Overtriage in trauma - what are the causes?

Trauma triage criteria as predictors of severe injury - a Swedish multicenter cohort study

BACKGROUND

Adequate performance of trauma team activation (TTA) criteria is important in order to accurately triage trauma patients. The Swedish National Trauma Triage Criteria (SNTTC) consists of 29 criteria that trigger either a Trauma Alert, the highest level of TTA, or a Trauma Response. This study aimed to evaluate the SNTTC and its accuracy in predicting a severely injured patient in a multicenter setting.

METHODS

A cohort study in Sweden involving six trauma receiving hospitals. Data was collected from the Swedish Trauma Registry. Some 626 patients were analyzed with regard to the specific criteria used to initiate the TTA, injury severity with New Injury Severity Score (NISS) and emergency interventions. Sensitivity, specificity, positive predictive value (PPV) and positive likelihood ratio (LR+) of the criteria were calculated, as well as undertriage and overtriage.

RESULTS

All 29 criteria of SNTTC had a sensitivity > 80% for identifying a severely injured patient. The 16 Trauma Alert Criteria had a lower sensitivity of 62.6% but higher LR+ (3.5 vs all criteria 1.4), specificity (82.3 vs 39.1%) and PPV (55.4 vs 37.6%) and the highest accuracy (AUC 0.724). When using only the six physiological criteria, sensitivity (44.8%) and accuracy (AUC 0.690) decreased while LR+ (6.7), specificity (93.3%) and PPV (70.2%) improved.

CONCLUSION

SNTTC is efficient in identifying severely injured patients. The current set of criteria exhibits the best sensitivity compared to other examined combinations and no additional criterion was found to improve the protocol enough to promote a change.

Avoiding immediate whole-body trauma CT: a prospective observational study in stable trauma patients

High energy blunt trauma patients with normal vital signs are usually investigated with a Contrast Enhanced Computed Tomography (CECT) for torso injuries. CECT involves high levels of radiations, often showing no injuries in patients over-triaged to the trauma center. The aim of our study was to suggest an alternative diagnostic protocol based on Emergency Room (ER) tests (physical exam, blood tests, extended FAST, Chest and Pelvis X-ray) to avoid CECT in selected patients. A prospective cohort study was conducted from September 2018 to September 2019. Five hundred patients fulfilled the inclusion criteria. Patients received torso-CECT scan only if they had at least one positive ER test. The validity of the single component of the protocol and the global validity of the ER tests to detect torso injuries was assessed through sensitivity, specificity, positive (PPV) and negative (NPV) predictive value, positive (+ LR) and negative (- LR) likelihood ratio. Multivariate analysis was performed to identify independent predictors of torso injuries. One hundred and seventy patients received a torso-CECT scan because of positive ER tests. ER tests showed a global sensitivity for torso injuries of 86.96% (95% CI 80.17-92.08) specificity of 83.98%(95% CI 79.79-87.60), PPV of 67.42% (95% CI 61.83-72.54), NPV of 94.41% (95% CI 91.63-96.30) + LR of 5.43 (95% CI 4.25-6.93), - LR of 0.16 (95% CI 0.10-0.24). ER tests in an experienced center seem to be able to identify more severe blunt trauma patients needing CECT. Further studies are advisable to confirm these results.

Changing from a two-tiered to a one-tiered trauma team activation protocol: a before-after observational cohort study investigating the clinical impact of undertriage

BACKGROUND

The aim of this study was to compare the effect of the change in TTA protocol from a two-tier to one-tier, with focus on undertriage and mortality.

MATERIAL AND METHODS

A before-after observational cohort study based on data extracted from the Stavanger University Hospital Trauma registry in the transition period from two-tier to a one-tier TTA protocol over two consecutive 1-year periods (2017-2018). Comparative analysis was done between the two time-periods for descriptive characteristics and outcomes. The main outcomes of interest were undertriage and mortality.

RESULTS

During the study period 1234 patients were included in the registry, of which 721 (58%) were in the two-tier and 513 (42%) in the one-tier group. About one in five patients (224/1234) were severely injured (ISS > 15). Median age was 39 in the two-tier period and 43 years in the one-tier period (p = 0.229). Median ISS was 5 for the two-tier period vs 9, in the one-tier period (p = 0.001). The undertriage of severely injured patients in the two-tier period was 18/122 (15%), compared to 31/102 (30%) of patients in the one-tier period (OR = 2.5; 95% CI 1.8-4.52). Overall mortality increased significantly between the two TTA protocols, from 2.5 to 4.7% (p = 0.033), OR 0.51 (0.28-0.96) CONCLUSION: A protocol change from two-tiered TTA to one-tiered TTA increased the undertriage in our trauma system. A two-tiered TTA may be beneficial for better patient care.

