More than 20% of the patients with severe injuries were not transported to a level I trauma center. These patients are at risk for preventable morbidity and mortality. This finding indicates the need for improvement of the prehospital triage protocol.

Systematic review, level III.

IMPORTANCE Prehospital trauma triage protocols are used worldwide to get the right patient to the right hospital and thereby improve the chance of survival and avert lifelong disabilities. The American College of Surgeons Committee on Trauma set target levels for undertriage rates of less than 5%. None of the existing triage protocols has been able to achieve this target in isolation.OBJECTIVE To develop and validate a new prehospital trauma triage protocol to improve current triage rates. DESIGN, SETTING, AND PARTICIPANTSIn this multicenter cohort study, all patients with trauma who were 16 years and older and transported to a trauma center in 2 different regions of the Netherlands were included in the analysis. MAIN OUTCOMES AND MEASURES A new prediction model was developed in the CentralNetherlands region based on prehospital predictors associated with severe injury. Severe injury was defined as an Injury Severity Score greater than 15. A full-model strategy with penalized maximum likelihood estimation was used to construct a model with 8 predictors that were chosen based on clinical reasoning. Accuracy of the developed prediction model was assessed in terms of discrimination and calibration. The model was externally validated in the Brabant region. RESULTSUsing data from 4950 patients with trauma from the Central Netherlands region for the design data set (58.3% male; mean [SD] age, 47 [21] years) and 6859 patients for the validation Brabant region (52.2% male; mean [SD] age, 51 [22] years), the following 8 significant predictors were selected for the prediction model: age; systolic blood pressure; Glasgow Coma Scale score; mechanism criteria; penetrating injury to the head, thorax, or abdomen; signs and/or symptoms of head or neck injury; expected injury in the Abbreviated Injury Scale thorax region; and expected injury in 2 or more Abbreviated Injury Scale regions. The prediction model showed a C statistic of 0.823 (95% CI, 0.813-0.832) and good calibration. The cutoff point with a minimum specificity of 50.0% (95% CI, 49.3%-50.7%) led to a sensitivity of 88.8% (95% CI, 87.5%-90.0%). External validation showed a C statistic of 0.831 (95% CI, 0.814-0.848) and adequate calibration. CONCLUSIONS AND RELEVANCEThe new prehospital trauma triage prediction model may lower undertriage rates to approximately 10% with an overtriage rate of 50%. The next step should be to implement this prediction model with the use of a mobile app for emergency medical services professionals.Question Can a new prehospital prediction model for trauma triage lower the undertriage rate to approximately 10%, with a maximum overtriage rate of 50%?Findings In this multicenter cohort study that included 4950 patients with trauma, 8 highly significant predictors associated with injury severity were selected for the prediction model. The new prehospital trauma triage prediction model was externally validated and may lower the undertriage rate to 11.2% with an overtriage rate of 50.0%. Meaning This prediction model can be integrated in a mobile...

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It is crucial to transport the right patient to the right hospital. Yet the quality of the full diagnostic strategy to determine the optimal receiving hospital is unknown. None of the investigated field triage protocols complied with current sensitivity targets. Improved efforts are needed to develop accurate child-specific tools to prevent undertriage and its potential life-threatening consequences.

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Background and Objectives: Malignant tumors of the calcaneus are rare but pose a treatment challenge. Aims: (1) describe the demographics of calcaneal malignancies in a large cohort; (2) describe survival after amputation versus limb-salvage surgery for high-grade tumors. Methods: Study group: a "pooled" cohort of patients with primary calcaneal malignancies treated at two cancer centers (1984−2015) and systematic literature review. Kaplan−Meier analyses described survival across treatment and diagnostic groups; proportional hazards modeling assessed mortality after amputation versus limb salvage. Results: A total of 131 patients (11 treated at our centers and 120 patients from 53 published studies) with a median 36-month follow-up were included. Diagnoses included Ewing sarcoma (41%), osteosarcoma (30%), and chondrosarcoma (17%); 5-year survival rates were 43%, 73% (70%, high grade only), and 84% (60%, high grade only), respectively. Treatment involved amputation in 52%, limb salvage in 27%, and no surgery in 21%. There was no difference in mortality following limb salvage surgery (vs. amputation) for high-grade tumors (HR 0.38; 95% CI 0.14−1.05), after adjusting for Ewing sarcoma diagnosis (HR 5.15; 95% CI 1.55−17.14), metastatic disease at diagnosis (HR 3.88; 95% CI 1.29−11.64), and age (per-year HR 1.04; 95% CI 1.02−1.07). Conclusions: Limb salvage is oncologically-feasible for calcaneal malignancies.

Purpose Severely injured patients should be treated at higher-level trauma centres, to improve chances of survival and avert life-long disabilities. Emergency medical service (EMS) providers must try to determine injury severity on-scene, using a prehospital trauma triage protocol, and decide the most appropriate type of trauma centre. The objective of this study is to investigate the role of EMS provider judgment in the prehospital triage process of trauma patients, by analysing the compliance rate to the protocol and administering a questionnaire among EMS providers. Methods All trauma patients transported to a trauma centre in two different regions of the Netherlands were analysed. Compliance rate was based on the number of patients meeting the triage criteria and transported to the corresponding level trauma centre. The questionnaire was administered among EMS providers. Descriptive statistics were used to analyse the data. Results For adult patients, the compliance rate to the level I criteria of the triage protocol was 72% in Central Netherlands and 42% in Brabant. For paediatric patients, this was 63% and 38% in Central Netherlands and Brabant, respectively. The judgment on injury severity was mostly based on the injury-type criteria. Additionally, the distance to a level I trauma centre influenced the decision for destination facility in the Brabant region. Conclusion The compliance rate varied between regions. Improvement of prehospital trauma triage depends on the accuracy of the protocol and compliance rate. A new protocol, including EMS provider judgment, might be the key to improvement in the prehospital trauma triage quality.