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Gold-Bersani D, Drennan IR, McGowan M, Nisenbaum R, Nolan B. Field trauma triage criteria associated with need for dedicated trauma center care: a single-center retrospective cohort study. CAN J EMERG MED 2024:10.1007/s43678-024-00722-3. [PMID: 38807018 DOI: 10.1007/s43678-024-00722-3] [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: 12/11/2023] [Accepted: 04/29/2024] [Indexed: 05/30/2024]
Abstract
INTRODUCTION Direct transport from the scene of injury to a trauma centre reduces saves lives. In Ontario, paramedics use the field trauma triage standard (FTTS) to determine if a patient meets trauma bypass criteria. Recent studies have questioned the efficacy of the FTTS in identifying severely injured patients. The objective of this study was to determine the predictive performance of the FTTS on the need for trauma center care in patients who were transported to a trauma center. METHODS This was a single-center health records study of patients transported by ambulance directly to a level 1 trauma center. Hospital based trauma center need and injury severity score-based need were defined. Bivariate associations with one or more FTTS criteria were tested using the Wilcoxon two-sample test for continuous variables, and the Chi-square or Fisher's exact test for categorical indicators. The sensitivity and specificity of each category of the FTTS were calculated. RESULTS There were 1427 patients included in the study, with 76% men, mean age of 40, and 76% had a blunt mechanism. The overall sensitivity and specificity of the FTTS was 90.9% and 20.8% for hospital-based need and 91.6% and 20.3 for injury severity need. The most sensitive variable for hospital-based need was physiologic criteria (53.7). Mechanism of injury was the most sensitive criteria for injury severity need (54.8). Physiological criteria had the highest association with hospital-based and injury severity need (adjusted odds ratios 7.5 [95% CI 5.8-9.8] and 5.1 [95% CI 3.9-6.7]). CONCLUSIONS The FTTS has fair performance in identifying the need for hospital-based and injury severity need. Systolic blood pressure less than 90 mmHg, Glasgow Coma Scale (motor) less than 6, and falls greater than 6 m were most predictive of trauma center need. Improving prehospital trauma triage is critical to ensure timely transport to a trauma centre.
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Affiliation(s)
| | - Ian R Drennan
- Department of Emergency Services and Sunnybrook Research Institute, Sunnybrook Health Science Center, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Division of Emergency Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Melissa McGowan
- Department of Emergency Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Rosane Nisenbaum
- Applied Health Research Centre, MAP Centre for Urban Health Solutions, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, a site of Unity Health Toronto, Toronto, ON, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Brodie Nolan
- Division of Emergency Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Emergency Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
- Li Ka Shing Knowledge Institute, St Michael's Hospital, a site of Unity Health Toronto, Toronto, ON, Canada.
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Beaumont-Boileau R, Nadeau A, Tardif PA, Malo C, Emond M, Moore L, Clément J, Mercier E. Performance of a provincial prehospital trauma triage protocol: A retrospective audit. TRAUMA-ENGLAND 2023. [DOI: 10.1177/14604086231156263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Objective To assess the accuracy of a five-step prehospital trauma triage protocol ( Échelle québécoise de triage préhospitalier en traumatologie (EQTPT)) to identify patients requiring urgent and specialized in-hospital trauma care in the Capitale-Nationale region – Québec. Methods The medical records of trauma patients transported by ambulance to one of the five participating emergency departments (EDs) between November 2016 and March 2017 were reviewed. Our primary outcome was the need for one of the following urgent and specialized trauma care: endotracheal intubation in the ED, administration of ≥ 2 blood products in the ED, angioembolization or surgery (excluding single limb surgery) < 24 h and admission to the intensive care unit (ICU) or in-hospital trauma-related death. Results A total of 902 patients were included. The median age was 63 (interquartile range (IQR) 51) and 494 (54.8%) were female. The main trauma mechanism was falls (n = 592), followed by motor vehicle accidents (n = 201). Eighty-two (9.1%) patients required at least one urgent and specialized trauma care. Of those, 44 (53.6%) were identified as requiring transport to a level one trauma centre (steps 1–3), 16 were identified as requiring transport to a centre with a lower level of trauma designation (steps 4–5) while 22 (26.8%) did not meet any of the EQTPT criteria. For steps 1 to 3, the sensitivity was 53.7% (95% confidence interval (CI) 42.9–64.4) and the specificity was 81.7% (95% CI 79.1–84.4) in identifying patients requiring specialized trauma care. Conclusion The EQTPT lacked sensitivity and was poorly specific to identify trauma patients who need specialized in-hospital trauma care.
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Affiliation(s)
- Roxane Beaumont-Boileau
- VITAM – Centre de recherche en santé durable de l’Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Alexandra Nadeau
- VITAM – Centre de recherche en santé durable de l’Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Pier-Alexandre Tardif
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Christian Malo
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Marcel Emond
- VITAM – Centre de recherche en santé durable de l’Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Lynne Moore
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
| | - Julien Clément
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
- Département de Chirurgie, CHU de Québec, Québec, Canada
| | - Eric Mercier
- VITAM – Centre de recherche en santé durable de l’Université Laval, Québec, Canada
- Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec – Université Laval, Québec, Canada
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Patel K, Diaz MJ, Taneja K, Batchu S, Zhang A, Mohamed A, Wolfe J, Patel UK. Predictors of inpatient admission likelihood and prolonged length of stay among cerebrovascular disease patients: A nationwide emergency department sample analysis. J Stroke Cerebrovasc Dis 2023; 32:106983. [PMID: 36641949 DOI: 10.1016/j.jstrokecerebrovasdis.2023.106983] [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: 07/22/2022] [Revised: 12/20/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
PURPOSE To examine the hospital- and patient-related factors associated with increased likelihood of inpatient admission and extended hospitalization. METHODS We applied multivariate logistic regression to a subset of ED hospital and patient characteristics linearly extrapolated from the 2019 National Emergency Department Sample database (n=626,508). Patient characteristics with 10 or fewer ED visits after national extrapolation were not reported in the current study to maintain patient confidentiality, in accordance with the HCUP Data Use Agreement. All selected ED visits represented a primary diagnosis of CVD (ICD-10 codes 160-168). All reported hospital and patient characteristics were subject to adjustment for covariates. P-values < 0.05 were considered statistically significant. MAIN FINDINGS Medicare beneficiaries report higher inpatient admission rates than uninsured OR 0.81 (0.73-0.91) and privately insured OR 0.86 (0.79-0.94) individuals. Black and Native-American patients were 37% and 55% more likely to be hospitalized long (>75th percentile) (OR 1.37 [1.25-1.50], OR 1.55 [1.14-2.10]). Northeast emergency departments reported an increased odds of admission compared to the Midwest OR (0.40-0.62), South OR 0.79 (0.63-0.98) and West OR 0.52 (0.39-0.69). Patients with multiple comorbidities (mCCI = 3+) were 226% more likely to have a longer stay OR 3.26 (3.09-3.45) than patients presenting with zero or few comorbidities. Level I, II, and III trauma centers report distinctly high odds of inpatient admission (OR 3.54 [2.84-4.42], OR 2.68 [2.14-3.35], OR 1.51 [1.25-1.84]). PRINCIPAL CONCLUSIONS Likelihoods of inpatient admission and long hospital stays were observably stratified through multiple, independently acting hospital and patient characteristics. Significant associations were stratified by race/ethnicity, location, and clinical presentation, among others. Attention to the factors reported here may serve well to mitigate emergency department crowding and its sobering impact on United States healthcare systems and patients.
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Affiliation(s)
- Karan Patel
- Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States.
| | | | - Kamil Taneja
- Renaissance School of Medicine at Stony Brook University, 100 Nicolls Rd, Stony Brook, NY, 11794, United States
| | | | - Alex Zhang
- Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States
| | - Aleem Mohamed
- Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States
| | - Jared Wolfe
- Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States
| | - Urvish K Patel
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, United States
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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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Coulombe P, Tardif PA, Nadeau A, Beaumont-Boileau R, Malo C, Emond M, Blanchard PG, Moore L, Mercier E. Accuracy of Prehospital Trauma Triage to Select Older Adults Requiring Urgent and Specialized Trauma Care. J Surg Res 2022; 275:281-290. [DOI: 10.1016/j.jss.2022.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 01/12/2022] [Accepted: 02/12/2022] [Indexed: 10/18/2022]
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Fuller G, Keating S, Turner J, Miller J, Holt C, Smith JE, Lecky F. Injured patients who would benefit from expedited major trauma centre care: a consensus-based definition for the United Kingdom. Br Paramed J 2021; 6:7-14. [PMID: 34970078 PMCID: PMC8669639 DOI: 10.29045/14784726.2021.12.6.3.7] [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: 11/11/2022] Open
Abstract
INTRODUCTION Despite the importance of treating the 'right patient in the right place at the right time', there is no gold standard for defining which patients should receive expedited major trauma centre (MTC) care. This study aimed to define a reference standard applicable to the United Kingdom (UK) National Health Service major trauma networks. METHODS A one-day facilitated roundtable expert consensus meeting was conducted at the University of Sheffield, UK, in September 2019. An expert panel of 17 clinicians was purposively sampled, representing all specialities relevant to major trauma management. A consultation process was subsequently held using focus groups with Public and Patient Involvement (PPI) representatives to review and confirm the proposed reference standard. RESULTS Four reference standard domains were identified, comprising: need for critical interventions; presence of significant individual anatomical injuries; burden of multiple minor injuries; and important patient attributes. Specific criteria were defined for each domain. PPI consultation confirmed all aspects of the reference standard. A coding algorithm to allow operationalisation in Trauma Audit and Research Network data was also formulated, allowing classification of any case submitted to their database for future research. CONCLUSIONS This reference standard defines which patients would benefit from expedited MTC care. It could be used as the target for future pre-hospital injury triage tools, for setting best practice tariffs for trauma care reimbursement and to evaluate trauma network performance. Future research is recommended to compare patient characteristics, management and outcomes of the proposed definition with previously established reference standards.
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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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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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Deeb AP, Phelos HM, Peitzman AB, Billiar TR, Sperry JL, Brown JB. Making the call in the field: Validating emergency medical services identification of anatomic trauma triage criteria. J Trauma Acute Care Surg 2021; 90:967-972. [PMID: 34016920 PMCID: PMC8243859 DOI: 10.1097/ta.0000000000003168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The National Field Triage Guidelines were created to inform triage decisions by emergency medical services (EMS) providers and include eight anatomic injuries that prompt transportation to a Level I/II trauma center. It is unclear how accurately EMS providers recognize these injuries. Our objective was to compare EMS-identified anatomic triage criteria with International Classification of Diseases-10th revision (ICD-10) coding of these criteria, as well as their association with trauma center need (TCN). METHODS Scene patients 16 years and older in the NTDB during 2017 were included. National Field Triage Guidelines anatomic criteria were classified based on EMS documentation and ICD-10 diagnosis codes. The primary outcome was TCN, a composite of Injury Severity Score greater than 15, intensive care unit admission, urgent surgery, or emergency department death. Prevalence of anatomic criteria and their association with TCN was compared in EMS-identified versus ICD-10-coded criteria. Diagnostic performance to predict TCN was compared. RESULTS There were 669,795 patients analyzed. The ICD-10 coding demonstrated a greater prevalence of injury detection. Emergency medical service-identified versus ICD-10-coded anatomic criteria were less sensitive (31% vs. 59%), but more specific (91% vs. 73%) and accurate (71% vs. 68%) for predicting TCN. Emergency medical service providers demonstrated a marked reduction in false positives (9% vs. 27%) but higher rates of false negatives (69% vs. 42%) in predicting TCN from anatomic criteria. Odds of TCN were significantly greater for EMS-identified criteria (adjusted odds ratio, 4.5; 95% confidence interval, 4.46-4.58) versus ICD-10 coding (adjusted odds ratio 3.7; 95% confidence interval, 3.71-3.79). Of EMS-identified injuries, penetrating injury, flail chest, and two or more proximal long bone fractures were associated with greater TCN than ICD-10 coding. CONCLUSION When evaluating the anatomic criteria, EMS demonstrate greater specificity and accuracy in predicting TCN, as well as reduced false positives compared with ICD-10 coding. Emergency medical services identification is less sensitive for anatomic criteria; however, EMS identify the most clinically significant injuries. Further study is warranted to identify the most clinically important anatomic triage criteria to improve our triage protocols. LEVEL OF EVIDENCE Care management, Level IV; Prognostic, Level III.
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Affiliation(s)
- Andrew-Paul Deeb
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Heather M. Phelos
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Andrew B. Peitzman
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Timothy R. Billiar
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Jason L. Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Joshua B. Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
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10
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Waalwijk JF, Lokerman RD, van der Sluijs R, Fiddelers AAA, Leenen LPH, van Heijl M, Poeze M. Priority accuracy by dispatch centers and Emergency Medical Services professionals in trauma patients: a cohort study. Eur J Trauma Emerg Surg 2021; 48:1111-1120. [PMID: 34019106 PMCID: PMC9001562 DOI: 10.1007/s00068-021-01685-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/28/2021] [Indexed: 12/04/2022]
Abstract
Purpose Priority-setting by dispatch centers and Emergency Medical Services professionals has a major impact on pre-hospital triage and times of trauma patients. Patients requiring specialized care benefit from expedited transport to higher-level trauma centers, while transportation of these patients to lower-level trauma centers is associated with higher mortality rates. This study aims to evaluate the accuracy of priority-setting by dispatch centers and Emergency Medical Services professionals. Methods This observational study included trauma patients transported from the scene of injury to a trauma center. Priority-setting was evaluated in terms of the proportion of patients requiring specialized trauma care assigned with the highest priority (i.e., sensitivity), undertriage, and overtriage. Patients in need of specialized care were defined by a composite resource-based endpoint. An Injury Severity Score ≥ 16 served as a secondary reference standard. Results Between January 2015 and December 2017, records of 114,459 trauma patients were collected, of which 3327 (2.9%) patients were in need of specialized care according to the primary reference standard. Dispatch centers and Emergency Medical Services professionals assigned 83.8% and 74.5% of these patients with the highest priority, respectively. Undertriage rates ranged between 22.7 and 65.5% in the different prioritization subgroups. There were differences between dispatch and transport priorities in 17.7% of the patients. Conclusion The majority of patients that required specialized care were assigned with the highest priority by the dispatch centers and Emergency Medical Services professionals. Highly accurate priority criteria could improve the quality of pre-hospital triage. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01685-1.
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Affiliation(s)
- Job F Waalwijk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Robin D Lokerman
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Audrey A A Fiddelers
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark van Heijl
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands
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Deeb AP, Phelos HM, Peitzman AB, Billiar TR, Sperry JL, Brown JB. The Whole is Greater Than the Sum of its Parts: GCS Versus GCS-Motor for Triage in Geriatric Trauma. J Surg Res 2021; 261:385-393. [PMID: 33493891 DOI: 10.1016/j.jss.2020.12.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/29/2020] [Accepted: 12/08/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Trauma field triage matches injured patients to the appropriate level of care. Prior work suggests the Glasgow Coma Scale motor (GCSm) is as accurate as the total GCS (GCSt) and easier to use. However, older patients present with higher GCS for a given injury, and as such, it is unclear if this substitution is advisable. Our objective was to compare the GCS deficit patterns between geriatric and adult patients presenting with severe traumatic brain injury (TBI), as well as the diagnostic performance of the GCSm versus GCSt within the field triage criteria in these populations. MATERIALS AND METHODS We conducted a retrospective, observational cohort study of patients ≥16 y in the National Trauma Data Bank 2007-2015. GCS deficit patterns were compared between adults (16-65) and geriatric patients (>65). Measures of diagnostic performance of GCSt≤13 versus GCSm≤5 criteria to predict trauma center need (TCN) were compared. RESULTS In total, 4,480,185 patients were analyzed (28% geriatric). Geriatric patients more frequently presented with non-motor-only deficits than adults (16.4% versus 12.4%, P < 0.001), and these patients demonstrated higher severe TBI (40.3% versus 36.7%, P < 0.001) and craniotomy (5.8% versus 5.1%, P < 0.001) rates. GCSt was more sensitive and accurate in predicting TCN for geriatric patients and had lower rates of undertriage as compared to GCSm. CONCLUSIONS Geriatric patients more frequently present with non-motor-only deficits after injury, and this is associated with severe head injury. Substitution of GCSm for GCSt would exacerbate undertriage in geriatric patients and, thus, the total GCS should be maintained for field triage in geriatric patients.
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Affiliation(s)
- Andrew-Paul Deeb
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Heather M Phelos
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew B Peitzman
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Timothy R Billiar
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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12
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Vassallo J, Fuller G, Smith JE. Relationship between the Injury Severity Score and the need for life-saving interventions in trauma patients in the UK. Emerg Med J 2020; 37:502-507. [PMID: 32748796 DOI: 10.1136/emermed-2019-209092] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 04/12/2020] [Accepted: 05/08/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Major trauma is the third leading cause of avoidable mortality in the UK. Defining which patients require care in a major trauma centre is a critical component of developing, evaluating and enhancing regional major trauma systems. Traditionally, trauma patients have been classified using the Injury Severity Score (ISS), but resource-based criteria have been proposed as an alternative. The aim of this study was to investigate the relationship between ISS and the use of life-saving interventions (LSI). METHODS Retrospective cohort study using the Trauma Audit Research Network database for all adult patients (aged ≥18 years) between 2006 and 2014. Patients were categorised as needing an LSI if they received one or more interventions from a previously defined list determined by expert consensus. RESULTS 193 290 patients met study inclusion criteria: 56.9% male, median age 60.0 years (IQR 41.2-78.8) and median ISS 9 (IQR 9-16). The most common mechanism of injury was falls <2 m (52.1%), followed by road traffic collisions (22.2%). 15.1% received one or more LSIs. The probability of a receiving an LSI increased with increasing ISS, but only a low to moderate correlation was evident (0.334, p<0.001). A clinically significant number of cases (5.3% and 7.6%) received an LSI despite having an ISS ≤8 or <15, respectively. CONCLUSIONS A clinically significant number of adult trauma patients requiring LSIs have an ISS below the traditional definition of major trauma. The traditional definition should be reconsidered and either lowered, or an alternative metric should be used.
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Affiliation(s)
- James Vassallo
- Emergency Department, Derriford Hospital, Plymouth, UK .,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Gordon Fuller
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jason E Smith
- Emergency Department, Derriford Hospital, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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13
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van der Sluijs R, Lokerman RD, Waalwijk JF, de Jongh MAC, Edwards MJR, den Hartog D, Giannakópoulos GF, van Grunsven PM, Poeze M, Leenen LPH, van Heijl M. Accuracy of pre-hospital trauma triage and field triage decision rules in children (P2-T2 study): an observational study. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:290-298. [PMID: 32014121 DOI: 10.1016/s2352-4642(19)30431-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/16/2019] [Accepted: 12/19/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adequate pre-hospital trauma triage is crucial to enable optimal care in inclusive trauma systems. Transport of children in need of specialised trauma care to lower-level trauma centres is associated with adverse patient outcomes. We aimed to evaluate the diagnostic accuracy of paediatric field triage based on patient destination and triage tools. METHODS We did a multisite observational study (P2-T2) of all children (aged <16 years) transported with high priority by ambulance from the scene of injury to any emergency department in seven of 11 inclusive trauma regions in the Netherlands. Diagnostic accuracy based on the initial transport destination was evaluated in terms of undertriage rate (ie, the proportion of patients in need of specialised trauma care who were initially transported to a lower-level paediatric or adult trauma centre) and overtriage rate (ie, the proportion of patients not requiring specialised trauma care who were transported to a level-I [highest level] paediatric trauma centre). The Dutch National Protocol of Ambulance Services and Field Triage Decision Scheme triage protocols were externally validated using data from this cohort against an anatomical (Injury Severity Score [ISS] ≥16) and a resource-based reference standard. FINDINGS Between Jan 1, 2015, and Dec 31, 2017, 12 915 children (median age 10·3 years, IQR 4·2-13·6) were transported to the emergency department with injuries. 4091 (31·7%) patients were admitted to hospital, of whom 129 (3·2%) patients had an ISS of 16 or greater and 227 (5·5%) patients used critical resources within a limited timeframe. Ten patients died within 24 h of arrival at the emergency department. Based on the primary reference standard (ISS ≥16), the undertriage rate was 16·3% (95% CI 10·8-23·7) and the overtriage rate was 21·2% (20·5-22·0). The National Protocol of Ambulance Services had a sensitivity of 53·5% (95% CI 43·9-62·9) and a specificity of 94·0% (93·4-94·6), and the Field Triage Decision Scheme had a sensitivity of 64·5% (54·1-74·1) and a specificity of 84·3% (83·1-85·5). INTERPRETATION Too many children in need of specialised care were transported to lower-level paediatric or adult trauma centres, which is associated with increased mortality and morbidity. Current protocols cannot accurately discriminate between patients at low and high risk, and highly sensitive and child-specific triage tools need to be developed to ensure the right patient is transported to the right hospital. FUNDING The Netherlands Organisation for Health Research and Development, Innovation Fund Health Insurers.
