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OBJECTIVES: The Centers for Disease Control and Preventions field triage guidelines (FTG) are routinely used by emergency medical services personnel for triaging injured patients. The most recent (2011) FTG contains physiologic, anatomic, mechanism, and special consideration steps. Our objective was to systematically review the criteria in the mechanism and special consideration steps that might be predictive of serious injury or need for a trauma center. METHODS: We conducted a systematic review of the predictive utility of mechanism and special consideration criteria for predicting serious injury. A research librarian searched in Ovid Medline, EMBASE, and the Cochrane databases for studies published between January 2011 and February 2021. Eligible studies were identified using a priori inclusion and exclusion criteria. Studies were excluded if they lacked an outcome for serious injury, such as measures of resource use, injury severity scores, mortality, or composite measures using a combination of outcomes. Given the heterogeneity in populations, measures, and outcomes, results were synthesized qualitatively focusing on positive likelihood ratios (LR+) whenever these could be calculated from presented data or adjusted odds ratios (aOR). RESULTS: We reviewed 2418 abstracts and 315 full-text publications and identified 42 relevant studies. The factors most predictive of serious injury across multiple studies were death in the same vehicle (LR+ 2.2-7.4), ejection (aOR 3.2-266.2), extrication (LR+ 1.1-6.6), lack of seat belt use (aOR 4.4-11.3), high speeds (aOR 2.0-2.9), concerning crash variables identified by vehicle telemetry systems (LR+ 4.7-22.2), falls from height (LR+ 2.4-5.9), and axial load or diving (aOR 2.5-17.6). Minor or inconsistent predictors of serious injury were vehicle intrusion (LR+ 0.8-7.2), cardiopulmonary or neurologic comorbidities (LR+ 0.8-3.1), older age (LR+ 0.6-6.8), or anticoagulant use (LR+ 1.1-1.8). CONCLUSIONS: Select mechanism and special consideration criteria contribute positively to appropriate field triage of potentially injured patients.

Background/Objective: This prospective, multicenter observational cohort study was carried out in 12 trauma centers in Germany and Switzerland. Its purpose was to evaluate the rate of undertriage, as well as potential consequences, and relate these with different Trauma Team Activation Protocols (TTA-Protocols), as this has not been done before in Germany. Methods: Each trauma center collected the data during a three-month period between December 2019 and February 2021. All 12 participating hospitals are certified as supra-regional trauma centers. Here, we report a subgroup analysis of undertriaged patients. Those included in the study were all consecutive adult patients (age ≥ 18 years) with acute trauma admitted to the emergency department of one of the participating hospitals by the prehospital emergency medical service (EMS) within 6 h after trauma. The data contained information on age, sex, trauma mechanism, pre- and in-hospital physiology, emergency interventions, emergency surgical interventions, intensive care unit (ICU) stay, and death within 48 h. Trauma team activation (TTA) was initiated by the emergency medical services. This should follow the national guidelines for severe trauma using established field triage criteria. We used various denominators, such as ISS, and criteria for the appropriateness of TTA to evaluate the undertriage in four groups. Results: This study included a total of 3754 patients. The average injury severity score was 5.1 points, and 7.0% of cases (n = 261) presented with an injury severity score (ISS) of 16+. TTA was initiated for a total of 974 (26%) patients. In group 1, we evaluated how successful the actual practice in the EMS was in identifying patients with ISS 16+. The undertriage rate was 15.3%, but mortality was lower in the undertriage cohort compared to those with a TTA (5% vs. 10%). In group 2, we evaluated the actual practice of EMS in terms of identifying patients meeting the appropriateness of TTA criteria; this showed a higher undertriage rate of 35.9%, but as seen in group 1, the mortality was lower (5.9% vs. 3.3%). In group 3, we showed that, if the EMS were to strictly follow guideline criteria, the rate of undertriage would be even higher (26.2%) regarding ISS 16+. Using the appropriateness of TTA criteria to define the gold standard for TTA (group 4), 764 cases (20.4%) fulfilled at least one condition for retrospective definition of TTA requirement. Conclusions: Regarding ISS 16+, the rate of undertriage in actual practice was 15.3%, but those patients did not have a higher mortality. [ABSTRACT FROM AUTHOR]

