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Yap SE, Wong HC, Chong SL, Ganapathy S, Ong GYK. Validation of motor component of Glasgow coma scale in lieu of total Glasgow coma scale as a pediatric trauma field triage tool. Am J Emerg Med 2024; 81:105-110. [PMID: 38733662 DOI: 10.1016/j.ajem.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 05/13/2024] Open
Abstract
INTRODUCTION Prehospital trauma triage and disability assessment of pediatric patients can be challenging on the field, especially in the pre-verbal age group. It would be useful if the same triage tool and criteria can be used for both adults and children to risk-stratify the need of higher acuity of trauma care. STUDY OBJECTIVE We aimed to investigate if using only the motor component of Glasgow Coma Scale (mGCS), as a quick field trauma triage tool, was non-inferior to total GCS (tGCS), and if mGCS <6 was non-inferior to tGCS <14, in predicting the need for intensive care or mortality in the pediatric population. METHODS We performed a retrospective review of patients <18-years-old, who presented to our emergency department (ED) with moderate (Injury Severity Score (ISS) 9-15) to severe (ISS > 15) traumatic injuries from January 2012 to December 2021. Using ED triage data, mortality and the need for intensive care unit (ICU) admission were used as surrogate outcomes to investigate if mGCS <6 was non-inferior to tGCS <14, and the area-under-the-receiver-operating-characteristic curve (AUROC) was used as a measure of comparability. RESULTS Among 582 included for analysis, the median age was 7-years-old (2-12), and most were male (63.4%). 22.4% patients demised or required ICU care. mGCS <6 had an AUROC of 0.75 (95% CI 0.70 to 0.79), which was non-inferior to tGCS <14; AUROC 0.76, (95% CI 0.72 to 0.81), for identifying children requiring ICU management or demised. The results shown here were based on the AUROCs that were used to evaluate the discriminatory ability of tGCS <14 and mGCS <6 in prediction of mortality and the need for ICU care. CONCLUSION Our study showed that mGCS was significantly associated with tGCS, and was non- inferior to the latter as a triage tool in pediatric trauma. It validated the use of mGCS <6 in lieu of tGCS <14 in the pre-hospital field triage of pediatric patients, in identification of children at risk of death or requiring ICU care. Larger prospective, observational studies using on-scene data would be required for more robust validation and determine optimal cut-offs.
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Affiliation(s)
- Shiyi Eileen Yap
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.
| | | | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - Sashikumar Ganapathy
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore; Duke-NUS Medical School, Singapore
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Fuller G, Baird J, Keating S, Miller J, Pilbery R, Kean N, McKnee K, Turner J, Lecky F, Edwards A, Rosser A, Fothergill R, Black S, Bell F, Smyth M, Smith JE, Perkins GD, Herbert E, Walters S, Cooper C. The accuracy of prehospital triage decisions in English trauma networks - a case-cohort study. Scand J Trauma Resusc Emerg Med 2024; 32:47. [PMID: 38773613 PMCID: PMC11110388 DOI: 10.1186/s13049-024-01219-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/24/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND Care for injured patients in England is provided by inclusive regional trauma networks. Ambulance services use triage tools to identify patients with major trauma who would benefit from expedited Major Trauma Centre (MTC) care. However, there has been no investigation of triage performance, despite its role in ensuring effective and efficient MTC care. This study aimed to investigate the accuracy of prehospital major trauma triage in representative English trauma networks. METHODS A diagnostic case-cohort study was performed between November 2019 and February 2020 in 4 English regional trauma networks as part of the Major Trauma Triage Study (MATTS). Consecutive patients with acute injury presenting to participating ambulance services were included, together with all reference standard positive cases, and matched to data from the English national major trauma database. The index test was prehospital provider triage decision making, with a positive result defined as patient transport with a pre-alert call to the MTC. The primary reference standard was a consensus definition of serious injury that would benefit from expedited major trauma centre care. Secondary analyses explored different reference standards and compared theoretical triage tool accuracy to real-life triage decisions. RESULTS The complete-case case-cohort sample consisted of 2,757 patients, including 959 primary reference standard positive patients. The prevalence of major trauma meeting the primary reference standard definition was 3.1% (n=54/1,722, 95% CI 2.3 - 4.0). Observed prehospital provider triage decisions demonstrated overall sensitivity of 46.7% (n=446/959, 95% CI 43.5-49.9) and specificity of 94.5% (n=1,703/1,798, 95% CI 93.4-95.6) for the primary reference standard. There was a clear trend of decreasing sensitivity and increasing specificity from younger to older age groups. Prehospital provider triage decisions commonly differed from the theoretical triage tool result, with ambulance service clinician judgement resulting in higher specificity. CONCLUSIONS Prehospital decision making for injured patients in English trauma networks demonstrated high specificity and low sensitivity, consistent with the targets for cost-effective triage defined in previous economic evaluations. Actual triage decisions differed from theoretical triage tool results, with a decreasing sensitivity and increasing specificity from younger to older ages.
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Affiliation(s)
- G Fuller
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK.
| | | | - S Keating
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK
| | - J Miller
- West Midlands Ambulance Service, Brierley Hill, UK
| | - R Pilbery
- Yorkshire Ambulance Service, Wakefield, UK
| | - N Kean
- South Western Ambulance Service, Exeter, UK
| | - K McKnee
- South Western Ambulance Service, Exeter, UK
| | - J Turner
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK
| | - F Lecky
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK
| | - A Edwards
- Trauma Audit and Research Network, Manchester, UK
| | - A Rosser
- West Midlands Ambulance Service, Brierley Hill, UK
| | | | - S Black
- South Western Ambulance Service, Exeter, UK
| | - F Bell
- Yorkshire Ambulance Service, Wakefield, UK
| | - M Smyth
- The University of Warwick, Coventry, UK
| | - J E Smith
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - E Herbert
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK
| | - S Walters
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK
| | - C Cooper
- School of Health and Related Research, University of Sheffield, Regent Court, Regent Street, Sheffield, S1 4DA, UK
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Malkoc A, GnanaDev R, Panchel D, Nguyen A, Glover K, GnanaDev D, Woodward B, Schwartz S. Increased Mortality in Patients Transferred to a Level 1 Trauma Center with Blunt and Penetrating Extremity Vascular Injuries. Ann Vasc Surg 2024; 106:115-123. [PMID: 38754580 DOI: 10.1016/j.avsg.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/12/2024] [Accepted: 03/10/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Trauma care depends on a complex transfer system to ensure timely and adequate management at major trauma centers. Patient outcomes depend on the reliability of triage in local or community hospitals and access to tertiary or quaternary trauma institutions. Patients with polytrauma, extremity trauma, or vascular injuries require multidisciplinary management at trauma hospitals. Our study investigated outcomes in this population at a level one trauma center in San Bernardino County, the largest geographic county in the contiguous United States. METHODS We conducted a retrospective review of all patients with extremity trauma who presented to a single level 1 trauma center over 10 years. The cohort was divided into following two groups: 1. transferred from another medical center for a higher level of care or 2. those who directly presented. Overall, 19,417 patients were identified, with 15,317 patients presenting directly and 3,830 patients transferred from an outside hospital. Extremity of vascular injuries was observed in 268 patients. Demographic data were ascertained, including the injury severity score, mechanism of injury, response level, arrival method, tertiary center emergency department disposition, and presence of vascular injury in the upper or lower extremities. Univariate and multivariate analyses were performed to assess patient mortality. RESULTS A total of 268 patients with vascular injuries were analyzed, including 207 nontransferred and 61 transferred patients. In the univariate analysis, injury severity score means were compared at 11.4 in nontransferred patients versus 8.4 in transferred (P < 0.001), 50% of blunt injury in the nontransferred group, and 28% in the transferred group (P < 0.001); in-hospital mortality was 4% in nontransferred patients versus 28% in the transferred group (P < 0.001). Multivariate logistic regression demonstrated that mortality is 8 times more likely if a patient with vascular extremity injuries is transferred from an outside hospital. A 10% mortality rate was observed in patients without blood transfusion within 4 hr of arrival to the trauma center and 3% mortality in transferred patients transfused blood. CONCLUSIONS Extremity trauma with vascular injury can be lethal if managed appropriately. Patients transferred to our level 1 trauma center had a substantial increase in mortality compared with nontransferred patients. Furthermore, the transfer distance was associated with increased mortality. Further research is required to address this vulnerable patient population.
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Affiliation(s)
- Aldin Malkoc
- Department of Surgery, Arrowhead Regional Medical Center, Colton, CA
| | - Raja GnanaDev
- Department of Surgery, Arrowhead Regional Medical Center, Colton, CA
| | - Dhruvi Panchel
- Department of Surgery, Arrowhead Regional Medical Center, Colton, CA
| | - Alexandra Nguyen
- Department of Surgery, Arrowhead Regional Medical Center, Colton, CA
| | - Keith Glover
- Department of Surgery, Arrowhead Regional Medical Center, Colton, CA; California University of Science and Medicine, Colton, CA
| | - Dev GnanaDev
- Department of Surgery, Arrowhead Regional Medical Center, Colton, CA; California University of Science and Medicine, Colton, CA
| | - Brandon Woodward
- Department of Surgery, Arrowhead Regional Medical Center, Colton, CA; California University of Science and Medicine, Colton, CA
| | - Samuel Schwartz
- Department of Surgery, Arrowhead Regional Medical Center, Colton, CA; California University of Science and Medicine, Colton, CA.
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Lenart EK, Byerly SE, Gross MG, Ali YM, Evans CR, Easterday TS, Howley IW, Kerwin AJ, Fischer PE, Filiberto DM. Clinical Implications of Over- and Under-Triage Using Need for Trauma Intervention and Cribari Indices. Am Surg 2024:31348241246181. [PMID: 38613475 DOI: 10.1177/00031348241246181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2024]
Abstract
BACKGROUND Need for Trauma Intervention (NFTI) score was proposed to help identify injured trauma patients while minimizing under (UT) and over triage (OT). Using a national database, we aimed to describe UT and OT of NFTI vs standard Cribari method (CM) and hypothesized triage sensitivity remains poor. METHODS The 2021 Trauma Quality Improvement Program (TQIP) database was queried. Demographics, mechanism, verification level, interfacility transfer (IF), and level of activation were collected. Patients were stratified by both NFTI [+ vs -] and CM [Injury severity score (ISS) < 15 vs > 15]. UT was defined as NFTI + or ISS >15 without full trauma activation. RESULTS 1,030,526 patients were identified in TQIP. 84,969 were UT and 97,262 were OT using NFTI while 94,020 were UT and 108,823 were OT using CM. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NFTI is 49%, 89%, 45%, and 90%, respectively vs 43%, 87%, 39%, and 89% of CM, respectively. Age was higher in the UT group using both scores (52 vs 42, P < .0001 and 54 vs 42, P < .0001, respectively). Using MLR, level 2 and 3 verification, blunt mechanism, female, IF, and older age were associated with UT in both NFTI and CM. Level 1 verification, penetrating mechanism, male, no IF, and younger age were associated with OT. CONCLUSIONS Current prehospital triage criteria have poor sensitivity for identifying severely injured trauma patients by both NFTI and CM. UT increases as age of the patient increases. Further studies are needed to improve triage.
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Affiliation(s)
- Emily K Lenart
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Saskya E Byerly
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Megan G Gross
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yasmin M Ali
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Cory R Evans
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Thomas S Easterday
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Isaac W Howley
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andy J Kerwin
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Peter E Fischer
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Dina M Filiberto
- Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
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Zylyftari S, Luger S, Blums K, Barthelmes S, Humm S, Baum H, Meckel S, Braun J, Lichy G, Heilgeist A, Kalra LP, Foerch C. GFAP point-of-care measurement for prehospital diagnosis of intracranial hemorrhage in acute coma. Crit Care 2024; 28:109. [PMID: 38581002 PMCID: PMC10996105 DOI: 10.1186/s13054-024-04892-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/27/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Prehospital triage and treatment of patients with acute coma is challenging for rescue services, as the underlying pathological conditions are highly heterogenous. Recently, glial fibrillary acidic protein (GFAP) has been identified as a biomarker of intracranial hemorrhage. The aim of this prospective study was to test whether prehospital GFAP measurements on a point-of-care device have the potential to rapidly differentiate intracranial hemorrhage from other causes of acute coma. METHODS This study was conducted at the RKH Klinikum Ludwigsburg, a tertiary care hospital in the northern vicinity of Stuttgart, Germany. Patients who were admitted to the emergency department with the prehospital diagnosis of acute coma (Glasgow Coma Scale scores between 3 and 8) were enrolled prospectively. Blood samples were collected in the prehospital phase. Plasma GFAP measurements were performed on the i-STAT Alinity® (Abbott) device (duration of analysis 15 min) shortly after hospital admission. RESULTS 143 patients were enrolled (mean age 65 ± 20 years, 42.7% female). GFAP plasma concentrations were strongly elevated in patients with intracranial hemorrhage (n = 51) compared to all other coma etiologies (3352 pg/mL [IQR 613-10001] vs. 43 pg/mL [IQR 29-91.25], p < 0.001). When using an optimal cut-off value of 101 pg/mL, sensitivity for identifying intracranial hemorrhage was 94.1% (specificity 78.9%, positive predictive value 71.6%, negative predictive value 95.9%). In-hospital mortality risk was associated with prehospital GFAP values. CONCLUSION Increased GFAP plasma concentrations in patients with acute coma identify intracranial hemorrhage with high diagnostic accuracy. Prehospital GFAP measurements on a point-of-care platform allow rapid stratification according to the underlying cause of coma by rescue services. This could have major impact on triage and management of these critically ill patients.
