Assessing the Feasibility of the American College of Surgeons' Benchmarks for the Triage of Trauma Patients
To test the feasibility of accomplishing the American College of Surgeons Committee on Trauma benchmarks of less than 5% undertriage (treatment of patients with moderate to severe injuries at nontrauma centers [NTCs]) and less than 50% overtriage (transfer of patients with minor injuries to trauma centers [TCs]) given current practice patterns by describing transfer patterns for patients taken initially to NTCs and estimating volume shifts and potential lives saved if full implementation were to occur.
Retrospective cohort study of adult trauma patients initially evaluated at NTCs in Pennsylvania (between April 1, 2001, and March 31, 2005). We used published estimates of mortality risk reduction associated with treatment at TCs.
Undertriage and overtriage rates, estimated patient volume shifts, and number of lives saved.
A total of 93,880 adult trauma patients were initially evaluated at NTCs in Pennsylvania between 2001 and 2005. Undertriage was 69%; overtriage was 53%. Achieving less than 5% undertriage would require the transfer of 18,945 patients per year, a 5-fold increase from current practice (3650 transfers per year). Given an absolute mortality risk reduction of 1.9% for patients with moderate to severe injuries treated at TCs, this change in practice would save 99 potential lives per year or would require 191 transfers per year to save 1 potential life.
Given current practice patterns, American College of Surgeons Committee on Trauma recommendations for the regionalization of trauma patients may not be feasible. To achieve 5% undertriage, TCs must increase their capacity 5-fold, physicians at NTCs must increase their capacity to discriminate between moderate to severe and other injuries, or the guidelines must be modified.
Available from: Huiyun Xiang
- "Using inpatient discharge data from 1997 and 1998 in 18 states representing all 4 US geographic regions, Nathens et al  found that 36.5% of patients with major trauma received care at centers not designated for trauma care. Another study found a secondary undertriage rate (triage after initial evaluation at NTC) as high as 69% in Pennsylvania . Our result is a conservative estimate, perhaps because our national estimates did not include 14% of major trauma patients in the 2010 NEDS due to lack of specific information about level of trauma care received. "
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There is evidence that regionalized trauma care and appropriate triage of major trauma patients improve patient outcomes. However, the national rate of undertriage and diagnoses of undertriaged patients are unknown.
We used the 2010 Nationwide Emergency Department Sample (NEDS) to estimate the national rate of undertriage, identify the prevalent diagnoses, and conduct a simulation analysis of the capacity increase required for level I and II trauma centers to accommodate undertriaged patients. Undertriaged patients were those with major trauma, Injury Severity Score (ISS) ≥ 16, who received definitive care at nontrauma centers (NTC) or level III trauma centers. The rate of undertriage was calculated with those receiving definitive care at a NTC center or level III center as a fraction of all major trauma patients.
The estimated number of major trauma patient discharges in 2010 was 232,448. Level of care was known for 197,702 major trauma discharges and 34.0% were undertriaged in emergency departments. Elderly patients were at a significantly higher risk of being undertriaged. Traumatic brain injury (TBI) was the most common diagnosis, 40.2 % of the undertriaged patient diagnoses. In order to accommodate all undertriaged patients, level I and II trauma centers nationally would have to increase their capacity by 51.5%.
We found that over 1/3 of U.S. ED major trauma patients were undertriaged and more than 40% of undertriaged diagnoses were TBIs. A significant capacity increase at Level I and II trauma centers to accommodate these patients appears not feasible.
Available from: Erika Frischknecht Christensen
- "When looking at e.g. trauma patients, the American College of Surgeons states that 5–10% undertriage is probably inevitable and overtriage of 30–50% is common in trauma-triage systems . Some quantity of overtriage is definitely needed to avoid oversights of severe conditions. "
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ABSTRACT: A criteria-based nationwide Emergency Medical Dispatch (EMD) system was recently implemented in Denmark. We described the system and studied its ability to triage patients according to the severity of their condition by analysing hospital admission and case-fatality risks.
