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Objectives: The present study aimed to identify the impact of age on current trauma team activation (TTA) processes and outcomes for patients with pelvic fractures. Methods: Adult patients with moderate and/or severe pelvic fractures (Abbreviated Injury Scale ≥ 2) between 1 January 2016 and 31 December 2021 were included utilising major trauma hospital data in Queensland. Characteristics of older (age ≥ 65) and younger patients including TTA, interventions and outcomes were examined. Multivariate analysis was used to determine factors associated with TTA in older patients. Results: Data from 637 patients was included. Despite comparable injury severity, a TTA was activated in fewer older people (older: 65% vs. younger: 79%, P < 0.001). Older patients had more falls leading to the trauma presentation (54.4% vs. 22.6%, P < 0.001), with higher initial systolic BP (131 vs. 125 mmHg, P = 0.04). Outcomes were worse for older people, with greater rates of in‐hospital complications (27.2% vs. 16.4%, P = 0.004), and longer hospital stays (12 vs. 8 days, P = 0.04). Fewer older patients could be discharged independently to home (46.3% vs. 74.5%, P < 0.001). In older patients, falls and haemodynamic parameters were strongly associated with the reduced likelihood of TTA (fall mechanism [odds ratio (OR)] 0.33; 95% confidence interval [CI] 0.15–0.74; P = 0.01; systolic BP [OR 0.98; 95% CI 0.97–0.99; P = 0.03], heart rate [OR 0.97; 95% CI 0.95–0.99; P = 0.02]). Conclusion: Current TTA criteria based on higher energy mechanisms and traditional vital sign thresholds are inadequate for identifying injury in older patients. Sensitive triage criteria and increased clinician awareness are required to enhance injury recognition and improve outcomes in older trauma patients. [ABSTRACT FROM AUTHOR]

Background: Two-tier trauma team activation (TTA)—protocols often fail to safely identify severely injured patients. A possible amendment to existing triage scores could be the measurement of serum lactate. The aim of this study was to determine the ability of the combination of serum lactate and age to predict severe injuries (ISS > 15). Methods: We conducted a retrospective cohort study in a single level one trauma center in a 20 months study-period and analyzed every trauma team activation (TTA) due to the mechanism of injury (MOI). Primary endpoint was the correlation between serum lactate (and age) and ISS and mortality. The validity of lactate (LAC) and lactate contingent on age (LAC + AGE) were assessed using the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. We used a logistic regression model to predict the probability of an ISS > 15. Results: During the study period we included 325 patients, 75 met exclusion criteria. Mean age was 43 years (Min.: 11, Max.: 90, SD: 18.7) with a mean ISS of 8.4 (SD: 8.99). LAC showed a sensitivity of 0.82 with a specificity of 0.62 with an optimal cutoff at 1.72 mmol/l to predict an ISS > 15. The AUC of the ROC for LAC was 0.764 (95% CI: 0.67–0.85). The LAC + AGE model provided a significantly improved predictive value compared to LAC (0.765 vs. 0.828, p < 0.001). Conclusions: The serum lactate concentration is able to predict injury severity. The prognostic value improves significantly taking the patients age into consideration. The combination of serum lactate and age could be a suitable Ad-on to existing two-tier triage protocols to minimize undertriage. Level of evidence: Level IV, retrospective cohort study. [ABSTRACT FROM AUTHOR]

Trauma triage occurs in suboptimal environments for making consequential decisions. Published triage studies demonstrate the extremes of the complexity/accuracy trade-off, either studying simple models with poor accuracy or very complex models with accuracies nearing published goals. Using a Level I Trauma Center's registry cases (n = 50 644), this study describes, uses, and derives observations from a methodology to more thoroughly examine this trade-off. This or similar methods can provide the insight needed for practitioners to balance understandability with accuracy. Additionally, this study incorporates an evaluation of group-based fairness into this trade-off analysis to provide an additional dimension of insight into model selection. Lastly, this paper proposes and analyzes a multi-model approach to mitigating trust-related trade-offs. The experiments allow us to draw several conclusions regarding the machine learning models in the domain of trauma triage and demonstrate the value of our trade-off analysis to provide insight into choices regarding model complexity, model accuracy, and model fairness. [ABSTRACT FROM AUTHOR]

Abstract Background Transfer of severely injured patients to trauma centers, either directly from the field or after evaluation at non-trauma centers, reduces preventable morbidity and mortality. Failure to transfer these patients appropriately (i.e., under-triage) remains common, and occurs in part because physicians at non-trauma centers make diagnostic errors when evaluating the severity of patients’ injuries. We developed Night Shift, a theory-based adventure video game, to recalibrate physician heuristics (intuitive judgments) in trauma triage and established its efficacy in the laboratory. We plan a type 1 hybrid effectiveness-implementation trial to determine whether the game changes physician triage decisions in real-life and hypothesize that it will reduce the proportion of patients under-triaged. Methods We will recruit 800 physicians who work in the emergency departments (EDs) of non-trauma centers in the US and will randomize them to the game (intervention) or to usual education and training (control). We will ask those in the intervention group to play Night Shift for 2 h within 2 weeks of enrollment and again for 20 min at quarterly intervals. Those in the control group will receive only usual education (i.e., nothing supplemental). We will then assess physicians’ triage practices for older, severely injured adults in the 1-year following enrollment, using Medicare claims, and will compare under-triage (primary outcome), 30-day mortality and re-admissions, functional independence, and over-triage between the two groups. We will evaluate contextual factors influencing reach, adoption, implementation, and maintenance with interviews of a subset of trial participants (n = 20) and of other key decision makers (e.g., patients, first responders, administrators [n = 100]). Discussion The results of the trial will inform future efforts to improve the implementation of clinical practice guidelines in trauma triage and will provide deeper understanding of effective strategies to reduce diagnostic errors during time-sensitive decision making. Trial registration ClinicalTrials.gov; NCT06063434 . Registered 26 September 2023.

Background: Transfer of severely injured patients to trauma centers, either directly from the field or after evaluation at non-trauma centers, reduces preventable morbidity and mortality. Failure to transfer these patients appropriately (i.e., under-triage) remains common, and occurs in part because physicians at non-trauma centers make diagnostic errors when evaluating the severity of patients' injuries. We developed Night Shift, a theory-based adventure video game, to recalibrate physician heuristics (intuitive judgments) in trauma triage and established its efficacy in the laboratory. We plan a type 1 hybrid effectiveness-implementation trial to determine whether the game changes physician triage decisions in real-life and hypothesize that it will reduce the proportion of patients under-triaged. Methods: We will recruit 800 physicians who work in the emergency departments (EDs) of non-trauma centers in the US and will randomize them to the game (intervention) or to usual education and training (control). We will ask those in the intervention group to play Night Shift for 2 h within 2 weeks of enrollment and again for 20 min at quarterly intervals. Those in the control group will receive only usual education (i.e., nothing supplemental). We will then assess physicians' triage practices for older, severely injured adults in the 1-year following enrollment, using Medicare claims, and will compare under-triage (primary outcome), 30-day mortality and re-admissions, functional independence, and over-triage between the two groups. We will evaluate contextual factors influencing reach, adoption, implementation, and maintenance with interviews of a subset of trial participants (n = 20) and of other key decision makers (e.g., patients, first responders, administrators [n = 100]). Discussion: The results of the trial will inform future efforts to improve the implementation of clinical practice guidelines in trauma triage and will provide deeper understanding of effective strategies to reduce diagnostic errors during time-sensitive decision making. Trial registration: ClinicalTrials.gov; NCT06063434. Registered 26 September 2023. [ABSTRACT FROM AUTHOR]

