Risk factors and mortality associated with undertriage after major trauma in a physician-led prehospital system: a retrospective multicentre cohort study

Recent Outcomes Research in Helicopter Emergency Medical Services: A Scoping Review of Publication Year 2023 Additions to the Helicopter Outcomes Assessment Research Database

OBJECTIVE

The purpose of this scoping review was to identify and characterize helicopter emergency medical services (HEMS) outcomes literature from 2023, with the goal of describing updates to the Critical Care Transport Collaborative Outcomes Research Effort HEMS Outcomes Assessment Research Database (HOARD).

METHODS

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines, a multireviewer approach was used to source and review articles published or in preprint databases from 2023. The articles included assessed a patient-centered outcome for HEMS versus a non-HEMS control group. Article characteristics included the journal impact factor (JIF), diagnostic group (trauma or nontrauma), and geographic origin. Categoric analyses comparing 2023 studies with HOARD studies from the previous decade (2013-2022) were executed with the Fisher exact test; nonnormal JIF data were described using median and interquartile range and analyzed (vs 2013-2022) with rank sum testing.

RESULTS

Of the initial records (N = 4,486), 4,410 were screened out, leaving 76 for full-text review. Of these, 58 were discarded, and 18 were classified as eligible for addition to HOARD. Most studies (14/18, 78%) focused on trauma, and an equally high proportion (14/18, 78%) came from North America. The median JIF was 2.4 (interquartile range, 1.2-3.6). Compared with HOARD studies from the previous decade, 2023 studies were similar with respect to diagnostic focus (P = .779), geographic origin (P = .171), and JIF (P = .531).

CONCLUSION

This scoping review provides information on 18 HEMS outcomes studies new to the evidence base in 2023.

Characteristics and demography of low energy fall injuries in patients > 60 years of age: a population-based analysis over a decade with focus on undertriage

BACKGROUND

An increasing group of elderly patients is admitted after low energy falls. Several studies have shown that this patient group tends to be severely injured and is often undertriaged.

METHODS

Patients > 60 years with low energy fall (< 1 m) as mechanism of injury were identified from the Stavanger University Hospital trauma registry. The study period was between 01.01.11 and 31.12.20. Patient and injury variables as well as clinical outcome were described. Undertriage was defined as patients with a major trauma, i.e., Injury Severity Score (ISS) > 15, without trauma team activation. Statistical analysis was performed using the Chi-squared test for categorical variables and the Mann-Whitney U test for continuous variables.

RESULTS

Over the 10-year study period, 388 patients > 60 years with low energy fall as mechanism of injury were identified. Median age was 78 years (IQR 68-86), and 53% were males. The location of major injury was head injury in 41% of the patients, lower extremities in 19%, and thoracic injuries in 10%. Thirty-day mortality was 13%. Fifty percent were discharged to home, 31% to nursing home, 9% in hospital mortality, and the remaining 10% were transferred to other hospitals or rehabilitation facilities. Ninety patients had major trauma, and the undertriage was 48% (95% confidence interval, 38 to 58%).

CONCLUSIONS

Patients aged > 60 years with low energy falls are dominated by head injuries, and the 30-day mortality is 13%. Patients with major trauma are undertriaged in half the cases mandating increased awareness of this patient group.

Performance of a provincial prehospital trauma triage protocol: A retrospective audit

Objective

To assess the accuracy of a five-step prehospital trauma triage protocol ( Échelle québécoise de triage préhospitalier en traumatologie (EQTPT)) to identify patients requiring urgent and specialized in-hospital trauma care in the Capitale-Nationale region – Québec.

Methods

The medical records of trauma patients transported by ambulance to one of the five participating emergency departments (EDs) between November 2016 and March 2017 were reviewed. Our primary outcome was the need for one of the following urgent and specialized trauma care: endotracheal intubation in the ED, administration of ≥ 2 blood products in the ED, angioembolization or surgery (excluding single limb surgery) < 24 h and admission to the intensive care unit (ICU) or in-hospital trauma-related death.

Results

A total of 902 patients were included. The median age was 63 (interquartile range (IQR) 51) and 494 (54.8%) were female. The main trauma mechanism was falls (n = 592), followed by motor vehicle accidents (n = 201). Eighty-two (9.1%) patients required at least one urgent and specialized trauma care. Of those, 44 (53.6%) were identified as requiring transport to a level one trauma centre (steps 1–3), 16 were identified as requiring transport to a centre with a lower level of trauma designation (steps 4–5) while 22 (26.8%) did not meet any of the EQTPT criteria. For steps 1 to 3, the sensitivity was 53.7% (95% confidence interval (CI) 42.9–64.4) and the specificity was 81.7% (95% CI 79.1–84.4) in identifying patients requiring specialized trauma care.

Conclusion

The EQTPT lacked sensitivity and was poorly specific to identify trauma patients who need specialized in-hospital trauma care.

Accuracy of a Prehospital Triage Protocol in Predicting In-Hospital Mortality and Severe Trauma Cases among Older Adults

Background: Prehospital trauma triage tools are not tailored to identify severely injured older adults. Our trauma triage protocol based on a three-tier trauma severity grading system (A, B, and C) has never been studied in this population. The objective was to assess its accuracy in predicting in-hospital mortality among older adults (≥65 years) and to compare it to younger patients. Methods: A retrospective multicenter cohort study, from 2011 to 2021. Consecutive adult trauma patients managed by a mobile medical team were prospectively graded A, B, or C according to the initial seriousness of their injuries. Accuracy was evaluated using sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. Results: 8888 patients were included (14.1% were ≥65 years). Overall, 10.1% were labeled Grade A (15.2% vs. 9.3% among older and younger adults, respectively), 21.9% Grade B (27.9% vs. 20.9%), and 68.0% Grade C (56.9% vs. 69.8%). In-hospital mortality was 7.1% and was significantly higher among older adults regardless of severity grade. Grade A showed lower sensitivity (50.5 (43.7; 57.2) vs. 74.6 (69.8; 79.1), p < 0.0001) for predicting mortality among older adults compared to their younger counterparts. Similarly, Grade B was associated with lower sensitivity (89.5 (84.7; 93.3) vs. 97.2 (94.8; 98.60), p = 0.0003) and specificity (69.4 (66.3; 72.4) vs. 74.6 (73.6; 75.7], p = 0.001) among older adults. Conclusions: Our prehospital trauma triage protocol offers high sensitivity for predicting in-hospital mortality including older adults.