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Evaluation der Aufnahmekriterien von Patienten nach Verkehrsunfall in den Schockraum. Notf Rett Med 2021. [DOI: 10.1007/s10049-020-00695-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Zusammenfassung
Hintergrund
Die aktuelle S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung der Deutschen Gesellschaft für Unfallchirurgie (DGU) empfiehlt bei einem Pkw-Unfall mit einer Geschwindigkeitsveränderung von delta >30 km/h die Versorgung in einem Schockraum ohne Berücksichtigung der Verletzungen des Patienten. Ziel dieser Studie war es zu untersuchen, ob Patienten, die ausschließlich aufgrund dieses Kriteriums über einen Schockraum aufgenommen wurden, relevante Verletzungen aufwiesen, die intensivmedizinische Behandlungen oder (Not‑)Operationen benötigten.
Methode
Nach einem Pkw-Unfall wurden Patienten ohne spezifische Verletzung, bei denen ausschließlich eine Geschwindigkeitsveränderung von delta >30 km/h vorlag (Empfehlungsgrad B der S3-Leitlinie), der Studiengruppe, Patienten mit Verletzungen gem. Empfehlungsgrad A der Leitlinie der Vergleichsgruppe zugeordnet. Ein schockraumrelevantes Trauma wurde als Injury Severity Score (ISS) ≥16, operative Versorgung innerhalb 24 h, intensivmedizinische Überwachung >24 h, Versterben während des Krankenhausaufenthalts sowie DGU-Basiskollektiv (MAIS3+ oder MAIS2 mit Intensivverweildauer >24 h bzw. Versterben während des Krankenhausaufenthalts) definiert.
Ergebnisse
Der Vergleich zeigte einen hochsignifikanten Unterschied in Bezug auf den mittleren ISS (p ≤ 0,001), ein schockraumrelevantes Trauma (ISS ≥16; p ≤ 0,001), eine intensivmedizinische Versorgung >24 h (p ≤ 0,001), Operation innerhalb von 24 h nach Krankenhausaufnahme (p ≤ 0,001), Letalität (p ≤ 0,001) sowie DGU-Basiskollektiv (p ≤ 0,001). Anhand dieser Ergebnisse konnte gezeigt werden, dass innerhalb der Studiengruppe (Geschwindigkeitsveränderung von delta >30 km/h; Empfehlungsgrad B der S3-Leitlinie) lediglich ein Patient eine Traumafolge aufwies, die eine intensivmedizinische Behandlung >24 h oder eine Operation nötig machte. Studien- und Vergleichsgruppen waren in Bezug auf das mittlere Alter (p = 1,778), das männliche Geschlecht (p = 0,1728) sowie die durchschnittliche Unfallgeschwindigkeit (p = 0,4606) vergleichbar.
Diskussion
Ein alleiniges Vorliegen eines Pkw-Unfalls mit einer Geschwindigkeitsveränderung von delta >30 km/h kann nicht als adäquater Prädiktor für ein schockraumrelevantes Trauma gesehen werden. Weitere Studien könnten durch eine Leitlinienanpassung eine weiterhin sichere und hochwertige Patientenversorgung bei Reduktion von personellen und finanziellen Belastungen ermöglichen.
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Gutierrez PS, Travers C, Geng Z, Little WK. Centralization of Prehospital Triage Improves Triage of Pediatric Trauma Patients. Pediatr Emerg Care 2021; 37:11-16. [PMID: 32195977 DOI: 10.1097/pec.0000000000002080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION This study describes the experience at a level 1 pediatric trauma center before and after the centralization of prehospital trauma triage, focusing on the rate of undertriage of trauma patients. Before centralization, emergency physicians were responsible for triaging these patients with mainly physiology-based criteria; after centralization, paramedics in a communication center performed this function using the same criteria. METHODS This retrospective study includes 10 years of pediatric trauma registry patients at our institution, 5 years before and after centralization of prehospital triage. Rates of undertriage were calculated by both the Cribari Method and by disposition from the emergency department. Logistic regression was used to assess the effect of centralization on the incidence of undertriage while adjusting for differences in case-mix. RESULTS Over the 10-year study period, 1862 trauma activations meeting inclusion and exclusion criteria were recorded in the trauma registry: 893 patients in the precentralization and 969 in the postcentralization groups. After centralization of the triage process, there were statistically significant decreases in the rates of undertriage from 8.7% to 4.2% (adjusted odds ratio, 0.49; 95% confidence interval, 0.33-0.73) when analyzed by the Cribari Method and from 37.7% to 27.7% when analyzed by disposition from the emergency department (adjusted odds ratio, 0.66; 95% confidence interval, 0.64-0.81). This represents a reduction in undertriage by 51.7% and 26.5%, respectively. CONCLUSIONS Centralization of prehospital trauma triage at a level 1 pediatric trauma facility significantly reduced undertriage rates. Trauma centers should consider similar processes to improve prehospital triage.