Introduction Pediatric trauma has long been one of the primary contributors to pediatric mortality. There are multiple cases in the literature involving cyanide (CN) toxicity, carbon monoxide (CO) toxicity, and smoke inhalation with thermal injury, but none in combination with mechanical trauma. Methods In this 45-minute simulation case, emergency medicine residents and fellows were asked to manage a pediatric patient with multiple life-threatening traumatic and metabolic concerns after being extracted from a van accident with a resulting fire. Providers were expected to identify and manage the patient's airway, burns, hemoperitoneum, and CO and CN toxicities. Results Forty learners participated in this simulation, the majority of whom had little prior clinical experience managing the concepts highlighted in it. All agreed or strongly agreed that the case was relevant to their work. After participation, learner confidence in the ability to manage each of the learning objectives was high. One hundred percent of learners felt confident or very confident in managing CO toxicity and completing primary and secondary surveys, while 97% were similarly confident in identifying smoke inhalation injury, preparing for a difficult airway, and managing CN toxicity. Discussion This case was a well-received teaching tool for the management of pediatric trauma and metabolic derangements related to fire injuries. While this specific case represents a rare clinical experience, it is within the scope of expected knowledge for emergency medicine providers and offers the opportunity to practice managing multisystem trauma.

Abstract Background Non-compliance with clinical practice guidelines in trauma remains common, in part because physicians make diagnostic errors when triaging injured patients. Deliberate practice, purposeful participation in a training task under the oversight of a coach, effectively changes behavior in procedural domains of medicine but has rarely been used to improve diagnostic skill. We plan a pilot parallel randomized trial to test the feasibility, acceptability, and preliminary effect of a novel deliberate practice intervention to reduce physician diagnostic errors in trauma triage. Methods We will randomize a national convenience sample of physicians who work at non-trauma centers (n = 60) in a 1:1 ratio to a deliberate practice intervention or to a passive control. We will use a customized, theory-based serious video game as the basis of our training task, selected based on its behavior change techniques and game mechanics, along with a coaching manual to standardize the fidelity of the intervention delivery. The intervention consists of three 30-min sessions with content experts (coaches), conducted remotely, during which physicians (trainees) play the game and receive feedback on their diagnostic processes. We will assess (a) the fidelity with which the intervention is delivered by reviewing video recordings of the coaching sessions; (b) the acceptability of the intervention through surveys and semi-structured interviews, and (c) the effect of the intervention by comparing the performance of trainees and a control group of physicians on a validated virtual simulation. We hypothesize that trainees will make ≥ 25% fewer diagnostic errors on the simulation than control physicians, a large effect size. We additionally hypothesize that ≥ 90% of trainees will receive their intervention as planned. Conclusions The results of the trial will inform the decision to proceed with a future hybrid effectiveness-implementation trial of the intervention. It will also provide a deeper understanding of the challenges of using deliberate practice to modify the diagnostic skill of physicians. Trial registration Clinical trials.gov ( NCT05168579 ); 23 December 2021.

Introduction: In Ontario, Canada, paramedics use the Field Trauma Triage Standard to identify patients at risk for severe injury. These triage criteria encompass physiologic, anatomic, mechanism of injury, and special considerations to identify patients that should be transported directly to a trauma center. Patients meeting any one of these criteria mandate direct transfer to a trauma center. This study evaluated whether severely injured trauma patients that underwent an interfacility transfer met these triage criteria. The secondary objective was to assess the impact of failed triage application on in-hospital mortality. Methods: This is a retrospective cohort study of interfacility trauma transfers to an adult trauma center over a 3-year period that were either admitted to the intensive care unit, received an operation within 4 h of arrival, or died within 48 h of arrival. Data were abstracted from the hospital's trauma registry and chart review of electronic medical records. Frequency of patients meeting pre-hospital triage criteria and which specific criteria were collected. Multivariable logistic regression was performed to assess the impact of missed pre-hospital triage on in-hospital mortality. Results: There were 1008 interfacility patients during the study period, of which 340 patients met inclusion criteria; 78.5% (n = 267) of interfacility transports had met at least one triage criteria. Most frequent criteria met were: Glasgow Coma Scale <14 (42.4%), high risk motor-vehicle collision (22.1%), and systolic blood pressure <90 mmHg (19.4%). When adjusted for injury severity score and age, patients who met triage criteria were not at increased odds of death (OR 2.38, 95% CI: 0.87–6.46) compared to interfacility patients that did not meet criteria. Conclusion: A majority of critically injured interfacility transfers met initial trauma triage criteria. These patients are at high risk for preventable morbidity and mortality. This study indicates the need to understand the barriers to pre-hospital adherence to trauma triage guidelines. [ABSTRACT FROM AUTHOR]

Trauma triage criteria are constantly being refined for improved identification of severely injured patients. When errors occur, they should be tracked, and triage criteria adjusted to minimize these events. Two time periods of trauma registry data at a single rural level II trauma center were retrospectively compared to evaluate demographics, injuries, and outcomes to identify triage errors. In 300 activated trauma patients during 2011, overtriage was 23% and undertriage was 3.7%. In 1035 activated trauma patients during 2019, overtriage was 20.5% and undertriage was 2.2%. Mortality decreased over time overall. In 2019, Trauma I patients were older, spent more time on the ventilator, and in the ICU (all P <.001). Trauma II patients were also older, had lower ISS, hospital days, and ventilator days (all P <.001). During rapid growth, evaluation of overtriage and undertriage can provide useful feedback for hospital staff to refine triage choices and improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Non-compliance with clinical practice guidelines in trauma remains common, in part because physicians make diagnostic errors when triaging injured patients. Deliberate practice, purposeful participation in a training task under the oversight of a coach, effectively changes behavior in procedural domains of medicine but has rarely been used to improve diagnostic skill. We plan a pilot parallel randomized trial to test the feasibility, acceptability, and preliminary effect of a novel deliberate practice intervention to reduce physician diagnostic errors in trauma triage. Methods: We will randomize a national convenience sample of physicians who work at non-trauma centers (n = 60) in a 1:1 ratio to a deliberate practice intervention or to a passive control. We will use a customized, theory-based serious video game as the basis of our training task, selected based on its behavior change techniques and game mechanics, along with a coaching manual to standardize the fidelity of the intervention delivery. The intervention consists of three 30-min sessions with content experts (coaches), conducted remotely, during which physicians (trainees) play the game and receive feedback on their diagnostic processes. We will assess (a) the fidelity with which the intervention is delivered by reviewing video recordings of the coaching sessions; (b) the acceptability of the intervention through surveys and semi-structured interviews, and (c) the effect of the intervention by comparing the performance of trainees and a control group of physicians on a validated virtual simulation. We hypothesize that trainees will make ≥ 25% fewer diagnostic errors on the simulation than control physicians, a large effect size. We additionally hypothesize that ≥ 90% of trainees will receive their intervention as planned. Conclusions: The results of the trial will inform the decision to proceed with a future hybrid effectiveness-implementation trial of the intervention. It will also provide a deeper understanding of the challenges of using deliberate practice to modify the diagnostic skill of physicians. Trial registration: Clinical trials.gov (); 23 December 2021. [ABSTRACT FROM AUTHOR]