Epidemiology of trauma admissions in a level 1 trauma center in Northern Italy: a nine-year study

The aim of this study was to analyze the results of 9 years of trauma care and data collection in a level 1 urban trauma center in Northern Italy. Overall, 6065 patients have been included in the study; the number of patients managed yearly has doubled between 2011 and 2019. This rise mostly involved patients with injury severity score (ISS) < 16. Most injuries (94%) were blunt. Road traffic accidents, especially involving motorcycles, were the most common cause of injury. Self-inflicted injuries were responsible for less than 5% of trauma but they were severe in 56% of cases. The median age was 38 and it remained constant over the years; 43% of patients had 14-39 years of age. Different characteristics and patterns of injury were observed for each age group and gender. Males were more likely to be injured in the central years of life while females presented a trimodal pattern in the age distribution. Young adults (14-39 years old) were overall at higher risk of self-harm. Overall mortality was equal to 5.2%. Most deceased were male and ≥ 65 years of age.

The impact of regionalized trauma care on the distribution of severely injured patients in the Netherlands

Background

Twenty years ago, an inclusive trauma system was implemented in the Netherlands. The goal of this study was to evaluate the impact of structured trauma care on the concentration of severely injured patients over time.

Methods

All severely injured patients (Injury Severity Score [ISS] ≥ 16) documented in the Dutch Trauma Registry (DTR) in the calendar period 2008–2018 were included for analysis. We compared severely injured patients, with and without severe neurotrauma, directly brought to trauma centers (TC) and non-trauma centers (NTC). The proportion of patients being directly transported to a trauma center was determined, as was the total Abbreviated Injury Score (AIS), and ISS.

Results

The documented number of severely injured patients increased from 2350 in 2008 to 4694 in 2018. During this period, on average, 70% of these patients were directly admitted to a TC (range 63–74%). Patients without severe neurotrauma had a lower chance of being brought to a TC compared to those with severe neurotrauma. Patients directly presented to a TC were more severely injured, reflected by a higher total AIS and ISS, than those directly transported to a NTC.

Conclusion

Since the introduction of a well-organized trauma system in the Netherlands, trauma care has become progressively centralized, with more severely injured patients being directly presented to a TC. However, still 30% of these patients is initially brought to a NTC. Future research should focus on improving pre-hospital triage to facilitate swift transfer of the right patient to the right hospital.

A profile of a major trauma centre of North West England between 2011 and 2018

This study examined the trends and patterns of major trauma (MT) activities, causes, mortality and survival at the Aintree Major Trauma Centre (MTC), Liverpool, between 2011 and 2018. The number of trauma team activations (TTAs) rose sharply over time (n = 699 in 2013; n = 1522 in 2018). The proportion of TTAs that involved MT patients decreased from 75.1% in 2013 to 67.4% in 2018. The leading cause of MT was a fall from less than 2 m (36%). There has been a fivefold increase in the overall number of trauma procedures between 2011 and 2018. Orthopaedic surgeons have performed 80% of operations (n = 7732), followed by neurosurgeons, oral and maxillofacial surgeons, and general trauma surgeons. Both types of fall (> 2 m and < 2 m) and road traffic accidents were the three leading causes of death during the study period. The observed mortality rates exceeded that of expected rates in years 2012, 2014, 2016 and 2017. The all-cause observed to expected mortality ratio was 1.08 between 2012 and 2018. A change in care for MT patients was not directly associated with improved survival, although the marginally ascending trend line in survival rates between 2012 and 2018 reflects a gradual positive change.

Severe thoracic or abdominal injury in major trauma patients can safely be ruled out by "Valutazione Integrata Bed Side" evaluation without total body CT scan

BACKGROUND

During the initial assessment of trauma patients, the severity of injury is very often not immediately recognizable. In trauma centers, a total body CT (TBCT) scan is routinely used to evaluate this kind of patients, even if it is burdened with health risk, economical costs, and logistical difficulties.

AIM

We investigated the use of a clinical guide to establish a safe alternative to this routine practice.

METHODS

We enrolled retrospectively 438 patients referring to the Emergency Department of Careggi University Hospital in Florence (Italy) over a 1-year period from 2014 to 2015, with the evidence of trauma and high-priority triage codes and then subjected to TBCT. We created a tool called VIBS ("Valutazione Integrata Bed Side") (from the Italian translation of "Bed Side Integrated Evaluation") which included all clinical, laboratory, and diagnostic data acquired bedside during the primary survey. Every VIBS profile was dichotomized in negative or positive if there was at least one altered item. We performed an analysis of correlation between VIBS and TBCT to determine sensibility, specificity, positive, and negative predictive value and likelihood ratio of VIBS.

RESULTS

Sensibility of VIBS in the prediction of positive CT scan was 100% and specificity was 31.7%. Positive and negative predictive value (95% C.I.) was 44.3 (38.8-49.5) and 100 (94.0-99.9). Positive and negative likelihood ratios were 1.464 and 0. Failure rate resulted in 0% and efficiency was 20.54%.

CONCLUSIONS

VIBS can safely rule out severe thoracic or abdominal injuries. This approach could limit the use of TBCT in one-fifth of suspected major trauma patients.

ISS alone, is not sufficient to correctly assign patients post hoc to trauma team requirement

Purpose

An injury severity score (ISS) ≥ 16 alone, is commonly used post hoc to define the correct activation of a trauma team. However, abnormal vital functions and the requirement of life-saving procedures may also have a role in defining trauma team requirement post hoc. The aim of this study was to describe their prevalence and mortality in severely injured patients and to estimate their potential additional value in the definition of trauma team requirement as compared to the definition based on ISS alone.

