Accuracy of prehospital triage protocols in selecting severely injured patients

Rein, Eveline A. J. van; Houwert, R Marijn; Gunning, Amy C.; Lichtveld, Rob A.; Leenen, Luke P. H.; Heijl, Mark van

doi:10.1097/ta.0000000000001516

Cited by 92 publications

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“…42 However, the model is a significant improvement compared with the existing protocols. 5,6,16,43 Whether further improvement of undertriage is achievable by solely improving the protocol is unclear. Previous studies have shown that addition of the judgment of EMS professionals can be useful in the identification of severely injured patients.…”

Section: Discussionmentioning

confidence: 99%

“…However, an ISS greater than 15 is the most used surrogate marker for a severely injured patient when evaluating prehospital trauma triage; therefore, we chose this variable to define a severely injured patient. 5…”

Section: Limitationsmentioning

confidence: 99%

“…However, none of the existing protocols can achieve the recommended triage rates. [5][6][7] All are simplistic and static tools, whereas patients are dynamic, and more advanced methods are available to use on the scene, such as a prediction model in a mobile app. 8,9 Undertriage occurs when severely injured patients are not transported to a higher-level trauma center and results in delayed care and increased mortality and morbidity.…”

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Development and Validation of a Prediction Model for Prehospital Triage of Trauma Patients

et al. 2019

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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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Section: Discussionmentioning

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Section: Limitationsmentioning

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Development and Validation of a Prediction Model for Prehospital Triage of Trauma Patients

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“…In this study, only a minority of the severely injured patients were identified by the triage protocol. A recent literature review showed that on a worldwide scale, the different triage protocols are not capable to accurately discriminate between patients with and without severe injuries [14]. Thus, efforts to improve the triage protocol are necessary.…”

Section: Discussionmentioning

confidence: 99%

“…Prehospital trauma triage protocols have been studied extensively over the past decades [11][12][13][14]. However, it is currently unknown what factors are associated with EMS provider judgment and to what extent compliance to the triage protocol influences quality of prehospital trauma triage.…”

Section: Introductionmentioning

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The role of emergency medical service providers in the decision-making process of prehospital trauma triage

Rein

Sadiqi

Lansink

et al. 2018

Eur J Trauma Emerg Surg

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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.

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

et al. 2023

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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.

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Accuracy of prehospital triage protocols in selecting severely injured patients

Abstract: Systematic review, level III.

Cited by 92 publications

References 50 publications

Development and Validation of a Prediction Model for Prehospital Triage of Trauma Patients

Development and Validation of a Prediction Model for Prehospital Triage of Trauma Patients

The role of emergency medical service providers in the decision-making process of prehospital trauma triage

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

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