Original research

Precision of field triage in patients brought to a trauma centre after introducing trauma team activation guidelines

Marius Rehn^1,2 , Torsten Eken³ , Andreas Jorstad Krüger^1,4 , Petter Andreas Steen^2,5 , Nils Oddvar Skaga^1,6 and Hans Morten Lossius¹

¹  Department of Research and Development, Norwegian Air Ambulance Foundation, Drobak, Norway

²  Faculty of Medicine, Faculty Division Ulleval University Hospital, University of Oslo, Norway

³  Department of Anaesthesiology, Aker University Hospital, Oslo, Norway

⁴  Department of Anaesthesiology and Emergency Medicine, St. Olav University Hospital, Trondheim, Norway

⁵  Prehospital division, Ulleval University Hospital, Oslo, Norway

⁶  Department of Anaesthesiology, Division of Emergency Medicine, Ulleval University Hospital, Oslo, Norway

author email corresponding author email

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17:1doi:10.1186/1757-7241-17-1

Published:	9 January 2009

Abstract

Background

Field triage is important for regional trauma systems providing high sensitivity to avoid that severely injured are deprived access to trauma team resuscitation (undertriage), yet high specificity to avoid resource over-utilization (overtriage). Previous informal trauma team activation (TTA) at Ulleval University Hospital (UUH) caused imprecise triage. We have analyzed triage precision after introduction of TTA guidelines.

Methods

Retrospective analysis of 7 years (2001–07) of prospectively collected trauma registry data for all patients with TTA or severe injury, defined as at least one of the following: Injury Severity Score (ISS) > 15, proximal penetrating injury, admitted ICU > 2 days, transferred intubated to another hospital within 2 days, dead from trauma within 30 days. Interhospital transfers to UUH and patients admitted by non-healthcare personnel were excluded. Overtriage is the fraction of TTA where patients are not severely injured (1-positive predictive value); undertriage is the fraction of severely injured admitted without TTA (1-sensitivity).

Results

Of the 4 659 patients included in the study, 2 221 (48%) were severely injured. TTA occurred 4 440 times, only 2 002 of which for severely injured (overtriage 55%). Overall undertriage was 10%. Mechanism of injury was TTA criterion in 1 508 cases (34%), of which only 392 were severely injured (overtriage 74%). Paramedic-manned prehospital services provided 66% overtriage and 17% undertriage, anaesthetist-manned services 35% overtriage and 2% undertriage. Falls, high age and admittance by paramedics were significantly associated with undertriage. A Triage-Revised Trauma Score (RTS) < 12 in the emergency department reduced the risk for undertriage compared to RTS = 12 (normal value). Field RTS was documented by anaesthetists in 64% of the patients compared to 33% among paramedics.

Patients subject to undertriage had an ISS-adjusted Odds Ratio for 30-day mortality of 2.34 (95% CI 1.6–3.4, p < 0.001) compared to those correctly triaged to TTA.

Conclusion

Triage precision had not improved after TTA guideline introduction. Anaesthetists perform precise trauma triage, whereas paramedics have potential for improvement. Skewed mission profiles makes comparison of differences in triage precision difficult, but criteria or the use of them may contribute. Massive undertriage among paramedics is of grave concern as patients exposed to undertriage had increased risk of dying.