Major trauma is a leading cause of unexpected death globally, with increasing age-adjusted death rates for unintentional injuries. Field triage schemes (FTSs) assist emergency medical technicians in identifying appropriate medical care facilities for patients. While full FTSs may improve sensitivity, step-by-step field triage is time-consuming. A simplified FTS (sFTS) that uses only physiological and anatomical criteria may offer a more rapid decision-making process. However, evidence for this approach is limited, and its performance in identifying all age groups requiring trauma center resources in Asia remains unclear. We conducted a multinational retrospective cohort study involving adult trauma patients admitted to emergency departments in the included countries from 2016 to 2020. Prehospital and hospital data were reviewed from the Pan-Asia Trauma Outcomes Study database. Patients aged ≥18 years transported by emergency medical services were included. Patients lacking data regarding age, sex, physiological criteria, or injury severity scores were excluded. We examined the performance of sFTS in all age groups and fine-tuned physiological criteria to improve sFTS performance in identifying high-risk trauma patients in different age groups. The sensitivity and specificity of the physiological and anatomical criteria for identifying major trauma (injury severity score ≥ 16) were 80.6% and 58.8%, respectively. The modified sFTS showed increased sensitivity and decreased specificity, with more pronounced changes in the young age group. Adding the shock index further increased sensitivity in both age groups. sFTS using only physiological and anatomical criteria is suboptimal for Asian adult patients with trauma of all age groups. Adjusting the physiological criteria and adding a shock index as a triage tool can improve the sensitivity of severely injured patients, particularly in young age groups. A swift field triage process can maintain acceptable sensitivity and specificity in severely injured patients. • Simplified field triage scheme is reliable in pre-hospital settings for trauma patient in Asia. • Modified field triage scheme increased sensitivity for major trauma prediction, especially in younger age group, implying tailored field triage scheme is warranted for different demographics and trauma mechanism. • The combination of modified field triage scheme with shock index further increased the sensitivity for major trauma prediction. [ABSTRACT FROM AUTHOR]

Abstract Background Providing optimal care for trauma, the leading cause of death for young adults, remains a challenge e.g., due to field triage limitations in assessing a patient’s condition and deciding on transport destination. Data-driven On Scene Injury Severity Prediction (OSISP) models for motor vehicle crashes have shown potential for providing real-time decision support. The objective of this study is therefore to evaluate if an Artificial Intelligence (AI) based clinical decision support system can identify severely injured trauma patients in the prehospital setting. Methods The Swedish Trauma Registry was used to train and validate five models – Logistic Regression, Random Forest, XGBoost, Support Vector Machine and Artificial Neural Network – in a stratified 10-fold cross validation setting and hold-out analysis. The models performed binary classification of the New Injury Severity Score and were evaluated using accuracy metrics, area under the receiver operating characteristic curve (AUC) and Precision-Recall curve (AUCPR), and under- and overtriage rates. Results There were 75,602 registrations between 2013–2020 and 47,357 (62.6%) remained after eligibility criteria were applied. Models were based on 21 predictors, including injury location. From the clinical outcome, about 40% of patients were undertriaged and 46% were overtriaged. Models demonstrated potential for improved triaging and yielded AUC between 0.80–0.89 and AUCPR between 0.43–0.62. Conclusions AI based OSISP models have potential to provide support during assessment of injury severity. The findings may be used for developing tools to complement field triage protocols, with potential to improve prehospital trauma care and thereby reduce morbidity and mortality for a large patient population.

Background: Providing optimal care for trauma, the leading cause of death for young adults, remains a challenge e.g., due to field triage limitations in assessing a patient's condition and deciding on transport destination. Data-driven On Scene Injury Severity Prediction (OSISP) models for motor vehicle crashes have shown potential for providing real-time decision support. The objective of this study is therefore to evaluate if an Artificial Intelligence (AI) based clinical decision support system can identify severely injured trauma patients in the prehospital setting. Methods: The Swedish Trauma Registry was used to train and validate five models – Logistic Regression, Random Forest, XGBoost, Support Vector Machine and Artificial Neural Network – in a stratified 10-fold cross validation setting and hold-out analysis. The models performed binary classification of the New Injury Severity Score and were evaluated using accuracy metrics, area under the receiver operating characteristic curve (AUC) and Precision-Recall curve (AUCPR), and under- and overtriage rates. Results: There were 75,602 registrations between 2013–2020 and 47,357 (62.6%) remained after eligibility criteria were applied. Models were based on 21 predictors, including injury location. From the clinical outcome, about 40% of patients were undertriaged and 46% were overtriaged. Models demonstrated potential for improved triaging and yielded AUC between 0.80–0.89 and AUCPR between 0.43–0.62. Conclusions: AI based OSISP models have potential to provide support during assessment of injury severity. The findings may be used for developing tools to complement field triage protocols, with potential to improve prehospital trauma care and thereby reduce morbidity and mortality for a large patient population. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to determine the impact of adding selected mechanism of injury (MOI) to the existing trauma diversion criteria adopted in Hong Kong. Method: This is a cross-sectional study based on the trauma registry of New Territory West Cluster (NTWC) of Hospital Authority from January 2017 to December 2019. All adult patients aged 18 years or above were recruited if their injury occurred in the catchment area of Pok Oi Hospital (POH) or Tin Shui Wai Hospital (TSWH). Performance of the protocol before and after MOI criteria being added in terms of over-diversion and under-diversion rate was determined. Model discrimination was evaluated by plotting the receiver operating characteristic curve, and the area under the curve was compared before and after MOI criteria added. Net reclassification improvement and integrated discrimination improvement indices were evaluated. Result: A total of 502 patients were included for analysis. Before MOI criteria were added, the over-diversion rate and under-diversion rate were 31.1% and 54.7%, respectively. After MOI criteria were added, the over-diversion rate and under-diversion rate were 33.1% and 34.3%, respectively. The receiver operating characteristic curve of current primary trauma diversion (PTD) criteria had an area under the curve of 66.9% (95% confidence interval: 63%–71%). After adding MOI criteria, the new receiver operating characteristic curve yielded an area under the curve of 73.7% (95% confidence interval: 70%–78%), which is significantly better (p < 0.001). Net reclassification improvement and integrated discrimination improvement indices indicated that including MOI criteria would improve the model prediction. Conclusion: Adding mechanism of injury can improve trauma diversion protocol performance. [ABSTRACT FROM AUTHOR]

