Time Delay in Motor Vehicle Accident Arrival: A Critical Analysis of Trauma Team Activation

Introduction This research aims to investigate the role of time since trauma (TST) in refining trauma team activation (TTA) criteria within a level I trauma center. We analyze the association between TST and post-emergency department (ED) disposition, proposing new insights for the enhancement of TTA criteria. Methods A retrospective analysis was conducted on a dataset comprising 3,693 patients presenting to a level I trauma center following motor vehicle accidents (MVAs) from 2016 to 2021. Data from a trauma registry, encompassing time of injury, time of ED arrival, TTA status, and post-ED disposition, were utilized. TST was calculated as the difference between the time of injury and the time of ED arrival. Patients that received TTA, full or partial, were categorized based on TST (less than one hour, one to two hours, and two or more hours). Statistical analyses, including chi-square tests, were performed using the Statistical Analysis System (SAS) (version 3.8, SAS Institute Inc., Cary, NC). Results Of the 1,261 patients meeting the criteria, 98.3% received TTA, with decreasing TTA rates observed with increasing TST (p = 0.0076). A significant association was found between TST and post-ED disposition for patients who received TTA (p = 0.0007). Compared to the other TST groups, a higher proportion of patients with a TST of two or more hours were admitted, sent to the intensive care unit (ICU), and sent to the operating room (OR).  Conclusion The study indicates a statistically significant relationship between TST and TTA rates, challenging our assumptions about the decreased need for TTA over time. While a longer TST was associated with a lower percentage of TTA, patients with a TST of two or more hours demonstrated increased rates of admission, ICU utilization, and surgical interventions. This suggests that TTA criteria may benefit from refinement to include patients with longer TST. Acknowledging study limitations, such as a small sample size and retrospective design, this research contributes valuable insights into potential considerations for optimizing trauma care protocols.

The Trauma Activation Review Committee: Response to Undertriage During a Period of Rapid Growth at a Level II Trauma Center

Trauma triage criteria are constantly being refined for improved identification of severely injured patients. When errors occur, they should be tracked, and triage criteria adjusted to minimize these events. Two time periods of trauma registry data at a single rural level II trauma center were retrospectively compared to evaluate demographics, injuries, and outcomes to identify triage errors. In 300 activated trauma patients during 2011, overtriage was 23% and undertriage was 3.7%. In 1035 activated trauma patients during 2019, overtriage was 20.5% and undertriage was 2.2%. Mortality decreased over time overall. In 2019, Trauma I patients were older, spent more time on the ventilator, and in the ICU (all P < .001). Trauma II patients were also older, had lower ISS, hospital days, and ventilator days (all P < .001). During rapid growth, evaluation of overtriage and undertriage can provide useful feedback for hospital staff to refine triage choices and improve patient outcomes.

Prehospital stroke triage: a modeling study on the impact of triage tools in different regions

BACKGROUND AND PURPOSE

Direct transportation to a thrombectomy-capable intervention center is beneficial for patients with ischemic stroke due to large vessel occlusion (LVO), but can delay intravenous thrombolytics (IVT). The aim of this modeling study was to estimate the effect of prehospital triage strategies on treatment delays and overtriage in different regions.

METHODS

We used data from two prospective cohort studies in the Netherlands: the Leiden Prehospital Stroke Study and the PRESTO study. We included stroke code patients within 6 hours from symptom onset. We modeled outcomes of RACE triage and triage with a personalized decision tool, using drip-and-ship as reference. Main outcomes were overtriage (stroke code patients incorrectly triaged to an intervention center), reduced delay to endovascular thrombectomy (EVT), and delay to IVT.

RESULTS

We included 1798 stroke code patients from four ambulance regions. Per region, overtriage ranged from 1-13% (RACE triage) and 3-15% (personalized tool). Reduction of delay to EVT varied by region between 24 ± 5 minutes (n = 6) to 78 ± 3 (n = 2), while IVT delay increased with 5 (n = 5) to 15 minutes (n = 21) for non-LVO patients. The personalized tool reduced delay to EVT for more patients (25 ± 4 minutes (n = 8) to 49 ± 13 (n = 5)), while delaying IVT with 3-14 minutes (8-24 patients). In region C, most EVT patients were treated faster (reduction of delay to EVT 31 ± 6 minutes (n = 35), with RACE triage and the personalized tool.

