Trauma stat and trauma minor: are we making the call appropriately?

Accuracy of the American College of Surgeons Minimum Criteria for Full Trauma Team Activation for Children

OBJECTIVE

Pediatric trauma centers use reports from emergency medical service providers to determine if a trauma team should be sent to the emergency department to prepare to care for the patient. Little scientific evidence supports the current American College of Surgeons (ACS) indicators for trauma team activation. The objective of this study was to determine the accuracy of the ACS Minimum Criteria for Full Trauma Team Activation for children as well as the accuracy of the modified criteria used at the local sites for trauma activation.

METHODS

Emergency medical service providers who transported an injured child aged 15 years or younger to a pediatric trauma center in 1 of 3 cities were interviewed after emergency department arrival. Emergency medical service providers were asked if each of the activation indicators were present based on their evaluation. The need for full trauma team activation was determined through a medical record review using a published criterion standard definition. Undertriage and overtriage rates and positive likelihood ratios (+LRs) were calculated.

RESULTS

Emergency medical service provider interviews were conducted and outcome data were obtained for 9483 children. There were 202 (2.1%) cases that met the criterion standard for need for trauma team activation. Based on the ACS Minimum Criteria, 299 (3.0%) cases should have received a trauma activation. The ACS Minimum Criteria undertriaged 44.1% and overtriaged 20% (+LR, 27.9; 95% confidence interval, 23.1-33.7). Based on the actual activation status using the local criteria, 238 cases received a full trauma activation, 45% were undertriaged, and 1.4% were overtriaged (+LR, 40.1; 95% confidence interval, 32.4-49.7). There was 97% agreement between the ACS Minimum Criteria and the actual local activation status at the receiving institution.

CONCLUSIONS

The ACS Minimum Criteria for Full Trauma Team Activation for children have a high rate of undertriage. Changes that individual institutions have made to improve the accuracy of activations at their institutions seem to have had a limited effect on decreasing undertriage.

Pediatric trauma triage: A Pediatric Trauma Society Research Committee systematic review

BACKGROUND

Significant variability exists in the triage of injured children with most systems using mechanism of injury and/or physiologic criteria. It is not well established if existing triage criteria predict the need for intervention or impact morbidity and mortality. This study evaluated existing evidence for pediatric trauma triage. Questions defined a priori were as follows: (1) Do prehospital trauma triage criteria reduce mortality? (2) Do prehospital trauma scoring systems predict outcomes? (3) Do trauma center activation criteria predict outcomes? (4) Do trauma center activation criteria predict need for procedural or operative interventions? (5) Do trauma bay pediatric trauma scoring systems predict outcomes? (6) What secondary triage criteria for transfer of children exist?

METHODS

A structured, systematic review was conducted, and multiple databases were queried using search terms related to pediatric trauma triage. The literature search was limited to January 1990 to August 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was applied with the methodological index for nonrandomized studies tool used to assess the quality of included studies. Qualitative analysis was performed.

RESULTS

A total of 1,752 articles were screened, and 38 were included in the qualitative analysis. Twelve articles addressed questions 1 and 2, 21 articles addressed question 3 to 5, and five articles addressed question 6. Existing literature suggest that prehospital triage criteria or scoring systems do not predict or reduce mortality, although selected physiologic parameters may. In contrast, hospital trauma activation criteria can predict the need for procedures or surgical intervention and identify patients with higher mortality; again, physiologic signs are more predictive than mechanism of injury. Currently, no standardized secondary triage/transfer protocols exist.

CONCLUSION

Evidence supporting the utility of prehospital triage criteria for injured children is insufficient, while physiology-based trauma system activation criteria do appropriately stratify injured children. The absence of strong evidence supports the need for further prehospital and secondary transfer triage-related research.

LEVEL OF EVIDENCE

Systematic review study, level II.

Factors that predict the need for early surgeon presence in the setting of pediatric trauma

INTRODUCTION

Evidence based variables predicting the need for surgeon presence (NSP) on arrival of an injured child are limited. We sought to identify prehospital factors that best correlate with NSP and highest level of activation in pediatric trauma. A secondary analysis was also performed to determine whether injury severity score (ISS) was predictive of NSP in pediatric trauma.