Unplanned transfer of trauma patients to the intensive care unit (ICU) carries an associated increase in mortality, hospital length of stay, and cost. Trauma teams need to determine which patients necessitate ICU admission on presentation rather than waiting to intervene on deteriorating patients. This study sought to develop a novel Clinical Risk of Acute ICU Status during Hospitalization (CRASH) score to predict the risk of unplanned ICU admission. The 2017 Trauma Quality Improvement Program database was queried for patients admitted to nonICU locations. The group was randomly divided into two equal sets (derivation and validation). Multiple logistic regression models were created to determine the risk of unplanned ICU admission using patient demographics, comorbidities, and injuries. The weighted average and relative impact of each independent predictor were used to derive a CRASH score. The score was validated using area under the curve. A total of 624,786 trauma patients were admitted to nonICU locations. From 312,393 patients in the derivation-set, 3769 (1.2%) had an unplanned ICU admission. A total of 24 independent predictors of unplanned ICU admission were identified and the CRASH score was derived with scores ranging from 0 to 32. The unplanned ICU admission rate increased steadily from 0.1% to 3.9% then 12.9% at scores of 0, 6, and 14, respectively. The area under the curve for was 0.78. The CRASH score is a novel and validated tool to predict unplanned ICU admission for trauma patients. This tool may help providers admit patients to the appropriate level of care or identify patients at-risk for decompensation. • Unplanned ICU admission is an important indicator of hospital performance. • 24 Independent predictors for unplanned intensive care unit (ICU) admission. • The CRASH score is a good predictor of unplanned ICU admission utilizing readily available data from admission. [ABSTRACT FROM AUTHOR]

The mechanism of injury (MOI) criteria assist in determining which patients are at high risk of severe injury and would benefit from direct transport to a trauma center. The goal of this study was to determine whether the prognostic performance of the Centers for Disease Control's (CDC) MOI criteria for motor vehicle collisions (MVCs) has changed during the decade since the guidelines were approved. Secondary objectives were to evaluate the performance of these criteria for different age groups and evaluate potential criteria that are not currently in the guidelines. Data were obtained from NASS and Crash Investigation Sampling System (CISS) for 2000–2009 and 2010–2019. Cases missing injury severity were excluded, and all other missing data were imputed. The outcome of interest was Injury Severity Score (ISS) ≥16. The area under the receiver operator characteristic (AUROC) and 95% confidence intervals (CIs) were obtained from 1,000 bootstrapped samples using national case weights. The AUROC for the existing CDC MOI criteria were compared between the 2 decades. The performance of the criteria was also assessed for different age groups based on accuracy, sensitivity, and specificity. Potential new criteria were then evaluated when added to the current CDC MOI criteria. There were 150,683 (weighted 73,423,189) cases identified for analysis. There was a small but statistically significant improvement in the AUROC of the MOI criteria in the later decade (2010–2019; AUROC = 0.77, 95% CI [0.76–0.78]) compared to the earlier decade (2000–2009; AUROC = 0.75, 95% CI [0.74–0.76]). The accuracy and specificity did not vary with age, but the sensitivity dropped significantly for older adults (0–18 years: 0.62, 19–54 years: 0.59, ≥55 years: 0.37, and ≥65 years: 0.36). The addition of entrapment improved the sensitivity of the existing criteria and was the only potential new criterion to maintain a sensitivity above 0.95. The MOI criteria for MVCs in the current CDC guidelines still perform well even as vehicle design has changed. However, the sensitivity of these criteria for older adults is much lower than for younger occupants. The addition of entrapment improved sensitivity while maintaining high specificity and could be considered as a potential modification to current MOI criteria. [ABSTRACT FROM AUTHOR]

Background: The identification of risk factors for severe injury is crucial in trauma triage and trauma team activation (TTA) depends on a sufficient triage. The aim of this study was to determine whether or not elevated serum lactate levels and age are risk factors for severe injury in TTA due to trauma mechanism. Methods: We conducted a retrospective cohort study in a single level one trauma center between September 2019 and May 2021 and analysed every TTA due to trauma mechanism. Primary endpoint of interest was the association of serum lactate as well as age with injury severity assessed by the injury severity score (ISS). Results: During the study period, we included 250 patients. Mean age was 43.3 years (Min.: 11, Max.: 90, SD: 18.7) and the initial lactate level was 1.7 mmol/L (SD: 0.95) with a mean ISS of 8.4 (SD: 8.99). The adjusted odds ratio (OR) for age > 65 being associated with an ISS > 16 is 9.7 (p < 0.001; 95% CI 4.01–25.58) and for lactate > 2.2 mmol/L being associated with an ISS > 16 is 6.29 (p < 0.001; 95% CI 2.93–13.48). A lactate level of > 4 mmol/L results in a 36-fold higher risk of severe injury with an ISS > 16 (OR 36.06; 95% CI 4–324.29). Conclusion: This study identifies age (> 65) and lactate (> 2.2 mmol/L) as independent risk factors for severe injury in a TTA due to trauma mechanism. Existing triage protocols might benefit from congruous amendments. [ABSTRACT FROM AUTHOR]

Background: The American College of Surgeons requires trauma centers to use six minimum criteria (ACS‐6) for full trauma team activation: hypotension, gunshot wound to the neck or torso, Glasgow Coma Scale (GCS) score < 9, respiratory compromise, transfers receiving blood transfusion, or physician discretion. Our goal was to evaluate the effect of adding varying shock index (SI) thresholds to the ACS‐6 in an adult trauma population with the hypothesis that SI would significantly improve sensitivity at the expense of an acceptable decrease in specificity. Methods: We performed a secondary analysis of EMS and trauma registry data from an urban Level I trauma center. Consecutive patients > 15 years of age were included from 1993 through 2006. SI at thresholds of ≥0.8, ≥0.85, ≥0.9, and ≥1 were evaluated. Primary outcome was emergency operative (within 1 h of arrival) or procedural (cricothyrotomy or thoracotomy) intervention (EOPI); secondary outcomes were Injury Severity Score (ISS) > 15, ISS > 24, a composite of EOPI or ISS > 15, and urgent operative intervention (within 4 h). Results: A total of 20,872 patients were included, 27% with an ISS > 15 and 5% who underwent EOPI. Sensitivity and specificity of the ACS‐6 alone for EOPI were 86% (95% confidence interval [CI] = 84% to 88%) and 81% (95% CI = 80% to 81%), respectively. Inclusion of SI thresholds of 0.8, 0.85, 0.9, and 1 resulted in sensitivities of 95% (95% CI = 93% to 96%), 93% (CI = 91% to 94%), 92% (95% CI = 90% to 93%), and 90% (95% CI = 88% to 92%), respectively, and specificities of 52% (95% CI = 51% to 52%), 59% (95% CI = 58% to 59%), 64% (95% CI = 64% to 65%), and 72% (95% CI = 71% to 73%), respectively. Similar trends were found for each secondary outcome. Conclusion: The addition of SI to the ACS‐6 for trauma team activation increased sensitivity for EOPI with a larger decrease in specificity across all thresholds. Inclusion of a SI threshold of ≥0.9 closely aligns with under‐ and overtriage benchmarks in this trauma registry cohort using a strict definition of trauma team activation need. [ABSTRACT FROM AUTHOR]