CONCLUSIONS

In this modeling study, we showed that prehospital triage reduced time to EVT without disproportionate IVT delay, compared to a drip-and-ship strategy. The effect of triage strategies and the associated overtriage varied between regions. Implementation of prehospital triage should therefore be considered on a regional level.

Association of In-Hospital Mortality and Trauma Team Activation: A 10-Year Study

Background: Early trauma team activation (TTA) may improve clinical outcomes through early diagnosis and timely intervention by a dedicated multidisciplinary team. Controversy seems to exist about the effect of establishing trauma team systems in traumatic injury populations. Our aim was to identify factors that may be associated with clinical outcomes in trauma injury and to investigate the effect of trauma team activation. Method: This retrospective descriptive study included all traumatic patients from the Taipei Tzu Chi Hospital Trauma Database. All prehospital vital signs, management, injury type, injury mechanisms, hospitalization history, and clinical outcomes were analyzed, and multivariable logistic regression was used to investigate the association between trauma team activation and clinical outcomes. Subgroups of TTA in minor injury and non-TTA in major injury were also analyzed. Result: In this study, a total of 11,946 patients were included, of which 10,831 (90.7%) patients were minor injury (ISS < 16), and 1115 (9.3%) patients were major injury (ISS ≥ 16). In the minor injury population, TTA had a higher intensive care unit (ICU) admission rate, operation rate, re-operation rate, and prolonged total length of stay (LOS). In the major injury population, TTA had a higher mortality rate, prolonged total LOS, and prolonged ICU LOS. After adjusting for mechanism of injury and injury severity, there was no association between in-hospital mortality and TTA, compared with the non-TTA group. However, the TTA group had a higher risk of ICU admission, prolonged ICU LOS, and prolonged total LOS. The subgroup analysis showed trauma team activation had a higher risk of mortality in the 60- to 80-year-old population, major injury (ISS ≥ 16), consciousness clear population, and non-head injury group. Conclusions: We found there was no significant association between in-hospital mortality and TTA. However, in the TTA group, there was a higher risk of ICU admission, prolonged total, LOS, and prolonged ICU LOS. In the subgroup analysis, TTA had a higher risk of mortality in the 60- to 80-year-old population, major injury (ISS ≥ 16), consciousness clear population, and non-head injury group. Our results reflect TTA-criteria-selected patients with greater ISS and a high risk of mortality.

Air Rescue for Pediatric Trauma in a Metropolitan Region of Brazil: Profiles, Outcomes, and Overtriage Rates

Besides ensuring a quick response and transport of trauma victims, helicopter support also involves risks to patients and professionals and has higher operational costs. Studying prehospital triage criteria and their relationship with patient overtriage and outcomes is important, particularly in newly established services and in developing countries with limited health budgets. This could help improve the use of the helicopter rescue and provide better management of the costs and risks related to it. The objective of this study was to determine the epidemiologic and severity profiles of pediatric victims of trauma attended by helicopter in a Brazilian Metropolitan Area to evaluate the outcomes and overtriage rates related to pediatric air rescue in the region. We conducted an observational and retrospective study using 49 hospital and prehospital records from victims of trauma aged <18 years old (yo) assisted by helicopter and then transferred to a tertiary University Hospital. Of the 49 patients, 39 (79.6%) individuals were male, and the mean age was 11.3 yo. Vehicular collisions accounted for 15 (30.6%) of the traumas, and traumatic brain injuries occurred in 28 (57.1%) cases. A total of 29 (59.1%) individuals had severe trauma (Injury Severity Score; ISS >15), and 34 (69.4%) required admission to the intensive care unit. Overtriage varied from 18.4 to 40.8% depending on the criteria used for its definition, being more frequent in individuals aged between 1 and 5 yo. Death occurred in 10 (20.4%) patients. On prehospital evaluation, we classified 29/32 (90.6%) patients with severe trauma according to the Pediatric Trauma Score (PTS ≤8) and 18/25 (72%) according to the Revised Trauma Score (RTS ≤11). Of these, 7/29 (24.1%) and 6/18 (33.3%), respectively, presented ISS <15 at in-hospital evaluation. None of the patients with PTS >8 and 3/7 (42.8%) of those with RTS >11 presented ISS >15. In conclusion, air rescue of pediatric trauma victims was used mainly for critically ill individuals, resulting in rates of overtriage compatible with that found in the literature. PTS showed the lowest rates of overtriage within excellent rates of undertriage.

