Evaluation of pre-hospital trauma triage criteria: a prospective study at a Danish level I trauma centre

Evaluating the impact of pre-hospital trauma team activation criteria

BACKGROUND

Little evidence exists studying the benefits of pre-hospital trauma team activation. Our study measured the impact of pre-hospital trauma team activation on 24-h survival. Our secondary objectives assessed the effects of pre-hospital trauma team activation on time to emergency procedure, computed tomography, blood transfusion, and critical administration threshold, as well as emergency department length of stay.

METHODS

We conducted a 40-month health records review on all trauma team activations at The Ottawa Hospital, a Level 1 Trauma Center. Outcomes were compared between pre-hospital and in-hospital trauma team activations. We used logistic and linear regression models to assess outcomes, while controlling for injury severity score, age, systolic blood pressure, and anti-coagulation use. A P value < 0.05 was considered statistically significant. A sensitivity analysis was also used to validate the primary outcome results.

RESULTS

Of the 1013 trauma team activations occurring during the study period, 762 patients were included. The mean age (41.3 vs. 43.8) and percentage of males (79.4% vs. 77.5%) for pre-hospital activations were similar to their counterparts. Pre-hospital activations did not have a statistically significant effect on 24-h mortality (14.4% vs. 4.5%; P = 0.30). However, pre-hospital activations did demonstrate a statistically significant reduction in time (minutes) to emergency procedure (18.0 vs. 27.0; P < 0.001), computed tomography (37.0 vs 42.0; P = 0.009), and blood transfusion (14.0 vs. 28.0; P < 0.001), as well as emergency department length of stay (101.0 vs. 171.0; P < 0.001).

CONCLUSION

When controlling for key covariates, pre-hospital trauma team activation did not have a significant effect on 24-h mortality, but did result in a significant reduction in time to emergency procedure, computed tomography, and blood transfusion, as well as emergency department length of stay. Our study demonstrates that pre-hospital trauma team activation can expedite patient intervention and disposition.

Refining triage practices by predicting the need for emergent care following major trauma: the experience of a level 1 adult trauma center

PURPOSE

We examined the predictability of selected parameters for establishing the need for urgent care following multi-trauma as a means to warrant the highest level of trauma activation and potentially improve over- and under-triage rates.

METHODS

In this retrospective cohort study of multi-trauma patients aged ≥ 16 years performed at a level 1 trauma center, trauma activation criteria and additional characteristics were examined with respect to treatment urgency, defined as: a direct disposition to the operating room or intensive care unit, initiating acute intervention in the trauma room, and in-hospital death within 7 days of admission.

RESULTS

We enrolled 1373 patients (median age 36.0 years). The following parameter were inserted into the final multivariable model: age > 75 years, male sex, Charlson comorbidity index, trauma circumstances and mechanism, signs of respiratory distress, systolic BP ≤ 110 and GCS ≤ 13. Adjusted independent predictors of acute care requirement were as follows: GCS ≤ 13 (aOR 5.27 [95% CI 3.45-8.05], p < 0.001), systolic BP ≤ 110 mmHg (aOR 2.15 [95% CI 1.45-3.21], p < 0 .001), respiratory distress (aOR 2.05 [95% CI 1.53-2.77], p < 0.001), and age ≥ 75 years (aOR 1.90 [95% CI 1.18-3.08], p = 0.008).

CONCLUSION

A GCS ≤ 13, systolic BP < 110 mmHg, signs of respiratory distress, and age > 75 years best predicted the need for acute care following multisystem trauma. Prospective studies are warranted to confirm the predictability of these criteria and to assess the extent to which their implementation will refine over- and under-triage rates.

Isolated vehicle rollover is not an independent predictor of trauma injury severity

OBJECTIVES

The objective of this study was to determine if vehicle rollover in a motor vehicle crash is an independent predictor of major injury.

METHODS

A retrospective cohort study of all patients injured in motor vehicle crashes presenting to a major trauma center between July 2012 and June 2016 was conducted. Crashes were classified into groups: non-rollover, isolated rollover (without other mechanisms of injury), or mixed-mechanism rollover (with other mechanisms of injury). Associations between rollover group, other covariates (entrapment, encapsulation, ejection, death on scene, high speed, seat belt usage, airbag deployment, trauma team activation), and major injury (injury severity score >15, major surgery, intensive care unit admission, or in-hospital death) were tested using binary logistic regression models. Vehicle rollover was categorized either as "present" or "absent" on 1 model or as either "none," "isolated," or "mixed mechanism" in the other.

