Trauma Team Activation at an Emergency Department

Background: Trauma team activation at a Level 1 trauma centre In Quebec, Canada, is primarily at the emergency department’s staff discretion. Trauma teams may be activated prehospital, based on information provided by field paramedics or in the emergency department based on the patient’s condition on arrival. In this study, we examined over and undertriage rates based on present trauma team activation criteria. We also examined if trauma team activation, for those patients solely meeting pre-hospital major trauma criteria, would result in significant overactivation of the trauma team. Methods: This is a single-centre retrospective medical record review. Primary ambulance transport reports from May 15, 2018 to December 31, 2020, were screened to identify patients aged ≥16 years who met pre-hospital trauma triage criteria to bypass community hospitals to arrive directly at the Level 1 trauma centre. We examined pre-hospital triage criteria, trauma team involvement, Injury Severity Scores (ISS) and final disposition. Patients were evaluated for over and undertriage and rates were compared to the rates assuming all patients were to have a trauma team activation. We considered patients overtriaged if they had a full trauma team activation but had an ISS <12 and were discharged from the emergency department. Undertriage was defined as any patient with an ISS ³12 and did not have a trauma team activation. Results: Of the 371 patients who met study inclusion criteria, 123 (33.3%) did not meet trauma team activation criteria, while 214 (57.7%) had a trauma team activation. Of these, 49 patients (13.2%) were undertriaged and 31 patients (8.4%) were overtriaged and 25.8% of the major trauma patients (ISS ³ 12) were undertriaged. A trauma team activation for all meeting field triage criteria increased overtriage to 25.3% and brought undertriage rates to 0%, with statistically significant differences based on the Wilcoxon signed ranks test (p<0.05). Conclusions: In this study, undertriage rates were well above 5%. Trauma team activation, based on local field trauma triage criteria adapted from the CDC-ACSCOT field triage criteria, eliminates undertriage and keeps overtriage rates below 35%. This research suggests that field triage criteria accurately predict major trauma and the need for the involvement of the trauma team and that the condition of the trauma patient in the pre-hospital setting is accurately predicting the need for advanced trauma care

Trauma team activation criteria as predictors of patient disposition from the emergency department

BackgroundSensitive decision making tools should assist prehospital personnel in the triage of injured patients, identifying those who require immediate lifesaving interventions and safely reducing unnecessary under- and overtriage. In 2014 a new trauma team activation (TTA) tool was implemented in Central Norway. The overall objective of this study was to evaluate the ability of the new TTA tool to identify severe injury.MethodsThis was a multi-center observational cohort study with retrospective data analysis. All patients received by trauma teams at seven hospitals in Central Norway between 01.01.2015 to 31.12.2015 were included. Severe injury was defined as Injury Severity Score (ISS) > 15. Overtriage was defined as the rate of patients with TTA and ISS < 15, whilst patients with TTA and ISS > 15 were defined as correctly triaged.ResultsA total of 1141 patients were identified, of which 998 were eligible for triage criteria analysis. Median age was 35 years (IQR 20–58) and the male proportion was 67%. Mechanism of injury was predominantly blunt trauma (96%) with transport related accidents (62%) followed by falls (22%) the most common. Overall, median injury severity score (ISS) was low and severely injured patients (ISS > 15) comprised 13% of the cohort. Utility of specific TTA criteria were: physiology 20%, anatomical injury 21%, mechanism of injury (MOI) 53% and special causes 6%. Overtriage among all patients was 87%, and for those with physiologic criteria 66%, anatomical injury 82%, mechanism of injury 97% and special causes criteria 92%, respectively.ConclusionsSevere injury was infrequent and there was a substantial rate of overtriage. The ability of the TTA tool was relatively insensitive in identifying severe injury, but showed increased performance when utilizing physiologic and anatomical injury criteria. Many of the TTA mechanism of injury criteria might be considered for removal from the triage tool due to substantial rates of overtriage. This has relevance for the proposed development of national Norwegian TTA criteria.