Old Age With a Traumatic Mechanism of Injury Should Be a Trauma Team Activation Criterion

BACKGROUND

Age is not a standard trauma team activation (TTA) criteria recommended by the Committee on Trauma. However, there is concern that vital signs in elderly patients are often unreliable. In addition, elderly patients are at risk after moderate trauma. At our institution, age ≥ 70 years with traumatic mechanisms of injury has been a TTA criterion for more than 15 years.

OBJECTIVE

Our aim was to determine whether age ≥70 years as a TTA criterion appropriately identifies patients in need of additional resources without significantly impacting overtriage rates.

METHODS

We conducted a retrospective trauma registry study of TTAs for age ≥ 70 years from January 2012-December 2016. Demographics, injury data, Injury Severity Score (ISS), procedures, emergency department (ED) disposition, and hospital data were collected. Primary outcome was mortality, secondary outcomes were intensive care unit (ICU) and hospital lengths of stay. Patients were stratified into meeting standard criteria (TTA-S) or activated based on age alone (TTA-A). TTA patients with ISS > 15, ED intubation, ICU admission, immediate operating room or catheter-based intervention, and mortalities were appropriately triaged.

RESULTS

During the study, there were 5436 total TTAs. Seven hundred and thirty-nine TTAs in patients aged ≥ 70 years, of which 198 (26.8%) were TTA-S and 541 (73.2%) were TTA-A. In the TTA-A group, 49 (9%) patients died, 149 (27.5%) had ISS > 15, 65 (12%) underwent immediate intervention, 72 (13%) had ED intubations, and 306 (56.6%) required admission to the ICU. The overtriage rate in the TTA-A group was 39.6%.

CONCLUSIONS

Elderly patients with severe trauma patients often do not meet the standard TTA criteria, resulting in potentially dangerous undertriage. Addition of age (≥70 years) criterion for TTA reduces undertriage and does not result in excessive overtriage.

Anticoagulated Trauma Patients: A Level I Trauma Center's Response to a Growing Geriatric Population

BACKGROUND

Injured older adults often receive delayed care in the emergency department (ED) because they do not meet criteria for trauma team activation (TTA). This is particularly dangerous for the increasing number of patients taking anticoagulant or antiplatelet (AC/AP) medication at the time of injury.

OBJECTIVES

The present study examined improvements in processes of care and triage accuracy when TTA criteria include an escalated response for older anticoagulated patients.

METHODS

A retrospective study was performed at a Level I trauma center. The study population (referred to as A55) included patients aged 55 years or older who were taking an AC/AP medication at the time of injury. Study periods included 11 months prior to the criteria change (Phase 1: July 2013-May 2014; n = 107) and 11 months after the change (Phase 2: July 2014-May 2015; n = 211). Differences were assessed with Kruskal-Wallis and chi-squared tests.

RESULTS

More A55 patients received a full or limited TTA after criteria were revised (70% vs. 26%, p < 0.001). Undertriage was reduced from 13% to 2% (p < 0.001). The trauma center significantly decreased time to first laboratory result, time to first computed tomography scan, and total time in ED prior to admission for A55 patients arriving from the scene of injury or by private vehicle.

CONCLUSION

Criteria that escalated the trauma response for A55 patients led to reductions in undertriage for anticoagulated older adults, as well as more timely mobilization of important clinical resources.