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Affiliation(s)
| | | | - Zhi Geng
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA
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Hagebusch P, Faul P, Naujoks F, Klug A, Hoffmann R, Schweigkofler U. Trauma-team-activation in Germany: how do emergency service professionals use the activation due to trauma mechanism? Results from a nationwide survey. Eur J Trauma Emerg Surg 2020; 48:393-399. [PMID: 32583072 DOI: 10.1007/s00068-020-01425-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/19/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Trauma team activation (TTA) requires significant human and financial resources. The implemented German guidelines reduced the mortality of severe injured patients significantly over the last decade. Up to now there is no two-tier trauma team activation protocol in Germany. A two-tier TTA [often activated due to trauma mechanism (TM)] is thought to be a reasonable way to maintain patient safety while increasing cost efficiency. METHODS We created an online survey addressed at the Emergency Medical Service in Germany to conduct a cross-sectional study. Both physicians and rescue service professionals (RSPs) were included. A minimum of 1550 participants answered questions in 4 different categories concerning the aspects of limited-TTA (L-TTA). Case studies were presented to evaluate the usage of TTA due to TM in the daily routine. RESULTS Eighty percent (n:1233) of the respondents wish for a possibility to activate a limited trauma team. Seventy-two percent (n: 1109) of the participants consider a L-TTA due to TM to be adequate. There were significant differences (p < 0.05) in the assessment and opinion on L-TTA among physicians and RSPs as well as different medical professions. The evaluated case studies showed diverse answers: depending on the profession, the same patient was ranked as severely injured by 54% and as minorly injured by 46% of the 1550 participants. CONCLUSIONS Members of the German Emergency Medical Service call for a two-tier TTA-protocol. Up to now we cannot fully recommend an automatic reduction of the trauma team when activated due to TM in Germany with the guidelines implemented. The profession might affect the L-TTA-behavior. Criteria for a L-TTA in Germany have to be defined and evaluated. LEVEL OF EVIDENCE IV, cross-sectional study.
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Affiliation(s)
- Paul Hagebusch
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt, Germany.
| | - Philipp Faul
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt, Germany
| | - Frank Naujoks
- Ministry of Health, City of Frankfurt, Breite Gasse 28, 60313, Frankfurt, Germany
| | - Alexander Klug
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt, Germany
| | - Uwe Schweigkofler
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt, Germany
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Stuke LE, Duchesne JC, Hunt JP, Marr AB, Meade PC, McSwain NE. Mechanism of Injury is not a Predictor of Trauma Center Admission. Am Surg 2020. [DOI: 10.1177/000313481307901116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Most trauma systems use mechanism of injury (MOI) as an indicator for trauma center transport, often overburdening the system as a result of significant overtriage. Before 2005 our trauma center accepted all MOI. After 2005 we accepted only those patients meeting anatomic and physiologic (A&P) triage criteria. Patients entered into the trauma center database were divided into two groups: 2001 to 2005 (Group 1) and 2007 to 2010 (Group 2) and also categorized based on trauma team activation for either A&P or MOI criteria. Overtriage was defined as patient discharge from the emergency department within 6 hours of trauma activation. A total of 9899 patients were reviewed. Group 1 had 6584 patients with 3613 (55%) activated for A&P criteria and 2971 (45%) for MOI. Group 2 had 3315 patients with 3149 (95%) activated for A&P criteria and 166 (5%) for MOI. Accepting only those patients meeting A&P criteria resulted in a decrease in the overtriage rate from 66 to 9 per cent. By accepting only those patients meeting A&P criteria, we significantly reduced our overtriage rate. Patients meeting MOI criteria were transported to community hospitals and transferred to the trauma center if major injuries were identified. Trauma center transport for MOI results in significant overtriage and may not be justified.