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Affiliation(s)
- Rogier van der Sluijs
- Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands.
| | - Robin D Lokerman
- Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Job F Waalwijk
- Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | | | - Michael J R Edwards
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Dennis den Hartog
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | | | | | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands; Network of Acute Care Limburg, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Mark van Heijl
- Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands; Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, Netherlands
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Crash Telemetry-Based Injury Severity Prediction is Equivalent to or Out-Performs Field Protocols in Triage of Planar Vehicle Collisions. Prehosp Disaster Med 2019; 34:356-362. [PMID: 31322099 DOI: 10.1017/s1049023x19004515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION With the increasing availability of vehicle telemetry technology, there is great potential for Advanced Automatic Collision Notification (AACN) systems to improve trauma outcomes by detecting patients at-risk for severe injury and facilitating early transport to trauma centers. METHODS National Automotive Sampling System Crashworthiness Data System (NASS-CDS) data from 1999-2013 were used to construct a logistic regression model (injury severity prediction [ISP] model) predicting the probability that one or more occupants in planar, non-rollover motor vehicle collisions (MVCs) would have Injury Severity Score (ISS) 15+ injuries. Variables included principal direction of force (PDOF), change in velocity (Delta-V), multiple impacts, presence of any older occupant (≥55 years old), presence of any female occupant, presence of right-sided passenger, belt use, and vehicle type. The model was validated using medical records and 2008-2011 crash data from AACN-enabled Michigan (USA) vehicles identified from OnStar (OnStar Corporation; General Motors; Detroit, Michigan USA) records. To compare the ISP to previously established protocols, a literature search was performed to determine the sensitivity and specificity of first responder identification of ISS 15+ for MVC occupants. RESULTS The study population included 924 occupants in 836 crash events. The ISP model had a sensitivity of 72.7% (95% Confidence Interval [CI] 41%-91%) and specificity of 93% (95% CI 92%-95%) for identifying ISS 15+ occupants injured in planar MVCs. The current standard 2006 Field Triage Decision Scheme (FTDS) was 56%-66% sensitive and 75%-88% specific in identifying ISS 15+ patients. CONCLUSIONS The ISP algorithm comparably is more sensitive and more specific than current field triage in identifying MVC patients at-risk for ISS 15+ injuries. This real-world field study shows telemetry data transmitted before dispatch of emergency medical systems can be helpful to quickly identify patients who require urgent transfer to trauma centers.
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15
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van der Sluijs R, Debray TPA, Poeze M, Leenen LPH, van Heijl M. Development and validation of a novel prediction model to identify patients in need of specialized trauma care during field triage: design and rationale of the GOAT study. Diagn Progn Res 2019; 3:12. [PMID: 31245626 PMCID: PMC6584978 DOI: 10.1186/s41512-019-0058-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/14/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Adequate field triage of trauma patients is crucial to transport patients to the right hospital. Mistriage and subsequent interhospital transfers should be minimized to reduce avoidable mortality, life-long disabilities, and costs. Availability of a prehospital triage tool may help to identify patients in need of specialized trauma care and to determine the optimal transportation destination. METHODS The GOAT (Gradient Boosted Trauma Triage) study is a prospective, multi-site, cross-sectional diagnostic study. Patients transported by at least five ground Emergency Medical Services to any receiving hospital within the Netherlands are eligible for inclusion. The reference standards for the need of specialized trauma care are an Injury Severity Score ≥ 16 and early critical resource use, which will both be assessed by trauma registrars after the final diagnosis is made. Variable selection will be based on ease of use in practice and clinical expertise. A gradient boosting decision tree algorithm will be used to develop the prediction model. Model accuracy will be assessed in terms of discrimination (c-statistic) and calibration (intercept, slope, and plot) on individual participant's data from each participating cluster (i.e., Emergency Medical Service) through internal-external cross-validation. A reference model will be externally validated on each cluster as well. The resulting model statistics will be investigated, compared, and summarized through an individual participant's data meta-analysis. DISCUSSION The GOAT study protocol describes the development of a new prediction model for identifying patients in need of specialized trauma care. The aim is to attain acceptable undertriage rates and to minimize mortality rates and life-long disabilities.
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Affiliation(s)
- Rogier van der Sluijs
- 0000 0004 0480 1382grid.412966.eDepartment of Traumatology, Maastricht University Medical Center, Maastricht, The Netherlands
- 0000000090126352grid.7692.aDepartment of Traumatology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, The Netherlands
| | - Thomas P. A. Debray
- 0000000120346234grid.5477.1Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- 0000000120346234grid.5477.1Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Martijn Poeze
- 0000 0004 0480 1382grid.412966.eDepartment of Traumatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Loek P. H. Leenen
- 0000000090126352grid.7692.aDepartment of Traumatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark van Heijl
- 0000000090126352grid.7692.aDepartment of Traumatology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, The Netherlands
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16
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Do Autopsies Still Matter? The Influence of Autopsy Data on Final Injury Severity Score Calculations. J Surg Res 2018; 233:453-458. [PMID: 30502285 DOI: 10.1016/j.jss.2018.08.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/05/2018] [Accepted: 08/24/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Despite a proven record of identifying injuries missed during clinical evaluation, the effect of autopsy on injury severity score (ISS) calculation is unknown. We hypothesized that autopsy data would alter final ISS and improve the accuracy of outcome data analyses. MATERIALS AND METHODS All trauma deaths from January 2010 through June 2014 were reviewed. Trauma registrars calculated Abbreviated Injury Scale and ISS from clinical documentation alone. The most detailed available autopsy report then was reviewed, and AIS/ISS recalculated. Predictors of ISS change were identified using multivariate logistic regression. RESULTS Seven hundred thirty-nine deaths occurred, of which 682 (92.3%) underwent autopsy (31% view-only, 3% with preliminary report, and 66% with full report). Patients undergoing full autopsy had a lower median age (39 versus 74 years, P < 0.01), a higher rate of penetrating injury (41.7% versus 0%, P < 0.01), and a higher emergency department mortality rate (30.8% versus 0%, P < 0.01) than those receiving view-only autopsy. Incorporating autopsy findings increased mean ISS (21.3 to 29.6, P < 0.001) and the percentage of patients with ISS ≥ 25 (49.9% to 69.2%, P < 0.001). Multivariate analysis identified length of stay, death in the emergency department, full rather than view-only autopsy, and presenting heart rate as variables associated with ISS increase. CONCLUSIONS Autopsy data significantly increased ISS values for trauma deaths. This effect was greatest in patients who died early in their course. Targeting this group, rather than all trauma patients, for full autopsy may improve risk-adjustment accuracy while minimizing costs.
