Defining the representativeness heuristic in trauma triage: A retrospective observational cohort study.
Journal
PloS one
ISSN: 1932-6203
Titre abrégé: PLoS One
Pays: United States
ID NLM: 101285081
Informations de publication
Date de publication:
2019
2019
Historique:
received:
13
07
2018
accepted:
29
01
2019
entrez:
9
2
2019
pubmed:
9
2
2019
medline:
14
11
2019
Statut:
epublish
Résumé
Under-triage of severely injured patients presenting to non-trauma centers (failure to transfer to a trauma center) remains problematic despite quality improvement efforts. Insights from the behavioral science literature suggest that physician heuristics (intuitive judgments), and in particular the representativeness heuristic (pattern recognition), may contribute to under-triage. However, little is known about how the representativeness heuristic is instantiated in practice. A multi-disciplinary group of experts identified candidate characteristics of "representative" severe trauma cases (e.g., hypotension). We then reviewed the charts of patients with moderate-to-severe injuries who presented to nine non-trauma centers in western Pennsylvania from 2010-2014 to assess the association between the presence of those characteristics and triage decisions. We tested bivariate associations using χ2 and Fisher's Exact method and multivariate associations using random effects logistic regression. We identified 235,605 injured patients with 3,199 patients (1%) having moderate-to-severe injuries. Patients had a median age of 78 years (SD 20.1) and mean Injury Severity Score of 10.9 (SD 3.3). Only 759 of these patients (24%) were transferred to a trauma center as recommended by the American College of Surgeons clinical practice guidelines. Representative characteristics occurred in 704 patients (22%). The adjusted odds of transfer were higher in the presence of representative characteristics compared to when they were absent (aOR 1.7, 95% CI: 1.4-2.0, p < 0.001). Most moderate-to-severely injured patients present without the characteristics representative of severe trauma. Presence of these characteristics is associated with appropriate transfer, suggesting that modifying physicians' heuristics in trauma may improve triage patterns.
Sections du résumé
BACKGROUND
Under-triage of severely injured patients presenting to non-trauma centers (failure to transfer to a trauma center) remains problematic despite quality improvement efforts. Insights from the behavioral science literature suggest that physician heuristics (intuitive judgments), and in particular the representativeness heuristic (pattern recognition), may contribute to under-triage. However, little is known about how the representativeness heuristic is instantiated in practice.
METHODS
A multi-disciplinary group of experts identified candidate characteristics of "representative" severe trauma cases (e.g., hypotension). We then reviewed the charts of patients with moderate-to-severe injuries who presented to nine non-trauma centers in western Pennsylvania from 2010-2014 to assess the association between the presence of those characteristics and triage decisions. We tested bivariate associations using χ2 and Fisher's Exact method and multivariate associations using random effects logistic regression.
RESULTS
We identified 235,605 injured patients with 3,199 patients (1%) having moderate-to-severe injuries. Patients had a median age of 78 years (SD 20.1) and mean Injury Severity Score of 10.9 (SD 3.3). Only 759 of these patients (24%) were transferred to a trauma center as recommended by the American College of Surgeons clinical practice guidelines. Representative characteristics occurred in 704 patients (22%). The adjusted odds of transfer were higher in the presence of representative characteristics compared to when they were absent (aOR 1.7, 95% CI: 1.4-2.0, p < 0.001).
CONCLUSIONS
Most moderate-to-severely injured patients present without the characteristics representative of severe trauma. Presence of these characteristics is associated with appropriate transfer, suggesting that modifying physicians' heuristics in trauma may improve triage patterns.
Identifiants
pubmed: 30735553
doi: 10.1371/journal.pone.0212201
pii: PONE-D-18-20858
pmc: PMC6368323
doi:
Types de publication
Comparative Study
Journal Article
Multicenter Study
Observational Study
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
e0212201Subventions
Organisme : NLM NIH HHS
ID : DP2 LM012339
Pays : United States
Organisme : NHLBI NIH HHS
ID : T32 HL007820
Pays : United States
Déclaration de conflit d'intérêts
The authors have declared that no competing interests exist.
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