Field triage guidelines recommend transport of head-injured patients on anticoagulants or antiplatelets to a higher-level trauma center based on studies suggesting a high incidence of traumatic intracranial hemorrhage (tICH). We compared the incidence of tICH in older adults transported by emergency medical services (EMS) with and without anticoagulation or antiplatelet use and evaluated the accuracies of different sets of field triage criteria to identify tICH. This was a prospective, observational study at five EMS agencies and 11 hospitals. Older adults (≥55 years) with head trauma and transported by EMS from August 2015 to September 2016 were eligible. EMS providers completed standardized data forms and patients were followed through emergency department (ED) or hospital discharge. We enrolled 1304 patients; 1147 (88%) received a cranial computed tomography (CT) scan and were eligible for analysis. Four hundred thirty-four (33%) patients had anticoagulant or antiplatelet use and 112 (10%) had tICH. The incidence of tICH in patients with (11%, 95% confidence interval [CI] 8%-14%) and without (9%, 95% CI 7%-11%) anticoagulant or antiplatelet use was similar. Anticoagulant or antiplatelet use was not predictive of tICH on adjusted analysis. Steps 1-3 criteria alone were not sensitive in identifying tICH (27%), whereas the addition of anticoagulant or antiplatelet criterion improved sensitivity (63%). Other derived sets of triage criteria were highly sensitive (>98%) but poorly specific (

Background: Advanced Trauma Life Support field triage utilizes the Glasgow Coma Scale (GCS) to assess the level of consciousness. However, prehospital care providers in low- and middle-income countries (LMICs) often use the Alert, Verbal, Pain, and Unresponsive (AVPU) scale to assess the level of consciousness. This study aimed to determine whether prehospital AVPU categorization correlates with mortality rates in trauma victims, similarly to GCS.Methods: In this cross-sectional study conducted between November 2015 and January 2016, we enrolled a convenience sample of prehospital trauma-related field activations. The primary outcome measure was the probability of death within 48 h for each category of AVPU.Results: In a convenience sample of 4514 activations, 1606 (35.6%) met exclusion criteria, four did not have AVPU, and four did not have GCS, leaving 2900 (64.2%) trauma activations with both AVPU and GCS available for analysis. Forty-eight-hour follow-up data were available for 2184 (75.3%) activations out of these 2900. The 48-h mortality rates for each category of AVPU were 1.1% (Alert), 4.3% (Verbal), 17.9% (Pain), 53.2% (Unresponsive); and, for each GCS-based injury severity category, they were 0.9% (Mild, GCS 13-15), 8.1% (Moderate, GCS 9-12), 43.5% (Severe, GCS ≤ 8). Overall, there was a statistically significant difference in GCS for each category of AVPU (p < 0.001) except between patients responding to verbal commands and those responding to pain (p = 0.18). The discriminative ability of AVPU (AUC 79.7% (95% CI 73.4-86.1)) and GCS (AUC 81.5% (95% CI 74.8-88.2)) for death within 48-h following hospital drop-off were comparable.Conclusion: EMT assessments of AVPU and GCS relate to each other, and AVPU predicts mortality at 48 h. Future studies using AVPU to assess the level of consciousness in prehospital trauma protocols may simplify their global application without impacting the overall quality of care. [ABSTRACT FROM AUTHOR]

Objective: Prehospital time affects survival in trauma patients. Mass casualty incidents (MCIs) are overwhelming events where medical care exceeds available resources. This study aimed at evaluating the prehospital time during MCIs and investigating the effect of triage. Methods: A retrospective analysis was performed using Florida's Event Medical Services Tracking and Reporting System database. All patients involved in MCIs during 2018 were accessed, and prehospital time intervals were evaluated and compared to that of non-MCIs. The effect of MCI triage and field triage (Field Triage Criteria) on prehospital time was evaluated. Results: In 2018, it was estimated that 2236 unique MCIs occurred in Florida, with a crude incidence of 10.1-10.9/100000 people. 2180 EMS units arrived at the hospital for patient disposition with a median alarm-to-hospital time of 43.74 minutes, significantly longer than non-MCIs (39.15 min; P < 0.001). MCI triage and field triage were both associated with shorter alarm-to-hospital time (39.37 min and 37.55 min, respectively). Conclusions: MCIs resulted in longer prehospital time intervals than non-MCIs. This finding suggests that additional efforts are needed to reduce the prehospital time for MCI patients. MCI triage and field triage were both associated with shorter alarm-to-hospital times. Widespread use may improve prehospital MCI care. [ABSTRACT FROM AUTHOR]