RESULTS

In 2446 motor vehicle crashes, there were 423 rollovers (196 isolated, 227 mixed mechanisms). Compared with crashes without rollovers, the prevalence of patients with major injury was lower in crashes with isolated rollovers and higher in crashes with mixed-mechanism rollovers (13.8% vs 9.5% vs 27.5%, respectively; P < 0.001). Rollover (present vs absent) was not an independent predictor of major injury (odds ratio [OR], 1.10; 95% confidence interval [CI], 0.78-1.53). Patients in crashes with mixed-mechanism but not isolated rollovers had increased odds (OR, 2.04; 95% CI, 1.41-2.96) of major injury compared with patients from crashes without rollovers.

CONCLUSIONS

Patients from crashes with isolated vehicle rollovers may not need to be transported to a trauma center as they carry a lower risk of injury.

Correlation between field triage criteria and the injury severity score of trauma patients in a French inclusive regional trauma system

Background

In France, the pre-hospital field triage of trauma patients is currently based on the Vittel criteria algorithm. This algorithm was originally created in 2002 before the stratification of trauma centers and, at the national level, has not been revised since. This could be responsible for the overtriage of trauma patients in Level I Trauma Centers. The principal aim of this study was to evaluate the correlation between each Vittel field triage criterion and trauma patients’ Injury Severity Score.

Methods

Our Level I Trauma Center receives an average of 300 trauma patients per year. Demographic and physiological data, along with the entire trauma patient management process and Vittel field triage criteria, are recorded in a local trauma registry. The Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) are calculated after a complete assessment of the trauma victim during their in-hospital management. Results were concerned with the presence of an ISS of greater than 15, which defined a major trauma patient; mortality within 30 days; and admission to the intensive care unit. This study is a registry analysis from January 2013 to September 2017.

Results

Of the 1373 patients in the registry, 1151 were included in the analysis with a mean age of 43 years (± 19) and a median ISS of 13 (IQR = 5–22), where 887 (77%) were male. Nine of the 24 Vittel criteria were associated with an ISS > 15. In a multivariate analysis, no criterion related to kinetic elements was significantly correlated with an ISS > 15, mortality within 30 days, or admission to intensive care. Three algorithm categories were predictive of a major trauma patient (ISS > 15): physiological variables, pre-hospital resuscitation, and physical injuries, while kinetic elements were not.

Conclusions

Criteria related to physiological variables, pre-hospital resuscitation, and physical injuries are the most relevant to predicting the severity of a trauma patient’s condition. A revision of the VCA could potentially have beneficial effects on the over and undertriage phenomena, which constitute ongoing medical and financial concerns.

Undertriage of major trauma patients at a university hospital: a retrospective cohort study

Background

Studies show increased mortality among severely injured patients not met by trauma team. Proper triage is important to ensure that all severely injured patients receive vital trauma care. In 2017 a new national trauma plan was implemented in Norway, which recommended the use of a modified version of “Guidelines for Field Triage of Injured Patients” to identify severely injured patients.

Methods

A retrospective study of 30,444 patients admitted to Haukeland University Hospital in 2013, with ICD-10 injury codes upon discharge. The exclusion criteria were department affiliation considered irrelevant when identifying trauma, patients with injuries that resulted in Injury Severity Score < 15, patients that did receive trauma team, and patients admitted > 24 h after time of injury. Information from patient records of every severely injured patient admitted in 2013 was obtained in order to investigate the sensitivity of the new guidelines.

Results

Trauma team activation was performed in 369 admissions and 85 patients were identified as major trauma. Ten severely injured patients did not receive trauma team resuscitation, resulting in an undertriage of 10.5%. Nine out of ten patients were men, median age 54 years. Five patients were 60 years or older. All of the undertriaged patients experienced fall from low height (< 4 m). Traumatic brain injury was seen in six patients. Six patients had a Glasgow Coma Scale score ≤ 13. The new trauma activation guidelines had a sensitivity of 95.0% in our 2013 trauma population. The degree of undertriage could have been reduced to 4.0% had the guidelines been implemented and correctly applied.

Conclusions

The rate of undertriage at Haukeland University Hospital in 2013 was above the recommendations of less than 5%. Use of the new trauma guidelines showed increased triage precision in the present trauma population.

