ACS COT Research Articles

Understanding the Impact of Trauma Admissions to Nonsurgical Services.

The American College of Surgeons Committee on Trauma (ACS COT) delineates trauma center standards, one of which limits the number of injured patients admitted to nonsurgical services. Performance improvement review of nonsurgical admissions (NSAs), particularly those with Injury Severity Score (ISS) > 9, is required. To examine trauma patients with NSA for appropriateness of admission and any potential clinical effect as a result of NSA. All trauma patients presenting to our ACS COT-verified level 1 trauma center in Southern California (05/2021-04/2022) were retrospectively screened. Nonsurgical admissions with ISS > 9 were included without exclusions. Appropriateness and clinical impact of NSA were assessed by the Trauma Medical Director (TMD) and Associate TMD. Forty patients met study criteria, with a mean age of 54years (range 5d-99y). The mean ISS was 19 (range 10-30). Nonsurgical admissions most commonly sustained traumatic brain injury (TBI) (n = 27, 68%) after ground level falls (GLF) (n = 32, 80%). All NSAs were evaluated by ≥1 surgical service, commonly neurosurgery (n = 33, 83%) and trauma surgery (n = 13, 33%). Sixteen patients (40%) died, 75% (n = 12) of which were secondary to catastrophic TBI. Upon detailed review, all NSAs were deemed appropriate and without potential clinical impact. All NSAs in this study were appropriate admissions without clinical effect from lack of surgical admission. Nonsurgical admissions were typically elderly patients with head injuries after GLF. With the anticipated increase in geriatric trauma due to our aging population, NSA with surgical consultation may be an important way to manage trauma admissions without compromising care of injured patients.

A predictive ambulance dispatch algorithm to the scene of a motor vehicle crash: the search for optimal over and under triage rates.

BackgroundCalls for emergency medical assistance at the scene of a motor vehicle crash (MVC) substantially contribute to the demand on ambulance services. Triage by emergency medical dispatch systems is therefore important, to ensure the right care is provided to the right patient, in the right amount of time. A lights and sirens (L&S) response is the highest priority ambulance response, also known as a priority one or hot response. In this context, over triage is defined as dispatching an ambulance with lights and sirens (L&S) to a low acuity MVC and under triage is not dispatching an ambulance with L&S to those who require urgent medical care. We explored the potential for crash characteristics to be used during emergency ambulance calls to identify those MVCs that required a L&S response.MethodsWe conducted a retrospective cohort study using ambulance and police data from 2014 to 2016. The predictor variables were crash characteristics (e.g. road surface), and Medical Priority Dispatch System (MPDS) dispatch codes. The outcome variable was the need for a L&S ambulance response. A Chi-square Automatic Interaction Detector technique was used to develop decision trees, with over/under triage rates determined for each tree. The model with an under/over triage rate closest to that prescribed by the American College of Surgeons Committee on Trauma (ACS COT) will be deemed to be the best model (under triage rate of ≤ 5% and over triage rate of between 25–35%.ResultsThe decision tree with a 2.7% under triage rate was closest to that specified by the ACS COT, had as predictors—MPDS codes, trapped, vulnerable road user, anyone aged 75 + , day of the week, single versus multiple vehicles, airbag deployment, atmosphere, surface, lighting and accident type. This model had an over triage rate of 84.8%.ConclusionsWe were able to derive a model with a reasonable under triage rate, however this model also had a high over triage rate. Individual EMS may apply the findings here to their own jurisdictions when dispatching to the scene of a MVC.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12873-022-00609-5.

Prehospital Tourniquet Use Should be a Trauma Team Activation Criterion.

Prehospital tourniquet application is not a standard trauma team activation (TTA) criterion recommended by the ACS COT. Tourniquet use has seen a resurgence recently with associated risks and benefits of more liberal usage. Our institution added tourniquet application as TTA criterion in January 2019. This study aimed to evaluate the effect this would have on patient care and overtriage. A prospective analysis was conducted for all TTA associated with tourniquets placed during 2019. An overtriage analysis was conducted utilizing a modified Cribari method as described in Resources for the Optimal Care of the Injured Patient, comparing patients that met standard TTA criteria (TTA-S), to those who met criteria due to tourniquet placement (TTA-T). During the study, there were 46 TTA with tourniquets. Mean prehospital tourniquet time was 80 minutes. Median ISS was 10, 8 (17%) had an ISS >15. Urgent operative intervention was needed in 74%, with 23% and 21% requiring orthopedic and vascular procedures, respectively. Tourniquets were correctly placed in 80% and clinically appropriate in 57%. Of these subjects, 25 (54%) were TTA-S and 21 TTA-T. Overtriage analysis was performed. Overtriage for TTA-T was 33.3%. Overtriage among TTA-S was 4%. Patients with prehospital tourniquets are frequently severely injured. The immediate presence of a trauma surgeon can have significant impacts in these cases. This is particularly important in a rural environment with long tourniquet times. Prehospital tourniquet application as a TTA criteria does not result in excessive overtriage.

The national trauma triage protocol: how EMS perspective can inform the guideline revision

ObjectivesThe Field Triage Guidelines (FTG) support emergency medical service (EMS) decisions regarding the most appropriate transport destination for injured patients. While the components of the algorithm are largely evidenced-based, the...

