By now, most trauma program personnel understand the concept of undertriage. Undertriage occurs when an incoming trauma patient needs a level of care in the emergency department that they don’t get. It could happen if they meet any activation criterion and no activation is called, or if they meet the highest-level criteria and a secondary-level one is called.

Some trauma professionals stop there, using only that binary definition. They met criteria, and the activation didn’t happen. Undertriage. Bad. As with anything in medicine, there are nuances. One of them is the concept of time. What if the patient meets your criteria, but the activation isn’t called right away?

Suppose the patient is hypotensive with a systolic pressure in the 60s on arrival. The emergency physician and a few helpers get to work, establishing IV access and hanging emergency blood. The MTP is activated. The usual initial assessment is carried out. About 20 minutes into the process, the emergency provider performs a FAST and identifies a large hemoperitoneum. He now calls the highest-level activation.

Is this undertriage? Of course. However, I have seen a few PI coordinators review a case like this and not flag it “because a highest-level activation was called.” It would still be undertriage if this patient were activated at the intermediate level before arrival and then upgraded after 20 minutes.

This situation is another example of the PI clock. When analyzing a case, it’s not just a binary decision of “did this happen or not?” It’s when the quality event happened. When does the PI clock start ticking in calling a trauma activation?

The answer is, “when the issue/criterion could first have been known.” What does this mean? When this patient arrives and is first confirmed to meet any criteria, the clock starts. If hypotensive on arrival, the clock starts when the reading is confirmed. If the patient comes in as an intermediate-level activation and becomes hypotensive 30 minutes later, the clock for the highest-level activation starts then.

In the real world, events don’t happen instantaneously. There must be a small grace period to allow the provider to confirm and respond. If the patient is hypotensive on arrival but is awake, alert, and communicating, it is reasonable to confirm the blood pressure to rule out an equipment issue. Once confirmed, it should take only a minute or two to call for the trauma activation.

How long of a grace period should be given? This can be determined by the trauma program, but should be no more than 5-10 minutes.

And what about a situation where an intermediate-level activation is called prior to patient arrival, but they clearly meet the highest-level activation criteria on arrival? The clock starts on arrival.

Bottom line: The undertriage PI clock starts ticking as soon as any criterion is met. If the appropriate level is not called within your brief grace period, then the PI program must flag it as undertriage and investigate.

I’ll further investigate the concept of the PI clock in my next series of posts.