All posts by TheTraumaPro

Q&A: Is Undertriage Bad?

After my discourses on under- and over-triage in the last week, I received an interesting question from a reader: although undertriage seems bad from a theoretical standpoint, are there any objective negative consequences?

As you might imagine, there is little literature on this topic. The incidence is low, so it’s tough to design a study with enough power to come to any solid conclusions. There are two studies that I can cite that shed as much light on the subject as possible.

The first looks at system undertriage at the EMS level. A Canadian study looked at patients with severe injuries (identified by ISS>15 after admission) who were taken to trauma centers (correct triage) vs non-trauma centers (undertriage). After solid statistical analysis of over 11,000 patients, they found that mortality in the undertriage group was 24% higher than the correctly triaged patients.

A second study looked at undertriage in one trauma center (1,424 patients) using their standard triage criteria, not ISS. The undertriage group had a significantly lower ISS (17 vs 25). The correctly triaged patients were more frequently intubated in the ED, more likely to be admitted to the ICU, and had longer ICU and hospital stays. Mortality was not significantly different. The problem with this study is that most of the undertriage group probably did not need a trauma activation, based on their lower ISS. The higher ISS patients (who met triage criteria) needed an airway earlier and required critical care more often. These data show that the institution probably needs to adjust its triage criteria!

Bottom line: The Canadian study shows the danger of undertriage prior to reaching definitive care. There is no good literature that illustrates its danger once the patient is at a trauma center. But there is support for the converse idea that appropriately triaged patients get definitive management sooner (airway, critical care). Any takers for designing the study to answer this question?

References:

  1. Survival of the fittest: the hidden cost of undertriage of major trauma. J Amer Col Surgeons, 211:804-811, Dec 2010.
  2. Outcome assessment of blunt trauma patients who are undertriaged. Surgery 148(2): 239-245, Aug 2010.

Undertriage Revisited

I’ve updated my original post on trauma undertriage when activating your trauma team. The initial post gave a general approach that was reasonably accurate as long as the number of missed activations was low. Here’s the new and improved version!

Trauma centers look at over- and undertriage rates as part of their performance improvement programs. Both are undesirable for a number of reasons. I’ll focus on undertriage today, why it happens and what can be done about it.

Undertriage in trauma care refers to the situation where a patient who meets criteria for a trauma activation does not get one. First, calculate your “magic number”, the number of patients who should have been trauma activations.

If you track the exact triage criteria met at your hospital, it is calculated as follows:

 Magic Number = (Number of ED trauma patients who met activation criteria
                                           but were not trauma activations)

If you don’t track the triage criteria, you can use ISS>15 as a surrogate to identify those patients who had severe enough injuries that should have triggered an activation. This is not as accurate, because you can’t know the ISS when the patient comes in, but it will do in a pinch. In that case, the magic number is:

Magic Number = (Number of ED trauma patients with ISS>15
                                           but were not trauma activations)

Your undertriage rate is then calculated as follows

                                        Magic Number
        ———————————————————–    x 100
           (Total number of trauma activations) + Magic Number

Undertriage is bad because patients who have serious injuries are not met by the full trauma team, and would benefit from the extra manpower and speed possible with an activation.

The most common causes for undertriage are:

  • Failure to apply activation criteria
  • Criteria are too numerous or confusing
  • Injuries or mechanism information is missed or underappreciated

Undertriage rates can range from 0% to infinity (if you never activate your trauma team). A general rule is to try to keep it below 5%.

If your overtriage rate is climbing past the 5% threshold, identify every patient who meets the ISS criterion and do a complete ED flow review as concurrently as possible. Look at their injuries/mechanism and your criteria. If the criteria are not on your activation list, consider adding them. If the criterion is there, then look at the process by which the activation gets called. Typically the ED physicians and nurses will be able to clarify the problem and help you get it solved. 