A call for standardization: Practice patterns and management of critical illness-related corticosteroid insufficiency in surgical intensive care units

IntroductionCritical illness-rlated corticosteroid insufficiency (CIRCI) is a known sequela of severe injury and illness, yet its diagnosis and management are challenging. We hypothesized that CIRCI has significant variability in its diagnosis and management within surgical intensive care units (SICUs). Our study aimed to assess the state of practice of CIRCI in the American College of Surgery Committee on Trauma (ACS COT) certified level 1 trauma centers. MethodsAn 11-item questionnaire was developed based on a CIRCI literature search with expert input from medical endocrinology, acute care surgeons, and surgical intensivists to assess practice patterns of CIRCI. Prior to distribution, it was validated across 2 separate institutions by board-certified critical care surgeons. The questionnaire was distributed to trauma intensivists within level 1 trauma centers in Southeast United States and was open from April 2019 to January 2020. ResultsA total of 56 responses were collected with a response rate of 70%. 72% of respondents indicated they evaluate or manage CIRCI on a weekly basis. In regards to the diagnosis of CIRCI, only 5% of respondents use a formal protocol and 32% do not use laboratory testing. While a majority of respondents (94%) use corticosteroids in septic shock, 67% of those surveyed have not implemented mineralocorticoids as part of the management. 83% of respondents indicated a knowledge gap exists in the therapeutic value of corticosteroids for hemorrhagic shock. ConclusionsThis study demonstrates extreme variability in the diagnosis and management of CIRCI. In particular most providers acknowledge a knowledge gap in the diagnosis of CIRCI and the role of corticosteroids in hemorrhagic shock. Few providers are using adjunctive mineralocorticoids in septic shock, although recent level 1 evidence have shown a survival benefit. These responses reflect an opportunity for national improvement in the management of CIRCI.

Trauma system performance improvement: a review of the literature and recommendations

Evaluation of trauma systems has matured over the last few decades. US trauma systems routinely undergo clinical and operational evaluation to ensure optimal care of the injured from the time of injury through reintegration with society. Assessments are carried out with the intent of defining optimal elements and rendering strategic recommendations for the trauma system. The framework for trauma system assessment was adopted from the Trauma Care Systems Planning and Development Act of 1990 which sought to create a consistent process and core functions to ensure a reproducible trauma system from prehospital through rehabilitation. Applying the core function of a public health model to trauma systems provided a process for enhancement of clinical care along the continuum through a framework that accentuates assessment, policy development and assurance while holding to the highest standards in trauma systems performance. A review of contemporary and evidence-based information regarding key strategies and processes related to the evaluation of trauma systems’ performance improvement was undertaken. The intent was to identify measurable metrics for trauma systems performance improvement and patient safety. There is a paucity of data related to specific metrics to evaluate the impact of trauma systems on performance and outcomes. The majority of publications focused on quality of trauma registry data, integration of prehospital data, and the core functions of a trauma system but lacked specific quantitative metrics to measure these core functions. The qualitative responses of “met or not met” can be subjective and equivocal. The American College of Surgeons Committee on Trauma (ACS COT) Trauma System Evaluation Committee has also developed qualitative minimal trauma system standards and implemented a comprehensive trauma system evaluation process. Trauma system-wide, risk adjusted, qualitative and quantitative metrics are recommended to address the full spectrum of injury which are essential to the advancement of the care of the injured patient.

The National Trauma Research Repository: Ushering in a New ERA of trauma research (Commentary).

Despite being the leading cause of death in the United States for individuals 46 years and younger and the primary cause of death among military service members, trauma care research has been underfunded for the last 50 years. Sustained federal funding for a coordinated national trauma clinical research program is required to advance the science of caring for the injured. The Department of Defense is committed to funding studies with military relevance; therefore, it cannot fund pediatric or geriatric trauma clinical trials. Currently, trauma clinical trials are often performed within a single site or a small group of trauma hospitals, and research data are not available for secondary analysis or sharing across studies. Data-sharing platforms encourage transfer of research data and knowledge between civilian and military researchers, reduce redundancy, and maximize limited research funding. In collaboration with the Department of Defense, trauma researchers formed the Coalition for National Trauma Research (CNTR) in 2014 to advance trauma research in a coordinated effort. CNTR's member organizations are the American Association for the Surgery of Trauma (AAST), the American College of Surgeons Committee on Trauma (ACS COT), the Eastern Association for the Surgery of Trauma (EAST), the Western Trauma Association (WTA), and the National Trauma Institute (NTI). CNTR advocates for sustained federal funding for a multidisciplinary national trauma research program to be conducted through a large clinical trials network and a national trauma research repository. The initial advocacy and research activities underway to accomplish these goals are presented.

Evaluation of pre‐hospital trauma triage criteria: a prospective study at a Danish level I trauma centre

The aim of the present study was to evaluate the precision of our trauma triage protocol [based on the American College of Surgeons, Committee on Trauma (ACS COT)] in identifying severely injured defined as an injury severity score (ISS) > 15. Our hypothesis was that isolated mechanism-of-injury criteria were responsible for a significant over-triage leading to over-use of our trauma team. A prospective cohort study. A level I trauma centre, Aarhus, Denmark. Among all injured patients admitted during a 6-month period in 2003 we identified severely injured. During the study period, trauma team activations were consecutively registered and triage criteria were prospectively collected. Sensitivity, specificity, positive predictive value, over-triage and under-triage were calculated. Out of 15,162 patients in the emergency department, 848 injured patients were included and 59 (7%) were severely injured. We had 242 trauma team activations with 54 (22%) severely injured. Sensitivity was 92%, specificity 76%, giving an over-triage of 24% and an under-triage of 8%. The positive predictive value was 22%. Among 60 patients with mechanism-of-injury as the only criterion, five were severely injured in contrast to 12 out of 20 patients with mechanism-of-injury combined with physiological and/or anatomical criteria. The positive predictive value of our triage protocol was low, only 22%. This was mainly as a result of a significant over-triage from isolated mechanism-of-injury criteria. We recommend revision of the triage protocol and reallocation of our trauma team resources.