Background: Paediatric age-adjusted shock index (SIPA) has emerged as a predictor of morbidity and mortality in trauma. Poor sensitivity and low generalisability demonstrated in previous studies have limited its use. We evaluate the use of SIPA in the general Australian paediatric trauma population and the combination of SIPA with GCS.Methods: All patients from January 2015 to August 2020 at a major Australian paediatric trauma centre were reviewed. Pre-arrival SIPA (pSIPA) and arrival SIPA (aSIPA) were calculated. If SIPA was elevated or the Glasgow Coma Scale ≤ 13, SIPA with mental state (SIPAms) was marked positive for pre-arrival (pSIPAms) and arrival (aSIPAms) respectively.Results/discussion: Data from 480 patients were analysed. pSIPA and aSIPA poorly predicted outcomes of morbidity. Only aSIPA predicted mortality. However, both pre-arrival and arrival SIPAms variables predict mortality, major trauma (ISS≥12), hospital LOS, need for ICU admission, and major surgery. Furthermore, median ISS and lactate were significantly higher in positive pSIPA, aSIPA, pSIPAms, and aSIPAms groups than negative. aSIPAms has a sensitivity of 76% and specificity of 70% for major trauma.Conclusion: Broad inclusion criteria reduce SIPA's ability to predict morbidity. Combining it with GCS improves this and is most valuable when calculated at arrival. In addition, the score is more reliable for major trauma (ISS≥12). Future studies should evaluate the use of SIPAms in activation criteria. [ABSTRACT FROM AUTHOR]

Background: Due to the overwhelming demand for trauma services, resulting from increasing emergency department attendances over the past decade, virtual fracture clinics (VFCs) have become the fashion to keep up with the demand and help comply with the BOA Standards for Trauma and Orthopaedics (BOAST) guidelines. In this article, we perform a systematic review asking, “How useful are VFCs?”, and what injuries and conditions can be treated safely and effectively, to help decrease patient face to face consultations. Our primary outcomes were patient satisfaction, clinical efficiency and cost analysis, and clinical outcomes. Methods: We performed a systematic literature search of all papers pertaining to VFCs, using the search engines PubMed, MEDLINE, and the Cochrane Database, according to the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) checklist. Searches were carried out and screened by two authors, with final study eligibility confirmed by the senior author. Results: In total, 21 records were relevant to our research question. Six orthopaedic injuries were identified as suitable for VFC review, with a further four discussed in detail. A reduction of face to face appointments of up to 50% was reported with greater compliance to BOAST guidelines (46.4%) and cost saving (up to £212,000). Conclusions: This systematic review demonstrates that the VFC model can help deliver a safe, more cost-effective, and more efficient arm of the trauma service to patients.

Under-triage in trauma remains prevalent, in part because of decisions made by physicians at non-trauma centers. We developed two digital behavior change interventions to recalibrate physician heuristics (pattern recognition), and randomized 688 emergency medicine physicians to use the interventions or to a control. In this observational follow-up, we evaluated whether exposure to the interventions changed physician performance in practice. We obtained 2016 – 2018 Medicare claims for severely injured patients, linked the names of trial participants to National Provider Identifiers (NPIs), and identified claims filed by trial participants for injured patients presenting to non-trauma centers in the year before and after their trial. The primary outcome measure was the triage status of severely injured patients. We linked 670 (97%) participants to NPIs, identified claims filed for severely injured patients by 520 (76%) participants, and claims filed at non-trauma centers by 228 (33%). Most participants were white (64%), male (67%), and had more than three years of experience (91%). Patients had a median Injury Severity Score of 16 (IQR 16 – 17), and primarily sustained neuro-trauma. After adjustment, patients treated by physicians randomized to the interventions experienced less under-triage in the year after the trial than before (41% versus 58% [-17%], P = 0.015); patients treated by physicians randomized to the control experienced no difference in under-triage (49% versus 56% [-7%], P = 0.35). The difference-in-the-difference was non-significant (10%, P = 0.18). It was feasible to track trial participants' performance in national claims. Sample size limitations constrained causal inference about the effect of the interventions. [ABSTRACT FROM AUTHOR]

Background: A pediatric field triage strategy that meets the national policy benchmark of ≥95% sensitivity would likely improve health outcomes but increase heath care costs. Our objective was to compare the cost-effectiveness of current pediatric field triage practices to an alternative field triage strategy that meets the national policy benchmark of ≥95% sensitivity.Study Design: We developed a decision-analysis Markov model to compare the outcomes and costs of the two strategies. We used a prospectively collected cohort of 3507 (probability weighted, unweighted n = 2832) injured children transported by 44 emergency medical services (EMS) agencies to 28 trauma and non-trauma centers in the Northwestern United States from 1/1/2011 to 12/31/2011 to derive the alternative field triage strategy and to populate model probability and cost inputs for both strategies. We compared the two strategies by calculating quality adjusted life years (QALYs) and health care costs over a time horizon from the time of injury until death. We set an incremental cost-effectiveness ratio threshold of less than $100,000 per QALY for the alternative field triage to be a cost-effective strategy.Results: Current pediatric field triage practices had a sensitivity of 87.4% (95% confidence interval [CI] 71.9 to 95.0%) and a specificity of 82.3% (95% CI 81.0 to 83.5%) and the alternative field triage strategy had a sensitivity of 97.3% (95% CI 82.6 to 99.6%) and a specificity of 46.1% (95% CI 43.8 to 48.4%). The alternative field triage strategy would cost $476,396 per QALY gained compared to current pediatric field triage practices and thus would not be a cost-effective strategy. Sensitivity analyses demonstrated similar findings.Conclusion: Current field triage practices do not meet national policy benchmarks for sensitivity. However, an alternative field triage strategy that meets the national policy benchmark of ≥95% sensitivity is not a cost-effective strategy. [ABSTRACT FROM AUTHOR]