Evaluating the ability of a trauma team activation tool to identify severe injury: a multicentre cohort study

Background

Sensitive decision making tools should assist prehospital personnel in the triage of injured patients, identifying those who require immediate lifesaving interventions and safely reducing unnecessary under- and overtriage. In 2014 a new trauma team activation (TTA) tool was implemented in Central Norway. The overall objective of this study was to evaluate the ability of the new TTA tool to identify severe injury.

Methods

This was a multi-center observational cohort study with retrospective data analysis. All patients received by trauma teams at seven hospitals in Central Norway between 01.01.2015 to 31.12.2015 were included. Severe injury was defined as Injury Severity Score (ISS) > 15. Overtriage was defined as the rate of patients with TTA and ISS < 15, whilst patients with TTA and ISS > 15 were defined as correctly triaged.

Results

A total of 1141 patients were identified, of which 998 were eligible for triage criteria analysis. Median age was 35 years (IQR 20–58) and the male proportion was 67%. Mechanism of injury was predominantly blunt trauma (96%) with transport related accidents (62%) followed by falls (22%) the most common. Overall, median injury severity score (ISS) was low and severely injured patients (ISS > 15) comprised 13% of the cohort. Utility of specific TTA criteria were: physiology 20%, anatomical injury 21%, mechanism of injury (MOI) 53% and special causes 6%. Overtriage among all patients was 87%, and for those with physiologic criteria 66%, anatomical injury 82%, mechanism of injury 97% and special causes criteria 92%, respectively.

Conclusions

Severe injury was infrequent and there was a substantial rate of overtriage. The ability of the TTA tool was relatively insensitive in identifying severe injury, but showed increased performance when utilizing physiologic and anatomical injury criteria. Many of the TTA mechanism of injury criteria might be considered for removal from the triage tool due to substantial rates of overtriage. This has relevance for the proposed development of national Norwegian TTA criteria.

Trauma facilities in Denmark - a nationwide cross-sectional benchmark study of facilities and trauma care organisation

Background

Trauma is a leading cause of death among adults aged < 44 years, and optimal care is a challenge. Evidence supports the centralization of trauma facilities and the use multidisciplinary trauma teams. Because knowledge is sparse on the existing distribution of trauma facilities and the organisation of trauma care in Denmark, the aim of this study was to identify all Danish facilities that care for traumatized patients and to investigate the diversity in organization of trauma management.

Methods

We conducted a systematic observational cross-sectional study. First, all hospitals in Denmark were identified via online services and clarifying phone calls to each facility. Second, all trauma care manuals on all facilities that receive traumatized patients were gathered. Third, anesthesiologists and orthopedic surgeons on call at all trauma facilities were contacted via telephone for structured interviews.

Results

A total of 22 facilities in Denmark were found to receive traumatized patients. All facilities used a trauma care manual and all had a multidisciplinary trauma team. The study found three different trauma team activation criteria and nine different compositions of teams who participate in trauma care. Training was heterogeneous and, beyond the major trauma centers, databases were only maintained in a few facilities.

Conclusion

The study established an inventory of the existing Danish facilities that receive traumatized patients. The trauma team activation criteria and the trauma teams were heterogeneous in both size and composition. A national database for traumatized patients, research on nationwide trauma team activation criteria, and team composition guidelines are all called for.

Electronic supplementary material

The online version of this article (10.1186/s13049-018-0486-1) contains supplementary material, which is available to authorized users.

A criteria-directed protocol for in-hospital triage of trauma patients

OBJECTIVE

To better match hospital resources to patients' needs of trauma care, a protocol for facilitating in-hospital triage decisions was implemented at a Swedish level I trauma centre. In the protocol, physiological parameters, anatomical injuries and mechanism of injury were documented, and used to activate full or limited trauma team response. The aim of this study was to evaluate the efficacy of the criteria-directed protocol to determine in-hospital trauma triage in an emergency department.

METHODS

Level of triage and triage rates were compared before and after implementation of the protocol. Overtriage and undertriage were assessed with injury severity score higher than 15 as the cutoff for defining major trauma. Medical records for undertriaged patients were retrospectively reviewed.

RESULTS

In 2011, 78% of 1408 trauma team activations required full trauma response, with an overtriage rate of 74% and an undertriage rate of 7%. In 2013, after protocol implementation, 58% of 1466 trauma team activations required full trauma response. Overtriage was reduced to 52% and undertriage was increased to 10%. However, there were no preventable deaths in the undertriaged patients.

CONCLUSION

A criteria-directed protocol for use in the emergency department was efficient in reducing overtriage rates without risking undertriaged patients' safety.

