All posts by TheTraumaPro

NFTI: A Nifty Tool To Replace The Cribari Grid?

In my last post, I reviewed the use of the Cribari grid for evaluating over- and under-triage at your trauma center.  This technique has been a mainstay for over a decade, but has its shortcomings. The most important one is that it relies only on the Injury Severity Score (ISS) to judge whether some type of mistriage occurred.  As you know, the ISS is usually calculated after discharge, so it can only be applied after the fact.

Two years ago, the group at Baylor University in Dallas sought to develop an alternate method of determining who needed a full trauma team activation. They chose resource utilization as their surrogate to select these cases. They reviewed 2.5 years of their own registry data (Level I center).  After several iterations, they settled on six “need for trauma intervention” (NFTI) criteria:

  • blood transfusion within 4 hours of arrival
  • discharge from ED to OR within 90 minutes of arrival
  • discharge from ED to interventional radiology (IR)
  • discharge from ED to ICU AND ICU length of stay at least 3 days
  • require mechanical ventilation during the first 3 days, excluding anesthesia
  • death within 60 hours of arrival

Patients who had at least one NFTI criterion were considered candidates for full trauma activation, and those who met none were not. Here are the factoids for this study:

  • There were a total of 2260 full trauma activations and 2348 partial activations during the study period (a little over 900 per year for each level)
  • Roughly 2/3 of full activations were NFTI +, and 1/3 were NFTI –
  • For partial activations, 1/4 were NFTI + and 3/4 were NFTI –
  • Only 13 of 561 deaths were NFTI – and all had DNR orders in place

The authors concluded that NFTI provides an assessment of both anatomy and physiology using only measures of early resource utilization. They believe that it self-adjusts for age, frailty, and comorbidities, and that it is a simple and effective tool for identifying major trauma patients.

Bottom line: This is an elegant attempt to improve upon the simple (yet admittedly flawed) Cribari matrix method for assessment of major trauma patient triage. It was thoughtfully designed and evaluated at this one center. The authors recognize that it is based on retrospective data, but so is the Cribari technique. 

I believe that it may be an adjunct to Cribari. The matrix identifies gross under- and over-triage, but still requires the trauma program to review the outliers to see if mistriage actually occurred. It is basically a “first pass” that seeks to over-identify potential problem patients.

NFTI is similar, but it focuses on those patients who really should have been a full trauma activation due to their early need for critical resources to deal with their injuries. But is it enough? In my next post, I’ll review the follow-on paper from this group as they apply it to multiple trauma centers. And I’ll add some final thoughts on the subject.

Reference: Asking a Better Question: Development and Evaluation of the Need For Trauma Intervention (NFTI) Metric as a Novel Indicator of Major Trauma. J Trauma Nursing 24(3):150-157, 2017.

The Cribari Grid And Over/Undertriage

Any trauma performance improvement professional understands the importance of undertriage and overtriage.  Overtriage occurs when a patient who does not meet trauma activation criteria gets one anyway. And undertriage is the converse, where no activation is called despite criteria being met. As you may expect, the latter is much more dangerous for the patient than the former.

I frequently get questions on the “Cribari grid” or “Cribari method” for calculating these numbers. Dr. Chris Cribari is a previous chair of the Verification Review Subcommittee of the ACS Committee on Trauma. He developed a table-format grid that provides a simplified method for calculating these numbers.

But remember, the gold standard for calculating over- and undertriage is examining each admission to see if they met any of your trauma activation triage criteria. The Cribari method is designed for those programs that do not check these on every admission. It is a surrogate that allows you to identify patients with higher ISS that might have benefited from a trauma activation.

So if you use the Cribari method, use it as a first pass to identify potential undertriage. Then, examine the chart of every patient in the undertriage list to see if they meet any of your activation criteria. If not, they were probably not undertriaged. However, you must then look at their injuries and overall condition to see if they might have been better cared for by your trauma team. If so, perhaps you need to add a new activation criterion. And then count that patient as undertriage, of course.

I’ve simplified the calculation process even more and provided a Microsoft Word document that automates the task for you. Just download the file, fill in four values in the table, update the formulas and voila, you’ve got your numbers! Instructions for manual calculations are also included. Download it by clicking the image below or the link at the end of this post.

cribarigrid

Download the calculator by clicking here

In my next post, I’ll examine how the NFTI score (need for trauma intervention) fits into the undertriage/overtriage calculations.

Related posts:

Appropriateness Of Nonsurgical Admissions

U.S. Trauma Centers that are verified by the American College of Surgeons must track the rate of trauma admissions to nonsurgical services. This is particularly important if the percentage of nonsurgical admissions exceeds 10% of their total admissions. The center’s performance improvement processes can then determine if the admission was appropriate and whether or not the trauma service should request a consult or transfer.

But how should we judge the appropriateness of nonsurgical admissions? There is tremendous variability in presenting mechanism and patient comorbidities. And the number of patients with some need for nonsurgical attention continues to grow with the rapidly increasing number of elderly falls.

