Increased mortality with undertriaged patients in a mature trauma center with an aggressive trauma team activation system.

Abstract

The American College of Surgeons Committee on Trauma (ACS-COT) has determined that a 5% pre-hospital undertriage [UT; defined as Injury Severity Score (ISS)>15 and not sent to a trauma center] is an acceptable rate for pre-hospital transfer to a non-trauma center. We sought to determine if this level of undertriage is acceptable within a mature Level II trauma center as a measure of the adequacy of its trauma activation system. Our trauma activation system encompasses anatomic, physiologic, and mechanism of injury criteria. We defined UT as ISS>15 and no trauma activation. All UT patients during the period 2000-2010 were compared to properly triaged patients (CT). The variables examined were mortality, emergency department (ED) length of stay (LOS), hospital LOS, complications, Coumadin use, and age >64 years. There were 18,324 patients admitted, with 1,156 (6.3%) UT. UT is associated with an increase in mortality [odds ratio (OR) 3.0; 95% confidence interval (CI) 2.4-3.8; p<0.001), longer ED LOS (OR 54.5; 95% CI 45.5-63.5; p<0.001), and longer hospital LOS (OR 1.7; 95% CI 1.4-2.1; p<0.001). In addition, UT patients had a two-fold increase in complications (OR 2.0; 95% CI 1.6-2.5; p<0.001). When controlling for age ≥65 years, Revised Trauma Score (RTS)>7.0, and one or moreco-morbidities, UT patients had 2.18 times higher odds of mortality than their CT counterparts (OR 2.18; 95% CI 1.57-3.01; p<0.001). Patients on pre-hospital Coumadin (OR 3.61; 95% CI 3.04-4.30; p<0.001) and age >64 years (OR 4.93; 95% CI 4.36-5.58; p<0.001) were significant predictors of being undertriaged. A p-value≤0.05 was considered to be significant. Standard trauma activation criteria may not be adequate to identify the at-risk severely injured trauma patient. Further refinement of in-house trauma triage protocols is necessary if trauma centers are to improve outcomes following trauma.