Background: To improve utilization of resources and reduce overtriage, two-tiered trauma team activation (TTA) system was implemented. The system activates a complete or selective trauma team (CTT, STT). Activation is based on the mechanism of injury (MOI), prehospital vital signs and injuries. Objectives: The objective was to evaluate the feasibility, effectiveness and safety of the implementation of a two-tiered system and whether the triage is done according to the TTA criteria. Methods: A prospective observational study was performed at the emergency department (ED) of a Level I trauma center. Data were collected on TTA criteria, patient demographics, MOI, prehospital vital signs, imaging modalities and blood gas analysis in the ED and inhospital data. Results: In 3 months, 186 patients were presented to the trauma resuscitation room. Thirty-four patients were excluded, 152 patients were included for analysis. Median age was 48 years (range 1–93), 64% were males. In 73%, the CTT was activated, in 27% the STT, the STT was upgraded three times. Seventy-nine patients had to be admitted, the median length of stay was 5 days (range 1–62). Thirty-eight patients needed Intensive Care Unit (ICU) admission; the median ICU stay was 3 days (range 1–33). Three patients died in the resuscitation room, in total, nine patients died. Overtriage was 29% and undertriage 7%. No significant difference was found for mortality, duration of hospital admission or ICU admission across the four groups (correct activation STT, undertriage, overtriage, and correct activation CTT). Conclusions: This TTA system identifies those patients in need of a CTT adequately with an undertriage percentage of 7%, indicative of improved care for the severely injured and a more appropriate use of resources. With this model, the overtriage is set to an acceptable percentage of 29%.

Introduction: South Africa has a high prevalence of trauma causing a significant healthcare and financial burden. Various scoring systems have been developed to guide trauma team activation (TTA). To date, however, there are no standardised criteria for TTA. The aim of this preliminary study was to analyse the practice of clinical judgement TTA when compared to the American College of Surgeons Committee on Trauma (ACS-COT) TTA guideline and the Loma Linda Rule for TTA. Methods: This was a retrospective analysis of trauma registry data over a one-year period from a Level 1 trauma centre in South Africa. Results: There were 9207 trauma patients that presented to the Emergency Department during the 1-year study period. The prevalence of trauma team activation by clinical judgement was 9.4%. Only 407 patients (48%) of the clinical judgement TTAs fulfilled the ACS-COT guidelines for TTA. Using the Loma Linda Rule, 456 patients (53.8%) of the clinical judgement TTAs fulfilled TTA criteria. Despite the over-triage by the clinical judgement TTA, almost two-thirds of the TTA patients were admitted to the intensive care or high care units. Conclusions: This preliminary study showed that TTA using healthcare provider clinical judgement resulted in trauma team over-activation when compared to the ACS-COT guideline and the Loma Linda Rule. Over-activation of the trauma team consumes valuable resources and potentially endangers those patients who actually need TTA and cannot receive it. Implementation of a standardised TTA tool could potentially aid in the optimisation of patient care and appropriate resource utilisation.

To determine the impact of the presence of an attending trauma surgeon during trauma team activation on system function and patient outcome. After a retrospective review of medical records and trauma registry, a comparative study between two American College of Surgeons Committee on Trauma Level I trauma centers was performed. One center (Hennepin County Medical Center) required a chief surgical resident, two junior residents, and a board-certified emergency medicine faculty to be present in the emergency department for all trauma team activations. The attending trauma surgeon was notified at the time of trauma team activation and was neither required to be present in the emergency department at time of patient arrival nor in the hospital 24 h/day. The other center (St. Paul Ramsey Medical Center) required a chief surgical resident, two junior residents, a board-certified emergency medicine faculty member, and an attending trauma surgeon to be present in the emergency department for all trauma activations and in hospital 24 hours/day. Over a 21-month period, all major trauma patients (Injury Severity Score > 15 or emergent operation within 4 hours of admission and any Injury Severity Score) that triggered trauma team activation were examined. Resuscitation time, time to incision, probability of survival, and mortality were analyzed. Resuscitation time was shorter at St. Paul Ramsey Medical Center when compared with Hennepin County Medical Center. Analysis by mechanism of injury demonstrates that this was true for blunt trauma (39+/-13 vs. 27+/-12 minutes, p = 0.001) and for penetrating trauma (28+/-14 vs. 24+/-17 minutes, p = 0.01). Subgroup analysis of penetrating trauma victims demonstrated that there was a significant difference in resuscitation times for gunshot wounds but not for stabs. There was no difference in how quickly operations could be initiated for blunt trauma patients. However, in penetrating cases, time to incision was significantly shorter at St. Paul Ramsey Medical Center (50+/-29 vs. 66+/-43 minutes, p = 0.01). There was no significant difference in mortality for any category of Trauma and Injury Severity Score probability of survival in blunt or penetrating trauma. Analysis of "in-house" and "out-house" time intervals demonstrated no difference in survival in any mechanism of injury, nor was there a difference in overall mortality. The presence of a trauma surgeon on the trauma team reduced resuscitation time and reduced time to incision for emergent operations, particularly in penetrating trauma. However, it had no measurable impact on mortality based on Trauma and Injury Severity Score probability of survival. Attending trauma surgeon presence on the trauma team improves in-hospital trauma system function without affecting patient outcome.