Methods

Retrospective analysis of a trauma registry including patients with trauma team activation from the years 2009 until 2015, who were 16 years of age or older and were brought to the trauma center directly from the scene. Patients were divided into a group with an ISS ≥ 16 vs. ISS < 16. For analysis a predefined list of abnormal vital functions and life-saving interventions was used.

Results

58,723 patients were included in the study (N = 32,653 with ISS ≥ 16; N = 26,070 with ISS < 16). From the total number of patients that required life-saving procedures or presented with abnormal vital functions 29.1% were found in the ISS < 16 group. From the ISS < 16 group, 36.7% of patients required life-saving procedures or presented with abnormal vital signs. The mortality of those was 8.1%.

Conclusions

Defining the true requirement of trauma team activation post hoc by using ISS ≥ 16 alone does miss a considerable number of subjects who require life-saving interventions or present with abnormal vital functions. Therefore, life-saving interventions and abnormal vital functions should be included in the definitions for trauma team requirement. Further studies have to evaluate, which life-saving procedures and abnormal vital functions are most relevant.

Undertriage in trauma: an ignored quality indicator?

BACKGROUND

Early identification of life-threatening injuries is essential to reduce morbidity and mortality in trauma patients. Failure to detect severe injury may cause delayed diagnosis and therapeutic interventions and is associated with increased morbidity. A national trauma system will contribute to ensure the optimal care for seriously injured patients throughout the treatment chain by, among other things, defining a sensitive triage tool for identifying severe injury and contribute to correct treatment destination. In 2017, a National trauma plan was implemented in Norway and several quality indicators were recommended to ensure an evaluation of potential gaps between achieved and desired quality, and thereby highlighting areas with potential for quality improvement. With this commentary, we want to draw attention to, what we believe is, an ignoring of an important quality indicator: undertriage in trauma.

MAIN BODY

Severely injured patients not met by a trauma team is commonly referred to as undertriage. An undertriage rate below 5 % is an internationally recognized quality indicator in trauma care and is emphasized in the Norwegian national trauma plan. However, whether hospitals measure and report data about undertriage, have received little attention. Therefore, a national survey was performed among Norwegian hospitals, where thirty-seven of forty trauma receiving hospitals contributed. The results of the survey showed that only half of Norwegian trauma hospitals were capable of providing these data. The results of this survey show that currently the national trauma system is not equipped to obtain important data on an important and specific quality indicator. An ongoing discussion at a national level is how to define severe injury, which may alter future definitions on undertriage.

CONCLUSIONS

Knowledge of undertriage in trauma is important to enhance patient safety, increase the precision of the triage tool and provide valuable learning information to individual hospitals and prehospital services. Currently only half of Norwegian hospitals who receive trauma patients report undertriage rates and unfortunately, only few hospital administrators request these data.

Characteristics of scene trauma patients discharged within 24-hours of air medical transport

Introduction

Helicopters play an important role in trauma; however, this service comes with safety risks, high transport costs, and downstream care charges.

Objective

Our objective was to determine the characteristics of early discharged trauma patients (<24 h length of stay) in order to reduce overtriage.

Methodology

Data were obtained from the trauma registries at one of two Level 1 trauma centers. Eligible patients included all scene trauma patients transported by helicopter to the Level 1 trauma centers from January 1, 2016, to December 31, 2017, who had a length of stay of 24 h or less. Patient factors such as age, gender, scene location, loaded miles, and transportation costs were collected. Trauma type, mechanism of injury, Abbreviated Injury Scale (AIS), Injury Severity Score, Revised Trauma Score, and prehospital vital signs were documented. Driving distances between the accident scene to local hospital, home of record to local hospital, and home of record to the Level I trauma center were also calculated for patients transported to Level 1 trauma center.

Results

Two hundred and twenty-six of 1042 total patients (21.7%) were discharged within 24 h of helicopter transport from the accident scene to trauma center. Less than 2% of patients were in the age group of 70 years or older. Only 2 (0.88%) patients discharged within 24 h had a prehospital systolic blood pressure <90 mmHg. For patients transported to Level 1 trauma center, the average loaded miles were 50.51 ± 14.99, with average transport charges being $27,921.19± $3536.61. Twenty-one percent of Level 1 trauma center patients were self-pay, and families typically drove 71.7 ± 123.23 miles to Level 1 trauma center versus 28.74 ± 40.62 to their local emergency department.

Conclusions

A significant number of patients transported from the scene are discharged within 24 h of admission to a trauma center. These patients rarely have prehospital hypotension, do not receive significant volumes of crystalloid resuscitation, and are infrequently over 70 years of age. One in five patients has no third-party coverage and assumes $27,921.19 in average transport charges.

Survey on worldwide trauma team activation requirement

Purpose

Trauma team activation (TTA) is thought to be essential for advanced and specialized care of very severely injured patients. However, non-specific TTA criteria may result in overtriage that consumes valuable resources or endanger patients in need of TTA secondary to undertriage. Consequently, criterion standard definitions to calculate the accuracy of the various TTA protocols are required for research and quality assurance purposes. Recently, several groups suggested a list of conditions when a trauma team is considered to be essential in the initial care in the emergency room. The objective of the survey was to post hoc identify trauma-related conditions that are thought to require a specialized trauma team that may be widely accepted, independent from the country’s income level.

