An analysis of overtriage and undertriage by advanced life support transport in a mature trauma system.
Adult
Advanced Trauma Life Support Care
/ statistics & numerical data
Aged
Aged, 80 and over
Female
Health Services Misuse
/ statistics & numerical data
Humans
Injury Severity Score
Male
Middle Aged
Pennsylvania
/ epidemiology
Registries
/ statistics & numerical data
Retrospective Studies
Transportation of Patients
/ statistics & numerical data
Trauma Centers
/ statistics & numerical data
Triage
/ statistics & numerical data
Wounds and Injuries
/ diagnosis
Journal
The journal of trauma and acute care surgery
ISSN: 2163-0763
Titre abrégé: J Trauma Acute Care Surg
Pays: United States
ID NLM: 101570622
Informations de publication
Date de publication:
05 2020
05 2020
Historique:
entrez:
23
4
2020
pubmed:
23
4
2020
medline:
28
8
2020
Statut:
ppublish
Résumé
While issues regarding triage of severely injured trauma patients are well publicized, little information exists concerning the difference between triage rates for patients transported by advanced life support (ALS) and basic life support (BLS). We sought to analyze statewide trends in undertriage (UT) and overtriage (OT) to address this question, hypothesizing that there would be a difference between the UT and OT rates for ALS compared with BLS over a 13-year period. All patients submitted to Pennsylvania Trauma Outcomes Study database from 2003 to 2015 were analyzed. Undertriage was defined as not calling a trauma alert for patients with an Injury Severity Score (ISS) of 16 or greater. Overtriage was defined as calling a trauma alert for patients with an ISS of 9 or less. A logistic regression was used to assess mortality between triage groups in ALS and BLS. A multinomial logistic regression assessed the adjusted impact of ALS versus BLS transport on UT and OT versus normal triage while controlling for age, sex, Glasgow Coma Scale, systolic blood pressure (SBP), pulse, Shock Index and injury year. A total of 462,830 patients met inclusion criteria, of which 115,825 had an ISS of 16 or greater and 257,855 had an ISS of 9 or less. Both ALS and BLS had significantly increased mortality when patients were undertriaged compared with the reference group. Multivariate analysis in the form of a multinomial logistic regression revealed that patients transported by ALS had a decreased adjusted rate of undertriage (relative risk ratio, 0.92; 95% confidence interval, 0.87-0.97; p = 0.003) and an increased adjusted rate of OT (relative risk ratio, 1.59; 95% confidence interval, 1.54-1.64; p < 0.001) compared with patients transported by BLS. Compared with their BLS counterparts, while UT is significantly lower, OT is substantially higher in ALS-further increasing the high levels of resource (over)utilization in trauma patients. Undertriage in both ALS and BLS are associated with increased mortality rates. Additional education, especially in the BLS provider, on identifying the major trauma victim may be warranted based on the results of this study. Epidemiological, Level III.
Sections du résumé
BACKGROUND
While issues regarding triage of severely injured trauma patients are well publicized, little information exists concerning the difference between triage rates for patients transported by advanced life support (ALS) and basic life support (BLS). We sought to analyze statewide trends in undertriage (UT) and overtriage (OT) to address this question, hypothesizing that there would be a difference between the UT and OT rates for ALS compared with BLS over a 13-year period.
METHODS
All patients submitted to Pennsylvania Trauma Outcomes Study database from 2003 to 2015 were analyzed. Undertriage was defined as not calling a trauma alert for patients with an Injury Severity Score (ISS) of 16 or greater. Overtriage was defined as calling a trauma alert for patients with an ISS of 9 or less. A logistic regression was used to assess mortality between triage groups in ALS and BLS. A multinomial logistic regression assessed the adjusted impact of ALS versus BLS transport on UT and OT versus normal triage while controlling for age, sex, Glasgow Coma Scale, systolic blood pressure (SBP), pulse, Shock Index and injury year.
RESULTS
A total of 462,830 patients met inclusion criteria, of which 115,825 had an ISS of 16 or greater and 257,855 had an ISS of 9 or less. Both ALS and BLS had significantly increased mortality when patients were undertriaged compared with the reference group. Multivariate analysis in the form of a multinomial logistic regression revealed that patients transported by ALS had a decreased adjusted rate of undertriage (relative risk ratio, 0.92; 95% confidence interval, 0.87-0.97; p = 0.003) and an increased adjusted rate of OT (relative risk ratio, 1.59; 95% confidence interval, 1.54-1.64; p < 0.001) compared with patients transported by BLS.
CONCLUSION
Compared with their BLS counterparts, while UT is significantly lower, OT is substantially higher in ALS-further increasing the high levels of resource (over)utilization in trauma patients. Undertriage in both ALS and BLS are associated with increased mortality rates. Additional education, especially in the BLS provider, on identifying the major trauma victim may be warranted based on the results of this study.
LEVEL OF EVIDENCE
Epidemiological, Level III.