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Affiliation(s)
- Sabina Zylyftari
- Department of Neurology, RKH Klinikum Ludwigsburg, Posilipostr. 4, 71640, Ludwigsburg, Germany
| | - Sebastian Luger
- Department of Neurology, RKH Klinikum Ludwigsburg, Posilipostr. 4, 71640, Ludwigsburg, Germany
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Kristaps Blums
- Department of Neurology, RKH Klinikum Ludwigsburg, Posilipostr. 4, 71640, Ludwigsburg, Germany
| | - Stephan Barthelmes
- Department of Neurology, RKH Klinikum Ludwigsburg, Posilipostr. 4, 71640, Ludwigsburg, Germany
| | - Sebastian Humm
- Department of Neurology, RKH Klinikum Ludwigsburg, Posilipostr. 4, 71640, Ludwigsburg, Germany
| | - Hannsjörg Baum
- Institute for Laboratory Medicine and Transfusion Medicine, RKH Regionale Kliniken Holding Und Services GmbH, Ludwigsburg, Germany
| | - Stephan Meckel
- Institute of Diagnostic and Interventional Neuroradiology, RKH Klinikum, Ludwigsburg, Germany
| | - Jörg Braun
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, RKH Klinikum, Ludwigsburg, Germany
- DRF Luftrettung, Stuttgart, Germany
| | - Gregor Lichy
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, RKH Klinikum, Ludwigsburg, Germany
- DRF Luftrettung, Stuttgart, Germany
| | - Andreas Heilgeist
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, RKH Klinikum, Ludwigsburg, Germany
| | - Love-Preet Kalra
- Department of Neurology, RKH Klinikum Ludwigsburg, Posilipostr. 4, 71640, Ludwigsburg, Germany.
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany.
| | - Christian Foerch
- Department of Neurology, RKH Klinikum Ludwigsburg, Posilipostr. 4, 71640, Ludwigsburg, Germany
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
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Andrews T, Meadley B, Gabbe B, Beck B, Dicker B, Cameron P. Review article: Pre-hospital trauma guidelines and access to lifesaving interventions in Australia and Aotearoa/New Zealand. Emerg Med Australas 2024; 36:197-205. [PMID: 38253461 DOI: 10.1111/1742-6723.14373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 11/12/2023] [Accepted: 01/02/2024] [Indexed: 01/24/2024]
Abstract
The centralisation of trauma services in western countries has led to an improvement in patient outcomes. Effective trauma systems include a pre-hospital trauma system. Delivery of high-level pre-hospital trauma care must include identification of potential major trauma patients, access and correct application of lifesaving interventions (LSIs) and timely transport to definitive care. Globally, many nations endorse nationwide pre-hospital major trauma triage guidelines, to ensure a universal approach to patient care. This paper examined clinical guidelines from all 10 EMS in Australia and Aotearoa/New Zealand. All relevant trauma guidelines were included, and key information was extracted. Authors compared major trauma triage criteria, all LSI included in guidelines, and guidelines for transport to definitive care. The identification of major trauma patients varied between all 10 EMS, with no universal criteria. The most common approach to trauma triage included a three-step assessment process: physiological criteria, identified injuries and mechanism of injury. Disparity between physiological criteria, injuries and mechanism was found when comparing guidelines. All 10 EMS had fundamental LSI included in their trauma guidelines. Fundamental LSI included haemorrhage control (arterial tourniquets, pelvic binders), non-invasive airway management (face mask ventilation, supraglottic airway devices) and pleural wall needle decompression. Variation in more advanced LSI was evident between EMS. Optimising trauma triage guidelines is an important aspect of a robust and evidence driven trauma system. The lack of consensus in trauma triage identified in the present study makes benchmarking and comparison of trauma systems difficult.
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Affiliation(s)
- Tim Andrews
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Clinical Operations, Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Ben Meadley
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Clinical Operations, Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Bridget Dicker
- Clinical Audit and Research, Hato Hone St John New Zealand, Auckland, New Zealand
- Paramedicine Department, Auckland University of Technology, Auckland, New Zealand
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
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Choi D, Park JW, Kwak YH, Kim DK, Jung JY, Lee JH, Jung JH, Suh D, Lee HN, Lee EJ, Kim JH. Comparison of age-adjusted shock indices as predictors of injury severity in paediatric trauma patients immediately after emergency department triage: A report from the Korean multicentre registry. Injury 2024; 55:111108. [PMID: 37858444 DOI: 10.1016/j.injury.2023.111108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/26/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Shock index paediatric-adjusted (SIPA) was presented for early prediction of mortality and trauma team activation in paediatric trauma patients. However, the derived cut-offs of normal vital signs were based on old references. We established alternative SIPAs based on the other commonly used references and compared their predictive values. METHODS We performed a retrospective review of all paediatric trauma patients aged 1-15 years in the Emergency Department (ED)-based Injury In-depth Surveillance (EDIIS) database from January 1, 2011 to December 31, 2019. A total of 4 types of SIPA values were obtained based on the references as follows: uSIPA based on the Nelson textbook of paediatrics 21st ed., SIATLS based on the ATLS 10th guideline, SIPALS based on the PALS 2020 guideline, and SIPA. In each SIPA group, the cut-off was established by dividing the group into 4 subgroups: toddler (age 1-3), preschooler (age 4-6), schooler (age 7-12), and teenager (age 13-15). We performed an ROC analysis and calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to compare the predicted values of each SIPA in mortality, ICU admission, and emergent surgery or intervention. RESULTS A total of 332,271 patients were included. The proportion of patients with an elevated shock index was 14.9 % (n = 49,347) in SIPA, 22.8 % (n = 75,850) in uSIPA, 0.3 % (n = 1058) in SIATLS, and 4.3 % (n = 14,168) in SIPALS. For mortality, uSIPA achieved the highest sensitivity (57.0 %; 95 % confidence interval 56.9 %-57.2 %) compared to SIPA (49.4 %, 95 % CI 49.2 %-49.5 %), SIATLS (25.5 %, 95 % CI 25.4 %-25.7 %), and SIPALS (43.8 %, 95 % CI 43.7 %-44.0 %), but there were no significant differences in the negative predictive value (NPV) or area under the curve (AUC). The positive predictive value (PPV) was highest in SIATLS (5.7 %, 95 % CI 5.6 %-5.8 %) compared to SIPA (0.2 %, 95 % CI 0.2 %-0.3 %), uSIPA (0.2 %, 95 % CI 0.2 %-0.2 %), and SIPALS (0.7 %, 95 % CI 0.7 %-0.8 %). The same findings were presented in ICU admission and emergent operation or intervention. CONCLUSION The ATLS-based shock index achieved the highest PPV and specificity compared to SIPA, uSIPA, and SIPALS for adverse outcomes in paediatric trauma.
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Affiliation(s)
- Dongmuk Choi
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Joong Wan Park
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Young Ho Kwak
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Do Kyun Kim
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae Yun Jung
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jin Hee Lee
- Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, Bundang-gu, Seong-Nam, 13620, Republic of Korea
| | - Jin Hee Jung
- Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Dongbum Suh
- Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, Bundang-gu, Seong-Nam, 13620, Republic of Korea
| | - Ha Ni Lee
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Eui Jun Lee
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jin Hee Kim
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
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Becker J, Kurland L, Höglund E, Hugelius K. Dynamic ambulance relocation: a scoping review. BMJ Open 2023; 13:e073394. [PMID: 38101827 PMCID: PMC10729233 DOI: 10.1136/bmjopen-2023-073394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 12/01/2023] [Indexed: 12/17/2023] Open
Abstract
OBJECTIVES Dynamic ambulance relocation means that the operators at a dispatch centre place an ambulance in a temporary location, with the goal of optimising coverage and response times in future medical emergencies. This study aimed to scope the current research on dynamic ambulance relocation. DESIGN A scoping review was conducted using a structured search in PubMed, Scopus and Web of Science. In total, 21 papers were included. RESULTS Most papers described research with experimental designs involving the use of mathematical models to calculate the optimal use and temporary relocations of ambulances. The models relied on several variables, including distances, locations of hospitals, demographic-geological data, estimation of new emergencies, emergency medical services (EMSs) working hours and other data. Some studies used historic ambulance dispatching data to develop models. Only one study reported a prospective, real-time evaluation of the models and the development of technical systems. No study reported on either positive or negative patient outcomes or real-life chain effects from the dynamic relocation of ambulances. CONCLUSIONS Current knowledge on dynamic relocation of ambulances is dominated by mathematical and technical support data that have calculated optimal locations of ambulance services based on response times and not patient outcomes. Conversely, knowledge of how patient outcomes and the working environment are affected by dynamic ambulance dispatching is lacking. This review has highlighted several gaps in the scientific coverage of the topic. The primary concern is the lack of studies reporting on patient outcomes, and the limited knowledge regarding several key factors, including the optimal use of ambulances in rural areas, turnaround times, domino effects and aspects of working environment for EMS personnel. Therefore, addressing these knowledge gaps is important in future studies.
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Affiliation(s)
- Julia Becker
- Institute for Disaster and Emergency Management, Berlin, Germany
| | - Lisa Kurland
- Örebro Univeristy, Faculty of Medicine and Health, Orebro, Sweden
- Örebro University Hospital, Orebro, Sweden
| | - Erik Höglund
- Örebro Univeristy, Faculty of Medicine and Health, Orebro, Sweden
- Ambulance Department, Örebro Country Council, Örebro, Sweden
| | - Karin Hugelius
- Örebro Univeristy, Faculty of Medicine and Health, Orebro, Sweden
- Ambulance Department, Örebro Country Council, Örebro, Sweden
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9
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Barrett JW, Williams J, Skene SS, Griggs JE, Bootland D, Leung J, Da Costa A, Ballantyne K, Davies R, Lyon RM. Head injury in older adults presenting to the ambulance service: who do we convey to the emergency department, and what clinical variables are associated with an intracranial bleed? A retrospective case-control study. Scand J Trauma Resusc Emerg Med 2023; 31:65. [PMID: 37908011 PMCID: PMC10619243 DOI: 10.1186/s13049-023-01138-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/18/2023] [Indexed: 11/02/2023] Open
Abstract
OBJECTIVE Most older adults with traumatic brain injuries (TBI) reach the emergency department via the ambulance service. Older adults, often with mild TBI symptoms, risk being under-triaged and facing poor outcomes. This study aimed to identify whether sufficient information is available on the scene to an ambulance clinician to identify an older adult at risk of an intracranial haemorrhage following a head injury. METHODS This was a retrospective case-control observational study involving one regional ambulance service in the UK and eight emergency departments. 3545 patients aged 60 years and over presented to one regional ambulance service with a head injury between the 1st of January 2020 and the 31st of December 2020. The primary outcome was an acute intracranial haemorrhage on head computed tomography (CT) scan in patients conveyed to the emergency department (ED). A secondary outcome was factors associated with conveyance to the ED by the ambulance clinician. RESULTS In 2020, 2111 patients were conveyed to the ED and 162 patients were found to have an intracranial haemorrhage on their head CT scan. Falls from more than 2 m (adjusted odds ratio (aOR) 3.45, 95% CI 1.78-6.40), chronic kidney disease (CKD) (aOR 2.80, 95% CI 1.25-5.75) and Clopidogrel (aOR 1.98, 95% CI 1.04-3.59) were associated with an intracranial haemorrhage. Conveyance to the ED was associated with patients taking anticoagulant and antiplatelet medication or a visible head injury or head injury symptoms. CONCLUSION This study highlights that while most older adults with a head injury are conveyed to the ED, only a minority will have an intracranial haemorrhage following their head injury. While mechanisms of injury such as falls from more than 2 m remain a predictor, this work highlights that Clopidogrel and CKD are also associated with an increased odds of tICH in older adults following a head injury. These findings may warrant a review of current ambulance head injury guidelines.