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Affiliation(s)
- Lance E. Stuke
- Department of Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Juan C. Duchesne
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - John P. Hunt
- Department of Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Alan B. Marr
- Department of Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Peter C. Meade
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Norman E. McSwain
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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Linder F, Holmberg L, Eklöf H, Björck M, Juhlin C, Mani K. Better compliance with triage criteria in trauma would reduce costs with maintained patient safety. Eur J Emerg Med 2019; 26:283-288. [PMID: 29438134 PMCID: PMC6594724 DOI: 10.1097/mej.0000000000000544] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 01/07/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate trauma triage criteria in terms of compliance, undertriage, and overtriage and identify risk factors for mistriage. METHODS In a retrospective cohort study, all consecutive trauma patients at a University Hospital in Sweden in 2012 were included. Patients were stratified into three groups on the basis of trauma team activation (full trauma team, limited trauma team, and no trauma team). Case records were reviewed for mechanism of injury, vital signs, and injuries. Compliance with alert criteria was evaluated and injury severity score combined with the Matrix method was used for assessment of overtriage and undertriage. RESULTS A total of 1424 trauma patients were included in the study. Seventy-three (5.1%) patients activated a full trauma team, 732 (51.4%) a limited trauma team, and 619 (43.5%) did not activate any trauma team. Undertriage was 2.7% [95% confidence interval (CI): 1.9-3.8%] and overtriage was 34.2% (95% CI: 23.5-46.3%) in the complete cohort. Compliance with 'trauma triage criteria' was assessed by comparing actual alerts with what was estimated to be the correct alert levels on the basis of prehospital case records. Compliance with full trauma team criteria was 80% (68-88%), limited trauma team was 54% (51-58%), and no trauma team was 79% (76-82%). Assuming full compliance with trauma criteria, the Matrix method resulted in an undertriage of 2.3% (95% CI: 1.6-3.3%) and an overtriage of 42.6% (95% CI: 32.4-53.2%). CONCLUSION The overtriage and undertriage in this study is in line with the recommendations of the American College of Surgeons Committee on Trauma. However, better compliance with trauma alert criteria would result in fewer trauma team activations without affecting patient safety.
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Affiliation(s)
- Fredrik Linder
- Department of Surgical Sciences, Section of Vascular Surgery
| | - Lina Holmberg
- Department of Surgical Sciences, Section of Vascular Surgery
| | - Hampus Eklöf
- Department of Surgical Sciences, Section of Radiology, Uppsala University, Uppsala, Sweden
| | - Martin Björck
- Department of Surgical Sciences, Section of Vascular Surgery
| | - Claes Juhlin
- Department of Surgical Sciences, Section of Vascular Surgery
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery
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Abstract
Introduction Major trauma in the elderly population has been increasingly reported over the past decade. Compared to younger populations, elderly patients may experience major trauma as a result of low mechanisms of injury (MOIs) and as a result, existing definitions for 'major trauma' should be challenged.This literature review provides an overview of previous conceptualisations of defining 'major trauma' and considers their utility in relation to the pre-hospital phase of care. Methods A systematic search strategy was performed using CINAHL, Cochrane Library and Web of Science (MEDLINE). Grey literature and key documents from cited references were also examined. Results A total of 121 articles were included in the final analysis. Predominantly, retrospective scoring systems, such as the Injury Severity Score (ISS), were used to define major trauma.Pre-hospital variables considered indicative of major trauma included: fatal outcomes, injury type/pattern, deranged physiology and perceived need for treatment sequelae such as intensive care unit (ICU) admission, surgical intervention or the administration of blood products.Within the pre-hospital environment, retrospective scoring systems as a means of identifying major trauma are of limited utility and should not detract from the broader clinical picture. Similarly, although MOI is often a useful consideration, it should be used in conjunction with other factors in identifying major trauma patients. Conclusions In the pre-hospital environment, retrospective scoring systems are not available and other variables must be considered. Based upon this review, a working definition of major trauma is suggested as: 'A traumatic event resulting in fatal injury or significant injury with accompanying deranged physiology, regardless of MOI, and/or is predicted to require significant treatment sequelae such as ICU admission, surgical intervention, or the administration of blood products'.
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Affiliation(s)
- Lee Thompson
- North East Ambulance Service NHS Foundation Trust; Northumbria University; Northern Trauma Network: ORCID iD: https://orcid.org/0000-0002-0820-1662
| | | | - Gary Shaw
- North East Ambulance Service NHS Foundation Trust
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Linder F, Holmberg L, Bjorck M, Juhlin C, Thorbjornsen K, Wisinger J, Polleryd P, Eklof H, Mani K. A prospective stepped wedge cohort evaluation of the new national trauma team activation criteria in Sweden - the TRAUMALERT study. Scand J Trauma Resusc Emerg Med 2019; 27:52. [PMID: 31039800 PMCID: PMC6492485 DOI: 10.1186/s13049-019-0619-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/25/2019] [Indexed: 11/10/2022] Open
Abstract
Background Trauma triage based on prehospital information facilitates correct allocation of in-hospital resources. The Swedish national two-tier trauma team activation (TTA) criteria were revised in 2016. The current study aimed to evaluate the safety and efficacy of the new criteria. Methods Five centres covering trauma care for 1.2 million inhabitants registered all trauma patients prospectively in the Swedish trauma registry (SweTrau) prior to and after stepwise introduction of new TTA criteria within the cohort (a prospective stepped-wedge cohort study design; period August 2016–November 2017). Evaluation of full- and limited-TTA frequency, under- and overtriage were performed at equal duration before and after this change. Results The centres registered 1948 patients, 1882 (96.6%) of which were included in the study. With new criteria, frequency of full-TTA was unchanged, while limited-TTA decreased with 46.3% (from 988 to 531). 30-day trauma mortality was unchanged. The overtriage was 107/150 (71.3%) with former criteria, and 104/144 (72.2%) with new criteria, p = 0.866. Undertriage was 50/1037 (4.8%) versus 39/551 (7.1%), p = 0.063. Undertriage was consistently > 20% in patients with fall injury. Among patients with Injury Severity Score (ISS) > 15, 50/93 (53.8%) did not initiate full-TTA with former, vs 39/79 (49.4%) with new criteria, p = 0.565. Age > 60-years was a risk factor for undertriage (OR 2.89, p < 0.001), while low fall injuries indicated a trend (OR 2.70, p = 0.051). Conclusions The newly implemented Swedish TTA criteria result in a reduction in limited TTA frequency, indicating an increased efficiency in use of resources. The over- and undertriage is unchanged compared to former criteria, thus upholding patient safety. Electronic supplementary material The online version of this article (10.1186/s13049-019-0619-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Fredrik Linder
- Department of Surgical Sciences, Uppsala University, 75185, Uppsala, Sweden.
| | - Lina Holmberg
- Department of Surgical Sciences, Uppsala University, 75185, Uppsala, Sweden
| | - Martin Bjorck
- Department of Surgical Sciences, Uppsala University, 75185, Uppsala, Sweden
| | - Claes Juhlin
- Department of Surgical Sciences, Uppsala University, 75185, Uppsala, Sweden
| | - Knut Thorbjornsen
- Department of Surgical Sciences, Uppsala University, 75185, Uppsala, Sweden.,Department of surgery, Gävle county hospital, Gävle, Sweden
| | - Jan Wisinger
- Department of surgery, Västerås county hospital, Västerås, Sweden
| | - Per Polleryd
- Department of surgery, Karlstad county hospital, Karlstad, Sweden
| | - Hampus Eklof
- Department of Surgical Sciences, Uppsala University, 75185, Uppsala, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, 75185, Uppsala, Sweden
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Gross T, Morell S, Amsler F. To What Extent Are Main Accident-Insurer Cases Representative of All Significantly Injured? A Swiss Monocenter Perspective. J Insur Med 2019; 48:65-78. [PMID: 31017516 DOI: 10.17849/insm-48-1-1-14.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background and Objectives.-Even though Switzerland has a compulsory insurance system, there is a lack of detailed information on the treatment and outcome following trauma. The objective of this evaluation was to examine to what extent cases insured by the largest accident-insurer (Suva) are representative of all significantly injured. Methods.-Trauma center analysis of all ≥16 year old trauma patients with a New Injury Severity Score (NISS) ≥8, comparing the characteristics of Suva- vs non-Suva cases (chi-square; univariate explained variance R2; multivariate logistic regression analysis, Nagelkerke R2). Results.-Over 7 years, 2233 trauma patients were treated at the hospital, of whom 29.4% were Suva-insured. Compared to non-Suva-insured, Suva cases were younger (41.6 vs 64.2, R2 = 0.23) and more often male (88.0% vs 59.4%; R2 = 0.08). In multivariate analysis, these two factors together explained 37.5% of the differences between groups. No other investigated factor explained more than 2%. If only those patients of obligatory working age were analyzed (n = 1264), Suva cases (50.6%) were more often male than non-Suva-insured (n = 562 [87.8%] vs n = 393 [63.0%], resp.; p<0.001, R2 = 0.08). In multivariate analysis, other factors taken together were only 2.6% of the variance. Conclusions.-Significantly injured patients in Switzerland may be considered comparable from a statistical point of view whether insured by the main accident-insurer or not, provided groups are adequately controlled for age and gender. Other differences appear to be only marginal. Respecting these limitations such data can justifiably be given as Swiss reference statistics and the relevant insurer outcome information used for international comparison.
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Affiliation(s)
- Thomas Gross
- Department of Traumatology, Cantonal Hospital, Tellstr.1, CH-5001 Aarau and
| | - Sabrina Morell
- Department of Traumatology, Cantonal Hospital, Tellstr.1, CH-5001 Aarau and
| | - Felix Amsler
- Amsler Consulting, Gundeldingerrain 111,CH-4059 Basel (FA)
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Suen KW, Chang AML, Au CKH. A Regional Study on Primary Trauma Diversion in Hong Kong. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791101800205] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Primary trauma diversion (PTD) allows ambulance crews to transport severely injured patients directly to trauma centres. It has been launched in Kowloon Central Cluster (KCC) of Hospital Authority, Hong Kong since 2006. Objective The study investigated the performance of PTD with a view to provide relevant information for further development. The compliance with PTD, under-triage and over-triage were the major outcomes measurement. Patients' characteristics and their clinical information were also described. Method This was a retrospective descriptive study. We reviewed and analyzed the data in our hospital trauma registry during the study period between 1st July 2006 and 30th June 2009. Result One hundred and sixty-three trauma patients were diverted to our trauma centre during the study period. The mean Injury Severity Score was 11.72 with 90 of them being classified as severely injured. We found that 47 and 73 patients were under and over triage respectively. About 74% eligible trauma patients were diverted to the trauma centre according to PTD criteria. Conclusion Although the initial experience of PTD in KCC is satisfactory, more severely injured patients will benefit from our trauma centre service by improving the under-triage rate. We also foresee a better compliance with trauma diversion in the future.