Methods

A set of questions was developed, centered around the level of agreement with the proposed post hoc criteria to define adequate trauma team activation. The participants gave feedback before they answered the survey to improve the quality of the questions. The finalized survey was conducted using an online tool and a word form. The income per capita of a country was rated according to the World Bank Country and Lending groups.

Results

The return rate was 76% with a total of 37 countries participating. The agreement with the proposed criteria to define post hoc correct requirements for trauma team activation was more than 75% for 12 of the 20 criteria. The rate of disagreement was low and varied between zero and 13%. The level of agreement was independent from the country’s level of income.

Conclusions

The agreement on criteria to post hoc define correct requirements for trauma team activation appears high and it may be concluded that the proposed criteria could be useful for most countries, independent from their level of income. Nevertheless, more discussions on an international level appear to be warranted to achieve a full consensus to define a universal set of criteria that will allow for quality assessment of over- and undertriage of trauma team activation as well as for the validation of field triage criteria for the most severely injured patients worldwide.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01334-z) contains supplementary material, which is available to authorized users.

Better compliance with triage criteria in trauma would reduce costs with maintained patient safety

OBJECTIVE

To evaluate trauma triage criteria in terms of compliance, undertriage, and overtriage and identify risk factors for mistriage.

METHODS

In a retrospective cohort study, all consecutive trauma patients at a University Hospital in Sweden in 2012 were included. Patients were stratified into three groups on the basis of trauma team activation (full trauma team, limited trauma team, and no trauma team). Case records were reviewed for mechanism of injury, vital signs, and injuries. Compliance with alert criteria was evaluated and injury severity score combined with the Matrix method was used for assessment of overtriage and undertriage.

RESULTS

A total of 1424 trauma patients were included in the study. Seventy-three (5.1%) patients activated a full trauma team, 732 (51.4%) a limited trauma team, and 619 (43.5%) did not activate any trauma team. Undertriage was 2.7% [95% confidence interval (CI): 1.9-3.8%] and overtriage was 34.2% (95% CI: 23.5-46.3%) in the complete cohort. Compliance with 'trauma triage criteria' was assessed by comparing actual alerts with what was estimated to be the correct alert levels on the basis of prehospital case records. Compliance with full trauma team criteria was 80% (68-88%), limited trauma team was 54% (51-58%), and no trauma team was 79% (76-82%). Assuming full compliance with trauma criteria, the Matrix method resulted in an undertriage of 2.3% (95% CI: 1.6-3.3%) and an overtriage of 42.6% (95% CI: 32.4-53.2%).

CONCLUSION

The overtriage and undertriage in this study is in line with the recommendations of the American College of Surgeons Committee on Trauma. However, better compliance with trauma alert criteria would result in fewer trauma team activations without affecting patient safety.

Epidemiology of paediatric trauma in Norway: a single-trauma centre observational study

Background

Trauma is a major cause of mortality and morbidity in children globally. The burden of injury shows substantial geographical differences, with a significant mortality reduction in children in Norway during the last four decades. The aim was to describe the current epidemiology, resource use and outcome for all potential severely injured paediatric patients admitted to a Norwegian trauma centre.

Methods

This was a single-centre retrospective observational study. All patients aged 0–17 years received by a trauma team between 01 January 2004 and 31 December 2016 (13 years) at St. Olav’s University Hospital were included. Severe injury was defined as Injury Severity Score > 15.

Results

A total of 873 patients were included, of which 536 (61%) were male. The median age was 13 years (IQR 7–16). Six per cent (n = 52) of the patients were transferred from other hospitals. Blunt trauma constituted 98%, with traffic (n = 532/61%) and falls (n = 233/27%) as the most common mechanisms. Eight patients (1%) died within 30 days of hospital admission. Fifteen per cent (n = 128) were severely injured. Among the patients transferred from another hospital, 46% (n = 24) had severe injuries. Helicopter Emergency Medical Services (HEMS) were more used in younger age groups and in patients more severely injured.

Conclusions

In a developed healthcare system, the number of potentially severely injured children is small and with very few deaths following trauma. Transport and falls represent the most common causes of injury throughout all age groups, though with a tendency towards more transport-related injuries with increasing age. In-hospital trauma care is characterized by a low threshold for a multidisciplinary reception, low use of intensive care and need for emergency surgical procedures, though with increased need in the older children.

Electronic supplementary material

The online version of this article (10.1186/s12245-019-0236-9) contains supplementary material, which is available to authorized users.

Proximal penetrating extremity injuries-An opportunity to decrease overtriage?

BACKGROUND

Penetrating injuries to the extremity proximal to the elbow or knee are anatomic criteria for full trauma team activation (FFTA) by the American College of Surgeon's Committee on Trauma standards. This criterion lacks objective evidence-based support. Overtriage of trauma team activation may result in excessive costs and resource burden at trauma centers. We hypothesized that FFTA for penetrating injuries to the proximal extremities by anatomic criteria alone may lead to significant overtriage.