Background: Little is known about vital signs during the very first minutes after an accident. This study aimed to describe the vital signs of motorcycle riders shortly after racetrack crashes and examine the clinical value of these data for the prehospital clinical assessments. Methods: A retrospective observational cohort based on data from medical records on 104 motorcycle accidents at a racetrack in Sweden, covering the season of 2019 (May 01 until September 17), was conducted. Both race and practice runs were included. In addition, data from the Swedish Trauma Registry were used for patients referred to the hospital. Kruskal-Wallis test and linear regression were calculated in addition to descriptive statistics. Results: In all, 30 riders (29%) were considered injured. Sixteen riders (15%) were referred to the hospital, and of these, five patients (5% of all riders) had suffered serious injuries. Aside from a decreased level of consciousness, no single vital sign or kinematic component observed within the early minutes after a crash was a strong clinical indicator of the occurrence of injuries. However, weak links were found between highsider or collision crashes and the occurrence of injuries. Conclusion: Except for a decreased level of consciousness, this study indicates that the clinical value of early measured vital signs might be limited for the pre-hospital clinical assessment in the motorsport environment. Also, an adjustment of general trauma triage protocols might be considered for settings such as racetracks. Using the context with medical professionals at the victim's side within a few minutes after an accident, that is common in motorsport, offers unique possibilities to increase our understanding of clinical signs and trauma in the early state after an accident. [ABSTRACT FROM AUTHOR]

Introduction: This study was aimed to assess if combining the evaluation of blood glucose level (BGL) and the Triage Revised Trauma Score (T-RTS) may result in a more accurate prediction of the actual clinical outcome, both in general adult population and in elderly patients with trauma.Methods: This is a retrospective cohort study, conducted in the emergency department (ED) of an urban teaching hospital, with an average ED admission rate of 75,000 patients per year. Those excluded: known diagnosis of diabetes, age <18 years old, pregnancy, and mild trauma (classified as isolate trauma of upper or lower limb, in absence of exposed fractures). A combined Revised Trauma Score Glucose (RTS-G) score was obtained adding to T-RTS: two for BGL <160mg/dL (8.9mmol/L); one for BGL ≥160mg/dL and < 200mg/dL (11.1mmol/L); and zero for BGL ≥ 200mg/dL. The primary outcome was a composite of patient's death in ED or admission to intensive care unit (ICU). Receiver Operating Characteristic (ROC) curve analysis was used to evaluate the overall performance of T-RTS and of the combined RTS-G score.Results: Among a total of 68,933 traumas, 9,436 patients (4,407 females) were enrolled, aged from 18 to 103 years; 4,288 were aged ≥65 years. A total of 577 (6.1%) met the primary endpoint: 38 patients died in ED (0.4%) and 539 patients were admitted to ICU. The T-RTS and BGL were independently associated to primary endpoint at multivariate analysis. The cumulative RTS-G score was significantly more accurate than T-RTS and reached the best accuracy in elderly patients. In general population, ROC area under curve (AUC) for T-RTS was 0.671 (95% CI, 0.661 - 0.680) compared to RTS-G ROC AUC 0.743 (95% CI, 0.734 - 0.752); P <.001. In patients ≥65 years, T-RTS ROC AUC was 0.671 (95% CI, 0.657 - 0.685) compared to RTS-G ROC AUC 0.780 (95% CI, 0.768 - 0.793); P <.001.Conclusions: Results showed RTS-G could be used effectively at ED triage for the risk stratification for death in ED and ICU admission of trauma patients, and it could reduce under-triage of approximately 20% compared to T-RTS. Comparing ROC AUCs, the combined RTS-G score performs significantly better than T-RTS and gives best results in patients ≥65 years. [ABSTRACT FROM AUTHOR]

Introduction: This study sought to compare outcomes of trauma patients taken directly from the field to a Level I trauma center (direct) versus patients that were first brought to a Level III trauma center prior to being transferred to a Level I (transfer) within our inclusive Delaware trauma system.Methods: A retrospective review of the Level I center's trauma registry was performed using data from 2013 to 2017 for patients brought to a single Level I trauma center from 2 surrounding counties. The direct cohort consisted of 362 patients, while the transfer cohort contained 204 patients. Linear regression analysis was performed to investigate hospital length of stay (LOS), while logistic regression was used for mortality, complications, and craniotomy. Covariates included age, gender, county, and injury severity score (ISS). Propensity score weighting was also performed between the direct and transfer cohorts.Results: When adjusting for age, gender, ISS, and county, transferred patients demonstrated worse outcomes compared with direct patients in both the regression and propensity score analyses. Transferred patients were at increased risk of mortality (odds ratio [OR] 2.17, CI 1.10-4.37, P = .027) and craniotomy (OR 3.92, CI 1.87-8.72, P < .001). Age was predictive of mortality (P < .001). ISS was predictive of increased risk of mortality (P < .001), increased LOS (P < .001), and craniotomy (P < .001). Older age, Sussex County, and higher ISS were predictive of patients being transferred (P < .001).Discussion: Delays in the presentation to our Level I trauma center resulted in worse outcomes. Patients that meet criteria should be considered for transport directly to the highest level trauma center in the system to avoid delays in care. [ABSTRACT FROM AUTHOR]

Introduction: The American College of Surgeons Committee on Trauma (ACS-CoT) sets standards for appropriate trauma activation criteria. Overtriage and undertriage rates are traditionally determined by the Cribari matrix using the Injury Severity Score (ISS). In 2016, the Need for Trauma Intervention (NFTI) criteria were developed by Baylor University Medical Center to overcome weaknesses in the Cribari matrix methodology. Methods: A retrospective review of trauma triage rates was conducted from March 2018 to February 2019. Overtriage rates were calculated using the Cribari matrix and then further evaluated using modified NFTI (MNFTI) criteria. Overtriaged patients meeting MNFTI criteria were considered appropriately triaged and deleted from the overtriage category, and adjusted triage rates were determined. Demographic, injury, and outcome data were compared between MNFTI-positive and MNFTI-negative groups. A logistic regression analysis was performed to assess for predictors of patient mortality. Results: Using the Cribari matrix, 248 patients were identified as overtriaged. Of these, 133 (53.6%) were found to meet MNFTI criteria. The average monthly overtriage rate was reduced from 55% using the Cribari matrix to 26% after applying the MNFTI criteria. Within the Cribari overtriage patient group, MNFTI-positive patients had significantly longer hospital length of stay (LOS) (3.7 vs. 6.0 days, p = .016), intensive care unit LOS (1.2 vs. 4.2 days, p < .001), and ventilator days (0.6 vs. 1.6 days, p = .002) than MNFTI- negative patients. A multivariable logistic regression analysis found that meeting any of the MNFTI criteria significantly increased the odds of mortality (OR = 10.38; 95% CI [3.87, 27.84], p < .001). Conclusions: Discharge ISS may not accurately reflect the patient's acuity on presentation. Applying MNFTI criteria to the Cribari matrix improved overtriage rates and may more accurately reflect need for full trauma team activation. Patients meeting MNFTI criteria had worse outcomes overall and had a 10-fold increase in the odds of mortality. [ABSTRACT FROM AUTHOR]