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Affiliation(s)
- J W Barrett
- South East Coast Ambulance Service NHS FT, Crawley, UK.
- University of Surrey, Guildford, UK.
| | - J Williams
- South East Coast Ambulance Service NHS FT, Crawley, UK
- Paramedic Clinical Research Unit, University of Hatfield, Hatfield, UK
| | | | - J E Griggs
- University of Surrey, Guildford, UK
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
| | - D Bootland
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
- University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - J Leung
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - A Da Costa
- Medway Maritime Hospital NHS FT, Gillingham, UK
| | - K Ballantyne
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - R Davies
- South East Coast Ambulance Service NHS FT, Crawley, UK
| | - R M Lyon
- University of Surrey, Guildford, UK
- Air Ambulance Charity Kent, Surrey and Sussex, Redhill, UK
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10
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Isgrò S, Giani M, Antolini L, Giudici R, Valsecchi MG, Bellani G, Chiara O, Bassi G, Latronico N, Cabrini L, Fumagalli R, Chieregato A, Sammartano F, Sechi G, Zoli A, Pagliosa A, Palo A, Valoti O, Carlucci M, Benini A, Foti G. Identifying Trauma Patients in Need for Emergency Surgery in the Prehospital Setting: The Prehospital Prediction of In-Hospital Emergency Treatment (PROPHET) Study. J Clin Med 2023; 12:6660. [PMID: 37892798 PMCID: PMC10607301 DOI: 10.3390/jcm12206660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/08/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Prehospital field triage often fails to accurately identify the need for emergent surgical or non-surgical procedures, resulting in inefficient resource utilization and increased costs. This study aimed to analyze prehospital factors associated with the need for emergent procedures (such as surgery or interventional angiography) within 6 h of hospital admission. Additionally, our goal was to develop a prehospital triage tool capable of estimating the likelihood of requiring an emergent procedure following hospital admission. We conducted a retrospective observational study, analyzing both prehospital and in-hospital data obtained from the Lombardy Trauma Registry. We conducted a multivariable logistic regression analysis to identify independent predictors of emergency procedures within the first 6 h from admission. Subsequently, we developed and internally validated a triage score composed of factors associated with the probability of requiring an emergency procedure. The study included a total of 3985 patients, among whom 295 (7.4%) required an emergent procedure within 6 h. Age, penetrating injury, downfall, cardiac arrest, poor neurological status, endotracheal intubation, systolic pressure, diastolic pressure, shock index, respiratory rate and tachycardia were identified as predictors of requiring an emergency procedure. A triage score generated from these predictors showed a good predictive power (AUC of the ROC curve: 0.81) to identify patients requiring an emergent surgical or non-surgical procedure within 6 h from hospital admission. The proposed triage score might contribute to predicting the need for immediate resource availability in trauma patients.
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Affiliation(s)
- Stefano Isgrò
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (S.I.); (M.G.); (A.B.)
| | - Marco Giani
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (S.I.); (M.G.); (A.B.)
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, 20126 Monza, Italy; (L.A.); (M.G.V.); (R.F.)
| | - Laura Antolini
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, 20126 Monza, Italy; (L.A.); (M.G.V.); (R.F.)
| | - Riccardo Giudici
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, 20162 Milan, Italy; (R.G.); (G.B.)
| | - Maria Grazia Valsecchi
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, 20126 Monza, Italy; (L.A.); (M.G.V.); (R.F.)
| | - Giacomo Bellani
- Department of Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, 38122 Trento, Italy;
- Centre for Medical Sciences CISMed, University of Trento, 38122 Trento, Italy
| | - Osvaldo Chiara
- Department of Emergency and Trauma Surgery, Niguarda Hospital, 20162 Milan, Italy;
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20100 Milan, Italy
| | - Gabriele Bassi
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, 20162 Milan, Italy; (R.G.); (G.B.)
| | - Nicola Latronico
- Department of Emergency, Spedali Civili University Hospital, 25123 Brescia, Italy;
| | - Luca Cabrini
- General and Neurosurgical Intensive Care Units, Ospedale di Circolo, 21100 Varese, Italy;
- Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, 21100 Varese, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, 20126 Monza, Italy; (L.A.); (M.G.V.); (R.F.)
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, 20162 Milan, Italy; (R.G.); (G.B.)
| | - Arturo Chieregato
- Department of Anesthesia and Intensive Care Medicine, Neuro Intensive Care, ASST Niguarda, 20162 Milan, Italy;
| | - Fabrizio Sammartano
- Emergency Department, Emergency and Trauma Surgery, ASST Santi Carlo e Paolo, 20142 Milan, Italy;
| | - Giuseppe Sechi
- Regional Agency of Emergency and Urgency (AREU), 20124 Milan, Italy; (G.S.); (A.Z.); (A.P.)
| | - Alberto Zoli
- Regional Agency of Emergency and Urgency (AREU), 20124 Milan, Italy; (G.S.); (A.Z.); (A.P.)
| | - Andrea Pagliosa
- Regional Agency of Emergency and Urgency (AREU), 20124 Milan, Italy; (G.S.); (A.Z.); (A.P.)
| | - Alessandra Palo
- Regional Agency of Emergency and Urgency (AREU), 27100 Pavia, Italy;
| | - Oliviero Valoti
- Regional Agency of Emergency and Urgency (AREU), 24121 Bergamo, Italy;
| | - Michele Carlucci
- General and Emergency Surgery Department, Ospedale San Raffaele, 20132 Milan, Italy;
| | - Annalisa Benini
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (S.I.); (M.G.); (A.B.)
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy; (S.I.); (M.G.); (A.B.)
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, 20126 Monza, Italy; (L.A.); (M.G.V.); (R.F.)
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11
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Benhamed A, Fraticelli L, Claustre C, Gossiome A, Cesareo E, Heidet M, Emond M, Mercier E, Boucher V, David JS, El Khoury C, Tazarourte K. Risk factors and mortality associated with undertriage after major trauma in a physician-led prehospital system: a retrospective multicentre cohort study. Eur J Trauma Emerg Surg 2023; 49:1707-1715. [PMID: 36508023 DOI: 10.1007/s00068-022-02186-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To assess the incidence of undertriage in major trauma, its determinant, and association with mortality. METHODS A multicentre retrospective cohort study was conducted using data from a French regional trauma registry (2011-2017). All major trauma (Injury Severity Score ≥ 16) cases aged ≥ 18 years and managed by a physician-led mobile medical team were included. Those transported to a level-II/III trauma centre were considered as undertriaged. Multivariable logistic regression was used to identify factors associated with undertriage. RESULTS A total of 7110 trauma patients were screened; 2591 had an ISS ≥ 16 and 320 (12.4%) of these were undertriaged. Older patients had higher risk for undertriage (51-65 years: OR = 1.60, 95% CI [1.11; 2.26], p = 0.01). Conversely, injury mechanism (fall from height: 0.62 [0.45; 0.86], p = 0.01; gunshot/stab injuries: 0.45 [0.22; 0.90], p = 0.02), on-scene time (> 60 min: 0.62 [0.40; 0.95], p = 0.03), prehospital endotracheal intubation (0.53 [0.39; 0.71], p < 0.001), and prehospital focussed assessment with sonography [FAST] (0.15 [0.08; 0.29], p < 0.001) were associated with a lower risk for undertriage. After adjusting for severity, undertriage was not associated with a higher risk of mortality (1.22 [0.80; 1.89], p = 0.36). CONCLUSIONS In our physician-led prehospital EMS system, undertriage was higher than recommended. Advanced aged was identified as a risk factor highlighting the urgent need for tailored triage protocol in this population. Conversely, the potential benefit of prehospital FAST on triage performance should be furthered explored as it may reduce undertriage. Fall from height and penetrating trauma were associated with a lower risk for undertriage suggesting that healthcare providers should remain vigilant of the potential seriousness of trauma associated with low-energy mechanisms.
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Affiliation(s)
- Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 5 Place d'Arsonval, 69437, Lyon, France.
| | | | - Clément Claustre
- RESUVal and RESCUe Network, Lucien Hussel Hospital, Vienne, France
| | - Amaury Gossiome
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 5 Place d'Arsonval, 69437, Lyon, France
| | - Eric Cesareo
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 5 Place d'Arsonval, 69437, Lyon, France
| | - Matthieu Heidet
- SAMU 94 and Emergency Department, Assistance Publique-Hôpitaux de Paris (AP-HP) University Hospital Henri Mondor, Créteil, France
- Université Paris-Est Créteil (UPEC), EA-3956 (CIR), Créteil, France
| | - Marcel Emond
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Eric Mercier
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Valérie Boucher
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Jean-Stéphane David
- Trauma Centre and Critical Care, Centre Hospitalier Universitaire Lyon Sud, Pierre-Bénite, France
| | - Carlos El Khoury
- RESUVal and RESCUe Network, Lucien Hussel Hospital, Vienne, France
- Emergency Department, Médipôle Hôpital Mutualiste, Villeurbanne, France
| | - Karim Tazarourte
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 5 Place d'Arsonval, 69437, Lyon, France
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12
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Kim K, Oh B. Prehospital triage in emergency medical services system: A scoping review. Int Emerg Nurs 2023; 69:101293. [PMID: 37150145 DOI: 10.1016/j.ienj.2023.101293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 03/10/2023] [Accepted: 03/26/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND During the prehospital phase, paramedics consider patients' condition according to illness, injury, disease and decide on transport to an appropriate hospital according to severity. This can affect patient survival and treatment prognosis, because despite intervention at this early stage, problems such as incorrect triage of severity and inappropriate hospital selection may occur, indicating a need for improvement in the process. PURPOSE The aim of this review is to identify the overall trend of research conducted on prehospital triage by analyzing the emergency medical services system and presenting future studies to practitioners and researchers. METHODS A scoping review was conducted of existing literature on research trends in relation to prehospital triage. The studies reviewed were identified using electronic databases such as PubMed, CINAHL, Cochrane Library, Web of Science, and Scopus. RESULTS Ninety-eight documents were finally selected and analyzed that focused on prehospital triage status, process accuracy, tools, guidelines, and protocols. CONCLUSION Research is proposed that focuses on various non-traumatic patient types, prehospital triage education, and development of training programs to reduce errors in the emergency patient handover process between prehospital and hospital health professionals and to improve patient health and quality of life.
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Affiliation(s)
- Kisook Kim
- Department of Nursing, Chung-Ang University, 84 Heukseok-Ro, Dongjack-Gu, Seoul, Republic of Korea.
| | - Booyoung Oh
- Department of Nursing, Chung-Ang University, 84 Heukseok-Ro, Dongjack-Gu, Seoul, Republic of Korea.
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13
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Jokšić-Mazinjanin R, Marić N, Đuričin A, Gojković Z, Vasović V, Rakić G, Jokšić-Zelić M, Saravolac S. Prehospital Trauma Scoring Systems for Evaluation of Trauma Severity and Prediction of Outcomes. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050952. [PMID: 37241183 DOI: 10.3390/medicina59050952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/22/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Trauma scoring systems in prehospital settings are supposed to ensure the most appropriate in-hospital treatment of the injured. AIM OF THE STUDY To determine the sensitivity and specificity of the CRAMS scale (circulation, respiration, abdomen, motor and speech), RTS score (revised trauma score), MGAP (mechanism, Glasgow Coma Scale, age, arterial pressure) and GAP (Glasgow Coma Scale, age, arterial pressure) scoring systems in prehospital settings in order to evaluate trauma severity and to predict the outcome. MATERIALS AND METHODS A prospective, observational study was conducted. For every trauma patient, a questionnaire was initially filled in by a prehospital doctor and these data were subsequently collected by the hospital. RESULTS The study included 307 trauma patients with an average age of 51.7 ± 20.9. Based on the ISS (injury severity score), severe trauma was diagnosed in 50 (16.3%) patients. MGAP had the best sensitivity/specificity ratio when the obtained values indicated severe trauma. The sensitivity and specificity were 93.4 and 62.0%, respectively, for an MGAP value of 22. MGAP and GAP were strongly correlated with each other and were statistically significant in predicting the outcome of treatment (OR 2.23; 95% Cl 1.06-4.70; p = 0.035). With a rise of one in the MGAP score value, the probability of survival increases 2.2 times. CONCLUSION MGAP and GAP, in prehospital settings, had higher sensitivity and specificity when identifying patients with a severe trauma and predicting an unfavorable outcome than other scoring systems.