The group at Southside Hospital in Bay Shore NY initially tracked all nonsurgical admissions and evaluated each individually at their community Level II trauma center. They then created and implemented a scoring system in order to develop a set of objective criteria that would predict patients better served with trauma consultation or admission.

The scoring tool was based on some of the information in the Optimal Resource Document, but was still somewhat arbitrary. The authors added criteria that reflected their own institutional philosophy of care. They explain their rationale clearly in the manuscript. Here is the final tool:

Criteria Points
Age > 65 years 1
3 or more comorbidities 1
ISS < 10 1
Ground level fall 1
No ICU admission 1
No need for surgical intervention 1
No blood products given 1

The maximum number of points possible is 7, with higher scores suggesting appropriateness for nonsurgical admission. The authors chose scores of 3 and 4 as the “grey zone” where further investigation was necessary to determine if a medical admission was proper. Lower numbers required trauma service admission, and higher ones did not.

The authors then examined changes in the percent of nonsurgical admissions after implementation, as well as mortality, morbidity, and hospital length of stay.

Here are the factoids:

  • Nonsurgical admission rates had historically been greater than 10% and had peaked at 28% at the time of scoring system implementation
  • After implementation, the nonsurgical admission rate dropped to under 10 %, where it remained for most of the time. There were a few spikes into the 14-17% range.
  • Mortality was insignificantly higher on the trauma service (2.1% vs 1.2%) as were complications (6.1% vs 5.5%)
  • Length of stay was statistically significantly longer on nonsurgical services (6.2 VS 5.1 days)

Bottom line: Centers that admit a large number of elderly falls patients may benefit from adopting this quick screening tool to determine the appropriate service. Ideally, all trauma patients would be admitted to the trauma service, but this is not feasible from a personnel and resource standpoint. If the number of potential nonsurgical admissions is high, applying a scoring system like this can help streamline the decision regarding admitting service.

Patients with very low scores (1-2) are obviously only appropriate for a trauma service admission. Likewise, those with very high scores (5-7) could easily and appropriately be managed on a hospital medicine service. The in-betweeners need more scrutiny by trauma program PI personnel to determine which service to admit to. 

Most importantly, don’t feel compelled to use this exact scoring system or threshold. Every hospital has different resources and a unique patient population. Add or remove criteria that you believe are appropriate. Adjust the threshold for added scrutiny as you see fit. Doing so will help keep your trauma PI workflow manageable.

Reference: Nonsurgical admissions with traumatic injury: medical patients are trauma patients, too. J Trauma Nursing 25(3):192-195, 2018.

Reminder: Trauma PI Coordinator Survey Results

This is a reminder to all that I am publishing the results of the Trauma PI Coordinator Survey next week. This white paper will be distributed in lieu of the usual monthly newsletter. And it will only be sent to current subscribers! Unlike normal newsletter issues, it will not be available via the usual blog post. For those that miss out, you will still be able to obtain it by subscribing to the newsletter at any time in the future.

Don’t miss it! Click this link right away to sign up now and/or download back issues.

Uber / Lyft For Medical Transport???

Yesterday I discussed nonstandard first responders (police). Today I’ll share some info on nonstandard ambulances.

In this day and age of ride sharing apps like Uber and Lyft, it is possible to get a cheap ride virtually anywhere there is car service and a smart phone. And of course, some people have used these services for transportation to the hospital in lieu of an ambulance ride. What might the impact be of ride services on patient transport, for both patient and EMS?

A paper in preparation suggests that ambulance service calls decreased by 7% after the introduction of UberX rides. Now, there are a lot of questions here, because the full paper has not yet been peer reviewed, and the results write-up is pretty sketchy. But it does beg the question.

Ambulance rides are expensive. Depending on region, they may range from $500-$5000. And although insurance may reduce the out of pocket cost, it can still be expensive. So what are the pros vs the cons of using Uber or Lyft for medical transport?

Pros:

  • Ride shares are inexpensive compared to an ambulance ride
  • They may arrive more quickly because they tend to circulate around an area, as opposed to using a fixed base
  • Riders may select their preferred hospital without being overridden by EMS (although it may be an incorrect choice)
  • May reduce EMS usage for low acuity patients

Cons:

  • No professional medical care available during the ride
  • May end up being slower due to lack of lights and siren
  • Damage fees of $250+ for messing up the car

Bottom line: Uber and Lyft are just another version of the “arrival by private vehicle” paradigm. Use of these services relies on the customer/patient having very good judgment and insight into their medical conditions and care needs. And from personal experience, this is not always the case. I would not encourage the general public to use these services for medical transport, and neither do the companies themselves!

Reference: Did UberX Reduce Ambulance Volume? Unpublished paper, October 24, 2017.

(This paper remains unpublished! Hmm… but the link will take you to a copy of the manuscript)