Validation and Refinement of a Rule to Predict Emergency Intervention in Adult Trauma Patients
Department of Emergency Medicine, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80206, USA. Annals of emergency medicine
(Impact Factor: 4.68).
06/2011; 58(2):164-71. DOI: 10.1016/j.annemergmed.2011.02.027
Trauma centers use "secondary triage" to determine the necessity of trauma surgeon involvement. A clinical decision rule, which includes penetrating injury, an initial systolic blood pressure less than 100 mm Hg, or an initial pulse rate greater than 100 beats/min, was developed to predict which trauma patients require emergency operative intervention or emergency procedural intervention (cricothyroidotomy or thoracotomy) in the emergency department. Our goal was to validate this rule in an adult trauma population and to compare it with the American College of Surgeons' major resuscitation criteria.
We used Level I trauma center registry data from September 1, 1995, through November 30, 2008. Outcomes were confirmed with blinded abstractors. Sensitivity, specificity, and 95% confidence intervals (CIs) were calculated.
Our patient sample included 20,872 individuals. The median Injury Severity Score was 9 (interquartile range 4 to 16), 15.3% of patients had penetrating injuries, 13.5% had a systolic blood pressure less than 100 mm Hg, and 32.5% had a pulse rate greater than 100 beats/min. Emergency operative intervention or procedural intervention was required in 1,099 patients (5.3%; 95% CI 5.0% to 5.6%). The sensitivities and specificities of the rule and the major resuscitation criteria for predicting emergency operative intervention or emergency procedural intervention were 95.6% (95% CI 94.3% to 96.8%) and 56.1% (95% CI 55.4% to 56.8%) and 85.5% (95% CI 83.3% to 87.5%) and 80.9% (95% CI 80.3% to 81.4%), respectively.
This new rule was more sensitive for predicting the need for emergency operative intervention or emergency procedural intervention directly compared with the American College of Surgeons' major resuscitation criteria, which may improve the effectiveness and efficiency of trauma triage.
Available from: Kevin Baumlin
- "Public health researchers can monitor hypertension prevalence in a community through collected ED vitals signs data  . Decision support tools can be triggered or adjusted based on vital sign analysis  . "
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ABSTRACT: Vital signs in our emergency department information system were entered into free-text fields for heart rate, respiratory rate, blood pressure, temperature and oxygen saturation.
We sought to convert these text entries into a more useful form, for research and QA purposes, upon entry into a data warehouse.
We derived a series of rules and assigned quality scores to the transformed values, conforming to physiologic parameters for vital signs across the age range and spectrum of illness seen in the emergency department.
Validating these entries revealed that 98% of free-text data had perfect quality scores, conforming to established vital sign parameters. Average vital signs varied as expected by age. Degradations in quality scores were most commonly attributed logging temperature in Fahrenheit instead of Celsius; vital signs with this error could still be transformed for use. Errors occurred more frequently during periods of high triage, though error rates did not correlate with triage volume.
In developing a method for importing free-text vital sign data from our emergency department information system, we now have a data warehouse with a broad array of quality-checked vital signs, permitting analysis and correlation with demographics and outcomes.
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Trauma centers use guidelines to determine when a trauma surgeon is needed in the emergency department (ED) on patient arrival. A decision rule from Loma Linda University identified patients with penetrating injury and tachycardia as requiring emergent surgical intervention. Our goal was to validate this rule and to compare it with the American College of Surgeons' Major Resuscitation Criteria (MRC).
We used data from 1993 through 2010 from 2 level 1 trauma centers in Denver, CO. Patient demographics, injury severity, times of ED arrival and surgical intervention, and all variables of the Loma Linda Rule and the MRC were obtained. The outcome, emergent intervention (defined as requiring operative intervention by a trauma surgeon within 1 hour of arrival to the ED or performance of cricothyroidotomy or thoracotomy in the ED), was confirmed using standardized abstraction. Sensitivities, specificities, and 95% confidence intervals were calculated.
There were 8,078 patients included, and 47 (0.6%) required emergent intervention. Of the 47 patients, the median age was 11 years (interquartile range [IQR] 7 to 14 years), 70% were male, 30% had penetrating mechanisms, and the median Injury Severity Score (ISS) was 25 (IQR 9 to 41). At the 2 institutions, the Loma Linda Rule had a sensitivity and specificity of 69% (95% CI 45% to 94%) and 76% (95% CI 69% to 83%), respectively, and the MRC had a sensitivity and specificity of 80% (95% CI 70% to 92%) and 81% (95% CI 77% to 85%), respectively.
Emergent surgical intervention is rare in the pediatric trauma population. Although precision of predictive accuracies of the Loma Linda Rule and MRC were limited by small numbers of outcomes, neither set of criteria appears to be sufficiently accurate to recommend their routine use.
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