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Affiliation(s)
- Radojka Jokšić-Mazinjanin
- Department of Emergency Medicine, Medical Faculty, University of Novi Sad, 21000 Novi Sad, Serbia
- Institute for Emergency Medical Services Novi Sad, 21000 Novi Sad, Serbia
| | - Nikolina Marić
- Institute for Emergency Medical Services Novi Sad, 21000 Novi Sad, Serbia
| | - Aleksandar Đuričin
- Department of Emergency Medicine, Medical Faculty, University of Novi Sad, 21000 Novi Sad, Serbia
- Institute for Emergency Medical Services Novi Sad, 21000 Novi Sad, Serbia
| | - Zoran Gojković
- Department of Surgery, Medical Faculty, University of Novi Sad, 21000 Novi Sad, Serbia
- Clinic for Orthopedic Surgery and Traumatology, University Clinical Center of Vojvodina, 21137 Novi Sad, Serbia
| | - Velibor Vasović
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Medical Faculty, University of Novi Sad, 21000 Novi Sad, Serbia
| | - Goran Rakić
- Department of Emergency Medicine, Medical Faculty, University of Novi Sad, 21000 Novi Sad, Serbia
- Department of Intensive Surgical Therapy, Institute for Child and Youth Health Care Vojvodina, Pediatric Surgery Clinic, 21000 Novi Sad, Serbia
| | | | - Siniša Saravolac
- Institute for Emergency Medical Services Novi Sad, 21000 Novi Sad, Serbia
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14
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Yu JY, Heo S, Xie F, Liu N, Yoon SY, Chang HS, Kim T, Lee SU, Hock Ong ME, Ng YY, Do shin S, Kajino K, Cha WC. Development and Asian-wide validation of the Grade for Interpretable Field Triage (GIFT) for predicting mortality in pre-hospital patients using the Pan-Asian Trauma Outcomes Study (PATOS). THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 34:100733. [PMID: 37283981 PMCID: PMC10240358 DOI: 10.1016/j.lanwpc.2023.100733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/24/2023] [Accepted: 02/19/2023] [Indexed: 03/07/2023]
Abstract
Background Field triage is critical in injury patients as the appropriate transport of patients to trauma centers is directly associated with clinical outcomes. Several prehospital triage scores have been developed in Western and European cohorts; however, their validity and applicability in Asia remains unclear. Therefore, we aimed to develop and validate an interpretable field triage scoring systems based on a multinational trauma registry in Asia. Methods This retrospective and multinational cohort study included all adult transferred injury patients from Korea, Malaysia, Vietnam, and Taiwan between 2016 and 2018. The outcome of interest was a death in the emergency department (ED) after the patients' ED visit. Using these results, we developed the interpretable field triage score with the Korea registry using an interpretable machine learning framework and validated the score externally. The performance of each country's score was assessed using the area under the receiver operating characteristic curve (AUROC). Furthermore, a website for real-world application was developed using R Shiny. Findings The study population included 26,294, 9404, 673 and 826 transferred injury patients between 2016 and 2018 from Korea, Malaysia, Vietnam, and Taiwan, respectively. The corresponding rates of a death in the ED were 0.30%, 0.60%, 4.0%, and 4.6% respectively. Age and vital sign were found to be the significant variables for predicting mortality. External validation showed the accuracy of the model with an AUROC of 0.756-0.850. Interpretation The Grade for Interpretable Field Triage (GIFT) score is an interpretable and practical tool to predict mortality in field triage for trauma. Funding This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (Grant Number: HI19C1328).
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Affiliation(s)
- Jae Yong Yu
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, Seoul, South Korea
- Digital & Smart Health Office, Tan Tock Seng Hospital, Singapore
| | - Sejin Heo
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, Seoul, South Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Feng Xie
- Programme in Health Services and Systems Research, Duke–National University of Singapore Medical School, Singapore
- Department of Biomedical Data Science, Stanford University, Stanford, USA
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, USA
| | - Nan Liu
- Programme in Health Services and Systems Research, Duke–National University of Singapore Medical School, Singapore
- Health Service Research Centre, Singapore Health Services, Singapore
- Institute of Data Science, National University of Singapore, Singapore
| | - Sun Yung Yoon
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, Seoul, South Korea
| | - Han Sol Chang
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, Seoul, South Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Taerim Kim
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, Seoul, South Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Se Uk Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Marcus Eng Hock Ong
- Programme in Health Services and Systems Research, Duke–National University of Singapore Medical School, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Yih Yng Ng
- Digital & Smart Health Office, Tan Tock Seng Hospital, Singapore
| | - Sang Do shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Kentaro Kajino
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Moriguchi, Japan
| | - Won Chul Cha
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, Seoul, South Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Digital Innovation Center, Samsung Medical Center, Seoul, South Korea
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15
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Benhamed A, Emond M, Mercier E, Heidet M, Gauss T, Saint-Supery P, Yadav K, David JS, Claustre C, Tazarourte K. Accuracy of a Prehospital Triage Protocol in Predicting In-Hospital Mortality and Severe Trauma Cases among Older Adults. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1975. [PMID: 36767343 PMCID: PMC9916137 DOI: 10.3390/ijerph20031975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 06/18/2023]
Abstract
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.
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Affiliation(s)
- Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 69123 Lyon, France
| | - Marcel Emond
- Centre de Recherche, CHU de Québec-Université Laval, Québec, QC G1J 1Z4, Canada
| | - Eric Mercier
- Centre de Recherche, CHU de Québec-Université Laval, Québec, QC G1J 1Z4, Canada
| | - Matthieu Heidet
- SAMU 94, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), 75610 Paris, France
| | - Tobias Gauss
- Anaesthesia Critical Care, Grenoble Alpes University Hospital, 38700 Grenoble, France
| | - Pierre Saint-Supery
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 69123 Lyon, France
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON K1Y 4E9, Canada
| | - Jean-Stéphane David
- Service d’Anesthésie-Réanimation, Centre Hospitalier Universitaire Lyon Sud, Hospices Civils de Lyon, 69310 Pierre-Bénite, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, 69100 Lyon, France
| | - Clement Claustre
- RESUVal Trauma Network, Centre Hospitalier Lucien Hussel, 38200 Vienne, France
| | - Karim Tazarourte
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 69123 Lyon, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, 69100 Lyon, France
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Yuksen C, Angkoontassaneeyarat C, Thananupappaisal S, Laksanamapune T, Phontabtim M, Namsanor P. Accuracy of Trauma on Scene Triage Screening Tool (Shock Index, Reverse Shock Index Glasgow Coma Scale and National Early Warning Score) to Predict the Severity of Emergency Department Triage: A Retrospective Cross-Sectional Study. Open Access Emerg Med 2023; 15:79-91. [PMID: 36974278 PMCID: PMC10039710 DOI: 10.2147/oaem.s403545] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
Introduction Prehospital trauma care includes on-scene assessments, essential treatment, and facilitating transfer to an appropriate trauma center to deliver optimal care for trauma patients. While the Simple Triage and Rapid Treatment (START), Revised Triage Sieve (rTS), and National Early Warning Score (NEWS) tools are user-friendly in a prehospital setting, there is currently no standardized on-scene triage protocol in Thailand Emergency Medical Service (EMS). Therefore, this study aims to evaluate the precision of these tools (SI, rSIG, and NEWS) in predicting the severity of trauma patients who are transferred to the emergency department (ED). Methods This study was a retrospective cross-sectional and diagnostic research conducted on trauma patients transferred by EMS to the ED of Ramathibodi Hospital, a university-affiliated super tertiary care hospital in Bangkok, Thailand, from January 2015 to September 2022. We compared the on-scene triage tool (SI, rSIG, and NEWS) and ED triage tool (Emergency Severity Index) parameters, massive transfusion protocol (MTP), and intensive care unit (ICU) admission with the area under ROC (univariable analysis) and diagnostic odds ratio (multivariable logistic regression analysis). The optimal cut-off threshold for the best parameter was determined by selecting the value that produced the highest area under the ROC curve. Results A total of 218 patients were traumatic patients transported by EMS to the ED, out of which 161 were classified as ESI levels 1-2, while the remaining 57 patients were categorized as levels 3-5 on the ESI triage scale. We found that NEWS was a more accurate triage tool to discriminate the severity of trauma patients than rSIG and SI. The area under the ROC was 0.74 (95% CI 0.70-0.79) (OR 18.98, 95% CI 1.06-337.25), 0.65 (95% CI 0.59-0.70) (OR 1.74, 95% CI 0.17-18.09) and 0.58 (95% CI 0.52-0.65) (OR 0.28, 95% CI 0.04-1.62), respectively (P-value <0.001). The cut point of NEWS to discriminate ESI levels 1-2 and levels 3-5 was >6 points. Conclusion NEWS is the best on-scene triage screening tool to predict the severity at the emergency department, massive transfusion protocol (MTP), and intensive care unit (ICU) admission compared with other triage tools SI and rSIG.
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Affiliation(s)
- Chaiyaporn Yuksen
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chuenruthai Angkoontassaneeyarat
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Correspondence: Chuenruthai Angkoontassaneeyarat, Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phaya Thai, Ratchathewi, Bangkok, 10400, Thailand, Email
| | - Sorawat Thananupappaisal
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thanakorn Laksanamapune
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Malivan Phontabtim
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pamorn Namsanor
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Adebayo O, Bhuiyan ZA, Ahmed Z. Exploring the effectiveness of artificial intelligence, machine learning and deep learning in trauma triage: A systematic review and meta-analysis. Digit Health 2023; 9:20552076231205736. [PMID: 37822960 PMCID: PMC10563501 DOI: 10.1177/20552076231205736] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/18/2023] [Indexed: 10/13/2023] Open
Abstract
Background The development of artificial intelligence (AI), machine learning (ML) and deep learning (DL) has advanced rapidly in the medical field, notably in trauma medicine. We aimed to systematically appraise the efficacy of AI, ML and DL models for predicting outcomes in trauma triage compared to conventional triage tools. Methods We searched PubMed, MEDLINE, ProQuest, Embase and reference lists for studies published from 1 January 2010 to 9 June 2022. We included studies which analysed the use of AI, ML and DL models for trauma triage in human subjects. Reviews and AI/ML/DL models used for other purposes such as teaching, or diagnosis were excluded. Data was extracted on AI/ML/DL model type, comparison tools, primary outcomes and secondary outcomes. We performed meta-analysis on studies reporting our main outcomes of mortality, hospitalisation and critical care admission. Results One hundred and fourteen studies were identified in our search, of which 14 studies were included in the systematic review and 10 were included in the meta-analysis. All studies performed external validation. The best-performing AI/ML/DL models outperformed conventional trauma triage tools for all outcomes in all studies except two. For mortality, the mean area under the receiver operating characteristic (AUROC) score difference between AI/ML/DL models and conventional trauma triage was 0.09, 95% CI (0.02, 0.15), favouring AI/ML/DL models (p = 0.008). The mean AUROC score difference for hospitalisation was 0.11, 95% CI (0.10, 0.13), favouring AI/ML/DL models (p = 0.0001). For critical care admission, the mean AUROC score difference was 0.09, 95% CI (0.08, 0.10) favouring AI/ML/DL models (p = 0.00001). Conclusions This review demonstrates that the predictive ability of AI/ML/DL models is significantly better than conventional trauma triage tools for outcomes of mortality, hospitalisation and critical care admission. However, further research and in particular randomised controlled trials are required to evaluate the clinical and economic impacts of using AI/ML/DL models in trauma medicine.