METHODS

This was a retrospective, single institution study of injured patients age ≤ 16 years delivered from scene to our Pediatric Level I trauma center between January 2016 and June 2017. 526 patients had complete data available for analysis. NSP was previously described as the presence of any of these factors: intubation, transfusion, emergent operation with the trauma team/craniotomy with the neurosurgery team, vasopressors, interventional radiology, spinal cord Injury, chest tube, emergency department thoracotomy, intracranial pressure monitor, pericardiocentesis, or death in the trauma bay. Multivariable analysis was performed with covariates of interest including scene and ED arrival vitals and interventions.

RESULTS

Independent predictors of NSP and highest level of activation were GCS of ≤12 (OR 22.3), penetrating trauma (OR 5.4), and hypotension (age adjusted) (OR 10.2). We also found that ISS ≥ 16 was a poor indicator of NSP with a sensitivity of only 61%.

CONCLUSION

A validated model based on these variables may be useful in predicting NSP and highest level of activation prior to arrival of pediatric trauma patients. NSP may augment assessment of over and undertriage in pediatric trauma patients as compared to the ISS/Cribari system alone. Level of evidence Level III, retrospective cohort study.

A Systematic Review of Hospital Trauma Team Activation Criteria for Children

OBJECTIVES

Hospital trauma activation criteria are intended to identify children who are likely to require aggressive resuscitation or specific surgical interventions that are time sensitive and require the resources of a trauma team at the bedside. Evidence to support criteria is limited, and no prior publication has provided historical or current perspectives on hospital practices toward informing best practice. This study aimed to describe the published variation in (1) highest level of hospital trauma team activation criteria for pediatric patients and (2) hospital trauma team membership and (3) compare these finding to the current ACS recommendations.

METHODS

Using an Ovid MEDLINE In-Process & Other Non-Indexed Citations search, any published description of hospital trauma team activation criteria for children that used information captured in the prehospital setting was identified. Only studies of children were included. If the study included both adults and children, it was included if the number of children assessed with the criteria was included.

RESULTS

Eighteen studies spanning 20 years and 13,184 children were included. Hospital trauma team activation and trauma team membership were variable. Nearly all (92%) of the trauma criteria used physiologic factors. Penetrating trauma (83%) was frequently included in the trauma team activation criteria. Mechanisms of injury (52%) were least likely to be included in the highest level of activation. No predictable pattern of criterion adoption was found. Only 2 of the published criteria and 1 of published trauma team membership are consistent with the current American College of Surgeons recommendations.

CONCLUSIONS

Published hospital trauma team activation criteria and trauma team membership for children were variable. Future prospective studies are needed to define the optimal hospital trauma team activation criteria and trauma team membership and assess its impact on improving outcomes for children.

The utility of a "trauma 1 OP" activation at a level 1 pediatric trauma center

PURPOSE

To expedite flow of injured children suspected to require operative intervention, a "trauma 1 OP" (T1OP) activation classification was created. The purpose of this study was to review this strategy at a level 1 pediatric trauma center.

METHODS

A retrospective review of T1OP activations between 2003 and 2015 was performed. Children suspected of requiring neurosurgical intervention were classified as trauma 1 OP neuro (T1OP(N)). Comparisons were made to trauma 1 (T1) patients who required emergent operative intervention, excluding orthopedic injuries.

RESULTS

Overall, 461 T1OP activations occurred (72% T1OP(N)) compared to 129 T1 activations requiring emergent surgery. Demographics were not significantly different between groups, although T1OP patients were slightly younger and more often experienced falls or were victims of abuse. Compared to T1 activations, T1OP activations had a significantly higher mortality rate (21% vs. 7%, p<0.001). Repeat head imaging was more common in the T1OP(N) group compared to imaged children in the T1 group (20% vs. 37%, p=0.05). T1OP(N) patients more often went directly to the OR (45% vs. 33%, p=0.02) and did so in a significantly faster period of time (32min vs. 53min, p<0.001).

CONCLUSIONS

Use of the T1OP activations appropriately triaged surgical patients, resulting in significantly faster transport times to the OR.

LEVEL OF EVIDENCE

II, prognosis study.

Establishing a standard for assessing the appropriateness of trauma team activation: a retrospective evaluation of two outcome measures

BACKGROUND

Trauma team activation (TTA) is a well-recognised standard of care to provide rapid stabilisation of patients with time-critical, life-threatening injuries. TTA is associated with a substantial use of valuable hospital resources that may adversely impact upon the care of other patients if not carefully balanced. This study aimed to determine which of the two outcome measures would be a better standard for assessing the appropriateness of TTA at a paediatric centre: retrospective major trauma classification as defined within our state, and the use of emergency department high-level resources as recently published by Falcone et al (Falcone Interventions; FI).