Purpose: Priority-setting by dispatch centers and Emergency Medical Services professionals has a major impact on pre-hospital triage and times of trauma patients. Patients requiring specialized care benefit from expedited transport to higher-level trauma centers, while transportation of these patients to lower-level trauma centers is associated with higher mortality rates. This study aims to evaluate the accuracy of priority-setting by dispatch centers and Emergency Medical Services professionals. Methods: This observational study included trauma patients transported from the scene of injury to a trauma center. Priority-setting was evaluated in terms of the proportion of patients requiring specialized trauma care assigned with the highest priority (i.e., sensitivity), undertriage, and overtriage. Patients in need of specialized care were defined by a composite resource-based endpoint. An Injury Severity Score ≥ 16 served as a secondary reference standard. Results: Between January 2015 and December 2017, records of 114,459 trauma patients were collected, of which 3327 (2.9%) patients were in need of specialized care according to the primary reference standard. Dispatch centers and Emergency Medical Services professionals assigned 83.8% and 74.5% of these patients with the highest priority, respectively. Undertriage rates ranged between 22.7 and 65.5% in the different prioritization subgroups. There were differences between dispatch and transport priorities in 17.7% of the patients. Conclusion: The majority of patients that required specialized care were assigned with the highest priority by the dispatch centers and Emergency Medical Services professionals. Highly accurate priority criteria could improve the quality of pre-hospital triage. [ABSTRACT FROM AUTHOR]

Introduction: To improve the quality of criteria for trauma-team-activation it is necessary to identify patients who benefited from the treatment by a trauma team. Therefore, we evaluated a post hoc criteria catalogue for trauma-team-activation which was developed in a consensus process by an expert group and published recently. The objective was to examine whether the catalogue can identify patients that died after admission to the hospital and therefore can benefit from a specialized trauma team mostly. Materials and methods: The catalogue was applied to the data of 75,613 patients from the TraumaRegister DGU® between the 01/2007 and 12/2016 with a maximum abbreviated injury score (AIS) severity ≥ 2. The endpoint was hospital mortality, which was defined as death before discharge from acute care. Results: The TraumaRegister DGU® dataset contains 18 of the 20 proposed criteria within the catalogue which identified 99.6% of the patients who were admitted to the trauma room following an accident and who died during their hospital stay. Moreover, our analysis showed that at least one criterion was fulfilled in 59,785 cases (79.1%). The average ISS in this group was 21.2 points (SD 9.9). None of the examined criteria applied to 15,828 cases (average ISS 8.6; SD 5). The number of consensus-based criteria correlated with the severity of injury and mortality. Of all deceased patients (8,451), only 31 (0.37%) could not be identified on the basis of the 18 examined criteria. Where only one criterion was fulfilled, mortality was 1.7%; with 2 or more criteria, mortality was at least 4.6%. Discussion: The consensus-based criteria identified nearly all patients who died as a result of their injuries. If only one criterion was fulfilled, mortality was relatively low. However, it increased to almost 5% if two criteria were fulfilled. Further studies are necessary to analyse and examine the relative weighting of the various criteria. Summary: Our instrument is capable to identify severely injured patients with increased in-hospital mortality and injury severity. However, a minimum of two criteria needs to be fulfilled. Based on these findings, we conclude that the criteria list is useful for post hoc analysis of the quality of field triage in patients with severe injury. [ABSTRACT FROM AUTHOR]

Background: Prehospital trauma triage is essential to get the right patient to the right hospital. However, the national field triage guidelines proposed by the American College of Surgeons have proven to be relatively insensitive when identifying severe traumas., Objective: This study aimed to build a prehospital triage model to predict severe trauma and enhance the performance of the national field triage guidelines., Methods: This was a multisite prediction study, and the data were extracted from the National Trauma Data Bank between 2017 and 2019. All patients with injury, aged 16 years of age or older, and transported by ambulance from the injury scene to any trauma center were potentially eligible. The data were divided into training, internal, and external validation sets of 672,309; 288,134; and 508,703 patients, respectively. As the national field triage guidelines recommended, age, 7 vital signs, and 8 injury patterns at the prehospital stage were included as candidate variables for model development. Outcomes were severe trauma with an Injured Severity Score ≥16 (primary) and critical resource use within 24 hours of emergency department arrival (secondary). The triage model was developed using an extreme gradient boosting model and Shapley additive explanation analysis. The model's accuracy regarding discrimination, calibration, and clinical benefit was assessed., Results: At a fixed specificity of 0.5, the model showed a sensitivity of 0.799 (95% CI 0.797-0.801), an undertriage rate of 0.080 (95% CI 0.079-0.081), and an overtriage rate of 0.743 (95% CI 0.742-0.743) for predicting severe trauma. The model showed a sensitivity of 0.774 (95% CI 0.772-0.776), an undertriage rate of 0.158 (95% CI 0.157-0.159), and an overtriage rate of 0.609 (95% CI 0.608-0.609) when predicting critical resource use, fixed at 0.5 specificity. The triage model's areas under the curve were 0.755 (95% CI 0.753-0.757) for severe trauma prediction and 0.736 (95% CI 0.734-0.737) for critical resource use prediction. The triage model's performance was better than those of the Glasgow Coma Score, Prehospital Index, revised trauma score, and the 2011 national field triage guidelines RED criteria. The model's performance was consistent in the 2 validation sets., Conclusions: The prehospital triage model is promising for predicting severe trauma and achieving an undertriage rate of <10%. Moreover, machine learning enhances the performance of field triage guidelines., (©Qi Chen, Yuchen Qin, Zhichao Jin, Xinxin Zhao, Jia He, Cheng Wu, Bihan Tang. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 30.09.2024.)

Introduction: Recent revisions of national field triage guidelines recommend the addition of age-specific systolic blood pressure (SBP) measurement for identifying the most severely injured children requiring transport to a trauma center. The purpose of this study was to determine the frequency in which blood pressures are documented by Emergency Medical Service (EMS) providers and the role this measurement has had, among other factors, in triage decisions., Methods: This is an exploratory descriptive study with a retrospective review from the trauma registry database of all pediatric trauma admissions that arrived by EMS at a level II pediatric trauma center from January 1, 2019 to December 31, 2022., Results: Two hundred ninety-eight patient records of patients aged 0 to 14 were included. EMS providers documented blood pressure in 70.1% of the total sample. A significant difference in the frequency of this documentation was seen between ages zero to nine and = > 10 years (χ 2 (1,298) = 28.98 p <0.001). No children ages zero to nine years had SBP of < 70 mmHg + (2x age in years) documented by EMS. There were two children aged = > 10 who had a documented SBP < 90 and 12 children with documented EMS heart rate > SBP., Conclusion: Many children transported by EMS in this hospital's catchment area did have a field blood pressure measurement documented, but the frequency was significantly less in younger-aged children. The blood pressure measurements of children determined to have severe injuries in the sample did not meet the inclusion criteria for high risk of serious injury by the newly established national guidelines. This suggests other prehospital criteria, such as mechanism of injury or visual cues, prompted EMS to transport these pediatric trauma patients to a regional trauma center for specialized care., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review Board of Good Samaritan University Hospital Office issued approval 2023.06.20.07.15. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Frederick et al.)

Background:  Mass casualty incident (MCI) training effectively increases trainees' knowledge and confidence when implemented in a live, in-person setting. In-person MCI training is resource-intensive, but virtual MCI training models are an alternative with similar effectiveness at a lesser cost. However, most of these validated virtual options are based on high-tech virtual reality (VR) programs. We designed and implemented a low-tech, low-cost virtual MCI training model for third-year medical students, using Google Jamboard TM (Google, Mountain View, CA) and Zoom TM  (Zoom Video Communications, Inc., San Jose, CA) as the primary technological platforms., Methods:  Learners were instructed on the adult simple triage and rapid treatment (START) and the pediatric JumpSTART triage algorithms over Zoom TM . In small groups, students used a gameboard on Google Jamboard TM to simulate a scene at an MCI where they were tasked with triaging 25 patients in 30 minutes, followed by a debriefing session. Students were surveyed on their perceived understanding of the triage algorithms and confidence before and after the event using a 5-point Likert scale (poor, fair, good, very good, and excellent). Pre- and post-event scores were compared using paired, two-sample, and two-tailed t-tests. We considered a p value of <0.01 significant to correct for multiplicity using the Bonferroni method., Results:  Learners reported an increased understanding of the triage algorithms (adult and pediatric), scene setup, and understanding of emergency medical service training/transportation, as well as increased confidence in participating in an MCI (all p < 0.001)., Conclusions:  Virtual MCI training can be used as an alternative or supplement to in-person MCI training. Low-tech virtual MCI training models can increase the accessibility of these valuable training activities without sacrificing the quality of learning. Areas for further investigation include low-tech virtual MCI training models' ability to effectively recreate situational and environmental distractions and other challenges better simulated by in-person and high-tech VR training events., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Campbell University Institutional Review Board issued approval 890. The Campbell University Institutional Review Board determined this study is not human subjects research as defined by 45 CFR 46.102(e). Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Kolb et al.)

Purpose: Trauma team activation (TTA) is thought to be essential for advanced and specialized care of very severely injured patients. However, non-specific TTA criteria may result in overtriage that consumes valuable resources or endanger patients in need of TTA secondary to undertriage. Consequently, criterion standard definitions to calculate the accuracy of the various TTA protocols are required for research and quality assurance purposes. Recently, several groups suggested a list of conditions when a trauma team is considered to be essential in the initial care in the emergency room. The objective of the survey was to post hoc identify trauma-related conditions that are thought to require a specialized trauma team that may be widely accepted, independent from the country's income level. Methods: A set of questions was developed, centered around the level of agreement with the proposed post hoc criteria to define adequate trauma team activation. The participants gave feedback before they answered the survey to improve the quality of the questions. The finalized survey was conducted using an online tool and a word form. The income per capita of a country was rated according to the World Bank Country and Lending groups. Results: The return rate was 76% with a total of 37 countries participating. The agreement with the proposed criteria to define post hoc correct requirements for trauma team activation was more than 75% for 12 of the 20 criteria. The rate of disagreement was low and varied between zero and 13%. The level of agreement was independent from the country's level of income. Conclusions: The agreement on criteria to post hoc define correct requirements for trauma team activation appears high and it may be concluded that the proposed criteria could be useful for most countries, independent from their level of income. Nevertheless, more discussions on an international level appear to be warranted to achieve a full consensus to define a universal set of criteria that will allow for quality assessment of over- and undertriage of trauma team activation as well as for the validation of field triage criteria for the most severely injured patients worldwide. [ABSTRACT FROM AUTHOR]

Abstract Background In France, the pre-hospital field triage of trauma patients is currently based on the Vittel criteria algorithm. This algorithm was originally created in 2002 before the stratification of trauma centers and, at the national level, has not been revised since. This could be responsible for the overtriage of trauma patients in Level I Trauma Centers. The principal aim of this study was to evaluate the correlation between each Vittel field triage criterion and trauma patients’ Injury Severity Score. Methods Our Level I Trauma Center receives an average of 300 trauma patients per year. Demographic and physiological data, along with the entire trauma patient management process and Vittel field triage criteria, are recorded in a local trauma registry. The Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) are calculated after a complete assessment of the trauma victim during their in-hospital management. Results were concerned with the presence of an ISS of greater than 15, which defined a major trauma patient; mortality within 30 days; and admission to the intensive care unit. This study is a registry analysis from January 2013 to September 2017. Results Of the 1373 patients in the registry, 1151 were included in the analysis with a mean age of 43 years (± 19) and a median ISS of 13 (IQR = 5–22), where 887 (77%) were male. Nine of the 24 Vittel criteria were associated with an ISS > 15. In a multivariate analysis, no criterion related to kinetic elements was significantly correlated with an ISS > 15, mortality within 30 days, or admission to intensive care. Three algorithm categories were predictive of a major trauma patient (ISS > 15): physiological variables, pre-hospital resuscitation, and physical injuries, while kinetic elements were not. Conclusions Criteria related to physiological variables, pre-hospital resuscitation, and physical injuries are the most relevant to predicting the severity of a trauma patient’s condition. A revision of the VCA could potentially have beneficial effects on the over and undertriage phenomena, which constitute ongoing medical and financial concerns.

Introduction: Although the term "golden hour" is a well-known concept among trauma system and emergency medical service providers, the relationship between time and trauma patient outcome and the process of prehospital care for road trauma patients in rural settings are poorly understood. As the underlying basis for triage decision-making, the estimated transport interval to trauma center is usually absent in the existing studies. Method: In this study, the crash data between 2013 and 2017 were obtained from the Fatality Analysis Reporting System, and the estimated intervals were calculated by using a Geographic Information System software. By comparing the estimated intervals with actual emergency medical services records, the field triage patterns for road patients were investigated at the state and county levels. Results and Conclusions: With the help of the interval prediction maps, the different triage patterns among counties were identified. Further, the average fatalities per 100,000 population by county from the National Highway Traffic Safety Administration were adopted to clarify the associated outcomes. The linear regression analysis results revealed that, for most states, all intervals except the notification interval had a significant correlation with the mortality. The estimated interval had a more significant relationship with the mortality than the actual transport interval. Practical applications: These findings indicated that adhering to the "golden hour" without regarding the destination may not be helpful for the survival of road trauma patients. The regression analyses and the interval maps can be used to identify patterns of inappropriate destination selection so that prospective decision-making can be improved. [ABSTRACT FROM AUTHOR]

Objective: Guidelines suggest that Traumatic Brain Injury (TBI) related hospitalizations are best treated at Level I or II trauma centers because of continuous neurosurgical care in these settings. This population-based study examines TBI hospitalization treatment paths by age groups. Methods: Trauma center utilization and transfers by age groups were captured by examining the total number of TBI hospitalizations from National Inpatient Sample (NIS) and the number of TBI hospitalizations and transfers in the Trauma Data Bank National Sample Population (NTDB-NSP). TBI cases were defined using diagnostic codes. Results: Of the 351,555 TBI related hospitalizations in 2012, 47.9% (n = 168,317) were directly treated in a Level I or II trauma center, and an additional 20.3% (n = 71,286) were transferred to a Level I or II trauma center. The portion of the population treated at a trauma center (68.2%) was significantly lower than the portion of the U.S. population who has access to a major trauma center (90%). Further, nearly half of all transfers to a Level I or II trauma center were adults aged 55 and older (p < 0.001) and that 20.2% of pediatric patients arrive by non-ambulatory means. Conclusion: Utilization of trauma center resources for hospitalized TBIs may be low considering the established lower mortality rate associated with treatment at Level I or II trauma centers. The higher transfer rate for older adults may suggest rapid decline amid an unrecognized initial need for a trauma center care. A better understanding of hospital destination decision making is needed for patients with TBI. [ABSTRACT FROM AUTHOR]