Timely and accurate triage of upper extremity injuries is critical, but current perfusion monitoring technologies have shortcomings. These limitations are especially pronounced in patients with darker skin tones. This pilot study evaluates a Eulerian Video Magnification (EVM) algorithm combined with color channel waveform extraction to enable video-based measurement of hand and finger perfusion. Videos of 10 volunteer study participants with Fitzpatrick skin types III–VI were taken in a controlled environment during normal perfusion and tourniquet-induced ischemia. Videos were EVM processed, and red/green/blue color channel characteristics were extracted to produce waveforms. These videos were assessed by surgeons with a range of expertise in hand injuries. The videos were randomized and presented in 1 of 3 ways: unprocessed, EVM processed, and EVM with waveform output (EVM+waveform). Survey respondents indicated whether the video showed an ischemic or perfused hand or if they were unable to tell. We used group comparisons to evaluate response accuracy across video types, skin tones, and respondent groups. Of the 51 providers to whom the surveys were sent, 25 (49%) completed them. Using the Pearson χ2 test, the frequencies of correct responses were significantly higher in the EVM+waveform category than in the unprocessed or EVM videos. Additionally, the agreement was higher among responses to the EVM+waveform questions than among responses to the unprocessed or EVM processed. The accuracy and agreement from the EVM+waveform group were consistent across all skin pigmentations evaluated. Video-based EVM processing combined with waveform extraction from color channels improved the surgeon's ability to identify tourniquet-induced finger ischemia via video across all skin types tested. Eulerian Video Magnification with waveform extraction improved the assessment of perfusion in the distal upper extremity and has potential future applications, including triage, postsurgery vascular assessment, and telemedicine. [ABSTRACT FROM AUTHOR]

Objective: Older adults make up a rapidly increasing proportion of motor vehicle occupants and previous studies have demonstrated that this population is more susceptible to traumatic injuries. The CDC recommends that patients anticipated to have severe injuries (Injury Severity Score [ISS] ≥ 16) be transported to a trauma center. The recommended target rate for undertriage is ≤ 5% and for overtriage is ≤ 50%. Several regression-based algorithms for injury prediction have been developed in order to predict severe injury in occupants involved in a motor vehicle collision (MVC). The objective of this study to was to determine if the accuracy of regression-based injury severity prediction algorithms decreases for older adults. Methods: Data were obtained from the National Automotive Sampling System – Crashworthiness Data System (NASS-CDS) from the years 2000–2015. Adult occupants involved in non-rollover MVCs were included. Regression-based injury risk models to predict severe injury (ISS ≥ 16) were developed using random split-samples with the following variables: age, delta-V, direction of impact, belt status, and number of impacts. Separate models were trained using data from the following age groups: (1) all adults, (2) 15–54 years, (3) ≥45 years, (4) ≥55 years, and (5) ≥65 years. The models were compared using the mean receiver operating characteristic area under curve (ROC-AUC) after 1,000 iterations of training and testing. The predicted rates of overtriage were then determined for each group in order to achieve an undertriage rate of 5%. Results: There were 24,577 occupants (6,863,306 weighted) included in this analysis. The injury prediction model trained using data from all adults did not perform as well when tested on older adults (ROC-AUC: 15–54 years: 0.874 [95% CI: [0.851–0.895]; 45+ years: 0.837 [95% CI: 0.802–869]; 55+ years: 0.821 [95% CI: 0.775–0.864]; and 65+ years: 0.813 [95% CI: 0.754–0.866]). The accuracy of this model decreased in each decade of life. The performance did not change significantly when age-specific data were used to train the prediction models (ROC-AUC: 18–54 years: 0.874 [95% CI: 0.851–0.896]; 45+ years: 0.836 [95% CI: 0.798–0.871]; 55+ years: 0.822 [95% CI: 0.779–0.864]; and 65+ years: 0.808 [95% CI: 0.748–0.868]). In order to achieve an undertriage rate of 5%, the predicted overtriage rate by these models were 50% for occupants 15–54 years, 61% for occupants ≥ 55 years, 70% for occupants ≥ 55 years, and 71% for occupants ≥ 65 years. Conclusion: The results of this study indicate that it is more difficult to accurately predict severe injury in older adults involved in MVCs, which has the potential to result in significant overtriage. This decreased accuracy is likely due to variations in fragility in older adults. These findings indicate that special care should be taken when using regression-based prediction models to determine the appropriate hospital destination for older occupants. [ABSTRACT FROM AUTHOR]

Efficient trauma systems rely on field and emergency department (ED) personnel to triage patients to the appropriate level of care. Undertriage puts patients at risk, whereas overtriage results in system strain. Although much research has focused on prehospital triage, little is known about trauma triage processes within the ED. We investigated the timing of trauma consultation in the ED of a level I trauma center. We hypothesized that patient characteristics and injury type would be associated with time to consultation, with women, Black patients, older patients, and those with head and torso injuries experiencing longer time to consult. Patients aged ≥18 y referred to the trauma service via consultation were recruited retrospectively. Bivariable and multivariable negative binomial regressions were used to assess the association between patient and injury characteristics and time to consult. We used multivariable logistic regression adjusted for patient and injury characteristics to assess for association between time to consult and mortality and length of stay. Among 588 adult consult patients, median time to consult was 177 min (interquartile range 106-265). In multivariable analysis, Black patients had longer time to consult (incidence rate ratio [IRR] 1.33, 95% confidence interval [CI] 1.10, 1.60) as did women (IRR 1.15, 95% CI 1.02, 1.29). Head injury was associated with shorter time to consult (IRR 0.81, 95% CI 0.71, 0.92). Time to consult was not associated with mortality or length of stay. Patient demographics and injury characteristics influenced the timing of trauma consultation. More robust criteria for equitable evaluation of patients are needed to eliminate disparities, prevent delays, and streamline care. [ABSTRACT FROM AUTHOR]

Study Objective: The aim of this study is to determine the accuracy of pre-hospital trauma notifications and the effects of inaccurate information on trauma triage.Methods: This study was conducted at a level-1 trauma center over a two-year period. Data was collected from pre-notification forms on trauma activations that arrived to the emergency department via ambulance. Trauma activations with pre-notification were compared to those without notification and pre-notification forms were assessed for accuracy and completeness.Results: A total of 2186 trauma activations were included in the study, 1572 (71.9%) had pre-notifications, 614 (28.1%) did not and were initially under-triaged. Pre-notification forms were completed for 1505 (95.7%) patients, of which EMS provided incomplete/inaccurate information for 1204 (80%) patients and complete/accurate information for 301 (20%) patients. Missing GCS/AVPU score (1099, 91.3%), wrong age (357, 29.6%), and missing vitals (303, 25.2%) were the main problems. Missing/wrong information resulted in trauma tier over-activation in 25 (2.1%) patients and under-activation in 20 (1.7%) patients. Under-triaged patients were predominantly male (18, 90%), sustained a fall (9, 45%), transported by BLS EMS teams (12, 60%), and arrived on a weekday (13, 65%) during the time period of 11 pm-7 am (9, 45%). A total of 13 (65%) required emergent intubation, 2 (10%) required massive transfusion activation, 7 (35%) were admitted to ICU, 3 (15%) were admitted directly to the OR, and 1 (15%) died.Conclusion: EMS crews frequently provide inaccurate pre-hospital information or do not provide any pre-hospital notification at all, which results in over/under triage of trauma patients. [ABSTRACT FROM AUTHOR]