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Holst JA, Perman SM, Capp R, Haukoos JS, Ginde AA. Undertriage of Trauma-Related Deaths in U.S. Emergency Departments. West J Emerg Med 2016; 17:315-23. [PMID: 27330664 PMCID: PMC4899063 DOI: 10.5811/westjem.2016.2.29327] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 02/14/2016] [Accepted: 02/17/2016] [Indexed: 02/03/2023] Open
Abstract
Introduction Accurate field triage of critically injured patients to trauma centers is vital for improving survival. We sought to estimate the national degree of undertriage of trauma patients who die in emergency departments (EDs) by evaluating the frequency and characteristics associated with triage to non-trauma centers. Methods This was a retrospective cross-sectional analysis of adult ED trauma deaths in the 2010 National Emergency Department Sample (NEDS). The primary outcome was appropriate triage to a trauma center (Level I, II or III) or undertriage to a non-trauma center. We subsequently focused on urban areas given improved access to trauma centers. We evaluated the associations of patient demographics, hospital region and mechanism of injury with triage to a trauma versus non-trauma center using multivariable logistic regression. Results We analyzed 3,971 included visits, representing 18,464 adult ED trauma-related deaths nationally. Of all trauma deaths, nearly half (44.5%, 95% CI [43.0–46.0]) of patients were triaged to non-trauma centers. In a subgroup analysis, over a third of urban ED visits (35.6%, 95% CI [34.1–37.1]) and most rural ED visits (86.4%, 95% CI [81.5–90.1]) were triaged to non-trauma centers. In urban EDs, female patients were less likely to be triaged to trauma centers versus non-trauma centers (adjusted odds ratio [OR] 0.83, 95% CI [0.70–0.99]). Highest median household income zip codes (≥$67,000) were less likely to be triaged to trauma centers than lowest median income ($1–40,999) (OR 0.54, 95% CI [0.43–0.69]). Compared to motor vehicle trauma, firearm trauma had similar odds of being triaged to a trauma center (OR 0.90, 95% CI [0.71–1.14]); however, falls were less likely to be triaged to a trauma center (OR 0.50, 95 %CI [0.38–0.66]). Conclusion We found that nearly half of all trauma patients nationally and one-third of urban trauma patients, who died in the ED, were triaged to non-trauma centers, and thus undertriaged. Sex and other demographic disparities associated with this triage decision represent targeted opportunities to improve our trauma systems and reduce undertriage.
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Affiliation(s)
- Jenelle A Holst
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado; Denver Health Medical Center, Department of Emergency Medicine, Denver, Colorado
| | - Sarah M Perman
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Roberta Capp
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Jason S Haukoos
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado; Denver Health Medical Center, Department of Emergency Medicine, Denver, Colorado
| | - Adit A Ginde
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
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Beck H, Mittal S, Madigan D, Burd RS. Reassessing mechanism as a predictor of pediatric injury mortality. J Surg Res 2015; 199:641-6. [PMID: 26197948 PMCID: PMC4636960 DOI: 10.1016/j.jss.2015.06.043] [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: 04/23/2015] [Revised: 05/28/2015] [Accepted: 06/17/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND The use of mechanism of injury as a predictor of injury outcome presents practical challenges because this variable may be missing or inaccurate in many databases. The purpose of this study was to determine the importance of mechanism of injury as a predictor of mortality among injured children. METHODS The records of children (<15-y-old) sustaining a blunt injury were obtained from the National Trauma Data Bank. Models predicting injury mortality were developed using mechanism of injury and injury coding using either abbreviated injury scale post-dot values (low-dimensional injury coding) or injury International Classification of Diseases, Ninth Revision codes and their two-way interactions (high-dimensional injury coding). Model performance with and without inclusion of mechanism of injury was compared for both coding schemes, and the relative importance of mechanism of injury as a variable in each model type was evaluated. RESULTS Among 62,569 records, a mortality rate of 0.9% was observed. Inclusion of mechanism of injury improved model performance when using low-dimensional injury coding but was associated with no improvement when using high-dimensional injury coding. Mechanism of injury contributed to 28% of model variance when using low-dimensional injury coding and <1% when high-dimensional injury coding was used. CONCLUSIONS Although mechanism of injury may be an important predictor of injury mortality among children sustaining blunt trauma, its importance as a predictor of mortality depends on the approach used for injury coding. Mechanism of injury is not an essential predictor of outcome after injury when coding schemes are used that better characterize injuries sustained after blunt pediatric trauma.