Falls In The Elderly: The Consequences

Falls among the elderly are a huge problem. Our trauma service typically has 6-12 elders who have sustained significant injuries on it at any given time. About a third of people living at home over the age of 65 fall in a given year. At 80 years and up, half fall every year.

Because of this, falls are the leading cause of ED visits due to an injury for those over 65. What exactly are the societal consequences of all these falls? A yet to be published study from the Netherlands looked at injuries, costs and quality of life after falls in the elderly.

The top 5 most common injuries included simple wounds, wrist and hip fractures, and brain injuries. Although hip fracture typically was #5 in the 65-74 age groups, it was uniformly #1 in the 85+ group. Patterns were similar in both men and women. Interestingly, hip fractures were by far the most expensive, making up 43% of the cost of all injuries (total €200M). The next closest injuries by total cost, superficial injuries and femur fracture, made up only 7% of the total each!

As you can imagine, quality of life suffered after falls as well. A utility score based on the EQ-5D, a validated quality of life score, was lower in fall victims. Even after 9 months, this score did not return to baseline. About 70% of elders who were admitted after their falls described mobility problems and 64% had problems with their usual activities. Over a quarter expressed problems with anxiety or depression.

Bottom line: An array of falls prevention programs are available. They need to be more aggressively implemented to reduce costs and improve the quality of life of our elders.

Reference: Social consequences of falls in the older population: injuries, healthcare costs, adn long-term reduced quality of life. J Trauma (in press), 2011.

Trauma Overtriage: Why Is It Bad?

Back in December I talked about the dangers of undertriaging trauma patients (click here to review). What about the opposite problem, overtriage?

First, how do you calculate your overtriage rate? It’s pretty simple. Use your trauma registry to count how many patients arriving in the ED were trauma activations but didn’t meet any criteria:

(Number of ED trauma patients who were trauma activations
                         but did not meet activation criteria)

        ——————————————————–           x 100
                  (Total number of trauma activations)

This can only be accurately determined if the activation criteria are recorded on each patient. If not, use the following equation:

 (Number of ED trauma patients who were trauma activations
                                     with ISS <= 15)
       ———————————————————           x 100
                  (Total number of trauma activations)

Values can range from 0% to 100%. The usually acceptable overtriage rate is 50-80%. What happens when the overtriage rate is too high? You wear out your trauma team. They are being called for patients with injuries that don’t warrant it.

The solution for overtriage? Change your activation criteria, or add a second level trauma response that doesn’t require as many people to respond. This requires a thoughtful analysis of your existing criteria so you can decide what needs to be changed or discarded.

The danger? More undertriage. Over- and undertriage go hand in hand. As overtriage decreases, undertriage increases. You need to strike a balance so that the undertriage rate stays below 5%. This makes an excellent performance improvement (PI) program project!

Treating Bile Leaks After Liver Trauma

Nonoperative management is the standard of care for most solid organ injuries, including the liver. More serious injury may require operative intervention. Unlike the spleen, however, the liver has a higher complication rate when managed nonoperatively or operatively. One of the more troubling problems is the persistent bile leak. Our radiology colleagues do a great job a draining collections, but what should we do if the bile keeps pouring out?

ERCP seems like a reasonable choice. But does it work? The Shock Trauma Center looked at their experience over a 6 year period. They included both blunt and penetrating injuries to the liver, and found a total of 26 patients in their database. All but 2 underwent an initial attempt at operative control of the bile leak. All but one had ERCP performed within 3 weeks of admission.

They found that ERCP resulted in decreased drain output within 2 days. All bile leaks stopped within 7 months, with an average closure time of 47 days. There were no complications from ERCP itself.

Bottom line: consider ERCP part of your armamentarium when dealing with major liver injuries. Depending on patient condition, it might even be used as the initial approach to controlling a bile leak. If the leak does not decrease significantly or close in a reasonable period of time (not yet defined), operative intervention will still be required.

Reference: Endoscopic retrograde cholangiopancreatography is an effective treatment for bile leak after severe liver trauma. J Trauma, in press, 2011.