METHODS

A 3-year retrospective review (2013-2015) was completed of all patients evaluated at an urban Level I trauma center with isolated penetrating extremity injuries. Data included the number of full and limited trauma team activations as well as criterion met, Injury Severity Score (ISS), injury, limb characteristics, and disposition. Overtriage was defined as FFTA for an ISS of 15 or less, with a goal rate less than 50%.

RESULTS

We identified 6,335 total trauma team activations with 795 isolated penetrating extremity injuries. Of these injuries, 413 (51.9%) were injuries proximal to the joint. Within this subgroup, 71.2% of patients were discharged from the emergency department with a median ISS of 1 and no additional intervention. Only 5.3% of patients that did not meet additional FFTA criteria underwent immediate operative intervention. By comparison, 21% of FFTAs and 5.8% of limited trauma team activations underwent immediate operative intervention during the 3-year period. Of the 413 isolated penetrating proximal-extremity injuries, only one had an ISS of 15 or greater, resulting in a 99.7% overtriage rate.

CONCLUSION

Penetrating injuries to the extremities are common in urban trauma centers. Full trauma team activation based on anatomic, rather than physiologic, criteria may lead to a significant overtriage rate. Further distinction in the level of trauma team activation may be made based on hard signs of neurovascular injury.

LEVEL OF EVIDENCE

Epidemiological study, level III; Care Management, level IV.

A prospective stepped wedge cohort evaluation of the new national trauma team activation criteria in Sweden - the TRAUMALERT study

Background

Trauma triage based on prehospital information facilitates correct allocation of in-hospital resources. The Swedish national two-tier trauma team activation (TTA) criteria were revised in 2016. The current study aimed to evaluate the safety and efficacy of the new criteria.

Methods

Five centres covering trauma care for 1.2 million inhabitants registered all trauma patients prospectively in the Swedish trauma registry (SweTrau) prior to and after stepwise introduction of new TTA criteria within the cohort (a prospective stepped-wedge cohort study design; period August 2016–November 2017). Evaluation of full- and limited-TTA frequency, under- and overtriage were performed at equal duration before and after this change.

Results

The centres registered 1948 patients, 1882 (96.6%) of which were included in the study. With new criteria, frequency of full-TTA was unchanged, while limited-TTA decreased with 46.3% (from 988 to 531). 30-day trauma mortality was unchanged. The overtriage was 107/150 (71.3%) with former criteria, and 104/144 (72.2%) with new criteria, p = 0.866. Undertriage was 50/1037 (4.8%) versus 39/551 (7.1%), p = 0.063. Undertriage was consistently > 20% in patients with fall injury. Among patients with Injury Severity Score (ISS) > 15, 50/93 (53.8%) did not initiate full-TTA with former, vs 39/79 (49.4%) with new criteria, p = 0.565. Age > 60-years was a risk factor for undertriage (OR 2.89, p < 0.001), while low fall injuries indicated a trend (OR 2.70, p = 0.051).

Conclusions

The newly implemented Swedish TTA criteria result in a reduction in limited TTA frequency, indicating an increased efficiency in use of resources. The over- and undertriage is unchanged compared to former criteria, thus upholding patient safety.

Electronic supplementary material

The online version of this article (10.1186/s13049-019-0619-1) contains supplementary material, which is available to authorized users.

Delays in arrival and treatment in emergency departments: Women, children and non-trauma consultations the most at risk in humanitarian settings

INTRODUCTION

Delays in arrival and treatment at health facilities lead to negative health outcomes. Individual and external factors could be associated with these delays. This study aimed to assess common factors associated with arrival and treatment delays in the emergency departments (ED) of three hospitals in humanitarian settings.

METHODOLOGY

This was a cross-sectional study based on routine data collected from three MSF-supported hospitals in Afghanistan, Haiti and Sierra Leone. We calculated the proportion of consultations with delay in arrival (>24 hours) and in treatment (based on target time according to triage categories). We used a multinomial logistic regression model (MLR) to analyse the association between age, sex, hospital and diagnosis (trauma and non-trauma) with these delays.

RESULTS

We included 95,025 consultations. Males represented 65.2%, Delay in arrival was present in 27.8% of cases and delay in treatment in 27.2%. The MLR showed higher risk of delay in arrival for females (OR 1.2, 95% CI 1.2-1.3), children <5 (OR 1.4, 95% CI 1.4-1.5), patients attending to Gondama (OR 30.0, 95% CI 25.6-35.3) and non-trauma cases (OR 4.7, 95% CI 4.4-4.8). A higher risk of delay in treatment was observed for females (OR 1.1, 95% CI 1.0-1.1), children <5 (OR 2.0, 95% CI 1.9-2.1), patients attending to Martissant (OR 14.6, 95% CI 13.9-15.4) and non-trauma cases (OR 1.6, 95% CI 1.5-1.7).

CONCLUSIONS

Women, children <5 and non-trauma cases suffered most from delays. These delays could relate to educational and cultural barriers, and severity perception of the disease. Treatment delay could be due to insufficient resources with consequent overcrowding, and severity perception from medical staff for non-trauma patients. Extended community outreach, health promotion and support to community health workers could improve emergency care in humanitarian settings.

