A consensus-based criterion standard for trauma center need

Lerner, E. Brooke; Willenbring, Brian D.; Pirrallo, Ronald G.; Brasel, Karen J.; Cady, Charles E.; Colella, M. Riccardo; Cooper, Arthur; Cushman, Jeremy T.; Gourlay, David M.; Jurkovich, Gregory J.; Newgard, Craig D.; Salomone, Jeffrey P.; Sasser, Scott M.; Shah, Manish N.; Swor, Robert A.; Wang, Stewart C.

doi:10.1097/ta.0000000000000189

Cited by 50 publications

(55 citation statements)

References 23 publications

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“…Another criterion standard definition exists for the evaluation of the field triage guidelines that assist EMS providers in identifying patients who need the resources of a trauma center. 26 All of the patients who are eligible for a trauma team activation will be at a facility where the full breadth of resources are available but the team that can provide the resources will need to be assembled either prior to the patients arrival or while the patient is waiting. Therefore, the goal of the criterion standard definition for trauma team activation was to identify interventions that the patient will need immediately after arrival, since trauma team activation prior to patient arrival will improve outcome only for those patients with conditions that are extremely time sensitive.…”

Section: Discussionmentioning

confidence: 99%

A consensus-based criterion standard definition for pediatric patients who needed the highest-level trauma team activation

Lerner

Drendel

Falcone

et al. 2015

Journal of Trauma and Acute Care Surgery

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Background Verbal prehospital reports on an injured patient’s condition are typically used by trauma centers to determine if a trauma team should be present in the emergency department prior to patient arrival (i.e., trauma team activation). Efficacy studies of trauma team activation protocols cannot be conducted without a criterion standard definition for which pediatric patients need a trauma team activation. Objective To develop a consensus-based criterion standard definition for pediatric patients who needed the highest-level trauma team activation. Methods Ten local and national experts in emergency medicine, emergency medical services, and trauma were recruited to participate in a Modified Delphi survey process. The initial survey was populated based on outcomes that had been used in previously published literature on trauma team activation. The criterion standard definition for trauma team activation was refined iteratively based on survey responses until at least 80% agreement was achieved for each criterion. Results After five voting rounds a consensus-based definition for pediatric trauma team activation was developed. Twelve criteria were identified along with a corresponding time interval in which each criterion had to occur. The criteria include receiving specific surgery types, interventional radiology, advanced airway management, thoracostomy, blood products, spinal injury, emergency cesarean section, vasopressors, burr hole or other procedure to relieve intracranial pressure, pericardiocentesis, thoracotomy, and death in the emergency department. All expert panel members voted in all 5 voting rounds, except 1 member missed rounds 1 and 2. Each criterion had greater than 80% agreement from the panel. Conclusion A criterion standard definition for the highest-level pediatric trauma team activation was developed. This criterion standard definition will advance trauma research by allowing investigators to determine the accuracy and effectiveness of highest-level pediatric trauma team activation protocols. Level of Evidence/Study type Qualitative

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Section: Discussionmentioning

confidence: 99%

A consensus-based criterion standard definition for pediatric patients who needed the highest-level trauma team activation

Lerner

Drendel

Falcone

et al. 2015

Journal of Trauma and Acute Care Surgery

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“…This was defined according to a published consensus-based standard, and included any one of the following criteria: (1) >1 unit of blood in the ED; (2) spinal cord injury; (3) advanced airway placed prehospital or in the ED; (4) thoracotomy within 48hrs of admission; (5) pericardiocentesis within 24hrs of admission; (6) intracranial pressure monitoring; (7) interventional radiology procedure within 4hrs of admission; (8) Abdominal/Thoracic/Vascular/Neurologic surgical procedure within 24hrs of admission; (9) death. 21 Presence of ACS activation criteria were determined for each patient using prehospital vital signs, ICD-9 diagnosis codes, and mechanism of injury data. We also performed a sensitivity analysis of this definition, using a surgical procedure within 2hrs to capture truly emergent procedures.…”

Section: Methodsmentioning

confidence: 99%

Prehospital lactate improves accuracy of prehospital criteria for designating trauma activation level

