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

Abstract

Background: In regional trauma systems, emergency medical service (EMS) providers render an important function by performing prehospital triage for severely injured patients and transporting them to regional trauma centers. Since 2016, a regional trauma center has been providing trauma surgeon-provided prehospital medical guidance for EMS providers through a trauma hotline to guide field triage, treatment, and transport. This study analyzedthe effects and clinical outcomes of a regional trauma center-led performance improvement program that followed closed-loop principles for EMS providers. Methods: Data from the regional trauma center databases (2016–2021) were collected, and patients with trauma with an Injury Severity Score (ISS) >15 in the Gyeonggi province who were injured, regardless of whether they visited the trauma center directly or not, were included. After adjusting for severity and baseline demographics through propensity score matching, clinical outcomes were analyzed using logistic regression, and the results were expressed as relative risks with 95% confidence intervals (95% CIs). Results: We included 3017 patients from the 6-year study period. Correct triage and undertriage were performed in 2528 and 489 patients, respectively. Prehospital medical directions and feedback were provided 432 times (32.1%) in 2016 and increased to 1505 times (96.8%) in 2021 (z=11.342, p<0.001). The undertriage rate decreased from 32.7% (n=55/168) to 6.3% (n=52/820) (z=−13.689, p<0.001), and the overall mortality decreased from 21.4% to 10% (z=−5.96, p<0.001). After propensity score matching, 484 correctly triaged and 484 undertriaged patients were identified for subgroup analyses. The in-hospital mortality of undertriaged and correctly triaged patients was 20.5% (n=99) and 12.6% (n=61), respectively. The relative risk (95% CI)for undertriaged over correctly-triaged patients regardingin-hospital mortality, length of intensive care unit (ICU) stay, and mechanical ventilation duration was 1.78 (1.26–2.52, p=0.001), 1.01 (1.00–1.02, p=0.052; mean ± standard deviation [SD] 12.2±20.2 vs. 10.0±13.5), and 1.01 (1.00–1.02, p=0.048, mean ± SD 7.2±17.9 vs. 5.2±10.9), respectively. Conclusion: Undertriage was associated with increased in-hospital mortality, length of ICU stay, and mechanical ventilation duration. The closed-loop communication program for EMS providers improved the undertriage rate. Specifically, in the early stages of regional trauma-system development, the trauma center-led trauma hotline feedback and case-based education programs can be effective models to facilitate prehospital patient triage and centralization of patients with severe trauma to trauma centers.