Motorcyclists and pillion passengers with open lower-limb fractures: a study using TARN data 2007-2014

Introduction We aimed to identify population demographics of motorcyclists and pillion passengers with isolated open lower-limb fractures, to ascertain the impact of the revised 2009 British Orthopaedic Association/British Association of Plastic Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4), in terms of time to skeletal stabilisation and soft-tissue coverage, and to observe any impact on patient movement. Methods Retrospective cohort data was collected by the Trauma Audit and Research Network (TARN). A longitudinal analysis was performed between two timeframes in England (pre-and post-BOAST 4 revision): 2007-2009 and 2010-2014. Results A total of 1564 motorcyclists and 64 pillion passengers were identified. Of these, 93% (1521/1628) were male. The median age for males was 30.5 years and 36.7 years for females. There was a statistically significant difference in the number of patients who underwent skeletal stabilisation (49% vs 65%, P < 0.0001), the time from injury to skeletal stabilisation (7.33 hours vs 14.3 hours, P < 0.0001) and the proportion receiving soft-tissue coverage (26% vs 43%, P < 0.0001). There was no difference in the time from injury to soft-tissue coverage (62.3 hours vs 63.7 hours, P = 0.726). The number of patients taken directly to a major trauma centre (or its equivalent) increased between the two timeframes (12.5% vs, 41%, P < 0.001). Conclusions Since the 2009 BOAST 4 revision, there has been no difference in the time taken from injury to soft-tissue coverage but the time from injury to skeletal stabilisation is longer. There has also been an increase in patient movement to centres offering joint orthopaedic and plastic care.

Evaluation of a trauma team activation protocol revision: a prospective cohort study

Background

Correct triage based on prehospital information contributes to a better outcome for potentially seriously injured patients. In 2011 we changed the trauma team activation (TTA) criteria in our center in order to improve the high over- and undertriage properties of the protocol. Five criteria that were unable to predict severe injury were removed. In the present study, we evaluated the protocol revision by comparing over- and undertriage in the former and present set of criteria.

Methods

All severely injured patients (Injury Severity Score (ISS) > 15) and all patients admitted with TTA in the period of 01.01.2013 – 31.12.2014 were included in the study. We defined overtriage as the fraction of patients with TTA when ISS ≤15 and undertriage as the fraction of patients without TTA when ISS > 15. We also evaluated triage with the occurrence of emergency procedures immediately after admission.

Results

324 patients were included, 164 patients had ISS>15, 287 were admitted with TTA. Over- and undertriage were 74 % and 28 % respectively. When we used emergency procedure as reference, the figures were 83 % and 15 % respectively. Undertriaged patients had significantly more neurosurgical injuries and were significantly more often transferred from an acute care hospital.

Discussion

Over- and undertriage are almost the same as before the criteria were revised, and higher thanrecommended levels.

Conclusions

Revision of the TTA criteria has not improved triage, and further measures are necessary to achieveacceptable levels.

Nine out of ten trauma calls to a Norwegian hospital are avoidable: a retrospective analysis

Background

Our aim was to estimate the degree of overtriage (Injury Severity Score [ISS] ≤ 15) of trauma call patients in Nordland Hospital Bodø, Norway. We also determined the transportation time from injury to hospital admission.

Methods

We used data from our Acute Medical Information System, ambulance records and patient charts relating to ISS and estimation of response and transport times. Data were collected for all trauma call patients in the period from the establishment of the trauma call system in June 2008 until the 31st of December 2010.

Results

We identified 421 out of 458 possible trauma call patients with sufficient clinical information available for ISS scoring. Of these 385 had an ISS ≤15. Overtriage was 91.5% (95% CI: 88.8%–94.2%). Median time from injury to the arrival of transport, and from injury to arrival in hospital, was 36 minutes and 1 hour 27 minutes, respectively.

Conclusions

To our knowledge 91.5% is the highest overtriage ever published. There is a need for narrowing the trauma call criteria. This could be achieved by implementing clinical observations during the long transportation time.

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).

Evaluation of a university hospital trauma team activation protocol

BACKGROUND

Admission with a multidisciplinary trauma team may be vital for the severely injured patient, as this facilitates rapid diagnosis and treatment. On the other hand, patients with minor injuries do not need the trauma team for adequate care. Correct triage is important for optimal resource utilization. The aim of the study was to evaluate our criteria for activating the trauma team, and identify suboptimal criteria that might be changed in the interest of precision.

