Simple tweak could improve ER over-triage

No consensus exists in the literature on the use of uniform emergency room trauma team activation criteria (ERTTAC). At present, excessive over- or under-triage rates continue to be a challenge for most trauma centres. Swiss researchers evaluating the application of ERTTAC, published for use in the German TraumaNetwork DGU®, at their institution observed higher under- and over-triage rates than recommended by the American College of Surgeons (ACS).

"Under-triage was mainly caused by non-compliance to the triage protocol. If the ERTTAC had been applied properly in all cases, the resulting theoretical under-triage rate would conform well to the recommendations of the American College of Surgeons," according to the research published in the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine.

Published trauma triage protocols are highly divergent. For this study, the researchers chose the most up-to-date ERTTAC published by and recommended for use in the German TraumaNetwork DGU®. These criteria were developed from the evidence-based recommendations for the treatment of the severely injured as published by the German Society for Trauma Society (DGU®), but are less strict. For example, for the TraumaNetwork DGU® ERTTAC a Glasgow Coma Scale (GCS) < 14 was chosen as an alert criterion for ERTTA instead of a GCS < 9 as given in the evidence-based recommendations. This principal decision for a more aggressive inclusion of trauma patients in the ER aimed to reduce the risk of missing severe trauma cases.

The current study included consecutive adult (age > 15 years) trauma patients treated at the emergency department of a level II trauma centre from 01.01.2013–31.12.2015. All data were collected prospectively. To identify over- and under-triage, patients with an Injury Severity Score (ISS) > 15 were defined as requiring specific emergency room (ER) management. ANOVA, Student’s t-test and chi-square analysis were used for statistical analysis with mean values ± standard deviation.

In all, 1,378 adult injured (64% male) received ER trauma team treatment (mean age 48.3 ± 21.2 years; ISS 9.7 ± 9.6) during the observation period. Of those, 326 ER patients (23.7%) were diagnosed with an ISS > 15, which proved to be an over-triage of 76.3%. 80/406 trauma patients with an ISS > 15 were not referred to the ER, resulting in an actual under-triage rate of 19.7%, mainly because the criteria list was not observed. Effectively applying ERTTAC according to the protocol in all cases would have reduced under-triage to 2.0% (8/406), the research team said.

Notably, the most frequent trigger for trauma team activation was injury mechanism (65%). A simulation revealed that omitting the criterion ‘passenger of car or truck’ (n = 326) would have prevented over-triage in 257 cases, as such lowering over-triage rate to 62.4% and at the same time increasing under-triage by only 8 cases to 7.1%.

"According to our data excluding the trauma mechanism criteria for car and truck injuries could improve the over-triage rate importantly without relevantly increasing under-triage of the severely injured," the researchers explained. "If other centres confirm these pilot results and manage to strictly execute the ERTTAC as published for the TraumaNetwork DGU® in daily routine, sufficiently low under-triage rates in relation to the ACS recommendations may be expected."
 
Source: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine