Accuracy of Prehospital Triage of Adult Patients With Traumatic Injuries Following Implementation of a Trauma Triage Intervention

Abstract

ImportanceAdequate prehospital triage is pivotal to enable optimal care in inclusive trauma systems and reduce avoidable mortality, lifelong disabilities, and costs. A model has been developed to improve the prehospital allocation of patients with traumatic injuries and was incorporated in an application (app) to be implemented in prehospital practice.ObjectiveTo evaluate the association between the implementation of a trauma triage (TT) intervention with an app and prehospital mistriage among adult trauma patients.Design, Setting, and ParticipantsThis population-based, prospective quality improvement study was conducted in 3 of the 11 Dutch trauma regions (27.3%), with full coverage of the corresponding emergency medical services (EMS) regions participating in this study. Participants included adult patients (age ≥16 years) with traumatic injuries who were transported by ambulance between February 1, 2015, and October 31, 2019, from the scene of injury to any emergency department in the participating trauma regions. Data were analyzed between July 2020 and June 2021.ExposuresImplementation of the TT app and the awareness of need for adequate triage created by its implementation (ie, the TT intervention).Main Outcomes and MeasuresThe primary outcome was prehospital mistriage, evaluated in terms of undertriage and overtriage. Undertriage was defined as the proportion of patients with an Injury Severity Score (ISS) of 16 or greater who were initially transported to a lower-level trauma center (designated to treat patients who are mildly and moderately injured) and overtriage as the proportion of patients with an ISS of less than 16 who were initially transported to a higher-level trauma center (designated to treat patients who are severely injured).ResultsA total of 80 738 patients were included (40 427 [50.1%] before and 40 311 [49.9%] after implementation of the intervention), with a median (IQR) age of 63.2 (40.0-79.7) years and 40 132 (49.7%) male patients. Undertriage decreased from 370 of 1163 patients (31.8%) to 267 of 995 patients (26.8%), while overtriage rates did not increase (8202 of 39 264 patients [20.9%] vs 8039 of 39 316 patients [20.4%]). The implementation of the intervention was associated with a statistically significantly reduced risk for undertriage (crude risk ratio [RR], 0.95; 95% CI, 0.92 to 0.99, P = .01; adjusted RR, 0.85; 95% CI, 0.76-0.95; P = .004), but the risk for overtriage was unchanged (crude RR, 1.00; 95% CI, 0.99-1.00; P = .13; adjusted RR, 1.01; 95% CI, 0.98-1.03; P = .49).Conclusions and RelevanceIn this quality improvement study, implementation of the TT intervention was associated with improvements in rates of undertriage. Further research is needed to assess whether these findings are generalizable to other trauma systems.

Right patient to the right place: the impact of a 6-year regional trauma center-led prehospital trauma education program on patient outcomes

“…Haas et al reported that non-trauma center transport in patients with severe trauma increased early mortality by 30% [10]. The American College of Surgeons Committee on Trauma (ACS-COT) recommends an undertriage rate target of 5% or less in the regional trauma system [27,28]. Although there may be differences by country or region, the subject of initial trauma triage is the EMS provider, which is the same in South Korea [4,29].…”

Prospective validation of a hospital triage predictive model to decrease undertriage: an EAST multicenter study

“…35 36 Notably, van Rein et al 20 from the Netherlands created a field triage prediction model and validated the model in a mobile application across multiple Dutch regions. 37 On validation of the model, a total of 80 738 adult patients were included: 40 427 (50.1%) before implementation of the triage intervention and 40 311 (49.9%) after implementation. After implementation of the mobile application with the model, undertriage decreased from 31.8% to 26.8%.…”

“…Overtriage rates did not increase (20.9% vs. 20.4% of patients). 37 The model was also externally validated in a cohort of patients from the UK, and the AUROC was 0.75, while undertriage remained at 17% with an overtriage of 50%. The authors concluded that the model did not meet the ACSCOT recommendations, 38 and it is unclear how this model would perform in the USA.…”

Trauma Patient Volume and the Quality of Care: A Scoping Review

“…Studies using a smartphone application with a prediction model that help emergency medical services in the triage of trauma patients have been initiated [ 32 ]. Recent data suggests that such smartphone applications may lower the under-triage from 32% to 27% (adjusted OR for under-triage of 0.78; 95%CI: 0.63–0.96) without an increase in over-triage [ 33 ]. However, further work is required to enhance the prehospital triage for the direct transfer of severely injured patients to MTCs.…”