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17
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van Rein EA, van der Sluijs R, Houwert RM, Gunning AC, Lichtveld RA, Leenen LP, van Heijl M. Effectiveness of prehospital trauma triage systems in selecting severely injured patients: Is comparative analysis possible? Am J Emerg Med 2018; 36:1060-1069. [DOI: 10.1016/j.ajem.2018.01.055] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/16/2018] [Accepted: 01/18/2018] [Indexed: 10/18/2022] Open
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18
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Ahn KO, Kim SC, Park JO, Shin SD, Song KJ, Hong KJ. Validation of the criteria for early critical care resource use in assessing the effectiveness of field triage. Am J Emerg Med 2017; 36:257-261. [PMID: 28780982 DOI: 10.1016/j.ajem.2017.07.091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/20/2017] [Accepted: 07/30/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND This study aimed to validate the criteria for early critical care resource (CCR) use as an outcome predictor for seriously injured patients triaged in the field by comparing the effectiveness of the criteria for early CCR use with that of criteria defined by an Injury Severity Score (ISS) >15. METHODS We analysed data from seriously injured trauma patients who were triaged using a field triage protocol by emergency medical service providers (EMS-ST patients). Early CCR use was defined as the use of any of the following treatment modalities or outcomes: advanced airway management, blood transfusion, or interventional radiology (<4h), emergency operation or cardiopulmonary resuscitation, or thoracotomy (<24h), or admission for spinal cord injury. The primary endpoint was inhospital mortality. We generated area under the receiver operating characteristic (AUROC) curves to compare the value of the early CCR use criteria with that of the ISS >15 criteria in the discrimination between survivors and non-survivors. RESULTS Of the 14,352 adult EMS-ST patients, 9299 were enrolled in this study. Approximately 19.6% required early CCR use, and 18.0% had an ISS >15. The rate of in-hospital mortality was 9.4%. The AUROC values for the performances of the early CCR use and ISS>15 criteria in the prediction of in-hospital mortality were 0.89 (95% confidence interval [CI] 0.85-0.91) and 0.84 (95% CI 0.79-0.86), respectively (p<0.01). CONCLUSION The early CCR use criteria demonstrated better performance than the ISS >15 criteria in the prediction of mortality in EMS-ST patients.
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Affiliation(s)
- Ki Ok Ahn
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, 101 Daehak-Ro, Jongno-Gu, Seoul 03080, South Korea; Department of Emergency Medicine, Myongji Hospital, 55, Hwasu-ro 14beon-gil, Deogyang-gu, Goyang-si, Gyeonggi-do 10475, South Korea
| | - Sang Chul Kim
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, 101 Daehak-Ro, Jongno-Gu, Seoul 03080, South Korea; Department of Emergency Medicine, Chungbuk National University Hospital, 776, 1sunhwan-ro, Seowon-gu, Cheongju-si, Chungcheongbuk-do 28644, South Korea.
| | - Ju Ok Park
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, 101 Daehak-Ro, Jongno-Gu, Seoul 03080, South Korea; Department of Emergency Medicine, Hallym University College of Medicine and Dongtan Sacred Heart Hospital, 7 Keunjaebong-gil, Hwaseong-si, Gyeonggi-do 18450, South Korea
| | - Sang Do Shin
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, 101 Daehak-Ro, Jongno-Gu, Seoul 03080, South Korea; Department of Emergency Medicine, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul 03080, South Korea
| | - Kyoung Jun Song
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, 101 Daehak-Ro, Jongno-Gu, Seoul 03080, South Korea; Department of Emergency Medicine, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul 03080, South Korea
| | - Ki Jeong Hong
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, 101 Daehak-Ro, Jongno-Gu, Seoul 03080, South Korea; Department of Emergency Medicine, Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, South Korea
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Pike I, Khalil M, Yanchar NL, Tamim H, Nathens AB, Macpherson AK. Establishing an injury indicator for severe paediatric injury. Inj Prev 2016; 23:118-123. [PMID: 27512110 DOI: 10.1136/injuryprev-2016-042028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/17/2016] [Accepted: 06/24/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Routinely gathered injury data, such as hospitalisations, may be subject to variation from sources other than injury incidence. There is a need for an indicator that defines severe injury, which may be less vulnerable to fluctuations due to changes in care policies. The purpose of this study was to identify International Classification of Diseases-10 codes associated with severe paediatric injuries and to specify and validate a severe paediatric injury indicator. METHODS Two data sets that included the ISS and the survival risk ratio were used to produce a list of diagnoses to define severe paediatric injury. The list was sent to trauma surgeons who classified each code as severe enough or not severe enough to require care in a trauma centre. The indicator was fully specified, then validated by using a different data set to validate the codes in a real-world situation. RESULTS Sixty diagnoses were identified as representing severe paediatric injury. Following specification, the indicator was applied to an existing comprehensive data set of paediatric injuries. The decline in hospitalisation of paediatric injuries was significantly steeper for severe than non-severe injuries, suggesting that factors related to the decline in this trauma subset are unlikely to be related to changes in access or other components of trauma care delivery. CONCLUSIONS This indicator can be used for the evaluation of trends in severe paediatric trauma and will help identify populations at risk. This research may inform policies and procedures for referrals of severe childhood injury to appropriate levels of care.
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Affiliation(s)
- Ian Pike
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,BC Injury Research and Prevention Unit, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Mina Khalil
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
| | - Natalie L Yanchar
- Division of Pediatric General Surgery, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Hala Tamim
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
| | - Avery B Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alison K Macpherson
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
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Follin A, Jacqmin S, Chhor V, Bellenfant F, Robin S, Guinvarc'h A, Thomas F, Loeb T, Mantz J, Pirracchio R. Tree-based algorithm for prehospital triage of polytrauma patients. Injury 2016; 47:1555-61. [PMID: 27161834 DOI: 10.1016/j.injury.2016.04.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 04/10/2016] [Accepted: 04/18/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is a need for better allocation of medical resources in polytrauma, by optimizing both the over and undertriage rates. The goal of this study is to provide a new working definition for polytrauma based on the prediction of the need for specialized trauma care. METHODS This is a prospective, observational study, performed in a specialized trauma center in Paris. All consecutive patients admitted for a trauma at a major trauma center in Paris were included in the study. The primary outcome was the need for specialized trauma care as defined by the North American consensus. The explanatory variables included basic variables collected on scene. The modeling approach relied on recursive partitioning based decision trees. Its prediction performance was evaluated both internally and externally on a validation cohort, and compared to the MGAP (Mechanism, Glasgow coma scale, Age and Arterial pressure) score. MEASUREMENTS AND MAIN RESULTS 1160 patients were included in the analysis over a 3-year period (2012-2014), out of which 41% needed specialized trauma care as defined by the recent US guidelines. The decision tree outperformed the MGAP and reached an area under the receiver operating characteristic curve of 0.82 [0.79-0.84]. This optimal decision rule was associated with a sensitivity of 0.94 [0.92-0.96], a specificity of 0.48 [0.44-0.52]. A conservative decision rule (refer to a trauma center all patient with a predicted probability ≥0.34) would result in an undertriage rate of 5.7% and an overtriage of 52.3% (respectively 7% and 64% in the validation cohort). CONCLUSIONS Our tree-based decision algorithm is a user-friendly and reliable alternative to the preexisting scores, which offers good performance to predict the need for specialized trauma care.