Introduction: Cross-border firing are increasingly being common in the modern era. The injuries resulting from these low intensity conflicts are a source of anxiety among treating physicians and their respective governments. The provisions are required to minimise the suffering of the victims viz. Mode of injuries, mortality patterns, adequacy of treatment at pre-hospital and tertiary care hospital and provisions to decrease morbidity and mortality for the people living in these areas. Materials and Methods: A retrospective study was conducted in GMCH, Jammu who suffered injuries due to cross border firing in the month of October, 2014. 68 patients were reported in the causality wing. All the patients were referred from level 2 trauma centre. There were 51 males and 17 females out of which 5 were children. The cause of injury, involvement of organ system, cause of mortality and morbidity and loopholes in prehospital management were identified. Results: Sharpnel were the most common cause of injury followed by indirect trauma. The common cause of mortality was abdominal and thoracic injuries. There were 4 deaths at hospital 2 of which were brought dead and 2 died during the course of treatment. There were twenty patients with extremity injuries, fourteen with chest trauma, eleven with abdomen including parineal injuries, three with head injuries, eight with ENT injuries, three with eye injuries and nine with splinters in the back out of which two were in the spinal canal. Conclusion: Prehospital stabilisation, early transport, in-transit resuscitation, immediate surgery if required and implementation of triage model and ATLS protocol has been the key to reduce mortality and morbidity. [ABSTRACT FROM AUTHOR]

Objective To examine clinical and health-related quality of life (HRQOL) outcomes and predictors of HRQOL for uncomplicated field triage ST-elevation myocardial infarction (STEMI) patients aged ≥70 years and <70 years after primary percutaneous coronary intervention (PPCI). Background Pre-hospital field triage for PPCI is associated with lower mortality but the impact of age and other factors on HRQOL remains unknown. Methods 77 field triage STEMI patients were assessed for HRQOL using the Short Form-12 (SF-12) and the Seattle Angina Questionnaire (SAQ) at 4 weeks and 6 months after PPCI. Results Regression analysis showed improvements in SF-12 domains and angina stability for older people. Age predicted lower physical function ( p = 0.001) and better SAQ QOL at 6 months ( p = 0.003). Conclusion Age, length of hospitalization, recurrent angina and hypertension were important predictors of HRQOL with PPCI. Assessment of HRQOL combined with increased support for physical and emotional recovery is needed to improve clinical care for field triage PPCI patients. [ABSTRACT FROM AUTHOR]

Research on field triage of injured patients is limited by the lack of a widely used criterion standard for defining trauma center need. Injury Severity Score (ISS) >15 has been a commonly used outcome measure in research for determining trauma center need that has never been validated. A multidisciplinary team recently published a consensus-based criterion standard definition of trauma center need, but this measure has not yet been validated. The objective was to determine if the consensus-based criterion standard can be obtained by medical record review and compare patients identified as needing a trauma center by the consensus-based criterion standard vs. ISS >15. A subanalysis of data collected during a 2-year prospective cohort study of 4,528 adult trauma patients transported by EMS to a single trauma center was conducted. These data included ICD-9-CM codes, treatment times, and other patient care data. Presence of the consensus-based criterion standard was determined for each patient. ISS was calculated based on ICD-9-CM codes assigned for billing. The consensus-based criterion standard could be applied to 4,471 (98.7%) cases. ISS could be determined for 4,506 (99.5%) cases. Based on an ISS >15, 8.9% of cases were identified as needing a trauma center. Of those, only 48.2% met the consensus-based criterion standard. Almost all patients that did not meet the consensus-based criterion standard, but had an ISS >15 were diagnosed with chest (rib fractures (100/205 cases)/pneumothorax (57/205 cases), closed head (without surgical intervention 88/205 cases), vertebral (without spinal cord injury 45/205 cases), and/or extremity injuries (39/205 cases). There were 4,053 cases with an ISS <15. 5.0% of those with an ISS <15 met the consensus-based criterion standard with the majority requiring surgery (139/203 cases) or a blood transfusion (60/203 cases). The kappa coefficient of agreement for ISS and the consensus-based criterion standard was 0.43. We determined that the consensus-based criterion standard could be identified through a medical record review. Use of the consensus-based criterion standard for field triage research will more accurately identify injured patients who need the resources of a trauma center when compared to ISS. [ABSTRACT FROM PUBLISHER]