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Affiliation(s)
- Oluwasemilore Adebayo
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Zunira Areeba Bhuiyan
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
- Centre for Trauma Sciences Research, University of Birmingham, Edgbaston, Birmingham, UK
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18
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The influence of inter-hospital transfers on mortality in severely injured patients. Eur J Trauma Emerg Surg 2023; 49:441-449. [PMID: 36048180 PMCID: PMC9925487 DOI: 10.1007/s00068-022-02087-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The importance of treating severely injured patients in higher-level trauma centers is undisputable. However, it is uncertain whether severely injured patients that were initially transported to a lower-level trauma center (i.e., undertriage) benefit from being transferred to a higher-level trauma center. METHODS This observational study included all severely injured patients (i.e., Injury Severity Score ≥ 16) that were initially transported to a lower-level trauma center within eight ambulance regions. The exposure of interest was whether a patient was transferred to a higher-level trauma center. Primary outcomes were 24-h and 30-day mortality. Generalized linear models including inverse probability weights for several potential confounders were constructed to evaluate the association between transfer status and mortality. RESULTS We included 165,404 trauma patients that were transported with high priority to a trauma center, of which 3932 patients were severely injured. 1065 (27.1%) patients were transported to a lower-level trauma center of which 322 (30.2%) were transferred to a higher-level trauma center. Transferring undertriaged patients to a higher-level trauma center was significantly associated with reduced 24-h (relative risk [RR] 0.26, 95%-CI 0.10-0.68) and 30-day mortality (RR 0.65, 0.46-0.92). Similar results were observed in patients with critical injuries (24-h: RR 0.35, 0.16-0.77; 30-day: RR 0.55, 0.37-0.80) and patients with traumatic brain injury (24-h: RR 0.31, 0.11-0.83; 30-day: RR 0.66, 0.46-0.96). CONCLUSIONS A minority of the undertriaged patients are transferred to a higher-level trauma center. An inter-hospital transfer appears to be safe and may improve the survival of severely injured patients initially transported to a lower-level trauma center.
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Portelli Tremont JN, Caldas RA, Cook N, Udekwu PO, Moore SM. Low initial in-hospital end-tidal carbon dioxide predicts poor patient outcomes and is a useful trauma bay adjunct. Am J Emerg Med 2022; 56:45-50. [DOI: 10.1016/j.ajem.2022.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/11/2022] [Accepted: 03/17/2022] [Indexed: 11/28/2022] Open
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20
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Tazarourte K, Harris T. Cognitive support: An effective way to enhance the Trauma Brain Injury guidelines implementation? Anaesth Crit Care Pain Med 2022; 41:101076. [PMID: 35472589 DOI: 10.1016/j.accpm.2022.101076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Karim Tazarourte
- SAMU 69/Urgences Hôpital Edouard Herriot, Hospices civils de Lyon, Lyon Cedex, France; Universite LYON 1 RESHAPE U 1290 Lyon 69003, France.
| | - Tim Harris
- Department of Emergency Medicine, Queen Mary University, London, United Kingdom; Department of Academic Affairs, Hamad Medical Corporation, Qatar
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21
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Ceklic E, Tohira H, Ball S, Brown E, Brink D, Bailey P, Brits R, Finn J. A predictive ambulance dispatch algorithm to the scene of a motor vehicle crash: the search for optimal over and under triage rates. BMC Emerg Med 2022; 22:74. [PMID: 35524169 PMCID: PMC9074212 DOI: 10.1186/s12873-022-00609-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 03/17/2022] [Indexed: 11/18/2022] Open
Abstract
Background Calls for emergency medical assistance at the scene of a motor vehicle crash (MVC) substantially contribute to the demand on ambulance services. Triage by emergency medical dispatch systems is therefore important, to ensure the right care is provided to the right patient, in the right amount of time. A lights and sirens (L&S) response is the highest priority ambulance response, also known as a priority one or hot response. In this context, over triage is defined as dispatching an ambulance with lights and sirens (L&S) to a low acuity MVC and under triage is not dispatching an ambulance with L&S to those who require urgent medical care. We explored the potential for crash characteristics to be used during emergency ambulance calls to identify those MVCs that required a L&S response. Methods We conducted a retrospective cohort study using ambulance and police data from 2014 to 2016. The predictor variables were crash characteristics (e.g. road surface), and Medical Priority Dispatch System (MPDS) dispatch codes. The outcome variable was the need for a L&S ambulance response. A Chi-square Automatic Interaction Detector technique was used to develop decision trees, with over/under triage rates determined for each tree. The model with an under/over triage rate closest to that prescribed by the American College of Surgeons Committee on Trauma (ACS COT) will be deemed to be the best model (under triage rate of ≤ 5% and over triage rate of between 25–35%. Results The decision tree with a 2.7% under triage rate was closest to that specified by the ACS COT, had as predictors—MPDS codes, trapped, vulnerable road user, anyone aged 75 + , day of the week, single versus multiple vehicles, airbag deployment, atmosphere, surface, lighting and accident type. This model had an over triage rate of 84.8%. Conclusions We were able to derive a model with a reasonable under triage rate, however this model also had a high over triage rate. Individual EMS may apply the findings here to their own jurisdictions when dispatching to the scene of a MVC. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00609-5.
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Affiliation(s)
- Ellen Ceklic
- Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia.
| | - Hideo Tohira
- Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia.,Emergency Medicine, Medical School, The University of Western Australia, Perth, Australia
| | - Stephen Ball
- Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia.,St John Western Australia, Belmont, WA, Australia
| | | | - Deon Brink
- Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia.,St John Western Australia, Belmont, WA, Australia
| | - Paul Bailey
- Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia.,St John Western Australia, Belmont, WA, Australia
| | | | - Judith Finn
- Prehospital, Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia.,Emergency Medicine, Medical School, The University of Western Australia, Perth, Australia.,St John Western Australia, Belmont, WA, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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22
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Comparing outcomes between patients transferred from a critical access hospital versus directly from scene to a level 1 trauma center. Am J Surg 2022; 224:828-833. [DOI: 10.1016/j.amjsurg.2022.01.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 01/28/2022] [Accepted: 01/30/2022] [Indexed: 11/18/2022]
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23
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Organ Donation after Damage Control Strategy in Trauma Patients: Experience from First Level Trauma Center in Italy. Life (Basel) 2022; 12:life12020214. [PMID: 35207501 PMCID: PMC8877798 DOI: 10.3390/life12020214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/25/2022] [Accepted: 01/27/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Organ donation (OD) remains the only therapeutic option for end-stage disease in some cases. Unfortunately, the gap between donors and recipients is still substantial. Trauma patients represent a potential yet underestimated pool of organ donors. In this article, we present our data on OD after damage control strategy (DCS). Materials and Methods: A retrospective, observational cohort study was conducted through a complete revision of data of consecutive adult trauma patients (>18 years old) who underwent OD after DCS between January 2018 and May 2021. Four subgroups were created [Liver (Li), Lungs (Lu), Heart (H), Kidneys (K)] to compare variables between those who donated the organ of interest and those who did not. Results: Thirty-six patients underwent OD after DCS. Six patients (16.7%) were excluded: 2(5.6%) for missing data about admission; 4(11.1%) didn’t receive DCS. Mean ISS was 47.2 (SD ± 17.4). Number of donated organs was 113 with an organs/patient ratio of 3.8. The functional response rate was 91.2%. Ten organs (8.8%) had primary nonfunction after transplantation: 2/15 hearts (13.3%), 1/28 livers (3.6%), 4/53 kidneys (7.5%) and 3/5 pancreases (60%). No lung primary nonfunction were registered. Complete results of subgroup analysis are reported in supplementary materials. Conclusion: Organ donation should be considered a possible outcome in any trauma patient. Aggressive damage control strategy doesn’t affect the functional response rate of transplanted organs.
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Pollard D, Fuller G, Goodacre S, van Rein EAJ, Waalwijk JF, van Heijl M. An economic evaluation of triage tools for patients with suspected severe injuries in England. BMC Emerg Med 2022; 22:4. [PMID: 35016621 PMCID: PMC8753918 DOI: 10.1186/s12873-021-00557-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 12/07/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Many health care systems triage injured patients to major trauma centres (MTCs) or local hospitals by using triage tools and paramedic judgement. Triage tools are typically assessed by whether patients with an Injury Severity Score (ISS) ≥ 16 go to an MTC and whether patients with an ISS < 16 are sent to their local hospital. There is a trade-off between sensitivity and specificity of triage tools, with the optimal balance being unknown. We conducted an economic evaluation of major trauma triage tools to identify which tool would be considered cost-effective by UK decision makers. METHODS A patient-level, probabilistic, mathematical model of a UK major trauma system was developed. Patients with an ISS ≥ 16 who were only treated at local hospitals had worse outcomes compared to being treated in an MTC. Nine empirically derived triage tools, from a previous study, were examined so we assessed triage tools with realistic trade-offs between triage tool sensitivity and specificity. Lifetime costs, lifetime quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for each tool and compared to maximum acceptable ICERs (MAICERs) in England. RESULTS Four tools had ICERs within the normal range of MAICERs used by English decision makers (£20,000 to £30,000 per QALY gained). A low sensitivity (28.4%) and high specificity (88.6%) would be cost-effective at the lower end of this range while higher sensitivity (87.5%) and lower specificity (62.8%) was cost-effective towards the upper end of this range. These results were sensitive to the cost of MTC admissions and whether MTCs had a benefit for patients with an ISS between 9 and 15. CONCLUSIONS The cost-effective triage tool depends on the English decision maker's MAICER for this health problem. In the usual range of MAICERs, cost-effective prehospital trauma triage involves clinically suboptimal sensitivity, with a proportion of seriously injured patients (at least 10%) being initially transported to local hospitals. High sensitivity trauma triage requires development of more accurate decision rules; research to establish if patients with an ISS between 9 and 15 benefit from MTCs; or, inefficient use of health care resources to manage patients with less serious injuries at MTCs.
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Affiliation(s)
- Daniel Pollard
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Gordon Fuller
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Eveline A J van Rein
- Department of Traumatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Job F Waalwijk
- Department of Traumatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mark van Heijl
- Department of Traumatology, University Medical Center Utrecht, Utrecht, the Netherlands
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Kregel HR, Hatton GE, Isbell KD, Henriksen HH, Stensballe J, Johansson PI, Kao LS, Wade CE. Shock-Induced Endothelial Dysfunction is Present in Patients With Occult Hypoperfusion After Trauma. Shock 2022; 57:106-112. [PMID: 34905531 PMCID: PMC9148678 DOI: 10.1097/shk.0000000000001866] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Shock-induced endothelial dysfunction, evidenced by elevated soluble thrombomodulin (sTM) and syndecan-1 (Syn-1), is associated with poor outcomes after trauma. The association of endothelial dysfunction and overt shock has been demonstrated; it is unknown if hypoperfusion in the setting of normal vital signs (occult hypoperfusion [OH]) is associated with endothelial dysfunction. We hypothesized that sTM and Syn-1 would be elevated in patients with OH when compared to patients with normal perfusion. METHODS A single-center study of patients requiring highest-level trauma activation (2012-2016) was performed. Trauma bay arrival plasma Syn-1 and sTM were measured by enzyme-linked immunosorbent assay. Shock was defined as systolic blood pressure (SBP) <90 mm Hg or heart rate (HR) ≥120 bpm. OH was defined as SBP ≥ 90, HR < 120, and base excess (BE) ≤-3. Normal perfusion was assigned to all others. Univariate and multivariable analyses were performed. RESULTS Of 520 patients, 35% presented with OH and 26% with shock. Demographics were similar between groups. Patients with normal perfusion had the lowest Syn-1 and sTM, while patients with OH and shock had elevated levels. OH was associated with increased sTM by 0.97 ng/mL (95% CI 0.39-1.57, p = 0.001) and Syn-1 by 14.3 ng/mL (95% CI -1.5 to 30.2, p = 0.08). Furthermore, shock was associated with increased sTM by 0.64 (95% CI 0.02-1.30, p = 0.04) and with increased Syn-1 by 23.6 ng/mL (95% CI 6.2-41.1, p = 0.008). CONCLUSIONS Arrival OH was associated with elevated sTM and Syn-1, indicating endothelial dysfunction. Treatments aiming to stabilize the endothelium may be beneficial for injured patients with evidence of hypoperfusion, regardless of vital signs.