Background: Prehospital identification of shock in trauma patients lacks accurate markers. Low end tidal carbon dioxide (ETCO 2 ) correlates with mortality in intubated patients. The predictive value of ETCO 2 obtained by nasal capnography cannula (NCC) is unknown. We hypothesized that prehospital ETCO 2 values obtained by NCC and in-line ventilator circuit (ILVC) would be predictive of mortality., Methods: This was a prospective, observational, multicenter study. ETCO 2 values were collected by a NCC or through ILVC. AUROCs were compared with prehospital systolic blood pressure (SBP) and shock index (SI). The Youden index defined optimal cutoffs., Results: Of 550 enrolled patients, 487 (88.5%) had ETCO 2 measured through an NCC. Median age was 37 (27-52) years; 76.5% were male; median ISS was 13 (5-22). Mortality was 10.4%. Minimum prehospital ETCO 2 significantly predicted mortality with an AUROC of 0.76 (CI 0.69-0.84; Youden index ​= ​22 ​mmHg), outperforming SBP with an AUROC of 0.68; (CI 0.62-0.74, p ​= ​0.04) and shock index with an AUROC of 0.67 (CI 0.59-0.74, p ​= ​0.03)., Conclusion: Prehospital ETCO 2 measured by non-invasive NCC or ILVC may be predictive of mortality in injured patients., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper, (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: It is common practice for hospitals to use a trauma team activation criteria (TTAC) to identify patients at risk of major trauma and to activate a multidisciplinary team to receive such patients on arrival to the ED. The aims of this study are to describe the frequency of individual criteria and the ability of one currently used system to predict major trauma, and to estimate the effect of simplified criteria on the prediction.Design and Setting: A retrospective observational study of the entire cohort of adult patients who a) received trauma team activation or b) were included in the trauma registry of Royal Darwin Hospital in 2015. From the original clinical record all components of the TTAC, and corresponding outcomes, were extracted for each case. The predictive effect of each criterion, adjusted for the presence of others, was assessed by logistic regression. The poorest predictors were sequentially "dropped" to develop a number of models of which the predictive value of the resulting hypothetical TTAC was calculated.Main Outcome Measures: Major trauma (MT) was defined as a death in ED, immediate operative intervention or direct admission to ICU. Overtriage was defined as activation of the trauma team without major trauma. Undertriage was defined as major trauma without trauma team activation.Results: 794 trauma presentations were reviewed, 428 of those presentations met TTAC. Major trauma was present in 135 (32%) of those with TTAC hence overtriage was 68%. Criteria based on mechanism of injury (MOI) were responsible for over half of the overtriage and were collectively present without other activation criteria in only 10 MTs (6%). Removal of the criteria with the worst predictive value decreased overtriage to 50% before a rise in undertriage to beyond 24%.Conclusion: A number of criteria including those based on MOI decrease the accuracy of TTAC and lead to high rates of overtriage. Airway, respiratory and neurological compromise were the best predictors of MT. Any criteria simplification should be introduced in the context of a further audit of TTAC performance, as the estimates of the separate criteria in the current TTAC are not robustto bias or to undetected correlation. [ABSTRACT FROM AUTHOR]

Purpose Patient triage to the appropriate destination is critical to prehospital trauma care. Triage decisions are challenging in a region without collocated pediatric and adult trauma centers. Methods A regional survey was administered to emergency medical response units identifying variability and confusion regarding factors influencing patient disposition. A course was developed to guide the triage of pediatric and pregnant trauma patients. Pre- and posttests were administered to address course principles, including decision making and triage. Results A total of 445 participants completed the course at 22 sites representing 88 different prehospital provider agencies. Pre- and posttests were administered to 62% of participants with an average score improvement of 53.4% (pretest range 30% to 56.6%; posttest range 85% to 100%). Improvements were seen in all categories including major and minor trauma in pregnancy, major trauma in adolescence, and knowledge of age limits and triage protocols. Conclusion Education on triage guidelines and principles of pediatric resuscitation is essential for appropriate prehospital trauma management. Pre- and posttests may be used to demonstrate short term efficacy, while ongoing evaluations of practice patterns and follow-up surveys are needed to demonstrate longevity of acquired knowledge and identify areas of persistent confusion. Level of Evidence Level IV, Case Series without Standardized. [ABSTRACT FROM AUTHOR]

Background Spectral analysis of continuous blood pressure and heart rate variability provides a quantitative assessment of autonomic response to hemorrhage. This may reveal markers of mortality as well as endpoints of resuscitation. Methods Fourteen male Yorkshire pigs, ranging in weight from 33 to 36 kg, were included in the analysis. All pigs underwent laparotomy and then sustained a standardized retrohepatic inferior vena cava injury. Animals were then allowed to progress to class 3 hemorrhagic shock and where then treated with abdominal sponge packing followed by 6 h of crystalloid resuscitation. If the pigs survived the 6 h resuscitation, they were in the survival (S) group, otherwise they were placed in the nonsurvival (NS) group. Fast Fourier transformation calculations were used to convert the components of blood pressure and heart rate variability into corresponding frequency classifications. Autonomic tones are represented as the following: high frequency (HF) = parasympathetic tone, low frequency (LF) = sympathetic, and very low frequency (VLF) = renin-angiotensin aldosterone system. The relative sympathetic to parasympathetic tone was expressed as LF/HF ratio. Results Baseline hemodynamic parameters were equal for the S ( n = 11) and NS groups. LF/HF was lower at baseline for the NS group but was higher after hemorrhage and the resuscitation period indicative of a predominately parasympathetic response during hemorrhagic shock before mortality. HF signal was lower in the NS group during the resuscitation indicating a relatively lower sympathetic tone during hemorrhagic shock, which may have contributed to mortality. Finally, the NS group had a lower VLF signal at baseline (e.g., [S] 16.3 ± 2.5 versus [NS] 4.6 ± 2.9 P < 0.05,) which was predictive of mortality and hemodynamic instability in response to a similar hemorrhagic injury. Conclusions An increased LF/HF ratio, indicative of parasympathetic predominance following injury and during resuscitation of hemorrhagic shock was a marker of impending death. Spectral analysis of heart rate variability can also identify autonomic lability following hemorrhagic injuries with implications for first responder triage. Furthermore, a decreased VLF signal at baseline indicates an additional marker of hemodynamic instability and marker of mortality following a hemorrhagic injury. These data indicate that continuous quantitative assessment of autonomic response can be a predictor of mortality and potentially guide resuscitation of patients in hemorrhagic shock. [ABSTRACT FROM AUTHOR]