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Affiliation(s)
- Arnaud Follin
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Université Paris 5 Descartes, Sorbonne Paris Cite, Paris, France.
| | - Sébastien Jacqmin
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Université Paris 5 Descartes, Sorbonne Paris Cite, Paris, France.
| | - Vibol Chhor
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Université Paris 5 Descartes, Sorbonne Paris Cite, Paris, France.
| | - Florence Bellenfant
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Université Paris 5 Descartes, Sorbonne Paris Cite, Paris, France.
| | - Ségolène Robin
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Université Paris 5 Descartes, Sorbonne Paris Cite, Paris, France.
| | - Alain Guinvarc'h
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Université Paris 5 Descartes, Sorbonne Paris Cite, Paris, France.
| | - Frank Thomas
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Université Paris 5 Descartes, Sorbonne Paris Cite, Paris, France.
| | - Thomas Loeb
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Université Paris 5 Descartes, Sorbonne Paris Cite, Paris, France; SAMU 92, Hôpital Raymond Poincare, Université de Versailles St Quentin, Garches, France.
| | - Jean Mantz
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Université Paris 5 Descartes, Sorbonne Paris Cite, Paris, France.
| | - Romain Pirracchio
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Université Paris 5 Descartes, Sorbonne Paris Cite, Paris, France; Department of Anesthesia and Perioperative Care, San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, USA; Département de Biostatistique et Informatique Médicale, INSERM U1153, équipe ECSTRA, Hôpital Saint Louis, Université Paris Diderot, Sorbonne Paris Cite, Paris, France; Division of Biostatistics, School of Public Health, University of California Berkeley, Berkeley, USA.
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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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Newgard CD, Meier EN, McKnight B, Drennan IR, Richardson D, Brasel K, Schreiber M, Kerby JD, Kannas D, Austin M, Bulger EM. Understanding traumatic shock: out-of-hospital hypotension with and without other physiologic compromise. J Trauma Acute Care Surg 2015; 78:342-51. [PMID: 25757121 PMCID: PMC4355920 DOI: 10.1097/ta.0000000000000478] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Among trauma patients with out-of-hospital hypotension, we evaluated the predictive value of systolic blood pressure (SBP) with and without other physiologic compromise for identifying trauma patients requiring early critical resources. METHODS This was a secondary analysis of a prospective cohort of injured patients 13 years or older with out-of-hospital hypotension (SBP ≤ 90 mm Hg) who were transported by 114 emergency medical service agencies to 56 Level I and II trauma centers in 11 regions of the United States and Canada from January 1, 2010, through June 30, 2011. The primary outcome was early critical resource use, defined as blood transfusion of 6 U or greater, major nonorthopedic surgery, interventional radiology, or death within 24 hours. RESULTS Of 3,337 injured patients with out-of-hospital hypotension, 1,094 (33%) required early critical resources and 1,334 (40%) had serious injury (Injury Severity Score [ISS] ≥ 16). Patients with isolated hypotension required less early critical resources (14% vs. 52%), had less serious injury (20% vs. 61%), and had lower mortality (24 hours, 1% vs. 26%; in-hospital, 3% vs. 34%). The standardized probability of requiring early critical resources was lowest among patients with blunt injury and isolated moderate hypotension (0.12; 95% confidence interval, 0.09-0.15) and steadily increased with additional physiologic compromise, more severe hypotension, and penetrating injury (0.94; 95% confidence interval, 0.90-0.98). CONCLUSION A minority of trauma patients with isolated out-of-hospital hypotension require early critical resuscitation resources. However, hypotension accompanied by additional physiologic compromise or penetrating injury markedly increases the probability of requiring time-sensitive interventions. LEVEL OF EVIDENCE Prognostic study, level II.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Eric N. Meier
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Barbara McKnight
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Ian R. Drennan
- Rescu, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Derek Richardson
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
- Department of Emergency Medicine, San Francisco General Hospital, University of California-San Francisco, San Francisco, California
| | - Karen Brasel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Martin Schreiber
- Department of Surgery, Oregon Health & Science University, Portland, Oregon
| | - Jeffrey D. Kerby
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Delores Kannas
- Clinical Trials Center, University of Washington, Seattle, Washington
| | - Michael Austin
- Department of Emergency Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Eileen M. Bulger
- Department of Surgery, University of Washington, Seattle, Washington
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Brown JB, Gestring ML, Forsythe RM, Stassen NA, Billiar TR, Peitzman AB, Sperry JL. Systolic blood pressure criteria in the National Trauma Triage Protocol for geriatric trauma: 110 is the new 90. J Trauma Acute Care Surg 2015; 78:352-9. [PMID: 25757122 PMCID: PMC4620031 DOI: 10.1097/ta.0000000000000523] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Undertriage is a concern in geriatric patients. The National Trauma Triage Protocol (NTTP) recognized that systolic blood pressure (SBP) less than 110 mm Hg may represent shock in those older than 65 years. The objective was to evaluate the impact of substituting an SBP of less than 110 mm Hg for the current SBP of less than 90 mm Hg criterion within the NTTP on triage performance and mortality. METHODS Subjects undergoing scene transport in the National Trauma Data Bank (2010-2012) were included. The outcome of trauma center need was defined as Injury Severity Score (ISS) greater than 15, intensive care unit admission, urgent operation, or emergency department death. Geriatric (age > 65 years) and adult (age, 16-65 years) cohorts were compared. Triage characteristics and area under the curve (AUC) were compared between SBP of less than 110 mm Hg and SBP of less than 90 mm Hg. Hierarchical logistic regression was used to determine whether geriatric patients newly triaged positive under this change (SBP, 90-109 mm Hg) have a risk of mortality similar to those triaged positive with SBP of less than 90 mm Hg. RESULTS There were 1,555,944 subjects included. SBP of less than 110 mm Hg had higher sensitivity but lower specificity in geriatric (13% vs. 5%, 93% vs. 99%) and adult (23% vs. 10%, 90% vs. 98%) cohorts. AUC was higher for SBP of less than 110 mm Hg individually in both geriatric and adult (p < 0.01) cohorts. Within the NTTP, the AUC was similar for SBP of less than 110 mm Hg and SBP of less than 90 mm Hg in geriatric subjects but was higher for SBP of less than 90 mm Hg in adult subjects (p < 0.01). Substituting SBP of less than 110 mm Hg resulted in an undertriage reduction of 4.4% with overtriage increase of 4.3% in the geriatric cohort. Geriatric subjects with SBP of 90 mm Hg to 109 mm Hg had an odds of mortality similar to those of geriatric patients with SBP of less than 90 mm Hg (adjusted odds ratio, 1.03; 95% confidence interval, 0.88-1.20; p = 0.71). CONCLUSION SBP of less than 110 mm Hg increases sensitivity. SBP of less than 110 mm Hg has discrimination as good as that of SBP of less than 90 mm Hg, with superior improvements in undertriage relative to overtriage in geriatric patients. Geriatric patients newly triaged to be positive under this change have a risk of mortality similar to those under the current SBP criterion. This change in SBP criteria may be merited in geriatric patients, warranting further study to consider elevation to a Step 1 criterion in the NTTP. LEVEL OF EVIDENCE Diagnostic study, level IV.