Identifiants
pubmed: 32320177
doi: 10.1097/TA.0000000000002602
pii: 01586154-202005000-00017
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
704-709Références
Center for Disease Control and Prevention (CDC). Mortality in the United States. https://stacks.cdc.gov/view/cdc/60902. Revised December 2017. Accessed July 2019.
Hashmi ZG, Jarman MP, Uribe-Leitz T, Goralnick E, Newgard CD, Salim A, Cornwell E 3rd, Haider AH. Access delayed is access denied: relationship between access to trauma center care and pre-hospital death. J Am Coll Surg. 2019;228(1):9–20.
Sobrino J, Shafi S. Timing and causes of death after injuries. Proc (Bayl Univ Med Cent). 2013;26(2):120–123.
Ryynänen OP, Iirola T, Reitala J, Pälve H, Malmivaara A. Is advanced life support better than basic life support in prehospital care? A systematic review. Scand J Trauma Resusc Emerg Med. 2010;18:62–76.
Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes of basic versus advanced life support for out-of-hospital medical emergencies. Ann Intern Med. 2015;163(9):681–690.
Center for Disease Control and Prevention (CDC). Guidelines for field triage of injured patients: recommendations of the National Expert Panel on field triage, 2011. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm. Revised January 2012. Accessed July 2019.
Jones CMC, Cushman JT, Lerner EB, Fisher S, Seplaki CL, Veazie PJ, Wasserman EB, Dozier A, Shah MN. Prehospital trauma triage decision-making: a model of what happens between the 911 call and the hospital. Prehosp Emerg Care. 2016;20(1):6–14.
American College of Surgeons. Resources for optimal Care of the Injured Patient: committee on trauma. https://www.facs.org/quality-programs/trauma/tqp/center-programs/vrc/resources. Revised April 2014. Accessed July 2019.
Pennsylvania Department of Health. Emergency medical services—regulations. https://www.health.pa.gov/topics/EMS/Pages/Regulations.aspx. Revised July 2019. Accessed October 2019.
Holst JA, Perman SM, Capp R, Haukoos JS, Ginde AA. Undertriage of trauma-related deaths in U.S. emergency departments. West J Emerg Med. 2016;17(3):315–323.
Polites SF, Leonard JM, Glasgow AE, Zielinski MD, Jenkins DH, Habermann EB. Undertriage after severe injury among United States trauma centers and the impact on mortality. Am J Surg. 2018;214(4):813–818.
Haas B, Stukel TA, Gomez D, Zagorski B, De Mestral C, Sharma SV, Rubenfeld GD, Nathens AB. The mortality benefit of direct trauma center transport in a regional trauma system: a population-based analysis. J Trauma Acute Care Surg. 2012;72(6):1510–1515.
Wahlin RR. Prehospital care of severly injured trauma patients: studies on management, assessment, and outcome. Stockholm, Sweden: Karolinska Institutet; 2016.
Xiang H, Wheeler KK, Groner JI, Shi J, Haley KJ. Undertriage of major trauma patients in the US emergency departments. Am J Emerg Med. 2014;32(9):997–1004.
Barsi C, Harris P, Menaik R, Reis NC, Munnangi S, Elfond M. Risk factors and mortality associated with undertriage at a level I safety-net trauma center: a retrospective study. Open Access Emerg Med. 2016;8:103–110.
Davis JW, Dirks RC, Sue LP, Kaups KL. Attempting to validate the overtriage/undertriage matrix at a level I trauma center. J Trauma Acute Care Surg. 2017;83(6):1173–1178.
Newgard CD, Staudenmayer K, Hsia RY, Mann NC, Bulger EM, Holmes JF, Fleischman R, Gorman K, Haukoos J, McConnell KJ. The cost of overtriage: more than one-third of low-risk injured patients were taken to major trauma centers. Health Aff (Millwood). 2013;32(9):1591–1599.
Champion HR, Copes WS, Sacco WJ, Frey CF, Holcrofe JW, Hoyt DB, Weigelt JA. Improved predictions from a severity characterization of trauma (ASCOT) over Trauma and Injury Severity Score (TRISS): results of an independent evaluation. J Trauma Acute Care Surg. 1996;40:42–48.
West TA, Rivara FP, Cummings P, Jurkovich GJ, Maier RV. Harborview assessment for risk of mortality: an improved measure of injury severity on the basis of ICD-9-CM. J Trauma Acute Care Surg. 2000;49:530–541.
Osler TM, Rogers FB, Badger GJ, Healey M, Vane DW, Shackford SR. A simple mathematical modification of TRISS markedly improves calibration. J Trauma Acute Care Surg. 2002;53:630–634.
Norris RM, Woods R, Harbrecht B, et al. TRISS unexpected survivors: an outdated standard? J Trauma Acute Care Surg. 2002;52(2):229–234.
Guzzo JL, Bochicchio GV, Napolitano LM, Malone DL, Meyer W, Scalea TM. Prediction of outcomes in trauma: anatomic or physiologic parameters. J Am Coll Surg. 2005;201(6):891–897.