A Consensus-Based Criterion Standard for the Requirement of a Trauma Team

BACKGROUND

Trauma team activation (TTA) represents a considerable expenditure of trauma centre resources. It is mainly triggered by field triage criteria. The overall quality of the criteria may be evaluated based on the rate of over- and undertriage. However, there is no gold standard that defines which adult patients truly require a trauma team. The objective of this study was to develop consensus-based criteria defining the necessity for a trauma team.

METHODS

A consensus group was formed by trauma specialists experienced in emergency and trauma care with a specific interest in field triage and having previously participated in guideline development. A literature search was conducted to identify criteria that have already been used or suggested. The initial list of criteria was discussed in two Delphi round and two consensus conferences. The entire process of discussion and voting was highly standardized and extensively documented, resulting in a final list of criteria.

RESULTS

Initially 95 criteria were identified. This was subsequently reduced to 20 final criteria to appropriately indicate the requirement for attendance of a trauma team. The criteria address aspects related to injury severity, admission to an intensive care unit, death within 24 h, need for specified invasive procedures, need for surgical and/or interventional radiological procedures, and abnormal vital signs within a defined time period.

CONCLUSIONS

The selected criteria may be applied as a tool for research and quality control concerning TTA. However, future studies are necessary to further evaluate for possible redundancy in criteria that may allow for further reduction in criteria.

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.

Simple modification of trauma mechanism alarm criteria published for the TraumaNetwork DGU® may significantly improve overtriage - a cross sectional study

Background

No consensus exists in the literature on the use of uniform emergency room trauma team activation criteria (ERTTAC). Today excessive over- or undertriage rates continue to be a challenge for most trauma centres. Application of ERTTAC, published for use in the German TraumaNetwork DGU^®, at a Swiss trauma centre resulted in a high overtriage rate. The aim of the investigation was to analyse the ERTTAC in detail with the intention of possible improvement.

Methods

The investigation included consecutive adult (age > 15 years) trauma patients treated at the emergency department of a level II trauma centre from 01.01.2013–31.12.2015. All data were collected prospectively. To identify over- and undertriage, patients with an Injury Severity Score (ISS) > 15 were defined as requiring specific emergency room (ER) management. ANOVA, Student’s t-test and chi-square analysis were used for statistical analysis with mean values ± standard deviation.

Results

1378 adult injured (64% male) received ER trauma team treatment (mean age 48.3 ± 21.2 years; ISS 9.7 ± 9.6) during the observation period. Of those, 326 ER patients (23.7%) were diagnosed with an ISS > 15, which proved to be an overtriage of 76.3%. 80/406 trauma patients with an ISS > 15 were not referred to the ER, resulting in an actual undertriage rate of 19.7%, mainly because the criteria list was not observed. Effectively applying ERTTAC according to the protocol in all cases would have reduced undertriage to 2.0% (8/406). The most frequent trigger for trauma team activation was injury mechanism (65%). A simulation revealed that omitting the criterion ‘passenger of car or truck’ (n = 326) would have prevented overtriage in 257 cases, as such lowering overtriage rate to 62.4% and at the same time increasing undertriage by only 8 cases to 7.1%.

Conclusion

Application of ERTTAC as published for TraumaNetwork DGU^® resulted in a lower undertriage but higher overtriage rate than recommended by the American College of Surgeons. Omitting the criterion ‘passenger of car or truck’ markedly improved overtriage with only a minimal increase in undertriage.

Trial registration

NCT02165137; retrospectively registered 11. June 2014.

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.

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.

Accuracy of Perceived Estimated Travel Time by EMS to a Trauma Center in San Bernardino County, California

INTRODUCTION

Mobilization of trauma resources has the potential to cause ripple effects throughout hospital operations. One major factor affecting efficient utilization of trauma resources is a discrepancy between the prehospital estimated time of arrival (ETA) as communicated by emergency medical services (EMS) personnel and their actual time of arrival (TOA). The current study aimed to assess the accuracy of the perceived prehospital estimated arrival time by EMS personnel in comparison to their actual arrival time at a Level II trauma center in San Bernardino County, California.

METHODS

This retrospective study included traumas classified as alerts or activations that were transported to Arrowhead Regional Medical Center in 2013. We obtained estimated arrival time and actual arrival time for each transport from the Surgery Department Trauma Registry. The difference between the median of ETA and actual TOA by EMS crews to the trauma center was calculated for these transports. Additional variables assessed included time of day and month during which the transport took place.

RESULTS

A total of 2,454 patients classified as traumas were identified in the Surgery Department Trauma Registry. After exclusion of trauma consults, walk-ins, handoffs between agencies, downgraded traumas, traumas missing information, and traumas transported by agencies other than American Medical Response, Ontario Fire, Rialto Fire or San Bernardino County Fire, we included a final sample size of 555 alert and activation classified traumas in the final analysis. When combining all transports by the included EMS agencies, the median of the ETA was 10 minutes and the median of the actual TOA was 22 minutes (median of difference=9 minutes, p<0.0001). Furthermore, when comparing the difference between trauma alerts and activations, trauma activations demonstrated an equal or larger difference in the median of the estimated and actual time of arrival (p<0.0001). We also found month and time of day to be associated with variability in the difference between the median of the estimated and actual arrival time (p=0.0082 and p=0.0005 for month and time of the day, respectively).