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Affiliation(s)
- Joshua B Brown
- From the Division of General Surgery and Trauma (J.B.B., R.M.F., T.R.B., A.B.P., J.L.S.), Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and Division of Acute Care Surgery (M.L.G., N.A.S.), Department of Surgery, University of Rochester Medical Center, Rochester, New York
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Nakahara S, Matsuoka T, Ueno M, Mizushima Y, Ichikawa M, Yokota J. Extremity Injuries as Predictors of Emergency Care Resource Needs among Blunt Trauma Patients in Japan. Am Surg 2014. [DOI: 10.1177/000313481408000231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study aimed to exhaustively examine associations between prehospital variables and emergency care resource needs among blunt trauma patients. The study included blunt trauma patients aged 15 years or older who were admitted to a tertiary care medical center in Osaka, Japan, from January 2005 to December 2009. The primary end point was a composite measure of overall emergency care resource needs. Predictive variables were easily detectable upper and lower extremity injuries. A multivariate logistic regression model was used to identify associations between the predictive variables and the end point; this model included other covariates known to be associated with emergency care resource needs (demographic characteristics, mechanism of injury, and physiological parameters). Of 982 blunt trauma patients, 81 died, and 573 required overall emergency care resources. Upper extremity injury (odds ratio [OR], 2.60) and lower extremity injury (OR, 4.50) were significantly associated with overall emergency care resource needs after controlling for other covariates. The results of this study suggest that easily detectable extremity injuries may be useful predictors of the emergency care resource needs of trauma patients. Further studies are needed to validate the predictive values of these injuries and to determine ways to use information about extremity injuries to improve triage decisions.
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Affiliation(s)
- Shinji Nakahara
- Department of Epidemiology, Saint Marianna University, Kawasaki, Kanagawa, Japan
| | - Tetsuya Matsuoka
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, Izumisano, Osaka, Japan; the
| | - Masato Ueno
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, Izumisano, Osaka, Japan; the
| | - Yasuaki Mizushima
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, Izumisano, Osaka, Japan; the
| | - Masao Ichikawa
- City University of Tsukuba, Tsukuba, Ibaraki, Japan; and
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Scerbo M, Radhakrishnan H, Cotton B, Dua A, Del Junco D, Wade C, Holcomb JB. Prehospital triage of trauma patients using the Random Forest computer algorithm. J Surg Res 2013; 187:371-6. [PMID: 24484906 DOI: 10.1016/j.jss.2013.06.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 06/14/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Overtriage not only wastes resources but also displaces the patient from their community and causes delay of treatment for the more seriously injured. This study aimed to validate the Random Forest computer model (RFM) as means of better triaging trauma patients to level 1 trauma centers. METHODS Adult trauma patients with "medium activation" presenting via helicopter to a level 1 trauma center from May 2007 to May 2009 were included. The "medium activation" trauma patient is alert and hemodynamically stable on scene but has either subnormal vital signs or accumulation of risk factors that may indicate a potentially serious injury. Variables included in the RFM analysis were demographics, mechanism of injury, prehospital fluid, medications, vitals, and disposition. Statistical analysis was performed via the Random Forest algorithm to compare our institutional triage rate to rates determined by the RFM. RESULTS A total of 1653 patients were included in this study, of which 496 were used in the testing set of the RFM. In our testing set, 33.8% of patients brought to our level 1 trauma center could have been managed at a level 3 trauma center, and 88% of patients who required a level 1 trauma center were identified correctly. In the testing set, there was an overtriage rate of 66%, whereas using the RFM, we decreased the overtriage rate to 42% (P < 0.001). There was an undertriage rate of 8.3%. The RFM predicted patient disposition with a sensitivity of 89%, specificity of 42%, negative predictive value of 92%, and positive predictive value of 34%. CONCLUSIONS Although prospective validation is required, it appears that computer modeling potentially could be used to guide triage decisions, allowing both more accurate triage and more efficient use of the trauma system.
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Affiliation(s)
- Michelle Scerbo
- Division of Acute Care Surgery, Department of Surgery, Center for Translational Injury Research (CeTIR), University of Texas-Houston, Houston, Texas
| | - Hari Radhakrishnan
- Division of Acute Care Surgery, Department of Surgery, Center for Translational Injury Research (CeTIR), University of Texas-Houston, Houston, Texas
| | - Bryan Cotton
- Division of Acute Care Surgery, Department of Surgery, Center for Translational Injury Research (CeTIR), University of Texas-Houston, Houston, Texas
| | - Anahita Dua
- Division of Acute Care Surgery, Department of Surgery, Center for Translational Injury Research (CeTIR), University of Texas-Houston, Houston, Texas
| | - Deborah Del Junco
- Division of Acute Care Surgery, Department of Surgery, Center for Translational Injury Research (CeTIR), University of Texas-Houston, Houston, Texas
| | - Charles Wade
- Division of Acute Care Surgery, Department of Surgery, Center for Translational Injury Research (CeTIR), University of Texas-Houston, Houston, Texas
| | - John B Holcomb
- Division of Acute Care Surgery, Department of Surgery, Center for Translational Injury Research (CeTIR), University of Texas-Houston, Houston, Texas.
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Zhao LP, Gerdin M, Westman L, Rodriguez-Llanes JM, Wu Q, van den Oever B, Pan L, Albela M, Chen G, Zhang DS, Guha-Sapir D, von Schreeb J. Hospital stay as a proxy indicator for severe injury in earthquakes: a retrospective analysis. PLoS One 2013; 8:e61371. [PMID: 23585897 PMCID: PMC3621831 DOI: 10.1371/journal.pone.0061371] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 03/12/2013] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Earthquakes are the most violent type of natural disasters and injuries are the dominant medical problem in the early phases after earthquakes. However, likely because of poor data availability, high-quality research on injuries after earthquakes is lacking. Length of hospital stay (LOS) has been validated as a proxy indicator for injury severity in high-income settings and could potentially be used in retrospective research of injuries after earthquakes. In this study, we assessed LOS as an adequate proxy indicator for severe injury in trauma survivors of an earthquake. METHODS A retrospective analysis was conducted using a database of 1,878 injured patients from the 2008 Wenchuan earthquake. Our primary outcome was severe injury, defined as a composite measure of serious injury or resource use. Secondary outcomes were serious injury and resource use, analysed separately. Non-parametric receiver operating characteristics (ROC) and area under the curve (AUC) analysis was used to test the discriminatory accuracy of LOS when used to identify severe injury. An 0.7 RESULTS Our study shows that LOS discriminatory accuracy is poor for the primary outcome. However, LOS discriminatory accuracy is adequate for resource use, excluding critical orthopaedic interventions and debridement. CONCLUSIONS Length of hospital stay was not validated as a proxy indicator for severe injury in earthquake survivors. However, LOS was found to be a proxy for major nonorthopaedic surgery and blood transfusion. These findings can be useful for retrospective research on earthquake-injured patients when detailed hospital records are not available.