METHODS

The study is an observational, retrospective cohort-study. All patients admitted with the trauma team (n = 382), all severely injured (Injury Severity Score (ISS) >15) (n = 161), and all undergoing an emergency procedure aimed at counteracting compromised airways, respiration or circulation at our hospital (n = 142) during 2006-2007 were included. Data were recorded from the admission records and the electronic patient records. The trauma team activation protocol was evaluated against the occurrence of severe injury and the occurrence of emergency procedures.

RESULTS

A total of 441 patients were included. The overtriage was 71% and undertriage 32% when evaluating against ISS >15 as the standard of reference. When occurrence of emergency procedures was held as the standard of standard of reference, the over- and undertriage was 71% and 21%, respectively. Mechanism of injury-criteria for trauma team activation contributed the most to overtriage. The emergency procedures performed were mostly endotracheal intubation and external fixation of fractures. Less than 3% needed haemostatic laparotomy or thoracotomy. Approximately 2/3 of the overtriage represented isolated head or cervical spine injuries, and/or interhospital transfers.

CONCLUSIONS

The over- and undertriage of our protocol are both too high. To decrease overtriage we suggest omissions and modifications of some of the criteria. To decrease undertriage, transferred patients and patients with head injuries should be more thoroughly assessed against the trauma team activation criteria.

Differences in trauma team activation criteria among Norwegian hospitals

BACKGROUND

To ensure the rapid and correct triage of patients in potential need of specialized treatment, Norwegian hospitals are expected to establish trauma teams with predefined criteria for their activation. The objective of this study was to map and describe the criteria currently in use.

METHODS

We undertook a cross-sectional survey in the summer of 2008, using structured telephone interviews to all Norwegian hospitals that might admit severely injured patients.

RESULTS

Forty-nine hospitals were included, of which 48 (98%) had a trauma team and 20 had a hospital-based trauma registry. Criteria for trauma team activation were found at 46 (94%) hospitals. No single criterion was common to all hospitals. The median number of criteria per hospital was 23 (range 8-40), with a total number of 156 and wide variation with respect to physiological "cut-off" values. The mechanism of injury was commonly in use despite a well-known, large over-triage rate.

CONCLUSIONS

In recent years, Norwegian hospitals have gradually established trauma teams and criteria for their activation. These criteria show considerable variation, including physiological "cut-off" values.

Triage and mortality in 2875 consecutive trauma patients

BACKGROUND

Most studies on trauma and trauma systems have been conducted in the United States. We aimed to describe the factors predicting mortality in European trauma patients, with focus on triage.

METHODS

We prospectively registered all trauma patients in Eastern Denmark over 12 consecutive months. We analysed the flow of trauma patients through the system, the time spent at different locations, and we assessed the risk factors of mortality.

RESULTS

We included 2875 trauma patients, of whom 158 (5.5%) died before arrival at the hospital. Most patients (75.3%) were brought to local hospitals and patients primarily (n=82) or secondarily triaged (n=203) to the level I trauma centre were the most severely injured. Secondarily transferred patients spent a median of 150 min in the local hospital before transfer to the level I trauma centre and 48 min on transportation. Severe injury with an injury severity score >15 was seen in 345 patients, of whom 118 stayed at the local hospital. They had a significantly higher mortality than 116 of those secondarily transferred [45/118, 38.1% vs. 11/116, 9.7% (P<0.0001)]. Mortality within 30 days was 4.3% in admitted patients, and significant risk factors of death were violence [odds ratio (OR)=5.72], unconsciousness (OR=4.87), hypotension (OR=4.96), injury severity score >15 (OR=27.42), and age.

CONCLUSIONS

Around 50% of all trauma deaths occurred at the scene. Increased survival of severely injured patients may be achieved by early transfer to highly specialised care.

Outcomes in Pediatric Trauma Care in the Stockholm Region

BACKGROUND

Although trauma is a leading cause of pediatric mortality and morbidity in Sweden, few studies have examined the outcome of pediatric trauma.

OBJECTIVE

Here, we describe the age and gender distribution, injury mechanisms, injury severity, and outcome of pediatric trauma in the Stockholm region.

METHODS

This retrospective study comprises all trauma patients (age ≤ 15 years) admitted to a regional pediatric trauma center and all pediatric deaths due to trauma in Stockholm in 2002. Data from the trauma registry database were verified by comparison with medical records and autopsy reports. Outcome was measured by mortality and length of stay in a pediatric intensive care unit (PICU) and acute care hospital.