CONCLUSION

EMS personnel underestimate their travel time by a median of nine minutes, which may cause the trauma team to abandon other important activities in order to respond to the emergency department prematurely. The discrepancy between ETA and TOA is unpredictable, varying by month and time of day. As such, a better method of estimating patient arrival time is needed.

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.

Norwegian trauma care: a national cross-sectional survey of all hospitals involved in the management of major trauma patients

BACKGROUND

Approximately 10% of the Norwegian population is injured every year, with injuries ranging from minor injuries treated by general practitioners to major and complex injuries requiring specialist in-hospital care. There is a lack of knowledge concerning the caseload of potentially severely injured patients in Norwegian hospitals. Aim of the study was to describe the current status of the Norwegian trauma system by identifying the number and the distribution of contributing hospitals and the caseload of potentially severely injured trauma patients within these hospitals.

METHODS

A cross-sectional survey with a structured questionnaire was sent in the summer of 2012 to all Norwegian hospitals that receive trauma patients. These were defined by number of trauma team activations in the included hospitals. A literature review was performed to assess over time the development of hospitals receiving trauma patients.

RESULTS

Forty-one hospitals responded and were included in the study. In 2011, four trauma centres and 37 acute care hospitals received a total of 6,570 trauma patients. Trauma centres received 2,175 (33%) patients and other hospitals received 4,395 (67%) patients. There were significant regional differences between health care regions in the distribution of trauma patients between trauma centres and acute care hospitals. More than half (52.5%) of the hospitals received fewer than 100 patients annually. The national rate of hospital admission via trauma teams was 13 per 10,000 inhabitants. There was a 37% (from 65 to 41) reduction in the number of hospitals receiving trauma patients between 1988 and 2011.

CONCLUSIONS

In 2011, hospital acute trauma care in Norway was delivered by four trauma centres and 37 acute care hospitals. Many hospitals still receive a small number of potentially severely injured patients and only a few hospitals have an electronic trauma registry. Future development of the Norwegian trauma system needs to address the challenge posed by a scattered population and long geographical distances. The implementation of a trauma system, carefully balanced between centres with adequate caseloads against time from injury to hospital care, is needed and has been shown to have a beneficial effect in countries with comparable challenges.

What is optimal timing for trauma team alerts? A retrospective observational study of alert timing effects on the initial management of trauma patients

Background

Trauma teams improve the initial management of trauma patients. Optimal timing of trauma alerts could improve team preparedness and performance while also limiting adverse ripple effects throughout the hospital. The purpose of this study was to evaluate how timing of trauma team activation and notification affects initial in-hospital management of trauma patients.

Methods

Data from a single hospital trauma care quality registry were matched with data from a trauma team alert log. The time from patient arrival to chest X-ray, and the emergency department length of stay were compared with the timing of trauma team activations and whether or not trauma team members received a preactivation notification.

Results

In 2009, the trauma team was activated 352 times; 269 times met the inclusion criteria. There were statistically significant differences in time to chest X-ray for differently timed trauma team activations (P = 0.003). Median time to chest X-ray for teams activated 15–20 minutes prearrival was 5 minutes, and 8 minutes for teams activated <5 minutes before patient arrival. Timing had no effect on length of stay in the emergency department (P = 0.694). We found no effect of preactivation notification on time to chest X-ray (P = 0.474) or length of stay (P = 0.684).

Conclusion

Proactive trauma team activation improved the initial management of trauma patients. Trauma teams should be activated prior to patient arrival.

Calculating trauma triage precision: effects of different definitions of major trauma

BACKGROUND

Triage is the process of classifying patients according to injury severity and determining the priority for further treatment. Although the term "major trauma" represents the reference against which over- and undertriage rates are calculated, its definition is inconsistent in the current literature. This study aimed to investigate the effects of different definitions of major trauma on the calculation of perceived over- and undertriage rates in a Norwegian trauma cohort.

METHODS

We performed a retrospective analysis of patients included in the trauma registry of a primary, referral trauma centre. Two "traditional" definitions were developed based on anatomical injury severity scores (ISS >15 and NISS >15), one "extended" definition was based on outcome (30-day mortality) and mechanism of injury (proximal penetrating injury), one "extensive" definition was based on the "extended" definition and on ICU resource consumption (admitted to the ICU for >2 days and/or transferred intubated out of the hospital in ≤2 days), and an additional four definitions were based on combinations of the first four.

RESULTS

There were no significant differences in the perceived under- and overtriage rates between the two "traditional" definitions (NISS >15 and ISS >15). Adding "extended" and "extensive" to the "traditional" definitions also did not significantly alter perceived under- and overtriage. Defining major trauma only in terms of the mechanism of injury and mortality, with or without ICU resource consumption (the "extended" and "extensive" groups), drastically increased the perceived overtriage rates.

