Abstract
BackgroundWe conducted a systematic review to evaluate and compare the accuracy of pre-hospital triage tools for major trauma in the context of the development of the Italian National Institute of Health guidelines on major trauma integrated management.MethodsPubMed, Embase, and CENTRAL were searched up to November 2019 for studies investigating pre-hospital triage tools. The ROC (receiver operating characteristics) curve and net clinical benefit for all selected triage tools were performed. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies–2. Certainty of the evidence was judged with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.ResultsWe found 15 observational studies of 13 triage tools for adults and 11 for children. In adults, according to the ROC curve and the net clinical benefit, the most reliable tool was the Northern French Alps Trauma System (TRENAU), adopting injury severity score (ISS) > 15 as reference (sensitivity (Sn), 0.92; specificity (Sp), 0.41; 1 study; sample size, 2572; high certainty of the evidence). When mortality as reference was considered, the pre-hospital triage tool with the best net clinical benefit trajectory was the New Trauma Score (NTS) < 18 (Sn, 0.82; Sp, 0.86; 1 study; sample size, 1001; moderate certainty of the evidence). In children, high variability among all triage tools for sensitivity and specificity was found.ConclusionSensitivity and specificity varied across all available pre-hospital trauma triage tools. TRENAU and NTS are the best accurate triage tools for adults, whereas in the pediatric area a large variability prevents any firm conclusion.
Highlights
Injured trauma patients represent a global concern, responsible for over 5 million deaths each year and leaving even more patients with lifelong injury-related disabilities [1]
The 2006 American College of Surgeons (ACS) Committee on Trauma (COT) Optimal Resources Document (ORD) focused on pre-hospital triage, stated that “it was generally agreed” a rate of 25 to 50% of non-major trauma patients taken to a trauma center was acceptable to maintain a rate of major trauma patients taken to a non-trauma center at less than 5%
Characteristics of included studies None of the included studies were test-treatment Randomized controlled trials (RCT) allowing to establish a direct link between test and Accuracy of pre-hospital triage tools in adults A total of 13 studies reported data on triage tools accuracy [26–38]
Summary
Injured trauma patients represent a global concern, responsible for over 5 million deaths each year and leaving even more patients with lifelong injury-related disabilities [1]. In stressful situations and under great pressure, it can be difficult to make a correct estimate of injury severity [5] In this context, prehospital trauma triage is a critical step in transporting the right patient to the right hospital in a timely fashion; this makes pre-hospital care imperative as an integrated part of the whole health-care pathway [6]. The 2006 American College of Surgeons (ACS) Committee on Trauma (COT) Optimal Resources Document (ORD) focused on pre-hospital triage, stated that “it was generally agreed” a rate of 25 to 50% of non-major trauma patients taken to a trauma center (over triage) was acceptable to maintain a rate of major trauma patients taken to a non-trauma center (under triage) at less than 5%.
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