Prospective Validation of the National Field Triage Guidelines for Identifying Seriously Injured Persons

Newgard, Craig D.; Fu, Rongwei; Zive, Dana; Rea, Tom; Malveau, Susan; Daya, Mohamud; Jui, Jonathan; Griffiths, Denise; Wittwer, Lynn; Sahni, Ritu; Gubler, K. Dean; Chin, Jonathan; Klotz, Pat; Somerville, Stephanie; Beeler, Tina; Bishop, Tim; Garland, Tara; Bulger, Eileen M.

doi:10.1016/j.jamcollsurg.2015.10.016

Cited by 97 publications

(96 citation statements)

References 34 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…This study demonstrated that, although field triage sensitivity for identifying patients with serious injuries (Injury Severity Score 17 [ISS] ≥16; range, 0-75, with higher numbers indicating greater injury severity) appeared to be better in rural vs urban regions (81% vs 65.8%), only 12.5% of seriously injured rural patients were initially transported to major trauma centers and only 39.3% were ultimately cared for in major trauma centers. 16 However, the primary results of this study did not allow a detailed assessment of rural vs urban differences in trauma care.…”

mentioning

confidence: 90%

“…We conducted a preplanned secondary analysis of the prospective injury cohort of that study 16 to detail rural vs urban differences in field triage, processes of trauma care, injury severity, and mortality. We sought to use these data as an opportunity to address ongoing questions about differences in process and outcomes between urban and rural trauma patients.…”

mentioning

confidence: 99%

See 1 more Smart Citation

Evaluation of Rural vs Urban Trauma Patients Served by 9-1-1 Emergency Medical Services

Newgard

Bulger

et al. 2017

JAMA Surg

Self Cite

View full text Add to dashboard Cite

Importance Despite a large rural US population, there are potential differences between rural and urban regions in the processes and outcomes following trauma. Objectives To describe and evaluate rural vs urban processes of care, injury severity, and mortality among injured patients served by 9-1-1 emergency medical services (EMS). Design, Setting, and Participants This was a preplanned secondary analysis of a prospective cohort enrolled from January 1 through December 31, 2011, and followed up through hospitalization. The study included 44 EMS agencies transporting to 28 hospitals in 2 rural and 5 urban counties in Oregon and Washington. A population-based, consecutive sample of 67047 injured children and adults served by EMS (1971 rural and 65 076 urban) was enrolled. Among the 53 487 patients transported by EMS, a stratified probability sample of 17 633 patients (1438 rural and 16 195 urban) was created to track hospital outcomes (78.9% with in-hospital follow-up). Data analysis was performed from June 12, 2015, to May 20, 2016. Exposures Rural was defined at the county level by 60 minutes or more driving proximity to the nearest level I or II trauma center and/or rural designation in the Centers for Medicare & Medicaid Services ambulance fee schedule by zip code. Main outcomes and Measures Mortality (out-of-hospital and in-hospital), need for early critical resources, and transfer rates. Results Of the 53 487 injured patients transported by EMS (17 633 patients in the probability sample), 27 535 were women (51.5%); mean (SD) age was 51.6 (26.1) years. Rural vs urban sensitivity of field triage for identifying patients requiring early critical resources was 65.2% vs 80.5%, and only 29.4% of rural patients needing critical resources were initially transported to major trauma centers vs 88.7% of urban patients. After accounting for transfers, 39.8% of rural patients requiring critical resources were cared for in major trauma centers vs 88.7% of urban patients. Overall mortality did not differ between rural and urban regions (1.44% vs 0.89%; P = .09); however, 89.6% of rural deaths occurred within 24 hours compared with 64% of urban deaths. Rural regions had higher transfer rates (3.2% vs 2.7%) and longer transfer distances (median, 97.4 km; interquartile range [IQR], 51.7-394.5 km; range, 47.8-398.6 km vs 22.5 km; IQR, 11.6-24.6 km; range, 3.5-97.4 km). Conclusions and Relevance Most high-risk trauma patients injured in rural areas were cared for outside of major trauma centers and most rural trauma deaths occurred early, although overall mortality did not differ between regions. There are opportunities for improved timeliness and access to major trauma care among patients injured in rural regions.

show abstract

mentioning

confidence: 90%

mentioning

confidence: 99%

Evaluation of Rural vs Urban Trauma Patients Served by 9-1-1 Emergency Medical Services

Newgard

Bulger

et al. 2017

JAMA Surg

Self Cite

View full text Add to dashboard Cite

show abstract

“…Because some research has demonstrated higher estimates for under-triage than used for this study, 10,11 unbiased prospectively-derived values for under- and over-triage would further inform the cost models and may shift the cost-effectiveness results. We also assumed that EMS transport patterns based on triage status would remain the same under different triage strategies, though it is possible that these patterns would shift based on the perceived accuracy (or lack thereof) of “new” triage guidelines.…”