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Affiliation(s)
- Lu-Ping Zhao
- People's Hospital of Deyang City, Deyang, Sichuan province, China
| | - Martin Gerdin
- Health System and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Lina Westman
- Health System and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Höglandssjukhuset, Eksjö, Sweden
| | - Jose Manuel Rodriguez-Llanes
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium
| | - Qi Wu
- People's Hospital of Deyang City, Deyang, Sichuan province, China
| | - Barbara van den Oever
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium
| | - Liang Pan
- People's Hospital of Deyang City, Deyang, Sichuan province, China
| | - Manuel Albela
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium
| | - Gao Chen
- People's Hospital of Deyang City, Deyang, Sichuan province, China
| | - De-Sheng Zhang
- People's Hospital of Deyang City, Deyang, Sichuan province, China
| | - Debarati Guha-Sapir
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium
| | - Johan von Schreeb
- Health System and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Newgard CD, Fildes JJ, Wu L, Hemmila MR, Burd RS, Neal M, Mann NC, Shafi S, Clark DE, Goble S, Nathens AB. Methodology and Analytic Rationale for the American College of Surgeons Trauma Quality Improvement Program. J Am Coll Surg 2013; 216:147-57. [DOI: 10.1016/j.jamcollsurg.2012.08.017] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 08/12/2012] [Accepted: 08/20/2012] [Indexed: 10/27/2022]
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Newgard CD, Kampp M, Nelson M, Holmes JF, Zive D, Rea T, Bulger EM, Liao M, Sherck J, Hsia RY, Wang NE, Fleischman RJ, Barton ED, Daya M, Heineman J, Kuppermann N. Deciphering the use and predictive value of "emergency medical services provider judgment" in out-of-hospital trauma triage: a multisite, mixed methods assessment. J Trauma Acute Care Surg 2012; 72:1239-48. [PMID: 22673250 PMCID: PMC3376024 DOI: 10.1097/ta.0b013e3182468b51] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND "Emergency medical services (EMS) provider judgment" was recently added as a field triage criterion to the national guidelines, yet its predictive value and real world application remain unclear. We examine the use and independent predictive value of EMS provider judgment in identifying seriously injured persons. METHODS We analyzed a population-based retrospective cohort, supplemented by qualitative analysis, of injured children and adults evaluated and transported by 47 EMS agencies to 94 hospitals in five regions across the Western United States from 2006 to 2008. We used logistic regression models to evaluate the independent predictive value of EMS provider judgment for Injury Severity Score ≥ 16. EMS narratives were analyzed using qualitative methods to assess and compare common themes for each step in the triage algorithm, plus EMS provider judgment. RESULTS 213,869 injured patients were evaluated and transported by EMS over the 3-year period, of whom 41,191 (19.3%) met at least one of the field triage criteria. EMS provider judgment was the most commonly used triage criterion (40.0% of all triage-positive patients; sole criterion in 21.4%). After accounting for other triage criteria and confounders, the adjusted odds ratio of Injury Severity Score ≥ 16 for EMS provider judgment was 1.23 (95% confidence interval, 1.03-1.47), although there was variability in predictive value across sites. Patients meeting EMS provider judgment had concerning clinical presentations qualitatively similar to those meeting mechanistic and other special considerations criteria. CONCLUSIONS Among this multisite cohort of trauma patients, EMS provider judgment was the most commonly used field trauma triage criterion, independently associated with serious injury, and useful in identifying high-risk patients missed by other criteria. However, there was variability in predictive value between sites.
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Affiliation(s)
- Craig D Newgard
- Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, Oregon 97239-3098, USA.
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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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Fleischman RJ, McConnell KJ, Adams AL, Hedges JR, Newgard CD. Injury hospitalization as a marker for emergency medical services use in elderly patients. PREHOSP EMERG CARE 2010; 14:425-32. [PMID: 20586586 DOI: 10.3109/10903127.2010.493986] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The elderly utilize emergency medical services (EMS) at a higher rate than younger patients, yet little is known about the influence of injury on subsequent EMS utilization and costs. OBJECTIVE To assess injury hospitalization as a potential marker for subsequent EMS utilization and costs by Medicare patients. METHODS This observational study analyzed a retrospective cohort of all Medicare patients (> or = 67 years old) with an International Classification of Diseases, Ninth Revision (ICD-9) injury diagnosis admitted to 125 Oregon and Washington hospitals during 2001 and 2002 who survived to hospital discharge. The numbers of EMS transports and the total EMS costs were compared one year before and one year following the index hospitalization. RESULTS There were 30,655 injured elders in our cohort. Their median ICD-9-based injury severity score was 0.97, with 4.1% meeting a definition of serious injury and 37% having hip fractures. The mean (range) numbers of EMS transports before and after the injury were 0.5 (0-45) and 0.9 (0-56), for an unadjusted incidence rate ratio (IRR) of 1.7 (95% confidence interval [CI] 1.7-1.8). The increase in EMS utilization following an injury hospitalization was even greater after adjusting for risk period and other model predictors (IRR 2.4, 95% CI 2.3-2.5). Annual mean EMS costs rose 74% following the injury hospitalization, from $211 to $367 per person. The greatest increase was in nonemergent EMS use, accounting for 67% of the increase in the number of uses. Institutionalization in a skilled nursing or rehabilitation facility either before or after injury was strongly associated with the need for EMS care. CONCLUSION An injury hospitalization in the elderly serves as a sentinel marker for an abrupt increase in EMS utilization and costs, even after accounting for confounders.
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Affiliation(s)
- Ross J Fleischman
- The Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR 97239, USA.
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Newgard CD, Fleischman R, Choo E, Ma OJ, Hedges JR, McConnell KJ. Validation of length of hospital stay as a surrogate measure for injury severity and resource use among injury survivors. Acad Emerg Med 2010; 17:142-50. [PMID: 20370743 DOI: 10.1111/j.1553-2712.2009.00647.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES While hospital length of stay (LOS) has been used as a surrogate injury outcome when more detailed outcomes are unavailable, it has not been validated. This project sought to validate LOS as a proxy measure of injury severity and resource use in heterogeneous injury populations. METHODS This observational study used four retrospective cohorts: patients presenting to 339 California emergency departments (EDs) with a primary International Classification of Diseases, Ninth Revision (ICD-9), injury diagnosis (years 2005-2006); California hospital injury admissions (a subset of the ED population); trauma patients presenting to 48 Oregon EDs (years 1998-2003); and injured Medicare patients admitted to 171 Oregon and Washington hospitals (years 2001-2002). In-hospital deaths were excluded, as they represent adverse outcomes regardless of LOS. Duration of hospital stay was defined as the number of days from ED admission to hospital discharge. The primary composite outcome (dichotomous) was serious injury (Injury Severity Score [ISS] >or= 16 or ICD-9 ISS <or= 0.90) or resource use (major surgery, blood transfusion, or prolonged ventilation). The discriminatory accuracy of LOS for identifying the composite outcome was evaluated using receiver operating characteristic (ROC) analysis. Analyses were also stratified by age (0-14, 15-64, and >or=65 years), hospital type, and hospital annual admission volume. RESULTS The four cohorts included 3,989,409 California ED injury visits (including admissions), 236,639 California injury admissions, 23,817 Oregon trauma patients, and 30,804 Medicare injury admissions. Composite outcome rates for the four cohorts were 2.1%, 29%, 27%, and 22%, respectively. Areas under the ROC curves for overall LOS were 0.88 (California ED), 0.74 (California admissions), 0.82 (Oregon trauma patients), and 0.68 (Medicare patients). In general, the discriminatory value of LOS was highest among children, tertiary trauma centers, and higher volume hospitals, although this finding differed by the injury population and outcome assessed. CONCLUSIONS Hospital LOS may be a reasonable proxy for serious injury and resource use among injury survivors when more detailed outcomes are unavailable, although the discriminatory value differs by age and the injury population being studied.
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Affiliation(s)
- Craig D Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA.
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