trauma patients between November, 2011 and March, 2013. The primary outcome was development of MOF within 7 days of hospitalization, assessed using the Sequential Organ Failure Assessment Score. Hierarchical logistic regression analysis was performed to determine associations between the Denver ED TOF Score and MOF. Discrimination was assessed and quantified using a receiver operating characteristics (ROC) curve. The predictive accuracy of the Denver ED TOF score was compared with attending emergency physician estimation of the likelihood of MOF.

RESULTS

We included 2,072 patients with a median age of 46 years (interquartile range [IQR] 30 to 61 years); 68% were male. The median Injury Severity Score was 9 (IQR 5 to 17), and 88% of patients had blunt mechanism injury. Among participants, 1,024 patients (49%) were admitted to the ICU, and 77 (4%) died. Multiple organ failure occurred in 120 (6%; 95% CI 5% to 7%) patients and of these, 37 (31%; 95% CI 23% to 40%) died. The area under the ROC curve for the Denver ED TOF Score prediction of MOF was 0.89 (95% CI 0.86 to 0.91) and for physician estimation of the likelihood of MOF was 0.78 (95% CI 0.73 to 0.83).

CONCLUSIONS

The Denver ED TOF Score predicts development of MOF within 7 days of hospitalization. Its predictive accuracy outperformed attending emergency physician estimation of the risk of MOF.