Abstract
BackgroundNo consensus exists in the literature on the use of uniform emergency room trauma team activation criteria (ERTTAC). Today excessive over- or undertriage rates continue to be a challenge for most trauma centres. Application of ERTTAC, published for use in the German TraumaNetwork DGU®, at a Swiss trauma centre resulted in a high overtriage rate. The aim of the investigation was to analyse the ERTTAC in detail with the intention of possible improvement.MethodsThe investigation included consecutive adult (age > 15 years) trauma patients treated at the emergency department of a level II trauma centre from 01.01.2013–31.12.2015. All data were collected prospectively. To identify over- and undertriage, patients with an Injury Severity Score (ISS) > 15 were defined as requiring specific emergency room (ER) management. ANOVA, Student’s t-test and chi-square analysis were used for statistical analysis with mean values ± standard deviation.Results1378 adult injured (64% male) received ER trauma team treatment (mean age 48.3 ± 21.2 years; ISS 9.7 ± 9.6) during the observation period. Of those, 326 ER patients (23.7%) were diagnosed with an ISS > 15, which proved to be an overtriage of 76.3%. 80/406 trauma patients with an ISS > 15 were not referred to the ER, resulting in an actual undertriage rate of 19.7%, mainly because the criteria list was not observed. Effectively applying ERTTAC according to the protocol in all cases would have reduced undertriage to 2.0% (8/406). The most frequent trigger for trauma team activation was injury mechanism (65%). A simulation revealed that omitting the criterion ‘passenger of car or truck’ (n = 326) would have prevented overtriage in 257 cases, as such lowering overtriage rate to 62.4% and at the same time increasing undertriage by only 8 cases to 7.1%.ConclusionApplication of ERTTAC as published for TraumaNetwork DGU® resulted in a lower undertriage but higher overtriage rate than recommended by the American College of Surgeons. Omitting the criterion ‘passenger of car or truck’ markedly improved overtriage with only a minimal increase in undertriage.Trial registrationNCT02165137; retrospectively registered 11. June 2014.
Highlights
No consensus exists in the literature on the use of uniform emergency room trauma team activation criteria (ERTTAC)
During the same time period n = 80 trauma patients with an Injury Severity Score (ISS) > 15 arrived at the emergency department without ER trauma team activation (ERTTA), i.e., the actual undertriage rate was 19.7% (80 out of 406). 72 of these 80 patients in effect fulfilled at least one ERTTA criterion, i.e. the undertriage for this group would have been 2.0% if the ER trauma team had been activated according to the protocol
These eight patients presented with an age range of 17 to 79 years, an ISS from 17 to 29 and a RISC (Revised Injury Severity Score) from 1.4 to 62.5
Summary
No consensus exists in the literature on the use of uniform emergency room trauma team activation criteria (ERTTAC). No generally accepted international standard or national recommendations for ER trauma team activation (ERTTA) criteria (ERTTAC) were found in the literature, on the contrary, published trauma triage protocols are highly divergent [1,2,3,4,5,6]. For the TraumaNetwork DGU® ERTTAC a Glasgow Coma Scale (GCS) < 14 was chosen as an alert criterion for ERTTA instead of a GCS < 9 as given in the evidence-based recommendations. This principal decision for a more aggressive inclusion of trauma patients in the ER aimed to reduce the risk of missing severe trauma cases
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