METHODS

Trauma registry data and patients' charts between February 2011 and June 2013 were reviewed. Over-triage and under-triage rates for TTA, using both major trauma and FIs as outcome measures, were compared.

RESULTS

Totally, 280 patients received TTA, 243 met major trauma definition and 102 received one or more FIs. The rates of over-triage and under-triage were 39.7% (95% CI 35.0 to 44.6%) and 30.5% (95% CI 26.2 to 35.2%), when the major trauma definition was used as the outcome measure, and 67.5% (95% CI 62.2 to 72.5%) and 10.8% (95% CI 7.9 to 14.8%) when FI was used. Only 17.1% (95% CI 11.4% to 24.7%) of the under-triaged patients using the major trauma definition received one or more FIs.

CONCLUSIONS

Assessment of TTA appropriateness varied significantly based on the outcome measure used. FIs better reflected the use of acute-care TTA-related resources compared with the major trauma definition, and it should be used as the gold standard to prospectively assess and refine TTA criteria.

Is a two-tier trauma team activation system the most effective way to manage trauma in the UK?

This review describes the evidence exploring the use of a two-tier trauma team activation system, reviewing the background, history, data available and potential benefits and downsides. The current evidence suggests that a two-tier system may be a lean, cost-effective system, focussed on patient outcome, which could be implemented throughout the UK. Despite its current use in some hospitals, there is limited data from similar systems supporting this in a UK setting. Specific activation criteria need to be validated to ensure appropriate activation of trauma teams, ensuring optimal patient outcome and ensuring best practice.

Efficacy of a two-tiered trauma team activation protocol in a Norwegian trauma centre

BACKGROUND

A registry-based analysis revealed imprecise informal one-tiered trauma team activation (TTA) in a primary trauma centre. A two-tiered TTA protocol was introduced and analysed to examine its impact on triage precision and resource utilization.

METHODS

Interhospital transfers and patients admitted by non-healthcare personnel were excluded. Undertriage was defined as the fraction of major trauma victims (New Injury Severity Score over 15) admitted without TTA. Overtriage was the fraction of TTA without major trauma.

RESULTS

Of 1812 patients, 768 had major trauma. Overall undertriage was reduced from 28·4 to 19·1 per cent (P < 0·001) after system revision. Overall overtriage increased from 61·5 to 71·6 per cent, whereas the mean number of skilled hours spent per overtriaged patient was reduced from 6·5 to 3·5 (P < 0·001) and the number of skilled hours spent per major trauma victim was reduced from 7·4 to 7·1 (P < 0·001). Increasing age increased risk for undertriage and decreased risk for overtriage. Falls increased risk for undertriage and decreased risk for overtriage, whereas motor vehicle-related accidents showed the opposite effects. Patients triaged to a prehospital response involving an anaesthetist had less chance of both undertriage and overtriage.

CONCLUSION

A two-tiered TTA protocol was associated with reduced undertriage and increased overtriage, while trauma team resource consumption was reduced.

REGISTRATION NUMBER

NCT00876564 (http://www.clinicaltrials.gov).

Trauma activation: are we making the right call? A 3-year experience at a Level I pediatric trauma center

BACKGROUND

Trauma is the leading cause of death in children, accounting for half of all deaths in patients between birth and 18 years of age, and is the cause of a significant number of hospital admissions. We reviewed our experience at a Level I pediatric trauma center with a 2-level trauma activation (TA) system for mobilization of personnel over a 3-year period. The aim was to assess severity of injury of the trauma patients, resource use, and outcome.

METHODS

After obtaining institutional review board approval, a retrospective analysis of all trauma patients between January 2006 and December 2008 was performed. Data analyzed included number of admissions, level of TA (STAT vs ALERT), mechanism of injury, intensive care unit (ICU) admission, injury severity score (ISS), need for operative intervention, and survival.