The ACS Committee on Trauma specifies prehospital criteria that trigger trauma team activation (TTA). The study aims to define the relationship between TTA and time of day, mechanism of injury, and need for operative intervention. All trauma patients presenting to LAC+USC (January 2008-July 2018) after triggering TTA were screened. Patients were excluded if time of ED arrival was undocumented. Demographics, injury data, and outcomes were analyzed. After exclusions (<1%), 54,826 patients were enrolled. The median age was 35 [IQR 23-53]. The median Injury Severity Score was 4 [1-10]. The most common mechanisms of injury were falls (n = 14,166; 31%), auto versus pedestrian collisions (n = 11,921; 26%), and motor vehicle collisions (n = 11,024; 24%). Penetrating trauma comprised 16 per cent (n = 8,686). The busiest hour for TTAs was 19:00 to 20:00, although penetrating trauma was most common between 23:00 and 01:00. Emergent surgical intervention in absolute numbers was most frequent between 20:00 and 01:00. As a proportion of the number of TTAs per hour, emergent operative intervention was most frequent between 23:00 and 06:00. In conclusion, the volume of TTAs and the triggering mechanism of injury vary significantly by time of day. The need for operative intervention is highest overnight. This information can be used to help increase hospital preparedness and allocate resources accordingly.

Objectives & BackgroundAppropriate activation of multi-disciplinary trauma teams improves outcome for severely injured patients, but can disrupt normal service in the rest of the hospital. Derriford Hospital uses a two-tiered...

Background: For patients sustaining major trauma, decreasing time to definitive care remains a primary goal. Specialized trauma team involvement is essential for coordinating the emergency department care of complex major trauma patients. The aim of this study was to evaluate if the timing of trauma team involvement impacts length of stay and time to definitive care in the emergency department. Methods: This is a single-centre retrospective medical record review, including patients meeting Quebec pre-hospital triage criteria for major trauma from May 15, 2018 to December 31, 2020. We assessed time from patient arrival until departure from the resuscitation room, time to CT scan, time to disposition, and overall length of emergency department stay. Patients were grouped according to the timing of trauma team activation (TTA) as (1) pre-hospital notification, (2) on arrival in the emergency department, (3) receiving a trauma consult only, or (4) no trauma team involvement. Mean times and standard deviations were calculated, and group differences were assessed using the Kruskal-Wallis test and the independent sample Mann-Whitney U test. Results: We identified 371 patients meeting our inclusion criteria; there were no differences between groups in mean time spent in the resuscitation room based on the timing of trauma team involvement (45-51 minutes, p=0.422). A trauma team activation with pre-hospital notification was associated with a statistically significant shorter time to CT scan (62-81 minutes, p=0.010), time to disposition (6:37-13:41, p&lt;0.001), and total emergency department length of stay (9:22-23:16 hours: minutes, p&lt;0.001). Conclusion: Appropriate trauma team activation improves performance indicators used to evaluate the quality of care in the emergency department. This research suggests that pre-hospital trauma team activation should be considered the standard of care for all patients meeting pre-hospital field triage criteria for major trauma. Keywords: trauma, triage, pre-hospital, trauma team activation, trauma quality indicators