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Affiliation(s)
- Haley Beck
- Children’s National Medical Center, Division of Trauma and Burn Surgery, 111 Michigan Ave NW, Washington, DC 20010, USA
| | - Sushil Mittal
- Scibler Corporation, 1524 Vista Club Circle, #103, Santa Clara, CA, 95054 Santa Clara, CA 95054, USA
| | - David Madigan
- Department of Statistics, Columbia University, Room 1005 SSW, MC 4690, New York, NY 10027, USA
| | - Randall S. Burd
- Children’s National Medical Center, Division of Trauma and Burn Surgery, 111 Michigan Ave NW, Washington, DC 20010, USA
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Current views on the mechanisms of immune responses to trauma and infection. Cent Eur J Immunol 2015; 40:206-16. [PMID: 26557036 PMCID: PMC4637396 DOI: 10.5114/ceji.2015.52835] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/04/2015] [Indexed: 02/04/2023] Open
Abstract
According to the World Health Organization, post-traumatic mortality rates are still very high and show an increasing tendency. Disorders of innate immune response that may increase the risk of serious complications play a key role in the immunological system response to trauma and infection. The mechanism of these disorders is multifactorial and is still poorly understood. The changing concepts of systemic inflammatory response syndrome (SIRS) and compensatory anti-inflammatory response syndrome (CARS) early inflammatory response, presented in this work, have been extended to genetic studies. Overexpression of genes and increased production of immune response mediators are among the main causes of multiple organ dysfunction syndrome (MODS). Changes in gene expression detected early after injury precede the occurrence of subsequent complications with a typical clinical picture. Rapid depletion of energy resources leads to immunosuppression and persistent inflammation and immune suppression catabolism syndrome (PICS). Early diagnosis of immune disorders and appropriate nutritional therapy can significantly reduce the incidence of complications, length of hospital stay, and mortality. The study presents the development of knowledge and current views explaining the mechanisms of the immune response to trauma and infection.
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Evaluation of the Prehospital Index, presence of high-velocity impact and judgment of emergency medical technicians as criteria for trauma triage. CAN J EMERG MED 2015; 12:111-8. [DOI: 10.1017/s1481803500012136] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
ABSTRACTObjective:We sought to evaluate the performance of the Prehospital Index (PHI), the high-velocity impact (HVI) criterion and emergency medical technician (EMT) judgment for the prehospital triage of injured patients.Methods:The study population included all prehospital trauma patients transported by an emergency medical service to 2 level-I trauma centres for adults. All prehospital run sheets were linked to trauma registry data. The main outcome was severe trauma, defined as death within 72 hours, admission to the intensive care unit within 24 hours or an Injury Severity Score greater than 15. We assessed sensitivity, specificity and rates of overtriage.Results:Of 16 805 patients in the study population, 1113 (6.62%) had severe trauma. The combination of all 3 triage criteria (PHI score ≥ 4, HVI presence and EMT judgment) performed best for identifying patients with severe trauma, with a sensitivity of 74.2% but with an overtriage rate of 85.1%. Alone, EMT judgment had the highest sensitivity and a PHI score of 4 or greater had the lowest rate of overtriage.Conclusion:Although the combination of PHI score, HVI presence and EMT judgment offers the highest sensitivity for the identification of patients that could benefit from direct transport to a level-I trauma centre, overall sensitivity remains low and overtriage is high. More research is required to improve prehospital triage.