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Affiliation(s)
- Heather R. Kregel
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Gabrielle E. Hatton
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Kayla D. Isbell
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Hanne H Henriksen
- Section for Transfusion Medicine, Capital Region Blood Bank, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesia and Trauma Centre, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Per I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, University of Copenhagen, Copenhagen, Denmark
| | - Lillian S. Kao
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
| | - Charles E. Wade
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School at UTHealth, Houston, TX
- Center for Translational Injury Research, Houston, TX
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Waalwijk JF, Lokerman RD, van der Sluijs R, Fiddelers AAA, Leenen LPH, Poeze M, van Heijl M. Evaluating the effect of driving distance to the nearest higher level trauma centre on undertriage: a cohort study. Emerg Med J 2021; 39:457-462. [PMID: 34593562 DOI: 10.1136/emermed-2021-211635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/19/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND It is of great importance that emergency medical services professionals transport trauma patients in need of specialised care to higher level trauma centres to achieve optimal patient outcomes. Possibly, undertriage is more likely to occur in patients with a longer distance to the nearest higher level trauma centre. This study aims to determine the association between driving distance and undertriage. METHOD This prospective cohort study was conducted from January 2015 to December 2017. All trauma patients in need of specialised care that were transported to a trauma centre by emergency medical services professionals from eight ambulance regions in the Netherlands were included. Patients with critical resource use or an Injury Severity Score ≥16 were defined as in need of specialised care. Driving distance was calculated between the scene of injury and the nearest higher level trauma centre. Undertriage was defined as transporting a patient in need of specialised care to a lower level trauma centre. Generalised linear models adjusting for confounders were constructed to determine the association between driving distance to the nearest higher level trauma centre per 1 and 10 km and undertriage. A sensitivity analysis was conducted with a generalised linear model including inverse probability weights. RESULTS 6101 patients, of which 4404 patients with critical resource use and 3760 patients with an Injury Severity Score ≥16, were included. The adjusted generalised linear model demonstrated a significant association between a 1 km (OR 1.04; 95% CI 1.04 to 1.05) and 10 kilometre (OR 1.50; 95% CI 1.42 to 1.58) increase in driving distance and undertriage in patients with critical resource use. Also in patients with an Injury Severity Score ≥16, a significant association between driving distance (1 km (OR 1.06; 95% CI 1.06 to 1.07), 10 km (OR 1.83; 95% CI 1.71 to 1.95)) and undertriage was observed. CONCLUSION Patients in need of specialised care are less likely to be transported to the appropriate trauma centre with increasing driving distance. Our results suggest that emergency medical services professionals incorporate driving distance into their decision making regarding transport destinations, although distance is not included in the triage protocol.
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Affiliation(s)
- Job F Waalwijk
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands .,Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,Network Acute Care Limburg, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Robin D Lokerman
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Rogier van der Sluijs
- Center for Artificial Intelligence in Medicine & Imaging, Stanford University, Stanford, California, USA
| | - Audrey A A Fiddelers
- Network Acute Care Limburg, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,Network Acute Care Limburg, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Mark van Heijl
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.,Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, The Netherlands
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Martin MJ, Johnson A, Rott M, Kuchler A, Cole F, Ramzy A, Barbosa R, Long WB. Choosing wisely: A prospective study of direct to operating room trauma resuscitation including real-time trauma surgeon after-action review. J Trauma Acute Care Surg 2021; 91:S146-S153. [PMID: 33797495 DOI: 10.1097/ta.0000000000003176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Although several centers have direct to operating room (DOR) resuscitation programs, there are no published prospective studies on optimal patient selection, interventions, outcomes, or real-time surgeon assessments. METHODS Direct to operating room cases for 1 year were prospectively enrolled. Demographics, injury types/severity, triage criteria, interventions, and outcomes including Glasgow Outcome Scale score were collected. Detailed time-to-event and sequence data on initial lifesaving interventions (LSIs) or emergent surgeries were analyzed. A structured real-time attending surgeon assessment tool for each case was collected. Direct to operating room activation criteria were grouped into categories: mechanism, physiology, injury pattern, or emergency medical services (EMS) suspicion. RESULTS There were 104 DOR cases: male, 84%; penetrating, 80%; and severely injured (Injury Severity Score, >15), 39%. The majority (65%) required at least one LSI (median of 7 minutes from arrival), and 41% underwent immediate emergent surgery (median, 26 minutes). Blunt patients were more severely injured and more likely to undergo LSI (86% vs. 59%) but less likely to require emergent surgery (19% vs. 47%, all p < 0.05). Analysis of DOR criteria categories showed unique patterns in each group for interventions and outcomes, with EMS suspicion associated with the lowest need for DOR. Surgeon assessment tool results found that DOR was indicated in 84% and improved care in 63%, with a small subset identified (9%) where DOR had a negative impact. CONCLUSION Direct to operating room resuscitation facilitated timely emergent interventions in penetrating truncal trauma and a select subset of critically ill blunt patients. Unique intervention/outcome profiles were identified by activation criteria groups, with little utility among activations for EMS suspicion. Real-time surgeon assessment tool identified high- and low-yield DOR groups. LEVEL OF EVIDENCE Prospective observational study, level III.
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Affiliation(s)
- Matthew J Martin
- From the Trauma and Emergency Surgery Service (M.J.M., A.J., M.R., A.K., F.C., A.R., R.B., W.B.L.), Legacy Emanuel Medical Center, Portland, Oregon; Trauma Research Program (M.J.M.), Scripps Mercy Hospital, San Diego, California; and Department of Surgery (M.J.M.), Madigan Army Medical Center, Tacoma, Washington
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Endocrine Surgical Procedures During COVID-19: Patient Prioritization and Time to Surgery. J Surg Res 2021; 268:459-464. [PMID: 34416419 PMCID: PMC8302853 DOI: 10.1016/j.jss.2021.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND We tracked endocrine surgery patients with treatment delays due to COVID-19 to investigate the relationship between physician assigned priority scoring (PAPS), the Medically Necessary, Time Sensitive (MeNTS) scoring system and delay to surgery. MATERIAL & METHODS Patients scheduled for endocrine surgery or clinically evaluated during COVID-19-related elective surgery hold at our institution (2/26/20-5/1/20) were prospectively enrolled. PAPS was assigned based on categories of high, moderate, or low risk, consistent with the American College of Surgeons' priority system. MeNTS scores were calculated. The primary outcome was delay to surgery. Descriptive statistics were performed, and receiver operator characteristic (ROC) curves and area under the curve (AUC) values were calculated for PAPS and MeNTS. RESULTS Of 146 patients included, 68% (n = 100) were female; the median age was 60 years (IQR:43,67). Mean delay to surgery was significantly shorter (P = 0.01) in patients with high PAPS (35 d), compared with moderate (61 d) and low (79 d) PAPS groups. MeNTS scores were provided for 105 patients and were analyzed by diagnosis. Patients with benign thyroid disease (n = 17) had a significantly higher MeNTS score than patients with thyroid disease which was malignant/suspicious for malignancy (n = 44) patients (51.5 versus 47.6, P = 0.034). Higher PAPS correlated well with a delay to surgery of <30 d (AUC: 0.72). MeNTS score did not correlate well with delay to surgery <30 d (AUC: 0.52). CONCLUSION PAPS better predicted delay to surgery than MeNTS scores. PAPS may incorporate more complex components of clinical decision-making which are not captured in the MeNTS score.
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Sturms LM, Driessen MLS, van Klaveren D, Ten Duis HJ, Kommer GJ, Bloemers FW, den Hartog D, Edwards MJ, Leenhouts PA, van Zutphen S, Schipper IB, Spanjersberg R, Wendt KW, de Wit RJ, Poeze M, Leenen LP, de Jongh M. Dutch trauma system performance: Are injured patients treated at the right place? Injury 2021; 52:1688-1696. [PMID: 34045042 DOI: 10.1016/j.injury.2021.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 05/09/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The goal of trauma systems is to match patient care needs to the capabilities of the receiving centre. Severely injured patients have shown better outcomes if treated in a major trauma centre (MTC). We aimed to evaluate patient distribution in the Dutch trauma system. Furthermore, we sought to identify factors associated with the undertriage and transport of severely injured patients (Injury Severity Score (ISS) >15) to the MTC by emergency medical services (EMS). METHODS Data on all acute trauma admissions in the Netherlands (2015-2016) were extracted from the Dutch national trauma registry. An ambulance driving time model was applied to calculate MTC transport times and transport times of ISS >15 patients to the closest MTC and non-MTC. A multivariable logistic regression analysis was performed to identify factors associated with ISS >15 patients' EMS undertriage to an MTC. RESULTS Of the annual average of 78,123 acute trauma admissions, 4.9% had an ISS >15. The nonseverely injured patients were predominantly treated at non-MTCs (79.2%), and 65.4% of patients with an ISS >15 received primary MTC care. This rate varied across the eleven Dutch trauma networks (36.8%-88.4%) and was correlated with the transport times to an MTC (Pearson correlation -0.753, p=0.007). The trauma networks also differed in the rates of secondary transfers of ISS >15 patients to MTC hospitals (7.8% - 59.3%) and definitive MTC care (43.6% - 93.2%). Factors associated with EMS undertriage of ISS >15 patients to the MTC were female sex, older age, severe thoracic and abdominal injury, and longer additional EMS transport times. CONCLUSIONS Approximately one-third of all severely injured patients in the Netherlands are not initially treated at an MTC. Special attention needs to be directed to identifying patient groups with a high risk of undertriage. Furthermore, resources to overcome longer transport times to an MTC, including the availability of ambulance and helicopter services, may improve direct MTC care and result in a decrease in the variation of the undertriage of severely injured patients to MTCs among the Dutch trauma networks. Furthermore, attention needs to be directed to improving primary triage guidelines and instituting uniform interfacility transfer agreements.
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Affiliation(s)
| | | | - David van Klaveren
- Erasmus University Medical Centre, Department of Public Health, Rotterdam, The Netherlands
| | - Henk-Jan Ten Duis
- Erasmus University Medical Centre, Department of Public Health, Rotterdam, The Netherlands
| | - Geert Jan Kommer
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, Amsterdam University Medical Center, location VU, Amsterdam, the Netherlands
| | - Dennis den Hartog
- Department of Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Michael J Edwards
- Department of Trauma surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Peter A Leenhouts
- Department of Surgery, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - S van Zutphen
- Department of Surgery, ETZ Two Cities Hospital, Tilburg, The Netherlands
| | - Inger B Schipper
- Department of Trauma surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Klaus W Wendt
- Department of Trauma Surgery, University Medical Centre Groningen, University of Groningen
| | - Ralph J de Wit
- Department of Trauma Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Luke P Leenen
- Department of Trauma surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mariska de Jongh
- Brabant Trauma Registry, Network Emergency Care Brabant, Tilburg, the Netherlands
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Gianola S, Castellini G, Biffi A, Porcu G, Fabbri A, Ruggieri MP, Stocchetti N, Napoletano A, Coclite D, D'Angelo D, Fauci AJ, Iacorossi L, Latina R, Salomone K, Gupta S, Iannone P, Chiara O. Accuracy of pre-hospital triage tools for major trauma: a systematic review with meta-analysis and net clinical benefit. World J Emerg Surg 2021; 16:31. [PMID: 34112209 PMCID: PMC8193906 DOI: 10.1186/s13017-021-00372-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/18/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We conducted a systematic review to evaluate and compare the accuracy of pre-hospital triage tools for major trauma in the context of the development of the Italian National Institute of Health guidelines on major trauma integrated management. METHODS PubMed, Embase, and CENTRAL were searched up to November 2019 for studies investigating pre-hospital triage tools. The ROC (receiver operating characteristics) curve and net clinical benefit for all selected triage tools were performed. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies-2. Certainty of the evidence was judged with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS We found 15 observational studies of 13 triage tools for adults and 11 for children. In adults, according to the ROC curve and the net clinical benefit, the most reliable tool was the Northern French Alps Trauma System (TRENAU), adopting injury severity score (ISS) > 15 as reference (sensitivity (Sn), 0.92; specificity (Sp), 0.41; 1 study; sample size, 2572; high certainty of the evidence). When mortality as reference was considered, the pre-hospital triage tool with the best net clinical benefit trajectory was the New Trauma Score (NTS) < 18 (Sn, 0.82; Sp, 0.86; 1 study; sample size, 1001; moderate certainty of the evidence). In children, high variability among all triage tools for sensitivity and specificity was found. CONCLUSION Sensitivity and specificity varied across all available pre-hospital trauma triage tools. TRENAU and NTS are the best accurate triage tools for adults, whereas in the pediatric area a large variability prevents any firm conclusion.