RESULTS

In 3 years, there were 4502 patients entered. Trauma activation was initiated in 1315 patients (29.2%), divided between 211 STATs (4.7%) and 1104 ALERTs (24.5%). Mean patient age was 5.9 ± 4.1 years, 65% of the patients were boys, and blunt trauma accounted for 92% of the admissions. An ICU admission was required in 736 (16.3%) of the entire group, whereas 502 (38.2%) patients in the TA group were admitted to the ICU(1). The 154 STAT (21%) and 348 ALERT (47%) patients accounted for 68% of all ICU admissions(1). An ISS listed as severe (16-24) or very severe (>24) was found in 468 (10.4%) and 232 (5.2%) patients, respectively. An ISS listed as 16 or higher was found in 144 (68.2%) of the STATs and 264 (23.9%) of the ALERTs(1). Operative intervention was required in 2118 patients (47%). The overall mortality rate was 1.9%, and this increased to 5.8% in the TA group(1). There were 48 deaths (22.7%) in the STAT group, 29 deaths (2.6%) in the ALERT group, and 9 deaths (0.28%) in patients with no TA(1). When emergency department deaths were excluded, the remaining 60 deaths resulted in a mortality rate of 1.3%.

CONCLUSIONS

Our Level I pediatric trauma center manages a large volume of patients with significant acuity and, evidenced by a TA in 29% of the patients, a severe or very severe ISS in 16% of the patients, 16% of the patients requiring ICU admission, and 47% requiring operative intervention. The TA patients had markedly higher rates of ICU admission, ISS, and mortality. Deaths in the study were lower by almost an order of magnitude comparing TA STATs with TA ALERTs and TA ALERT patients with patients without TA. The TA criteria are in many ways very helpful and is integral to a Level I trauma center. However, opportunities were identified for improvement because of areas of "overutilization" and discordance between TA and ISS.

Let the surgeon sleep: trauma team activation for severe hypotension

BACKGROUND

Trauma centers must balance the need to bring the full resources of the trauma center to the sickest patients emphasizing a need for personnel resource allocation. Our level I academic trauma center changed the systolic blood pressure (SBP) requirement for trauma team activation (TTA) from 90 mm Hg to 80 mm Hg. This investigation was undertaken to determine the effects of such change.

METHODS

The hospital's trauma registry identified patients for two 18-month periods, pre and post the change in TTA criteria. Data elements included team activation level, emergency department length of stay, emergency department to operating room (OR) times, delay to OR, and Injury Severity Score.

RESULTS

Full TTA decreased as did the percentage of cases with TTA. Eleven patients were identified in the SBP <80 mm Hg group who would have had TTA before the change. All 11 had timely trauma surgery consults. No delays to OR were related to TTA. The percentage of cases with laparotomy occurring >2 hours after arrival was unchanged. One hundred ninety fewer TTA were called in an 18-month period. Inpatient mortality between the two groups was not significantly changed.

CONCLUSIONS

Changing criteria for TTA from SBP 90 mm Hg to <80 mm Hg preserves personnel without patient harm. Lowering the SBP for TTA is one method of preserving trauma surgery manpower.

Simulated pediatric trauma team management: assessment of an educational intervention

OBJECTIVES

Trauma is the leading cause of death in children. The quality of initial medical care received by injured children contributes to outcomes. Our objective was to assess effectiveness of an educational intervention on performance of emergency department (ED) teams during simulated pediatric trauma resuscitations.

METHODS

A prospective, preinterventional and postinterventional study was performed on a random, convenience sample of 17% of EDs in North Carolina. An unannounced simulated pediatric trauma resuscitation was conducted at each site, followed by an educational intervention and a second visit 6 months later. The key outcome measure was team performance on a clinical assessment tool previously described that included 44 resuscitation tasks deemed critical to appropriate management of pediatric trauma resuscitation.

RESULTS

All 18 sites consented and completed the study. Interrater reliability was excellent, weighted kappa = 0.80 (95% confidence interval, 0.76-0.84). After the educational intervention, the mean (+/- SD) number of the 44 tasks passed by each ED team increased from 17.7 +/- 4.3 to 26.6 +/- 5.8 (P < 0.001). At the individual task level, the scores on 37 (84%) of the 44 tasks improved, of which 11 (25%) of the 44 tasks improved significantly.

CONCLUSIONS

This study demonstrated that an on-site educational intervention was effective in improving the performance of ED teams during simulated pediatric trauma resuscitations. Postintervention performance was more consistent with the Pediatric Advanced Life Support and Advanced Trauma Life Support guidelines. Further studies are needed to determine if improved performance in a simulated scenario leads to improved performance and better clinical outcomes of critically injured children.

Trauma team activation and the impact on mortality

BACKGROUND

Trauma centers use injury mechanism, physiology, and anatomic criteria to determine the extent of trauma team activation (TTA). We examined whether physiologic variables in our three-tier TTA system stratified patients appropriately by injury severity and mortality.