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van Laarhoven JJEM, Lansink KWW, van Heijl M, Lichtveld RA, Leenen LPH. Accuracy of the field triage protocol in selecting severely injured patients after high energy trauma. Injury 2014; 45:869-73. [PMID: 24472800 DOI: 10.1016/j.injury.2013.12.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 12/05/2013] [Accepted: 12/24/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND For optimal treatment of trauma patients it is of great importance to identify patients who are at risk for severe injuries. The Dutch field triage protocol for trauma patients, the LPA (National Protocol of Ambulance Services), is designed to get the right patient, in the right time, to the right hospital. Purpose of this study was to determine diagnostic accuracy and compliance of this triage protocol. STUDY DESIGN Triage criteria were categorised into physiological condition (P), mechanism of trauma (M) and injury type (I). A retrospective analysis of prospectively collected data of all high-energy trauma patients from 2008 to 2011 in the region Central Netherlands is performed. Diagnostic parameters (sensitivity, specificity, negative predictive value, positive predictive value) of the field triage protocol for selecting severely injured patients were calculated including rates of under- and overtriage. Undertriage was defined as the proportion of severely injured patients (Injury Severity Score (ISS)≥16) who were transported to a level two or three trauma care centre. Overtriage was defined as the proportion of non-severely injured patients (ISS<16) who were transported to a level one trauma care centre. RESULTS Overall sensitivity and specificity of the field triage protocol was 89.1% (95% confidence interval (CI) 84.4-92.6) and 60.5% (95% CI 57.9-63.1), respectively. The overall rate of undertriage was 10.9% (95%CI 7.4-15.7) and the overall rate of overtriage was 39.5% (95%CI 36.9-42.1). These rates were 16.5% and 37.7%, respectively for patients with M+I-P-. Compliance to the triage protocol for patients with M+I-P- was 78.7%. Furthermore, compliance in patients with either a positive I+ or positive P+ was 91.2%. CONCLUSION The overall rate of undertriage (10.8%) was mainly influenced by a high rate of undertriage in the group of patients with only a positive mechanism criterion, therefore showing low diagnostic accuracy in selecting severely injured patients. As a consequence these patients with severe injury are undetected using the current triage protocol. As it has been shown that severely injured patients have better outcome in level one trauma care centres further optimisation of this protocol aiming at lowering undertriage is therefore essential, preferably without incrementing overtriage too much.
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Affiliation(s)
| | - K W W Lansink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M van Heijl
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R A Lichtveld
- Regional Ambulance Facilities Utrecht, RAVU, Utrecht, The Netherlands
| | - L P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Facteurs de risque de mortalité lors de traumatisme par défenestration. ANNALES FRANCAISES DE MEDECINE D URGENCE 2012. [DOI: 10.1007/s13341-012-0220-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Cudnik MT, Werman HA, White LJ, Opalek JM. Prehospital Factors Associated with Mortality in Injured Air Medical Patients. PREHOSP EMERG CARE 2012; 16:121-7. [DOI: 10.3109/10903127.2011.615011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Parsons V, O'Brien L. Paramedic clinical decision-making in mental health care: a new theoretical approach. ACTA ACUST UNITED AC 2011. [DOI: 10.12968/ippr.2011.1.2.72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Mechanism of Injury and Special Consideration Criteria Still Matter: An Evaluation of the National Trauma Triage Protocol. ACTA ACUST UNITED AC 2011; 70:38-44; discussion 44-5. [DOI: 10.1097/ta.0b013e3182077ea8] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Larsen KT, Uleberg O, Skogvoll E. Differences in trauma team activation criteria among Norwegian hospitals. Scand J Trauma Resusc Emerg Med 2010; 18:21. [PMID: 20406456 PMCID: PMC2874509 DOI: 10.1186/1757-7241-18-21] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 04/20/2010] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND To ensure the rapid and correct triage of patients in potential need of specialized treatment, Norwegian hospitals are expected to establish trauma teams with predefined criteria for their activation. The objective of this study was to map and describe the criteria currently in use. METHODS We undertook a cross-sectional survey in the summer of 2008, using structured telephone interviews to all Norwegian hospitals that might admit severely injured patients. RESULTS Forty-nine hospitals were included, of which 48 (98%) had a trauma team and 20 had a hospital-based trauma registry. Criteria for trauma team activation were found at 46 (94%) hospitals. No single criterion was common to all hospitals. The median number of criteria per hospital was 23 (range 8-40), with a total number of 156 and wide variation with respect to physiological "cut-off" values. The mechanism of injury was commonly in use despite a well-known, large over-triage rate. CONCLUSIONS In recent years, Norwegian hospitals have gradually established trauma teams and criteria for their activation. These criteria show considerable variation, including physiological "cut-off" values.