Background: Trauma is the leading cause of death in the patient group under 40 years of age. Within the prehospital management of seriously injured trauma victims the accuracy of the field triage by emergency physicians is of utmost importance. Objective: The aim of this study was to determine the accuracy of prehospital emergency physician field triage in road traffic accident victims. Material and methods: The study involved a retrospective analysis and comparison of prehospital and inhospital trauma records of road traffic accident victims treated by a Helicopter Emergency Medical Service (HEMS) team and transferred to a level I trauma centre. A comparison of prehospital and inhospital diagnostic findings was carried out according to an anatomical score (AIS). Results: Included in the analysis were 479 patients with a mean age of 37.0 ± 18.2 years, males 65.8 %, mean injury severity score (ISS) 15.5 ± 13.5, ISS > 16 in 41,1 % and mortality 7.3 %. The leading causes of injury were motor vehicle accidents (56.2 %), followed by motorcycle (24.0 %) and bicycle accidents (11.6 %) as well as truck accidents (4.0 %) and pedestrian accidents (4.2 %). The most common body regions injured (AIS ≥ 3) were the chest (37 %), head (25.1 %) and lower extremities (16.7 %). A correct prehospital field triage by emergency physicians was found for injuries with an AIS ≥ 3 of the head 77 %, chest 69 %, abdomen 51 %, pelvis 49 %, extremities 70 %, neck/cervical spine 67 % and thoracic/lumbar spine 70 %. Overlooked injuries in the prehospital setting (AIS ≥ 3) comprised predominantly injuries of the trunk (chest 12.6 %, abdomen 16.9 % and pelvis 15 %). Overlooked injuries were found significantly less for the head in patients with a Glasgow Coma Score ≤ 8 on arrival at the scene (5.4 % versus 19 %, p = 0.015), for the chest in patients with a SO ≤ 96 % on arrival at the scene (18.1 % versus 35.5 %, p = 0.004) and for the abdomen in patients with a systolic blood pressure < 90 mmHg on arrival at the scene (28.6 % versus 52.5 %, p = 0.025). Conclusion: Accurate field triage in seriously injured road accident victims, even by trained physicians, is difficult. This pertains especially to injuries to the abdomen and the pelvis. For the field triage a combination of anatomical and physiological criteria as well as the mechanism of injury should be used to increase accuracy. [ABSTRACT FROM AUTHOR]

Background. Ambulance transport of injured patients to the most appropriate medical care facility is an important decision. Trauma centers are designed and staffed to treat severely injured patients and are increasingly burdened by cases involving less-serious injury. Yet, a cost evaluation of the Field Triage national guideline has never been performed. Objectives. To examine the potential cost savings associated with overtriage for the 1999 and 2006 versions of the Field Triage Guideline. Methods. Data from the National Hospital Ambulatory Medical Care Survey and the National Trauma Databank (NTDB) produced estimates of injury-related ambulatory transports and exposure to the Field Triage guideline. Case costs were approximated using a cost distribution curve of all cases found in the NTDB. A two-way sensitivity analysis was also used to determine the impact of data uncertainty on medical costs and the reduction in trauma center visits (12%%) after implementation of the 2006 Field Triage guideline compared with the 1999 Field Triage guideline. Results. At a 40%% overtriage rate, the average case cost was $$16,434. The cost average of 44.2%% reduction in case costs if patients were treated in a non-trauma center compared with a trauma center was found in the literature. Implementation of the 2006 Field Triage guideline produced a $$7,264 cost savings per case, or an estimated annual national savings of $$568,000,000. Conclusion. Application of the 2006 Field Triage guideline helps emergency medical services personnel manage overtriage in trauma centers, which could result in a significant national cost savings. [ABSTRACT FROM AUTHOR]

Objectives: We evaluated the independent impact of field triage on treatment delay and long-term clinical outcome in a large contemporary, consecutive population of ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). Background: Reduction of treatment delay is crucial for patients with STEMI. Methods: From January 2005 to July 2008, 1,437 STEMI patients were treated with pPCI at a single high-volume invasive center. We present the 1-year outcome in this observational registry study. Results: A total of 616 patients were admitted by field triage and 821 by emergency departments. Baseline and angiographic variables were similar in the 2 populations. Patients admitted by field triage had a significantly shorter median door-to-balloon time compared with patients admitted by emergency department triage (83 min, interquartile range 67 to 100 min vs. 103 min, interquartile range 80 to 135 min; p < 0.001). Door-to-balloon times of less than the recommended 90 min were achieved in 61% of field triage patients, but only in 36% of nonfield-triage patients (p < 0.001). After adjustment for relevant baseline variables, patients admitted by field triage had a reduced risk of reaching the combined end point of all-cause mortality or nonfatal myocardial infarction (hazard ratio: 0.67; 95% confidence interval: 0.46 to 0.97; p = 0.035). Conclusions: This study shows that field triage of STEMI patients to pPCI significantly reduces treatment delay and improves outcome. These results emphasize the value of field triage as an important tool in the quest to improve clinical outcomes in STEMI patients undergoing pPCI. [Copyright &y& Elsevier]