Trauma team activation (TTA) criteria were first implemented in the Emergency Department (ED) of Songklanagarind Hospital in 2009 to treat severe trauma patients. To determine the efficacy of the TTA criteria on the acute trauma care process in the ED and the 28-day mortality rate. A 1-year prospective cohort study was conducted at the ED. Trauma patients who were 18years old and over who met the TTA criteria were enrolled. Demographic data, physiologic parameters, ED length of stay (EDLOS), and the injury severity score (ISS) were recorded. Multiple logistic regression was used to determine the factors affecting 28-day mortality. Institutional review board approval was obtained from the Prince of Songkla University. A total of 80 patients (74 male and 6 female) were eligible with a mean age of 34.3years old. Shock, penetrating torso injury, and pulse rate >120 beats per minute were the three most common criteria for trauma team consultation. At the ED, 9 patients (11.3%) were non-survivors, 30 patients (37.5%) needed immediate operation, and 41 patients (51.2%) were admitted. All of the arrest patients died (p<0.0001). The median time of EDLOS was 85min: 68min in the non-survivor group and 120min in the survivor group (p=0.028). The median ISS was 21.0 (1-75): 25.0 in the non-survivor group and 17.0 in the survivor group. When compared with pilot data prior to TTA implementation, the median time of EDLOS improved from 184 to 85min and the 28-day mortality rate decreased from 66.7 to 46.3%. The high ISS was a predictor of death. The trauma team activation criteria improved acute trauma care in the ED which was demonstrated by the decreased EDLOS and mortality rate. A high ISS is the sole parameter predicting mortality.

BackgroundField triage is important for regional trauma systems providing high sensitivity to avoid that severely injured are deprived access to trauma team resuscitation (undertriage), yet high specificity to avoid resource over-utilization (overtriage). Previous informal trauma team activation (TTA) at Ulleval University Hospital (UUH) caused imprecise triage. We have analyzed triage precision after introduction of TTA guidelines.MethodsRetrospective analysis of 7 years (2001–07) of prospectively collected trauma registry data for all patients with TTA or severe injury, defined as at least one of the following: Injury Severity Score (ISS) > 15, proximal penetrating injury, admitted ICU > 2 days, transferred intubated to another hospital within 2 days, dead from trauma within 30 days. Interhospital transfers to UUH and patients admitted by non-healthcare personnel were excluded. Overtriage is the fraction of TTA where patients are not severely injured (1-positive predictive value); undertriage is the fraction of severely injured admitted without TTA (1-sensitivity).ResultsOf the 4 659 patients included in the study, 2 221 (48%) were severely injured. TTA occurred 4 440 times, only 2 002 of which for severely injured (overtriage 55%). Overall undertriage was 10%. Mechanism of injury was TTA criterion in 1 508 cases (34%), of which only 392 were severely injured (overtriage 74%). Paramedic-manned prehospital services provided 66% overtriage and 17% undertriage, anaesthetist-manned services 35% overtriage and 2% undertriage. Falls, high age and admittance by paramedics were significantly associated with undertriage. A Triage-Revised Trauma Score (RTS) < 12 in the emergency department reduced the risk for undertriage compared to RTS = 12 (normal value). Field RTS was documented by anaesthetists in 64% of the patients compared to 33% among paramedics.Patients subject to undertriage had an ISS-adjusted Odds Ratio for 30-day mortality of 2.34 (95% CI 1.6–3.4, p < 0.001) compared to those correctly triaged to TTA.ConclusionTriage precision had not improved after TTA guideline introduction. Anaesthetists perform precise trauma triage, whereas paramedics have potential for improvement. Skewed mission profiles makes comparison of differences in triage precision difficult, but criteria or the use of them may contribute. Massive undertriage among paramedics is of grave concern as patients exposed to undertriage had increased risk of dying.