Brown

Lerner

Sperry

et al. 2016

Journal of Trauma and Acute Care Surgery

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Background Trauma activation level is determined by prehospital criteria. The American College of Surgeons (ACS) recommends trauma activation criteria; however, their accuracy may be limited. Prehospital lactate has shown promise in predicting trauma center resource requirements. Our objective was to investigate the added value of incorporating prehospital lactate in an algorithm to designate trauma activation level. Methods Air medical trauma patients undergoing prehospital lactate measurement were included. Algorithms using ACS activation criteria (ACS) and ACS activation criteria plus prehospital lactate (ACS+LAC) to designate trauma activation level were compared. Test characteristics and net reclassification improvement (NRI), which evaluates reclassification of patients among risk categories with additional predictive variables, were calculated. Algorithms were compared to predict trauma center need (TCN) defined as >1unit of blood in the ED; spinal cord injury; advanced airway; thoracotomy or pericardiocentesis; ICP monitoring; emergent operative or interventional radiology procedure; or death. Results There were 6,347 patients included. Twenty-eight percent had TCN. The ACS+LAC algorithm upgraded 256 patients and downgraded 548 patients compared to the ACS algorithm. The ACS+LAC algorithm versus ACS algorithm had a NRI of 0.058 (95%CI 0.044, 0.071; p<0.01), with an event NRI of −0.5% and non-event NRI of 6.2%. When weighted to favor changes in under-triage, the ACS+LAC still had a favorable overall reclassification (wNRI 0.041; 95%CI 0.028, 0.054; p=0.01). The ACS+LAC algorithm increased PPV, NPV, and accuracy. Over-triage was reduced 7.2%, while under-triage only increased 0.7%. The area under the curve (AUC) was significantly higher for the ACS+LAC algorithm (0.79 vs. 0.76, p<0.01). Conclusions The ACS+LAC algorithm reclassified patients to more appropriate levels of trauma activation when compared to the ACS algorithm. This overall benefit is achieved by significant reduction in over-triage relative to very small increase in under-triage. In the context of trauma team activation, this trade-off may be acceptable, especially in the current healthcare environment. Level of Evidence Diagnostic study, Level IV

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“…Our definition for early critical trauma resources is similar to a recent consensus definition for patients requiring immediate care in major trauma centers. 21 …”

Section: Methodsmentioning

confidence: 99%

“…Whether these findings reflect differences in statistical efficiency (e.g., a larger reference group in the dichotomous term) or chance is unclear. The definition used to identify this subgroup was based on expert consensus 21 and was similar to resource-based definitions used in many previous trauma studies, 29-36 though it is possible that a different definition for this subgroup would have produced different findings. Nonetheless, we did specify this subgroup analysis a priori and there is good biologic plausibility for the findings.…”

Section: Limitationsmentioning

confidence: 99%

Revisiting the “Golden Hour”: An Evaluation of Out-of-Hospital Time in Shock and Traumatic Brain Injury

Newgard

Meier

Bulger

et al. 2015

Annals of Emergency Medicine

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Study Objective We evaluated shock and traumatic brain injury (TBI) patients previously enrolled in an out-of-hospital clinical trial to test the association between out-of-hospital time and outcome. Methods This was a secondary analysis of shock and TBI patients ≥ 15 years enrolled in a Resuscitation Outcomes Consortium out-of-hospital clinical trial by 81 EMS agencies transporting to 46 Level I and II trauma centers in 11 sites (May 2006 through May 2009). Inclusion criteria were: SBP ≤ 70 mmHg or SBP 71 - 90 mmHg with heart rate ≥ 108 beats per minute (shock cohort) and Glasgow Coma Scale score ≤ 8 (TBI cohort); patients meeting both criteria were placed in the shock cohort. Primary outcomes were 28-day mortality (shock cohort) and 6-month Glasgow Outcome Scale - Extended (GOSE) ≤ 4 (TBI cohort). Results There were 778 patients in the shock cohort (26% 28-day mortality) and 1,239 patients in the TBI cohort (53% 6-month GOSE ≤ 4). Out-of-hospital time > 60 minutes was not associated with worse outcomes after accounting for important confounders in the shock cohort (adjusted odds ratio [aOR] 1.42, 95% CI 0.77-2.62) or TBI cohort (aOR 0.80, 95% CI 0.52-1.21). However, shock patients requiring early critical hospital resources and arriving > 60 minutes had higher 28-day mortality (aOR 2.37, 95% CI 1.05-5.37); this finding was not observed among a similar TBI subgroup. Conclusions Among out-of-hospital trauma patients meeting physiologic criteria for shock and TBI, there was no association between time and outcome. However, the subgroup of shock patients requiring early critical resources arriving after 60 minutes had higher mortality.

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A consensus-based criterion standard for trauma center need

Abstract: We developed a consensus-based functional criterion standard definition of needing the resources of a trauma center, which may help to standardize field triage research and quality assurance in trauma systems as well as allow for cross study comparisons.

Cited by 50 publications

References 23 publications

A consensus-based criterion standard definition for pediatric patients who needed the highest-level trauma team activation

A consensus-based criterion standard definition for pediatric patients who needed the highest-level trauma team activation

Prehospital lactate improves accuracy of prehospital criteria for designating trauma activation level

Revisiting the “Golden Hour”: An Evaluation of Out-of-Hospital Time in Shock and Traumatic Brain Injury

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