This was a register-based follow-up study of all 1-1-2 calls in a 6-month period that were triaged according to the Danish Index -- the new criteria-based dispatch protocol. Danish Index data were linked with hospital and vital status data from national registries. Confidence intervals (95%) for proportions with binomial data were computed using exact methods. To test for trend the Wald test was used.
Information on level of emergency according to the Danish Index rating was available for 67,135 patients who received ambulance service. Emergency level A (urgent cases) accounted for 51.4% (n = 34,489) of patients, emergency level B for 46.3% (n = 31,116), emergency level C for 2.1% (n = 1,391) and emergency level D for 0.2% (n = 139). For emergency level A, the median time from call receipt to ambulance dispatch was 2 min 1 s, and the median time to arrival was 6 min 11 s. Data concerning admission and case fatality was available for 55,270 patients. The hospital admission risk for emergency level A patients was 64.4% (95% CI = 63.8-64.9). There was a significant trend (p < 0.001) towards lower admission risks for patients with lower levels of emergency. The case fatality risk for emergency level A patients on the same day as the 1-1-2 call was 4.4% (95% CI = 4.1-4.6). The relative case-fatality risk among emergency level A patients compared to emergency level B--D patients was 14.3 (95% CI: 11.5-18.0).
The majority of patients were assessed as Danish Index emergency level A or B. Case fatality and hospital admission risks were substantially higher for emergency level A patients than for emergency level B--D patients. Thus, the newly implemented Danish criteria-based dispatch system seems to triage patients with high risk of admission and death to the highest level of emergency. Further studies are needed to determine the degree of over- and undertriage and prognostic factors.
Available from: Dana Mukamel
- "Study (PTOS) on patients admitted to Pennsylvania trauma centers between 2000 and 2009. The Pennsylvania population is representative of injured patients nationally (Mohan et al. 2011). The PTOS database is a populationbased statewide trauma registry that includes data on all patients admitted with traumatic injuries to accredited trauma centers in Pennsylvania meeting one or more of the PTOS inclusion criteria: admission to the Intensive Care Unit or step-down unit, hospital length-of-stay greater than 48 hours, hospital admissions transferred from another hospital, and transfers out to an accredited trauma center (2007). "
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To determine whether outcome disparities between black and white trauma patients have decreased over the last 10years. Data SourcePennsylvania Trauma Outcome Study. Study DesignWe performed an observational cohort study on 191,887 patients admitted to 28 Level 1 and Level II trauma centers. The main outcomes of interest were (1) death, (2) death or major complication, and (3) failure-to-rescue. Hospitals were categorized according to the proportion of black patients. Multivariate regression models were used to estimate trends in racial disparities and to assess whether the source of racial disparities was within or between hospitals. Principal FindingsTrauma patients admitted to hospitals with high concentrations of blacks (>20 percent) had a 45 percent higher odds of death (adj OR: 1.45, 95 percent CI: 1.09-1.92) and a 73 percent higher odds of death or major complication (adj OR: 1.73, 95 percent CI: 1.42-2.11) compared with patients admitted to hospitals treating low proportions of blacks. Blacks and whites admitted to the same hospitals had no difference in mortality (adj OR: 1.05, 95 percent CI: 0.87, 1.27) or death or major complications (adj OR: 1.01; 95 percent CI: 0.90, 1.13). The odds of overall mortality, and death or major complications have been reduced by 32 percent (adj OR: 0.68; 95 percent CI: 0.54-0.86) and 28 percent (adj OR: 0.72; 95 percent CI: 0.60-0.85) between 2000 and 2009, respectively. Racial disparities did not change over 10years. Conclusion
Despite the overall improvement in outcomes, the gap in quality of care between black and white trauma patients in Pennsylvania has not narrowed over the last 10years. Racial disparities in trauma are due to the fact that black patients are more likely to be treated in lower quality hospitals compared with whites.
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