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Emergency physician and nurse discretion accurately triage high-risk trauma patients

Abstract

Purpose

Prehospital trauma team activation (TTA) criteria allow for early identification of severely injured trauma patients. Although most TTA criteria are objective, one TTA criterion is subjective: emergency provider discretion. The study objective was to define the ability of emergency department physician and nurse discretion to accurately perform prehospital triage of high risk trauma patients.

Methods

All highest level TTAs arriving to our American College of Surgeons (ACS)-verified Level 1 trauma center (06/2015–08/2020) were included. Exclusions were undocumented prehospital vitals or discharge disposition. At our institution, TTAs are triggered for standard ACS TTA criteria and age > 70 with traumatic mechanism other than ground level fall. Patients meeting ≥ 1 criterion apart from “Emergency Provider Discretion” were defined as Standard TTAs and patients meeting only “Emergency Provider Discretion” were defined as Discretion TTAs. Univariable/multivariable analyses compared injury data and outcomes.

Results

4540 patients met inclusion/exclusion criteria: 3330 (73%) Standard TTAs and 1210 (27%) Discretion TTAs. Discretion TTAs were younger (34 vs. 37 years, p < 0.001) and more frequently injured by penetrating trauma (38% vs. 33%, p = 0.008), particularly stab wounds (64% vs. 29%). Overtriage rates were comparable after Discretion vs. Standard TTAs (33% vs. 31%, p = 0.141). Blood transfusion < 4 h (31% vs. 32%, p = 0.503) and ICU admission ≥ 3 days (25% vs. 27%, p = 0.058) were comparable between groups. Discretion TTA was independently associated with increased need for emergent surgery (OR 1.316, p = 0.005).

Conclusions

Emergency provider discretion accurately identifies major trauma, with comparable rates of overtriage as standard TTA criteria. Discretion TTAs were as likely as Standard TTAs to require early blood transfusion and prolonged ICU stay. After controlling for confounders, Discretion TTAs were significantly more likely to require emergent surgical intervention. Emergency provider discretion should be recognized as a valid method of identifying major trauma patients at high risk of need for intervention.

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References

  1. American College of Surgeons Committee on Trauma (ACS COT). Resources for Optimal Care of the Injured Patient, 6th Ed. Chicago, Il: American College of Surgeons, 2014.

  2. Davis JW, Dirks RC, Sue LP, Kaups KL. Attempting to validate the overtriage/undertriage matrix at a Level I trauma center. J Trauma Acute Care Surg. 2017;83(6):1173–8.

    Article  Google Scholar 

  3. Roden-Foreman JW, Rapier NR, Foreman ML, Zagel AL, Sexton KW, Beck WC, McGraw C, Coniglio RA, Blackmore AR, Holzmacher J, et al. Rethinking the definition of major trauma: the need for trauma intervention outperforms injury severity score and revised trauma score in 38 adult and pediatric trauma centers. J Trauma. 2019;87(3):658–65.

    Article  Google Scholar 

  4. Bardes JM, Benjamin E, Schellenberg M, Inaba K, Demetriades D. Old age with a traumatic mechanism of injury should be a trauma team activation criterion. J Emerg Med. 2019;57(2):151–5.

    Article  Google Scholar 

  5. Benjamin ER, Khor D, Cho J, Biswas S, Inaba K, Demetriades D. The age of undertriage: current trauma triage criteria underestimate the role of age and comorbidities in early mortality. J Emerg Med. 2018;55(2):278–87.

    Article  Google Scholar 

  6. Demetriades D, Karaiskakis M, Velmahos G, Alo K, Newton E, Murray J, Asensio J, Belzberg H, Berne T, Shoemaker W. Effect on outcome of early intensive management of geriatric trauma patients. Br J Surg. 2002;89(10):1319–22.

    CAS  Article  Google Scholar 

  7. Morris RS, Karam BS, Murphy PB, Jenkins P, Milia DJ, Hemmila MR, Haines KL, Puzio TJ, de Moya MA, Tignanelli CJ. Field-triage, hospital-triage and triage-assessment: a literature review of the current phases of adult trauma triage. J Trauma Acute Care Surg. 2021;90(6):e138–45.

    Article  Google Scholar 

  8. Morris RS, Davis NJ, Koestner A, Napolitano LM, Hemmila MR, Tignanelli CJ. Redefining the trauma triage matrix: the role of emergent interventions. J Surg Res. 2020;251:195–201.

    Article  Google Scholar 

  9. Abback PS, Brouns K, Moyer JD, Holleville M, Hego C, Jeantrelle C, Bout H, Rennuit I, Foucrier A, Codorniu A, Jurcisin I, Paugam-Burtz C, Gauss T. ISS is not an appropriate tool to estimate overtriage. Eur J Trauma Emerg Surg. 2022;48(2):1061–8.

    Article  Google Scholar 

  10. Lupton JR, Davis-O’Reilly C, Jungbauer RM, Newgard CD, Fallat ME, Brown JB, Mann NC, Jurkovich GJ, Bulger E, Gestring ML, Lerner EB, Chou R, Totten AM. Under-triage and over-triage using the field triage guidelines for injured patients: a systematic review. Prehosp Emerg Care. 2022;4:1–8.

    Article  Google Scholar 

  11. Kohn MA, Hammel JM, Bretz SW, Stangby A. Trauma team activation criteria as predictors of patient disposition from the emergency department. Acad Emerg Med. 2004;11(1):1–9.

    Article  Google Scholar 

  12. Schellenberg M, Biswas S, Bardes JM, Trust MD, Grabo D, Wilson A, Inaba K. Longer prehospital time decreases reliability of vital signs in the field: a dual center study. Am Surg. 2021;87(6):943–8.

    Article  Google Scholar 

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Funding

No funding was received for this study.

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Correspondence to Morgan Schellenberg.

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Conflict of interest

Authors Schellenberg, Docherty, Owattanapanich, Emigh, Lutterman, Karavites, Switzer, Wiepking, Chudnofsky, and Inaba declare that they have no conflict of interest.

Ethical approval

All procedures performed in this retrospective observational study involving human participants were in accordance with the ethical standards of the Institutional Review Board of the University of California (HS-20–00292) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

This study received a waiver for informed consent by the Institutional Review Board of the University of Southern California (HS-20–00292).

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Schellenberg, M., Docherty, S., Owattanapanich, N. et al. Emergency physician and nurse discretion accurately triage high-risk trauma patients. Eur J Trauma Emerg Surg (2022). https://doi.org/10.1007/s00068-022-02056-0

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Keywords

  • Trauma team activation
  • Triage
  • Prehospital care
  • Trauma systems
  • Need for trauma intervention