RESULTS

In all, 432 injured children were included. The median age was 10 years and 59% were males. The median injury severity score was 4 (interquartile range [IQR] 1-9) and 50% sustained head injuries. Mortality was low (1%) and the median length of hospital stay was 2 days (IQR 1-3); 19% stayed in a PICU and, of those, 89% stayed for one day. Comparison with medical records showed that much information in the trauma registry database was either incorrect or missing.

CONCLUSIONS

Many injuries were minor and half of the children were discharged home from the emergency department.Head injurieswere themost common injury in all age groups. The most severe head injuries were seen in the youngest group and were caused by falls. Trauma team activation criteria should be improved to avoid overutilization. The quality and completeness of data in the trauma registry must be enhanced.

Precision of field triage in patients brought to a trauma centre after introducing trauma team activation guidelines

BACKGROUND

Field triage is important for regional trauma systems providing high sensitivity to avoid that severely injured are deprived access to trauma team resuscitation (undertriage), yet high specificity to avoid resource over-utilization (overtriage). Previous informal trauma team activation (TTA) at Ulleval University Hospital (UUH) caused imprecise triage. We have analyzed triage precision after introduction of TTA guidelines.

METHODS

Retrospective analysis of 7 years (2001-07) of prospectively collected trauma registry data for all patients with TTA or severe injury, defined as at least one of the following: Injury Severity Score (ISS) > 15, proximal penetrating injury, admitted ICU > 2 days, transferred intubated to another hospital within 2 days, dead from trauma within 30 days. Interhospital transfers to UUH and patients admitted by non-healthcare personnel were excluded. Overtriage is the fraction of TTA where patients are not severely injured (1-positive predictive value); undertriage is the fraction of severely injured admitted without TTA (1-sensitivity).

RESULTS

Of the 4,659 patients included in the study, 2,221 (48%) were severely injured. TTA occurred 4,440 times, only 2,002 of which for severely injured (overtriage 55%). Overall undertriage was 10%. Mechanism of injury was TTA criterion in 1,508 cases (34%), of which only 392 were severely injured (overtriage 74%). Paramedic-manned prehospital services provided 66% overtriage and 17% undertriage, anaesthetist-manned services 35% overtriage and 2% undertriage. Falls, high age and admittance by paramedics were significantly associated with undertriage. A Triage-Revised Trauma Score (RTS) < 12 in the emergency department reduced the risk for undertriage compared to RTS = 12 (normal value). Field RTS was documented by anaesthetists in 64% of the patients compared to 33% among paramedics.Patients subject to undertriage had an ISS-adjusted Odds Ratio for 30-day mortality of 2.34 (95% CI 1.6-3.4, p < 0.001) compared to those correctly triaged to TTA.

CONCLUSION

Triage precision had not improved after TTA guideline introduction. Anaesthetists perform precise trauma triage, whereas paramedics have potential for improvement. Skewed mission profiles makes comparison of differences in triage precision difficult, but criteria or the use of them may contribute. Massive undertriage among paramedics is of grave concern as patients exposed to undertriage had increased risk of dying.

Pre-notification of arriving trauma patient at trauma centre: a retrospective analysis of the information in 700 consecutive cases

Background

Pre-notification of an arriving trauma patient, given by transporting emergency medical unit, is needed in terms of facilitating the admitting emergency department to get ready for the patient before the patient actually arrives. In the present study we retrospectively analyzed the pre-hospital information provided by 700 consecutive pre-notification mobile phone calls in terms to asses the response of trauma team activation regard to pre-notified information such as vital signs and level of consciousness, mechanism of injury (MOI), and estimated elapsed time (EET) from the time of pre-notification phone call to arrival.

Results

The median EET was 15 minutes (range 0 – 80 min, interquartile range 10 – 20 min). In 11% of the cases EET was 5 minutes or shorter. 17% of the patients were intubated and ventilated on scene at the time pre-notification phone call took place. The most commonly notified pre-hospitally diagnosed injuries were thoracic in 75 cases (11%), followed by unstable long bone (tibia, femur, humerus) fracture in 66 cases (9%), and abdominal injuries in 32 cases (5%). Trauma team was activated for 61% of 700 pre-notified patients. MOI without clinical symptoms was the reason for team activation in 75% of the cases. In 25% of the cases there were pre-hospitally observed clinical injuries or abnormalities in vital parameters.

Conclusion

Pre-notification phone call is of a crucial importance in organizing every day activities at a busy trauma centre, but it should not take place in too much advance. In any case, a pre-notification phone call, even on short notice, gives emergency department personnel some time to prepare for the incoming patient.