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Affiliation(s)
- Silvia Gianola
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Greta Castellini
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
| | - Annalisa Biffi
- National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Gloria Porcu
- National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL della Romagna, Forlì, Italy
| | | | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonello Napoletano
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Daniela Coclite
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Daniela D'Angelo
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Alice Josephine Fauci
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Laura Iacorossi
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Roberto Latina
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Katia Salomone
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Shailvi Gupta
- Adams Cowley Shock Trauma Center, University of Maryland, Baltimora, MD, USA
| | - Primiano Iannone
- Centro Eccellenza Clinica Qualità e Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Osvaldo Chiara
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, University of Milan, Piazza Ospedale Maggiore, Milan, Milano, Italy
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Morris RS, Karam BS, Murphy PB, Jenkins P, Milia DJ, Hemmila MR, Haines KL, Puzio TJ, de Moya MA, Tignanelli CJ. Field-Triage, Hospital-Triage and Triage-Assessment: A Literature Review of the Current Phases of Adult Trauma Triage. J Trauma Acute Care Surg 2021; 90:e138-e145. [PMID: 33605709 DOI: 10.1097/ta.0000000000003125] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Despite major improvements in the United States trauma system over the past two decades, prehospital trauma triage is a significant challenge. Undertriage is associated with increased mortality, and overtriage results in significant resource overuse. The American College of Surgeons Committee on Trauma benchmarks for undertriage and overtriage are not being met. Many barriers to appropriate field triage exist, including lack of a formal definition for major trauma, absence of a simple and widely applicable triage mode, and emergency medical service adherence to triage protocols. Modern trauma triage systems should ideally be based on the need for intervention rather than injury severity. Future studies should focus on identifying the ideal definition for major trauma and creating triage models that can be easily deployed. This narrative review article presents challenges and potential solutions for prehospital trauma triage.
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Affiliation(s)
- Rachel S Morris
- From the Department of Surgery (R.M., B.S.K., P.M., D.M., M.d.M.), Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery (P.J.), Indiana University, Indianapolis, Indiana; Department of Surgery (M.H.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (K.H.), Duke University, Durham, North Carolina; Department of Surgery (T.P.), University of Texas Health Science Center, Houston, Texas; Department of Surgery (C.T.), and Institute for Health Informatics (C.T.), University of Minnesota, Minneapolis; and Department of Surgery (C.T.), North Memorial Health Hospital, Robbinsdale, Minnesota
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Andrews R, Wynn MT, Vallmuur K, Elcock M, Rashford S, Bosley E, Ter Hofstede AH. Trauma by-pass guideline: A data-driven conformance analysis for road trauma cases in Queensland. Emerg Med Australas 2021; 33:1059-1065. [PMID: 34060229 DOI: 10.1111/1742-6723.13807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 02/02/2021] [Accepted: 04/27/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Study objectives were to (i) develop and test a whole-of-system method for identifying patients who meet a major trauma by-pass guideline definition; (ii) apply this method to assess conformance to the current 2006 guideline for a road trauma cohort; and (iii) leverage relevant findings to propose improvements to the guideline. METHODS Retrospective analysis of existing, routinely collected data relating to Queensland road trauma patients July 2015 to June 2017. Data from ambulance, aero-medical retrievals, ED, hospital and death registers were linked and used for analysis. Processes of care measured included: frequency of pre-hospital triage criteria, distribution of destination (trauma service level), compliance with guideline (recommended vs actual destination), trauma service level by threat to life (injury severity) (all modes of transport and aero-medical in particular), proportion of patients requiring only ED, transport pathway (direct vs inter-hospital transfer). RESULTS 3847 cases were identified from data as meeting criteria for major trauma by-pass. The top five most frequently used criteria for qualifying patients as meeting the major trauma by-pass guideline were pulse rate, vehicle rollover, possible spinal cord injury, respiration rate and entrapment. The study demonstrates a 65% conformance to the clinical guideline. Overtriaged patients (transported to higher trauma service than recommended) generally reveal International Classification of Disease Injury Severity Score representing a high threat to life. CONCLUSION Overall, the present study found good conformance, with overtriage rate as expected by clinicians. It is recommended to include data values to capture paramedics assessment of trauma level to enable more accurate assessment of conformance to guideline and future revision of the thresholds.
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Affiliation(s)
- Robert Andrews
- School of Information Systems, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Moe T Wynn
- School of Information Systems, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Kirsten Vallmuur
- Centre for Healthcare Transformation, Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Jamieson Trauma Institute, Metro North Hospital and Health Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Mark Elcock
- Retrieval Services Queensland, Queensland Health, Brisbane, Queensland, Australia
| | | | - Emma Bosley
- Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Arthur Hm Ter Hofstede
- School of Information Systems, Queensland University of Technology, Brisbane, Queensland, Australia
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Shanahan TAG, Fuller GW, Sheldon T, Turton E, Quilty FMA, Marincowitz C. External validation of the Dutch prediction model for prehospital triage of trauma patients in South West region of England, United Kingdom. Injury 2021; 52:1108-1116. [PMID: 33581872 DOI: 10.1016/j.injury.2021.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/12/2021] [Accepted: 01/22/2021] [Indexed: 02/02/2023]
Abstract
IMPORTANCE This paper investigates the use of a major trauma prediction model in the UK setting. We demonstrate that application of this model could reduce the number of patients with major trauma being incorrectly sent to non-specialist hospitals. However, more research is needed to reduce over-triage and unnecessary transfer to Major Trauma Centres. OBJECTIVE To externally validate the Dutch prediction model for identifying major trauma in a large unselected prehospital population of injured patients in England. DESIGN External validation using a retrospective cohort of injured patients who ambulance crews transported to hospitals. SETTING South West region of England. PARTICIPANTS All patients ≥16 years with a suspected injury and transported by ambulance in the year from February 1, 2017. EXCLUSION CRITERIA 1) Patients aged ≤15 years; 2) Non-ambulance attendance at hospital with injuries; 3) Death at the scene and; 4) Patients conveyed by helicopter. This study had a census sample of cases available to us over a one year period. INTERVENTIONS OR EXPOSURES Tested the accuracy of the prediction model in terms of discrimination, calibration, clinical usefulness, sensitivity and specificity and under- and over triage rates compared to usual triage practices in the South West region. MAIN OUTCOME MEASURE Major trauma defined as an Injury Severity Score>15. RESULTS A total of 68799 adult patients were included in the external validation cohort. The median age of patients was 72 (i.q.r. 46-84); 55.5% were female; and 524 (0.8%) had an Injury Severity Score>15. The model achieved good discrimination with a C-Statistic 0.75 (95% CI, 0.73 - 0.78). The maximal specificity of 50% and sensitivity of 83% suggests the model could improve undertriage rates at the expense of increased overtriage rates compared with routine trauma triage methods used in the South West, England. CONCLUSIONS AND RELEVANCE The Dutch prediction model for identifying major trauma could lower the undertriage rate to 17%, however it would increase the overtriage rate to 50% in this United Kingdom cohort. Further prospective research is needed to determine whether the model can be practically implemented by paramedics and is cost-effective.
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Affiliation(s)
- Thomas A G Shanahan
- University of Manchester, Faculty of Biology, Medicine and Health, School of Medical Sciences, Division of Cardiovascular Sciences, Oxford Road, Manchester, M13 9PL.
| | - Gordon Ward Fuller
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Trevor Sheldon
- Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London.
| | - Emily Turton
- School of Health and Related Research (ScHARR), The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA.
| | | | - Carl Marincowitz
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
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Sutherland M, Ehrlich H, McKenney M, Elkbuli A. Trauma outcomes for blunt and penetrating injuries by mode of transportation and day/night shift. Am J Emerg Med 2021; 48:79-82. [PMID: 33862389 DOI: 10.1016/j.ajem.2021.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/22/2021] [Accepted: 04/06/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Effective management of trauma patients is dependent on pre-hospital triage systems and proper in-hospital treatment regardless of time of admission. We aim to investigate any differences in adjusted all-cause mortality between day vs. night arrival for adult trauma patients who were transported to the hospital via ground emergency medical services (GEMS) and helicopter emergency medical services (HEMS) and to determine if care/outcomes are inferior when admitted during the night shift as compared to the day shift. METHODS Retrospective cohort analysis of adult blunt and penetrating injury patients requiring full team trauma activation at an American College of Surgeons Committee on Trauma (ACSCOT)-verified Level 1 trauma center from 2011 to 2019. Descriptive statistical analyses, chi-square analyses, independent-sample t-tests, and Fisher's exact tests were performed. Primary measurement outcome was adjusted observed/expected (O/E) mortality ratios utilizing TRISS methodology. RESULTS 8370 patients with blunt injuries and 1216 patients with penetrating injuries were analyzed. There were no significant differences in day vs. night O/Es overall (blunt 0.65 vs. 0.59; p = 0.46) (penetrating 0.88 vs. 0.87; p = 0.97). There also were no significant differences when stratified by GEMS (blunt 0.64 vs. 0.55; p = 0.08) (penetrating 0.88 vs. 1.10; p = 0.09) and HEMS admissions (blunt 0.76 vs. 0.75; p = 0.91) (penetrating 0.88 vs. 0.91; p = 0.85). CONCLUSIONS At an ACSCOT-verified Level 1 Trauma Center, care/outcomes of patients admitted during the night shift were not inferior to those admitted during the day shift. Trauma Center verification by the ACSCOT and multidisciplinary collaboration may allow for consistent care despite injury type and time of day.
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Affiliation(s)
- Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Haley Ehrlich
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA.
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Dijkink S, van Zwet EW, Krijnen P, Leenen LPH, Bloemers FW, Edwards MJR, Hartog DD, Leenhouts PA, Poeze M, Spanjersberg WR, Wendt KW, De Wit RJ, Van Zuthpen SWAM, Schipper IB. The impact of regionalized trauma care on the distribution of severely injured patients in the Netherlands. Eur J Trauma Emerg Surg 2021; 48:1035-1043. [PMID: 33712892 PMCID: PMC9001217 DOI: 10.1007/s00068-021-01615-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/05/2021] [Indexed: 11/18/2022]
Abstract
Background Twenty years ago, an inclusive trauma system was implemented in the Netherlands. The goal of this study was to evaluate the impact of structured trauma care on the concentration of severely injured patients over time. Methods All severely injured patients (Injury Severity Score [ISS] ≥ 16) documented in the Dutch Trauma Registry (DTR) in the calendar period 2008–2018 were included for analysis. We compared severely injured patients, with and without severe neurotrauma, directly brought to trauma centers (TC) and non-trauma centers (NTC). The proportion of patients being directly transported to a trauma center was determined, as was the total Abbreviated Injury Score (AIS), and ISS. Results The documented number of severely injured patients increased from 2350 in 2008 to 4694 in 2018. During this period, on average, 70% of these patients were directly admitted to a TC (range 63–74%). Patients without severe neurotrauma had a lower chance of being brought to a TC compared to those with severe neurotrauma. Patients directly presented to a TC were more severely injured, reflected by a higher total AIS and ISS, than those directly transported to a NTC. Conclusion Since the introduction of a well-organized trauma system in the Netherlands, trauma care has become progressively centralized, with more severely injured patients being directly presented to a TC. However, still 30% of these patients is initially brought to a NTC. Future research should focus on improving pre-hospital triage to facilitate swift transfer of the right patient to the right hospital.
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Affiliation(s)
- Suzan Dijkink
- Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Erik W van Zwet
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Michael J R Edwards
- Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter A Leenhouts
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Klaus W Wendt
- Department of Trauma Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ralph J De Wit
- Department of Trauma Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Inger B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
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Leijdesdorff HA, Gillissen S, Schipper IB, Krijnen P. Injury Pattern and Injury Severity of In-Hospital Deceased Road Traffic Accident Victims in The Netherlands: Dutch Road Traffic Accidents Fatalities. World J Surg 2021; 44:1470-1477. [PMID: 31897694 DOI: 10.1007/s00268-019-05348-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Further reduction in road traffic accident (RTA) fatalities is a key priority in the European Union. Since data on injury patterns related to mortality in RTAs are scarce, the aim of this study was to analyze injury patterns and injury severity of in-hospital RTA fatalities in the Netherlands. METHODS All in-hospital deceased RTA victims in the Netherlands during the period 2015-2016 were analyzed. Data were obtained from the National Trauma Registry. Injury patterns, injury severity, accident and patient characteristics of road user groups were compared. RESULTS A total of 497 deceased RTA victims were analyzed, of which most were bicyclists. All analyzed motorcyclists had an ISS ≥ 16. Head trauma was most frequent in pedestrians (73.7%) and bicyclists (71.3%). Thorax trauma was most frequent in motorcyclists and motorists (60.9% and 65.8%, respectively). RTA victims younger than 25 years were more severely injured (median ISS 38, interquartile range [IQR] 29-46) compared to RTA victims aged over 75 years (median ISS 25, IQR 13-30). More than 10% of the severely injured (ISS ≥ 16) RTA victims was not transported to a level I trauma center. The majority of this group was older than 75 years. CONCLUSIONS Further prevention of head trauma is needed to reduce RTA fatalities, especially in bicyclists. Also, undertriage of severe trauma in elderly RTA victims is obvious and should be addressed in the early phases of trauma care, especially during prehospital triage and initial care at admission.