&lt;b&gt;Introduction:&lt;/b&gt; This study characterizes patients with abdominal and/or pelvic trauma admitted to Emergency Departments (EDs) in Poland, focusing on differentiating stable from unstable cases. The objective is to inform of evidence-based guidelines for managing these injuries in both critical and non-critical trauma patients. &lt;br&gt;&lt;br&gt;&lt;b&gt;Aim:&lt;/b&gt; The study aims to characterize patients admitted to randomly selected Hospital Emergency Departments in Poland after abdominal and/or pelvic injury. It aims to provide evidence-based recommendations for managing abdominal and pelvic trauma. &lt;br&gt;&lt;br&gt;&lt;b&gt;Materials and methods:&lt;/b&gt; A retrospective analysis was conducted using anonymized medical records from three randomly selected EDs in Poland, representing Levels I, II, and III of the Polish Trauma Care System. Patients with abdominal and/ or pelvic trauma were identified and categorised by trauma type, injury mechanism, severity, and stability. Data were summarized using descriptive statistics, and relationships between variables were analyzed using the Chi-square or Fisher's exact test, with α = 0.05 for significance. &lt;br&gt;&lt;br&gt;&lt;b&gt;Results:&lt;/b&gt; Of 93,714 ED patients, 708 met the study criteria, with 215 confirmed cases of abdominal and/or pelvic trauma. Closed (blunt) injuries were predominant (96.3%), especially low-energy injuries among older adults. Mild trauma was most common (64.65%) according to the CRAMS scale, while severe injuries accounted for only 8.84%. A substantial proportion of patients were stable upon ED admission, with 69.3% of abdominal trauma and 100% of pelvic trauma patients exhibiting no signs of organ failure or peritoneal symptoms. The findings indicate a higher-than-expected prevalence of stable trauma cases, underscoring the need for guidelines to manage stable but potentially vulnerable patients. &lt;br&gt;&lt;br&gt;&lt;b&gt;Discussion:&lt;/b&gt; This study offers insights into the demographic and clinical characteristics of patients with abdominal and/or pelvic trauma in EDs, with a particular focus on differentiating stable from unstable trauma patients and addressing distinct clinical needs. By testing key hypotheses on trauma type, severity, and patient stability, the study brings attention to areas in trauma management that may benefit from revised protocols and resource allocation. Our findings underscore the importance of recognizing stable trauma patients as a significant but underrepresented group in trauma literature. Existing studies are often conducted in EDs located within trauma centres, which influences the patient populations represented in the literature. Additionally, a common inclusion criterion in such studies is trauma team activation or the explicit identification of unstable patients with systolic blood pressure below 90 mmHg. Research focusing on stable patients with abdominal and/ or pelvic trauma is rare and typically addresses aspects other than the specific characteristics of this group. However, in our study, a substantial proportion of patients with abdominal and/or pelvic trauma were clinically stable upon ED arrival. This has implications for ED triage, where prioritization often leans towards critically unstable cases, potentially overlooking the nuanced needs of stable patients who may still benefit from close monitoring to prevent deterioration. &lt;br&gt;&lt;br&gt;&lt;b&gt;Conclusions:&lt;/b&gt; This study reveals a significant proportion of stable, low-severity abdominal and pelvic trauma cases in Polish EDs, challenging the traditional focus on high-risk, unstable trauma. Recognizing stable patients' specific needs could optimize triage and resource allocation, reducing unnecessary admissions while maintaining quality care. Future guidelines should integrate protocols for stable trauma cases to improve ED efficiency and patient outcomes. &lt;br&gt;&lt;br&gt;&lt;b&gt;Significance:&lt;/b&gt; The findings of this study underscore the need for optimized resource allocation within EDs. Given the high proportion of clinically stable, low-severity trauma cases, current triage protocols may require adaptation to ensure efficient patient management. The current study provides evidence supporting the refinement of trauma protocols, particularly for geriatric trauma patients, whose stable presentations can be misleading. Additionally, research suggests that dedicated monitoring processes for stable trauma patients could reduce preventable complications, particularly in cases involving lowenergy blunt trauma. Expanding on existing assessment tools, including modified early warning scores (MEWS) and geriatric trauma triage criteria, could help differentiate stable but at-risk patients from those who can be safely discharged.

