327 Contribution of Pulse to Physiologic Criteria of Field Triage of Trauma Victims

Abstract

Out-of-hospital trauma triage criteria are used to identify patients at risk of serious injury, thereby transporting them to the appropriate treatment facility and ensuring that they receive proper level of care for the injury sustained. Physiologic criteria are generally perceived as the most important determinants of the need to transport patients to a trauma center. Step 1 of the National Trauma Triage Protocol use the physiologic criteria systolic blood pressure <90, respiratory rate (RR) <10 or >29 for adults and children and Glasgow Coma Scale <14. We assessed the improvement in triage accuracy and increase in overtriage by adding heart rate <50 or >120 criteria to the Step 1 criteria. Design-We conducted a retrospective, observational, population-based study of patients whose out-of-hospital experiences were recorded on a Trauma Out-of-Hospital Care Report which included checkboxes to record presence of any of the physiologic criteria. We determined the increased improvement in HR to predict outcomes of admission, ICU admission, hospital length of stay > 2 days, Injury Severity Score > 15, and need for major operative procedure or death. Setting-Suffolk County, NY, where, due to the contained nature of the County and the location of hospitals, very few patients requiring ambulance transport are taken to a facility outside of the County, creating essentially a closed natural system which consists of 13 hospitals and over 90 ambulance corps. Participants-All adults over 18 years old whose out-of-hospital experience was recorded on a Trauma Out-of-Hospital Care Report from 2003 through 2007. These cases were matched with the County's regional Trauma Registry in order to determine the association of trauma triage criteria with patient outcomes. This study was approved by the Stony Brook institutional review board. There were 17001 adult trauma patients included in the analysis; of these, 191 (1.1%) had a positive heart rate criterion. The sensitivity of Step 1 criteria ranged from 16% (length of stay > 2) to 35% (Injury Severity Score > 15); all specificities were above 97.5%. The improvement in outcome prediction and the increase in overtriage by including heart rate as a predictor are shown in the table. Nearly all patients with heart rate criterion and had the outcomes would have already been triaged to a trauma center due to the concurrent nature of physiologic criteria. The overtriage ratio, defined as the number of additional cases overtriaged by including heart rate divided by the number of additional outcomes predicted, range from 7.5 for admission to 20 for Injury Severity Score >15.Tabled 1Number of cases correctly triagedNumber of cases overtriagedOutcome (# w/outcome)All PC except HRAll PC plus HR# added by HRAll PC except HRAll PC plus HR# added by HRAdmission (516)89991033841375ICU (185)6065536744780LOS > 2 (467)7684835142877ISS > 15 (281)97101435043181MOR-D (285)7783637044979 Open table in a new tab Overtriage ratios suggest that using heart rate as a predictor may result in many unnecessary patients being transported to trauma centers relative to the number of those who are appropriate transfers. However, the low incidence of patients with the heart rate criterion would not crowd trauma centers.