METHODS

The trauma registry at our Level I trauma center was retrospectively reviewed for full (level 1 or L1), partial (level 2 or L2), and limited (level 3) adult TTA. Data were collected on age, injury severity score (ISS), hospital length of stay, systolic blood pressure (SBP), heart rate, respiratory rate (RR), Glasgow coma score (GCS), and intubation status. Penetrating injuries, traumatic arrests, and interfacility transfers were excluded. Data are median (25%75%). Statistical analysis included hazard ratios (HzR), Kruskal-Wallis, chi, and survival analyses. The p value overall was <0.05, and pair wise was <0.05 versus L1.

RESULTS

There were 494 adult TTAs for blunt injury from the scene out of 1,969 admissions. Variables associated with mortality (HzR; 95% confidence interval) by univariate analysis include SBP <90 (9.4; 4.2, 21.2), RR >29 or <10 (17.8; 4.8, 66.0), intubation status (4.5; 2.3, 8.9), and GCS <8 (9.7; 4.8, 19.9). When combined in a multivariate model to evaluate multiple predictors simultaneously, SBP <90 and GCS <8 appear to be the strongest predictors of mortality (RR and intubation were not significant in the presence of SBP and GCS). The three-tier system identified patients with increased ISS and early (< or =4 weeks) mortality risk. There was a statistically significant difference in survival between L1 and L2 at 38 days, but not for >38 days (p = 0.739).

CONCLUSIONS

TTA criteria selected patients with greater ISS and early mortality, but impact on long-term survival may not be appreciated. Full TTA criteria for blunt injury may be limited to GCS <8, SBP <90, RR >29 or <10, and intubation status.

Is There Evidence to Support the Need for Routine Surgeon Presence on Trauma Patient Arrival?

The trauma center certification requirements of the American College of Surgeons include the expectation that, whenever possible, general surgeons be routinely present at the emergency department arrival of seriously injured patients. The 2 historical factors that originally prompted this requirement, frequent exploratory laparotomies and emergency physicians without trauma training, no longer exist in most modern trauma centers. Research from multiple centers and in multiple varying formats has not identified improvement in patient-oriented outcomes from early surgeon involvement. Surgeons are not routinely present during the resuscitative phase of Canadian and European trauma care, with no demonstrated or perceived decrease in the quality of care. American trauma surgeons themselves do not consistently believe that their use in this capacity is either necessary or an efficient distribution of resources. There is not compelling evidence to support the assumption that trauma outcomes are improved by the routine presence of surgeons on patient arrival. Research is necessary to clarify which trauma patients require either emergency or urgent unique expertise of a general surgeon during the initial phase of trauma management. Individual trauma centers should be permitted the flexibility necessary to perform such research and to use such findings to refine and focus their secondary triage criteria.

Clinical decision rules for secondary trauma triage: predictors of emergency operative management

STUDY OBJECTIVE

Most injured patients taken by ambulance to hospital emergency departments do not require emergency surgery, yet most US trauma centers require a surgeon to be present on their arrival. If a clinical decision rule could be developed to accurately identify which injured patients require emergency operative intervention, then such "secondary triage" criteria could permit a trauma center to more efficiently use their surgeons' time.

METHODS

We analyzed 7.5 years of data (8,289 consecutive trauma activations) in our prospectively maintained Level I trauma center registry. We used classification and regression tree analyses to generate clinical decision rules using standard out-of-hospital variables to identify emergency operative intervention (within 1 hour) by a general surgeon (for adults) or a pediatric surgeon (if < or =14 years).

RESULTS

Emergency operative intervention occurred in 3.0% of adults and 0.35% of children. For adults, summoning a surgeon for any one of 3 criteria (penetrating mechanism, systolic blood pressure <96 mm Hg, pulse rate >104 beats/min) could reduce surgeon calls by 51.2% while failing to identify emergency operative intervention in only 0.08% (rule sensitivity 97.2% and specificity 48.6%). For children, no rule at all (ie, never automatically summoning a surgeon) would fail to identify emergency operative intervention in only 0.35% of patients, and use of a single criterion (penetrating mechanism) would reduce surgeon calls by 96.2% while failing to identify emergency operative intervention in only 0.09% (rule sensitivity 75.0% and specificity 96.5%).

CONCLUSION

We have derived simple decision rules for trauma centers that, if validated, could substantially reduce the need for routine surgeon presence on trauma patient arrival. These rules demonstrate low false-negative rates.