Different criteria are employed to activate trauma teams. Because of a growing concern about overtriage, the objective of this study was to investigate the performance of our trauma team's activation protocol. Injured patients with trauma team activation (TTA), admission to an intensive care unit or surgical intermediate care unit with a trauma diagnosis, or trauma-related death in the emergency department were investigated retrospectively from 1 January 2004 to 31 December 2005. Different TTA criteria were analysed with respect to sensitivity, positive predictive value (PPV) and overtriage (1 - PPV). Eight hundred and nine patients were included, 185 (23%) of whom had an Injury Severity Score (ISS) of more than 15. The performance of our protocol showed a sensitivity of 87%, PPV of 22% and overtriage of 78%. The mechanism of injury as a TTA criterion had a sensitivity of 14%, PPV of 7% and overtriage of 93%. Physiological/anatomical criteria and interfacility transfer showed higher PPV and less overtriage. Undertriage (no TTA despite ISS > 15) was identified in 23 patients (13%), 18 of whom were hospital transfers. A TTA protocol based on physiological, anatomical and interfacility transfer criteria seems to yield a higher precision than, in particular, that based on mechanism of injury criteria. Because of substantial overtriage in our hospital, the TTA protocol needs to be re-evaluated.

Introduction This research aims to investigate the role of time since trauma (TST) in refining trauma team activation (TTA) criteria within a level I trauma center. We analyze the association between TST and post-emergency department (ED) disposition, proposing new insights for the enhancement of TTA criteria. Methods A retrospective analysis was conducted on a dataset comprising 3,693 patients presenting to a level I trauma center following motor vehicle accidents (MVAs) from 2016 to 2021. Data from a trauma registry, encompassing time of injury, time of ED arrival, TTA status, and post-ED disposition, were utilized. TST was calculated as the difference between the time of injury and the time of ED arrival. Patients that received TTA, full or partial, were categorized based on TST (less than one hour, one to two hours, and two or more hours). Statistical analyses, including chi-square tests, were performed using the Statistical Analysis System (SAS) (version 3.8, SAS Institute Inc., Cary, NC). Results Of the 1,261 patients meeting the criteria, 98.3% received TTA, with decreasing TTA rates observed with increasing TST (p = 0.0076). A significant association was found between TST and post-ED disposition for patients who received TTA (p = 0.0007). Compared to the other TST groups, a higher proportion of patients with a TST of two or more hours were admitted,sent to the intensive care unit (ICU), and sent to the operating room (OR). Conclusion The study indicates a statistically significant relationship between TST and TTA rates, challenging our assumptions about the decreased need for TTA over time. While a longer TST was associated with a lower percentageof TTA, patients with a TST of two or more hours demonstrated increased rates of admission, ICU utilization, and surgical interventions. This suggests that TTA criteria may benefit from refinement to include patients with longer TST. Acknowledging study limitations, such as a small sample size and retrospective design, this research contributes valuable insights into potential considerations for optimizing trauma care protocols.

ObjectiveTo explore and analyze pediatric trauma care practices across designated pediatric trauma centers (PTCs) in Switzerland. The focus was on reception, trauma team activation (TTA), trauma team composition, patient volumes, and infrastructure.MethodsA national online survey was conducted among all eight PTCs in Switzerland using an 18-item questionnaire. The survey investigated organizational aspects, criteria for TTA, patient volume, and communication modalities in pediatric emergency departments (PEDs).ResultsAll PTCs responded, revealing varying methods of TTA, with reception of major trauma either within PEDs or at adjacent adult trauma facilities. Trauma team composition and activation criteria also differ among centers, with nonsurgeons often leading the teams and anesthesiologists being the default facilitators of airway management. TTA criteria vary widely, with the most common being the request of prehospital crew (62.5%) and physician discretion (50%). Trauma resuscitation is predominantly led by PED attendings (75%).ConclusionThis survey provides insights into the state of pediatric trauma care in Switzerland. The findings emphasize the importance of multidisciplinary teams and variability in trauma management practices, which are often tailored to local circumstances. Despite the study limitations of using self-reported data and the small sample size owing to the country's size, the results suggest that a national trauma registry would be helpful for the evaluation and optimization of pediatric trauma care protocols.