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Affiliation(s)
- Henry A Leijdesdorff
- Department of Trauma Surgery, K06-R, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands. .,Trauma Unit, Department of Surgery, Haaglanden Medical Center, The Hague, The Netherlands.
| | - Stijn Gillissen
- Department of Trauma Surgery, K06-R, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Inger B Schipper
- Department of Trauma Surgery, K06-R, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Pieta Krijnen
- Department of Trauma Surgery, K06-R, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
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Prehospital Intervals and In-Hospital Trauma Mortality: A Retrospective Study from a Level I Trauma Center. Prehosp Disaster Med 2020; 35:508-515. [PMID: 32674744 DOI: 10.1017/s1049023x20000904] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The increase in mortality and total prehospital time (TPT) seen in Qatar appear to be realistic. However, existing reports on the influence of TPT on mortality in trauma patients are conflicting. This study aimed to explore the impact of prehospital time on the in-hospital outcomes. METHODS A retrospective analysis of data on patients transferred alive by Emergency Medical Services (EMS) and admitted to Hamad Trauma Center (HTC) of Hamad General Hospital (HGH; Doha, Qatar) from June 2017 through May 2018 was conducted. This study was centered on the National Trauma Registry database. Patients were categorized based on the trauma triage activation and prehospital intervals, and comparative analysis was performed. RESULTS A total of 1,455 patients were included, of which nearly one-quarter of patients required urgent and life-saving care at a trauma center (T1 activations). The overall TPT was 70 minutes and the on-scene time (OST) was 24 minutes. When compared to T2 activations, T1 patients were more likely to have been involved in road traffic injuries (RTIs); experienced head and chest injuries; presented with higher Injury Severity Score (ISS: median = 22); and had prolonged OST (27 minutes) and reduced TPT (65 minutes; P = .001). Prolonged OST was found to be associated with higher mortality in T1 patients, whereas TPT was not associated. CONCLUSIONS In-hospital mortality was independent of TPT but associated with longer OST in severely injured patients. The survival benefit may extend beyond the golden hour and may depend on the injury characteristics, prehospital, and in-hospital settings.
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Accuracy of National Early Warning Score 2 (NEWS2) in Prehospital Triage on In-Hospital Early Mortality: A Multi-Center Observational Prospective Cohort Study. Prehosp Disaster Med 2019; 34:610-618. [PMID: 31648657 DOI: 10.1017/s1049023x19005041] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION In cases of mass-casualty incidents (MCIs), triage represents a fundamental tool for the management of and assistance to the wounded, which helps discriminate not only the priority of attention, but also the priority of referral to the most suitable center. HYPOTHESIS/PROBLEM The objective of this study was to evaluate the capacity of different prehospital triage systems based on physiological parameters (Shock Index [SI], Glasgow-Age-Pressure Score [GAP], Revised Trauma Score [RTS], and National Early Warning Score 2 [NEWS2]) to predict early mortality (within 48 hours) from the index event for use in MCIs. METHODS This was a longitudinal prospective observational multi-center study on patients who were attended by Advanced Life Support (ALS) units and transferred to the emergency department (ED) of their reference hospital. Collected were: demographic, physiological, and clinical variables; main diagnosis; and data on early mortality. The main outcome variable was mortality from any cause within 48 hours. RESULTS From April 1, 2018 through February 28, 2019, a total of 1,288 patients were included in this study. Of these, 262 (20.3%) participants required assistance for trauma and injuries by external agents. Early mortality within the first 48 hours due to any cause affected 69 patients (5.4%). The system with the best predictive capacity was the NEWS2 with an area under the curve (AUC) of 0.891 (95% CI, 0.84-0.94); a sensitivity of 79.7% (95% CI, 68.8-87.5); and a specificity of 84.5% (95% CI, 82.4-86.4) for a cut-off point of nine points, with a positive likelihood ratio of 5.14 (95% CI, 4.31-6.14) and a negative predictive value of 98.7% (95% CI, 97.8-99.2). CONCLUSION Prehospital scores of the NEWS2 are easy to obtain and represent a reliable test, which make it an ideal system to help in the initial assessment of high-risk patients, and to determine their level of triage effectively and efficiently. The Prehospital Emergency Medical System (PhEMS) should evaluate the inclusion of the NEWS2 as a triage system, which is especially useful for the second triage (evacuation priority).
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Brown E, Tohira H, Bailey P, Fatovich D, Pereira G, Finn J. A comparison of major trauma patient transport destination in metropolitan Perth, Western Australia. Australas Emerg Care 2019; 23:90-96. [PMID: 31668941 DOI: 10.1016/j.auec.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/25/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Despite evidence of a lower risk of death, major trauma patients are not always transported to Trauma Centres. This study examines the characteristics and outcomes of major trauma patients between transport destinations. METHODS A retrospective cohort study of major trauma patients (Injury Severity Score >15) transported by ambulance was undertaken. Cases were divided into transport destination groups: (1) Direct, those transported to the Trauma Centre directly from the scene; (2) Indirect, those transported to another hospital prior to Trauma Centre transfer and (3) Non-transfers, those transported to a non-Trauma Centre and never subsequently transferred. Median and interquartile range (IQR) were used to describe the groups and differences were assessed using the Kruskal-Wallis test for continuous variables and Pearson chi-square for categorical. RESULTS A total of 1625 patients were included. The median age was oldest in the non-transfers cohort (72 years IQR 46-84). This group had the highest proportion of falls from standing and head injuries (n = 298/400, 75%, p < 0.001). The non-transfers had the highest proportion of 30-day mortality (n = 134/400, 34%). CONCLUSIONS There were significant differences between the groups with older adults, falls and head injuries over-represented in the non-transfer group. Considering the ageing population, trauma systems will need to adapt.
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Affiliation(s)
- Elizabeth Brown
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; St John Western Australia, 209 Great Eastern Hwy, Bentley, WA, Australia.
| | - Hideo Tohira
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; Division of Emergency Medicine, The University of Western Australia, Bentley, WA, Australia.
| | - Paul Bailey
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; St John Western Australia, 209 Great Eastern Hwy, Bentley, WA, Australia.
| | - Daniel Fatovich
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; Emergency Medicine, Royal Perth Hospital, University of Western Australia, Bentley, WA, Australia; Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, WA, Australia.
| | - Gavin Pereira
- School of Public Health, Curtin University, Bentley, WA, Australia; Telethon Kids Institute, WA, Australia.
| | - Judith Finn
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, GPO Box U1987, Perth, WA 6845, Australia; St John Western Australia, 209 Great Eastern Hwy, Bentley, WA, Australia; Division of Emergency Medicine, The University of Western Australia, Bentley, WA, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
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Thoracic trauma in military settings: a review of current practices and recommendations. Curr Opin Anaesthesiol 2019; 32:227-233. [PMID: 30817399 DOI: 10.1097/aco.0000000000000694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW To examine current literature on thoracic trauma related to military combat and to explore its relevance to the civilian population. RECENT FINDINGS Damage control resuscitation (DCR) has improved the management of hemorrhaging trauma patients. Permissive hypotension below 110 mmHg and antifibrinolytic use during DCR is widely accepted, whereas the use of freeze-dried plasma and whole blood is gaining popularity. The Modified Physiologic Triaging Tool can be used for primary triage and it may have applications in civilian trauma systems. Although Tactical Combat Casualty Care protocol recommends the Cric-Key device for surgical cricothyroidotomies, other devices may offer comparable performance. Recommendations for regional anesthesia after blunt trauma are not well defined. Increasing amounts of evidence favor the use of extracorporeal membrane oxygenation for refractory hypoxemia and resuscitative endovascular balloon occlusion of the aorta (REBOA) for severe hemorrhage. REBOA outcomes are potentially improved by partial occlusion and small 7 Fr catheters. SUMMARY The Global War on Terror has provided opportunities to better understand and treat thoracic trauma in military settings. Trauma registries and other data sources have contributed to significant advancements in the management of thoracic trauma in military and civilian populations.
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Chesser TJ, Moran C, Willett K, Bouillon B, Sturm J, Flohé S, Ruchholtz S, Dijkink S, Schipper IB, Rubio-Suarez JC, Chana F, de Caso J, Guerado E. Development of trauma systems in Europe-reports from England, Germany, the Netherlands, and Spain. OTA Int 2019; 2:e019. [PMID: 37675253 PMCID: PMC10479367 DOI: 10.1097/oi9.0000000000000019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 11/26/2018] [Indexed: 09/08/2023]
Abstract
Major trauma systems have evolved in many European countries and have resulted in improved care in terms of mortality and morbidity. Many of the systems have similar history, with reports of either poor services, or a single disaster, driving change of policy and set up. We report on 4 European systems, looking at the background, set up and some of the results. Similar issues are identified including the importance of triage, the concentration of specialist skills which require patients to bypass hospitals, and the standardization of treatment protocols. The issues of rehabilitation and the increasing importance of measuring outcome with patient reported metrics are discussed.
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Affiliation(s)
- Tim Js Chesser
- Department of Trauma and Orthopaedics, North Bristol NHS Trust, Bristol
| | - Chris Moran
- National Clinical Director for Trauma, Professor of Orthopaedic Trauma Surgery, Nottingham University Hospitals NHS Trust, Nottingham
| | - Keith Willett
- National Director for Acute Care to NHS England, Professor of Orthopaedic Trauma Surgery, University of Oxford, Oxford, UK
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, University of Witten/Herdecke, Cologne Merheim Medical Center, Cologne, Germany
| | | | - Sascha Flohé
- Department of Trauma and Orthopaedic Surgery, City Hospital Solingen
| | - Steffen Ruchholtz
- Department of Trauma and Orthopaedic Surgery, University Hospital Marburg Germany
| | - Suzan Dijkink
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Inger B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Francisco Chana
- Hospital Universitario Gregorio Marañon. University Complutense of Madrid, Madrid
| | - Julio de Caso
- Hospital Universitario Santa Creu i Sant Pau. University Autonoma of Barcelona Barcelona
| | - Enrique Guerado
- Professor and Chairman Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Costa del Sol. University of Malaga. Marbella Malaga, Spain
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Plate JDJ, Peelen LM, Leenen LPH, Hietbrink F. Optimizing critical care of the trauma patient at the intermediate care unit: a cost-efficient approach. Trauma Surg Acute Care Open 2018; 3:e000228. [PMID: 30402563 PMCID: PMC6203138 DOI: 10.1136/tsaco-2018-000228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 09/13/2018] [Accepted: 09/17/2018] [Indexed: 02/03/2023] Open
Abstract
Background The aim of this study was to describe the case load, safety, and cost savings of critical care of the trauma patient provided at the surgical intermediate care unit (IMCU). Methods This cohort study included all trauma admissions between January 1, 2011 and January 7, 2015 at the general intensive care unit (ICU), stand-alone neuro(surgical) IMCU, and stand-alone (trauma) surgical IMCU. Trauma mechanism, Abbreviated Injury Scale score and Injury Severity Score (ISS), vital signs, laboratory parameters, admission duration, intubation duration, ICU transfer, and in-hospital mortality were prospectively collected. Hypothetical cost savings were calculated using the fixed cost price per IMCU (US$1500) and ICU (US$2500) admission day. Results A total of 1320 admissions were included, 675 (51.1%) at the IMCU and 645 (48.9%) at the ICU. Patients admitted at the IMCU had a median ISS of 17 (11, 22). Their median duration of admission was 32.8 hours (18.8, 62.5). At the IMCU, one patient died due to aneurogenic shock. A subsequent ICU transfer was required in 38 (5.6%) IMCU admissions. Of these transfers, four patients died due to neurological deterioration. At the ICU, the median ISS was 22 (14, 30). Nearly all (n=620, 96.3%) ICU trauma patients required mechanical ventilation. Expected total cost savings due to the presence of the IMCU were US$1 772 785. Discussion A substantial amount of trauma patients in need of critical care can safely be admitted at the IMCU, without the need for further mechanical ventilation. Thereby, the IMCU could fulfill an essential cost-saving role in the management of severely injured trauma patients. Level of evidence Level IV.
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Affiliation(s)
- Joost D J Plate
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Linda M Peelen
- Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, The Netherlands.,Departments of Anesthesiology and Intensive Care Medicine, Utrecht University, Utrecht, The Netherlands
| | - Luke P H Leenen
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Falco Hietbrink
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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Insurance Status Biases Trauma-system Utilization and Appropriate Interfacility Transfer. Ann Surg 2018; 268:681-689. [DOI: 10.1097/sla.0000000000002954] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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