CONCLUSION

Although the proportion of patients who were defined as having sustained major trauma increased when NISS-based definitions were substituted for ISS-based definitions, the outcomes of the triage precision calculations did not differ significantly between the two scales. Additionally, expanding the purely anatomic definition of major trauma by including proximal penetrating injury, 30-day mortality, ICU LOS greater than 2 days and transferred intubated out of the hospital at ≤2 days did not significantly influence the perceived triage precision. We recommend that triage precision calculations should include anatomical injury scaling according to NISS. To further enhance comparability of trauma triage calculations, researchers should establish a consensus on a uniform definition of major trauma.

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).

Patients Referred to a Norwegian Trauma Centre: effect of transfer distance on injury patterns, use of resources and outcomes

BACKGROUND

Triage and interhospital transfer are central to trauma systems. Few studies have addressed transferred trauma patients. This study investigated transfers of variable distances to OUH (Oslo University Hospital, Ullevål), one of the largest trauma centres in Europe.

METHODS

Patients included in the OUH trauma registry from 2001 to 2008 were included in the study. Demographic, injury, management and outcome data were abstracted. Patients were grouped according to transfer distance: ≤20 km, 21-100 km and > 100 km.

RESULTS

Of the 7.353 included patients, 5.803 were admitted directly, and 1.550 were transferred. The number of transfers per year increased, and there was no reduction in injury severity during the study period. Seventy-six per cent of the transferred patients were severely injured. With greater transfer distances, injury severity increased, and there were larger proportions of traffic injuries, polytrauma and hypotensive patients. With shorter distances, patients were older, and head injuries and injuries after falls were more common. The shorter transfers less often activated the trauma team: ≤20 km -34%; 21-100 km -51%; > 100 km -61%, compared to 92% of all directly admitted patients. The mortality for all transferred patients was 11%, but was unequally distributed according to transfer distance.

CONCLUSION

This study shows heterogeneous characteristics and high injury severity among interhospital transfers. The rate of trauma team assessment was low and should be further examined. The mortality differences should be interpreted with caution as patients were in different phases of management. The descriptive characteristics outlined may be employed in the development of triage protocols and transfer guidelines.

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.

Portable ultrasonography in mass casualty incidents: The CAVEAT examination

Ultrasonography used by practicing clinicians has been shown to be of utility in the evaluation of time-sensitive and critical illnesses in a range of environments, including pre-hospital triage, emergency department, and critical care settings. The increasing availability of light-weight, robust, user-friendly, and low-cost portable ultrasound equipment is particularly suited for use in the physically and temporally challenging environment of a multiple casualty incident (MCI). Currently established ultrasound applications used to identify potentially lethal thoracic or abdominal conditions offer a base upon which rapid, focused protocols using hand-carried emergency ultrasonography could be developed. Following a detailed review of the current use of portable ultrasonography in military and civilian MCI settings, we propose a protocol for sonographic evaluation of the chest, abdomen, vena cava, and extremities for acute triage. The protocol is two-tiered, based on the urgency and technical difficulty of the sonographic examination. In addition to utilization of well-established bedside abdominal and thoracic sonography applications, this protocol incorporates extremity assessment for long-bone fractures. Studies of the proposed protocol will need to be conducted to determine its utility in simulated and actual MCI settings.

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.

Cancellations of (helicopter-transported) mobile medical team dispatches in the Netherlands

Background

The trauma centre of the Trauma Center Region North-West Netherlands (TRNWN) has consensus criteria for Mobile Medical Team (MMT) scene dispatch. The MMT can be dispatched by the EMS-dispatch centre or by the on-scene ambulance crew and is transported by helicopter or ground transport. Although much attention has been paid to improve the dispatch criteria, the MMT is often cancelled after being dispatched. The aim of this study was to assess the cancellation rate and the noncompliant dispatches of our MMT and to identify factors associated with this form of primary overtriage.

Methods

By retrospective analysis of all MMT dispatches in the period from 1 July 2006 till 31 December 2006 using chart review, we conducted a consecutive case review of 605 dispatches. Four hundred and sixty seven of these were included for our study, collecting data related to prehospital triage, patient’s condition on-scene and hospital course.

Results

Average age was 35.9 years; the majority of the patients were male (65.3%). Four hundred and thirty patients were victims of trauma, sustaining injuries in most cases from blunt trauma (89.3%). After being dispatched, the MMT was cancelled 203 times (43.5%). Statistically significant differences between assists and cancellations were found for overall mortality, mean RTS, GCS and ISS, mean hospitalization, length and amount of ICU admissions (p < 0.001). All dispatches were evaluated by using the MMT-dispatch criteria and mission appropriateness criteria. Almost 26% of all dispatches were neither appropriate, nor met the dispatch criteria. Fourteen missions were appropriate, but did not meet the dispatch criteria. The remaining 318 dispatches had met the dispatch criteria, of which 135 (30.3%) were also appropriate. The calculated additional costs of the cancelled dispatches summed up to a total of € 34,448, amounting to 2.2% of the total MMT costs during the study period.

Conclusion

In our trauma system, the MMT dispatches are involved with high rates of overtriage. After being dispatched, the MMT is cancelled in almost 50% of all cases. We found an undertriage rate of 4%, which we think is acceptable. All cancellations were justified. The additional costs of the cancelled missions were within an acceptable range. According to this study, it seems to be possible to reduce the overtriage rate of the MMT dispatches, without increasing the undertriage rate to non-acceptable levels.

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.