Background The American College of Surgeons developed the National Field Triage Decision Scheme (NFTDS) that has been adapted by many trauma centers in the nation, but quantitative evidence of its efficacy is unclear. We compare the NFTDS and state of Ohio guidelines to the “observed” rates and with rates derived using a statistical model. Methods We used 4757 trauma records from 2008-2012 available from the state and calculated undertriage (UT) and overtriage (OT) rates. We then simulated the NFTDS and the state guidelines for those years and estimated the corresponding UT and OT rates. We finally compared these rates with those derived from a multivariate logistic regression model. Results For the state data, both NFTDS and state guidelines produced lower UT rate (∼9%) compared with the observed rate (∼17%), whereas the OT rates were higher (>85%) than the observed rates (∼54%). The statistical model identified novel factors that were not directly available in the NFTDS; change in responsiveness (odds ratio [OR] = 1.924) and complaint in body (OR = 3.140), back (OR = 1.890), chest (OR = 3.191), head (OR = 3.878), and abdomen (OR = 2.966). Although the statistical model performed similar to observed rates, it performed considerably better than NFTDS (UT = 1.93% versus 9.03%; OT = 66.42% versus 87.52%) and state guidelines (UT = 2.18% versus 8.72%; OT = 64.09% versus 86.52%). Conclusions The current NFTDS and state's triage guidelines do not appear to achieve the ACS recommendation of <5% UT and <35% OT rates in the state of Ohio. Inclusion of region-specific factors may help enhance the current NFTDS guidelines and aid in the first impression or judgment of the Emergency Medical Services personnel to improve trauma care and reduce cost. [ABSTRACT FROM AUTHOR]

Background: Trauma systems currently rely on imperfect and subjective tools to prioritize responses and resources, thus there is a critical need to develop a more accurate trauma severity score. Our objective was to modify the Rapid Emergency Medicine (REMS) Score for the trauma population and test its accuracy as a predictor of in-hospital mortality when compared to other currently used scores, including the Revised Trauma Score (RTS), the Injury Severity Score (ISS), the "Mechanism, Glasgow Coma Scale, Age and Arterial Pressure" (MGAP) score, and the Shock Index (SI) score.Methods: The two-part study design involved both a modification step and a validation step. The first step incorporated a retrospective analysis of a local trauma database (3680 patients) where three components of REMS were modified to more accurately represent the trauma population. Using clinical judgment and goodness-of-fit tests, systolic blood pressure was substituted for mean arterial pressure, the weighting of age was reduced, and the weighting of Glasgow Coma Scale was increased. The second part comprised validating the new modified REMS (mREMS) score retrospectively on a U.S. National Trauma Databank (NTDB) that included 429,711 patients admitted with trauma in 2012. The discriminate power of mREMS was compared to other trauma scores using the area under the receiver operating characteristic (AUC) curve.Results: Overall the mREMS score with an AUC of 0.967 (95% CI: 0.963-0.971) was demonstrated to be higher than RTS (AUC 0.959 [95% CI: 0.955-0.964]), ISS (AUC 0.780 [95% CI 0.770-0.791]), MGAP (AUC 0.964 [95% CI: 0.959-0.968]), and SI (AUC 0.670 [95% CI: 0.650-0.690]) in predicting in-hospital mortality on the NTDB.Conclusion: In the trauma population, mREMS is an accurate predictor of in-hospital mortality, outperforming other used scores. Simple and objective, mREMS may hold value in the pre-hospital and emergency department setting in order to guide trauma team responses. [ABSTRACT FROM AUTHOR]

Background Trauma triage decisions can be influenced by both knowledge and experience. Consequently, there may be substantial variability in computed tomography (CT) scans desired by emergency medicine physicians, surgical chief residents, and attending trauma surgeons. We quantified this difference and studied the effects of each group's decisions on missed injuries, cost, and radiation exposure. Methods All blunt trauma activations at an urban level 1 trauma center were studied over a 6-mo period. Three months into the study, a pan-scan protocol was introduced. Prior to CT imaging, providers separately completed a survey that asked which CT scans were desired for each patient. Based on the completed surveys, hypothetical missed injuries, radiation exposure, and cost were determined. Results The variability in the number of CT scans desired by each of the three providers and the resulting cost and radiation exposure were not statistically significant. Substantial variability was predominantly seen in the indications for the desired scans, with the difference between proportions ranging from 3.1%-68.7%. Agreement among the three providers was highest for head and c-spine scans (80%-100%) and lowest for maxillary face (57%-80%) and chest scans (52%-74%). Overall, the missed injury rate was similar for all the providers; chief residents missed significantly more major injuries than trauma attendings during the pan-scan period ( P = 0.03). Conclusions Trauma training and level of training did not have a substantial effect on radiological decisions during the initial trauma assessment. This study sheds light on the growing uniformity among providers with regard to medical decision-making in the initial work-up of trauma. [ABSTRACT FROM AUTHOR]

Background The American College of Surgeons Committee on Trauma (ACS-COT) view over- and undertriage rates based on trauma team activation (TTA) criteria as surrogate markers for quality trauma patient care. Undertriage occurs when classifying patients as not needing a TTA when they do. Over-triage occurs when a TTA is unnecessarily activated. ACS-COT recommends undertriage < 5% and overtriage 25–35%. We sought to improve the under-triage and over-triage rates at our Level II Pediatric Trauma Center by updating our outdated trauma team activation criteria in an evidence-based fashion to better identify severely injured children and improving adherance to following established trauma team activation criteria. Methods This study was designed prospectively as a Process Improvement Patient Safety (PIPS) project in two phases. Data was obtained from our trauma registry. Prior to the initiation of Phase I, the TTA was modified using the best available evidence at the time. A Base Station report was modified to include elements of the TTA to be checked when EMS called prior to arrival to guide in activation. Phase I of the study (April 1-June 30, 2011) involved improving adherence to activating a trauma according to our newly revised TTA criteria. Phase II of the study (July 1, 2011-June 30, 2012) moved the trauma team activation responsibility primarily to nursing (collaborating with MDs) and including activation criteria regarding transfers-in from outside hospitals. Triage rates were calculated using the Cribari method: undertriage = patients with an ISS > 15 for which a major or modified was not activated, and overtriage = patients with an ISS < 16 for which a major was activated. Results 2011 Q1 YTD data was used as a baseline comparison. Baseline undertriage was 15% and overtriage was 75%. Phase I demonstrated 90% use of the redesigned Base Station report reflecting the new TTA criteria and was validated by RN/MD signatures. This resulted in an undertriage rate of 10% (12/118) and an overtriage rate of 20% (1/5). During Phase II, there was 100% use of the newly redesigned Base Station report. Phase IIa (concluding the data collection for 2011) demonstrated an undertriage rate of 8.4% (19/226) and an overtriage rate of 38% (5/13). Data during Phase IIb indicated an undertriage rate of 4.7% (12/251 pts) and overtriage rate of 54% (7/13). During baseline phase of the study, 50% of major patients went to the OR from the ER. During Phase I all major activations required admission to the PICU (4) or the OR (1). Finally, during Q2 2012 (the last quarter of Phase II), 25% of majors went to OR (2/8), 50% to ICU (4/8), 12.5% to Med-Surg (1/8), and 12.5% to home (1/8). Conclusions Standardization of process resulted in improved, sustainable under-/overtriage rates. Undertriage rates dropped from 15% to 5% undertriage, the ACS-recommended standard. Appropriate triage appears to have correlated with appropriate utilization of resources. [ABSTRACT FROM AUTHOR]