Section: Discussionmentioning

confidence: 95%

“…Conversely, over-triage (1 – specificity) represents the proportion of patients without serious injuries transported to major trauma hospitals, a measure of resource waste and excess cost (national target ≤ 35% 6 ). Research suggests that under-triage is as high as 34% 7-11 and approximately 50% among older adults. 7,10-12 Revisions to the national guidelines have sought to reduce under-triage without increasing over-triage, 2 although under- and over-triage are inversely related.…”

Section: Introductionmentioning

confidence: 99%

Cost-Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services

Newgard

Yang

Nishijima

et al. 2016

Journal of the American College of Surgeons

Self Cite

View full text Add to dashboard Cite

Background The American College of Surgeons Committee on Trauma sets national targets for the accuracy of field trauma triage at ≥ 95% sensitivity and ≥ 65% specificity, yet the cost-effectiveness of realizing these goals is unknown. We evaluated the cost-effectiveness of current field trauma triage practices compared to triage strategies consistent with the national targets. Study Design This was a cost-effectiveness analysis using data from 79,937 injured adults transported by 48 emergency medical services (EMS) agencies to 105 trauma and non-trauma hospitals in 6 regions of the Western U.S. from 2006 through 2008. Incremental differences in survival, quality adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio (ICER; costs per QALY gained) were estimated for each triage strategy over a 1-year and lifetime horizon using a decision analytic Markov model. We considered an ICER threshold of less than $100,000 to be cost-effective. Results For these 6 regions, a high sensitivity triage strategy consistent with national trauma policy (sensitivity 98.6%, specificity 17.1%) would cost $1,317,333 per QALY gained, while current triage practices (sensitivity 87.2%, specificity 64.0%) cost $88,000 per QALY gained compared to a moderate sensitivity strategy (sensitivity 71.2%, specificity 66.5%). Refining EMS transport patterns by triage status improved cost-effectiveness. At the trauma system level, a high-sensitivity triage strategy would save 3.7 additional lives per year at a 1-year cost of $8.78 million, while a moderate sensitivity approach would cost 5.2 additional lives and save $781,616 each year. Conclusions A high-sensitivity approach to field triage consistent with national trauma policy is not cost effective. The most cost effective approach to field triage appears closely tied to triage specificity and adherence to triage-based EMS transport practices.

show abstract

“…An auto-calculated mREMS score would provide pre-hospital personnel and providers the ability to quickly and accurately understand the patient severity and the predicted risk of mortality. The score can help trauma patients be quickly triaged to the appropriate healthcare facility, based upon objective criteria, instead of the loosely utilized CDC field triage guidelines, which have been shown as insensitive in its ability to identify seriously injured patients [21]. With a statistically proven trauma score driving the triage of trauma patients, the CDC field triage guidelines could be supplemented or perhaps replaced with an objective algorithm, such as the mREMS score, to increase the likelihood that patients are taken to the most appropriate trauma facility.…”

Section: Discussionmentioning

confidence: 99%

11 The Modified Rapid Emergency Medicine Score: A Novel Trauma Triaging Tool for Predicting In-hospital Mortality

Miller

Nazir

McDonald

et al. 2016

Annals of Emergency Medicine

View full text Add to dashboard Cite

Objectives: Trauma systems currently rely on imperfect and subjective tools to prioritize responses and resources, thus there is a critical need to develop a more accurate trauma severity score. Our objective was to modify the Rapid Emergency Medicine Score (REMS is a simple, non-invasive, and objective version of the APACHE II score) for the trauma population and test its accuracy as a predictor of in-hospital mortality when compared to other currently used scores, including the Revised Trauma Score (RTS), the Injury Severity Score (ISS), the "Mechanism,

show abstract

Prospective Validation of the National Field Triage Guidelines for Identifying Seriously Injured Persons

Abstract: BACKGROUND-The national field trauma triage guidelines have been widely implemented in US trauma systems, but never prospectively validated. We sought to prospectively validate the guidelines, as applied by out-of-hospital providers, for identifying high-risk trauma patients.

Cited by 97 publications

References 34 publications

Evaluation of Rural vs Urban Trauma Patients Served by 9-1-1 Emergency Medical Services

Evaluation of Rural vs Urban Trauma Patients Served by 9-1-1 Emergency Medical Services

Cost-Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services

11 The Modified Rapid Emergency Medicine Score: A Novel Trauma Triaging Tool for Predicting In-hospital Mortality

Contact Info

Product

Resources

About