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Affiliation(s)
- Kristin T Larsen
- Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Oddvar Uleberg
- Department of Anaesthesia and Emergency Medicine, St Olav's University Hospital, Trondheim, Norway
| | - Eirik Skogvoll
- Department of Anaesthesia and Emergency Medicine, St Olav's University Hospital, Trondheim, Norway
- Institute for Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Giannakopoulos GF, Lubbers WD, Christiaans HMT, van Exter P, Bet P, Hugen PJC, Innemee G, Schubert E, de Lange-Klerk ESM, Goslings JC, Jukema GN. Cancellations of (helicopter-transported) mobile medical team dispatches in the Netherlands. Langenbecks Arch Surg 2010; 395:737-45. [PMID: 20084394 PMCID: PMC2908760 DOI: 10.1007/s00423-009-0576-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Accepted: 11/09/2009] [Indexed: 02/03/2023]
Abstract
Background The trauma centre of the Trauma Center Region North-West Netherlands (TRNWN) has consensus criteria for Mobile Medical Team (MMT) scene dispatch. The MMT can be dispatched by the EMS-dispatch centre or by the on-scene ambulance crew and is transported by helicopter or ground transport. Although much attention has been paid to improve the dispatch criteria, the MMT is often cancelled after being dispatched. The aim of this study was to assess the cancellation rate and the noncompliant dispatches of our MMT and to identify factors associated with this form of primary overtriage. Methods By retrospective analysis of all MMT dispatches in the period from 1 July 2006 till 31 December 2006 using chart review, we conducted a consecutive case review of 605 dispatches. Four hundred and sixty seven of these were included for our study, collecting data related to prehospital triage, patient’s condition on-scene and hospital course. Results Average age was 35.9 years; the majority of the patients were male (65.3%). Four hundred and thirty patients were victims of trauma, sustaining injuries in most cases from blunt trauma (89.3%). After being dispatched, the MMT was cancelled 203 times (43.5%). Statistically significant differences between assists and cancellations were found for overall mortality, mean RTS, GCS and ISS, mean hospitalization, length and amount of ICU admissions (p < 0.001). All dispatches were evaluated by using the MMT-dispatch criteria and mission appropriateness criteria. Almost 26% of all dispatches were neither appropriate, nor met the dispatch criteria. Fourteen missions were appropriate, but did not meet the dispatch criteria. The remaining 318 dispatches had met the dispatch criteria, of which 135 (30.3%) were also appropriate. The calculated additional costs of the cancelled dispatches summed up to a total of € 34,448, amounting to 2.2% of the total MMT costs during the study period. Conclusion In our trauma system, the MMT dispatches are involved with high rates of overtriage. After being dispatched, the MMT is cancelled in almost 50% of all cases. We found an undertriage rate of 4%, which we think is acceptable. All cancellations were justified. The additional costs of the cancelled missions were within an acceptable range. According to this study, it seems to be possible to reduce the overtriage rate of the MMT dispatches, without increasing the undertriage rate to non-acceptable levels.
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Affiliation(s)
- Georgios F Giannakopoulos
- Department of Trauma Surgery, VU University Medical Centre, 7F-018, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
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Abstract
Damage control orthopaedics (DCO) is a staged approach for the management of multiply injured patients. It is ideal for trauma patients presenting in an unstable or extremis physiological state. It focuses on the rapid resuscitation of these patients by providing temporary stabilisation of fractures while at the same time reducing the biological load of surgery. Early findings support its usefulness in controlling the lethal triad of hypothermia, acidosis and coagulopathy. Furthermore, recent evidence indicates that it regulates the evolving systemic inflammatory response, reducing the detrimental complications of adult respiratory distress syndrome, multiple organ dysfunction and subsequent mortality. Although DCO has been proven a useful surgical strategy for efficiently managing patients with multiple trauma, further work is required to establish fully its indications, results and cost implications.
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Affiliation(s)
- Peter V Giannoudis
- Academic Dept of Trauma & Orthopaedics, Leeds General Infirmary, Leeds, UK.
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Boyle MJ. The experience of linking Victorian emergency medical service trauma data. BMC Med Inform Decis Mak 2008; 8:52. [PMID: 19014622 PMCID: PMC2596105 DOI: 10.1186/1472-6947-8-52] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 11/17/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The linking of a large Emergency Medical Service (EMS) dataset with the Victorian Department of Human Services (DHS) hospital datasets and Victorian State Trauma Outcome Registry and Monitoring (VSTORM) dataset to determine patient outcomes has not previously been undertaken in Victoria. The objective of this study was to identify the linkage rate of a large EMS trauma dataset with the Department of Human Services hospital datasets and VSTORM dataset. METHODS The linking of an EMS trauma dataset to the hospital datasets utilised deterministic and probabilistic matching. The linking of three EMS trauma datasets to the VSTORM dataset utilised deterministic, probabilistic and manual matching. RESULTS There were 66.7% of patients from the EMS dataset located in the VEMD. There were 96% of patients located in the VAED who were defined in the VEMD as being admitted to hospital. 3.7% of patients located in the VAED could not be found in the VEMD due to hospitals not reporting to the VEMD. For the EMS datasets, there was a 146% increase in successful links with the trauma profile dataset, a 221% increase in successful links with the mechanism of injury only dataset, and a 46% increase with sudden deterioration dataset, to VSTORM when using manual compared to deterministic matching. CONCLUSION This study has demonstrated that EMS data can be successfully linked to other health related datasets using deterministic and probabilistic matching with varying levels of success. The quality of EMS data needs to be improved to ensure better linkage success rates with other health related datasets.
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Affiliation(s)
- Malcolm J Boyle
- Monash University, Department of Community Emergency Health and Paramedic Practice, PO Box 527, Frankston 3199, Victoria, Australia.
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