Category Archives: Trauma Center

The ACS “Gang Of 6” Trauma Activation Criteria

January 31, 2018 The Trauma Pro Leave a comment

For more than 10 years, all trauma centers verified by the American College of Surgeons (ACS) have been required to have a group of mandatory criteria for their highest level of trauma activation. I call these the gang of 6 (ACS-6). They are:

Hypotension (systolic < 90 torr for adults, age specific for children)
Gunshot to neck, chest, abdomen or extremities proximal to elbow or knee
GCS < 9 from trauma
Transfer patients receiving blood to maintain vital signs
Intubated patients from scene or patients with respiratory compromise transferred in (may already be intubated but still having compromise)
Emergency physician discretion

For the most part, it seems obvious that any one of these criteria would indicate a seriously injured patient needing rapid trauma team evaluation. But do all centers use these criteria?

The answer, detailed in a recently published paper, would seem to be no! Researchers at the Universities of Minnesota and Michigan looked at the Trauma Quality Improvement Program database for all Level I and II centers in Michigan over a three year period. They specifically analyzed the data to determine how many centers used all 6 criteria, and any differences in mortality between those that did and those that didn’t. They reviewed records for adults with blunt and penetrating trauma with an ISS > 5.

Here are the factoids:

More than 50,000 patient records were reviewed, and 12% met at least one of the ACS-6
Only 66% of patients with at least one ACS-6 criterion were full trauma activations (!!)
Compliance was poorest with hypotension (only half activated), compared to intubation (75%), central gunshot (75%), and coma (82%)
79% of patients meeting any ACS-6 criterion needed an intervention, with a third going emergently to the OR
Undertriaged patients (ACS-6 with no high level activation) were significantly more likely to die (30% vs 21%), and this was most pronounced in the coma group (47% vs 40%)

Bottom line: Physiologic trauma activation criteria are important, as is the central gunshot one! Although this is a database review subject to the usual flaws (retrospective, data accuracy), the numbers are large and the statistics are sound. And remember, this is an association study, so we don’t really know why the mortality numbers were different, just that they were.

Nevertheless, there is a lot to learn from it. Why don’t all centers use the ACS-6? They certainly have them in their criteria list, or they would have failed their verification visit. It’s because of undertriage! How does this happen? Two ways: either the information in the field is incorrect (GCS may be incorrectly estimated, hypotension may be transient), or personnel in the ED failed to activate properly.

This study shows the importance of rigidly adhering to the criteria. It found a 20% mortality reduction if all of the ACS-6 were applied properly. So make sure that your own trauma program regularly monitors for undertriage, especially with respect to the “gang of 6”!

Related posts:

Reference: Noncompliance with American College of Surgeons Committee on Trauma recommended criteria for full trauma team activation is associated with undertriage deaths. J Trauma 84(2):287-294, 2018.

Trauma Center

Trauma Team Activation: What’s It Like For Your Patient?

October 27, 2017 The Trauma Pro Leave a comment

Everyone worries about patient satisfaction these days, and rightly so. There’s quality of care, and there’s satisfaction with it. The two are tough to separate. Many hospitals administer surveys and questionnaires after discharge about the overall hospital stay. But who looks at the experience of going through a trauma activation?

A very recent paper from Cornell and Penn interviewed trauma patients within 2 days of the trauma activation, and provided a $25 incentive to participate. There were 14 questions presented during a verbal interview, all open-ended. Patients with abnormal mental status during trauma activation were excluded, and data was collected over a 7 month period.

Here are the factoids:

Most patients described fear and agitation, along with a loss of control
93% expressed concern about things other than themselves: family, work, safety
Many patients remarked on the removal of their clothing. Some were concerned that they could not afford to replace them.
Most participants noted that they received pain medicine early, but that it was not always effective immediately
All participants described the team as caring and expert at what they do
Patients appreciated the fact that team members introduced themselves and expressed concern for their wellbeing
They were very observant of communication, and picked up on sidebar communications as well

Bottom line: Don’t underestimate what your patient observes and experiences during a trauma resuscitation. Unless head injured or intoxicated, they are picking up on everything you say and do. The trauma activation needs to be as patient-centered as possible while maintaining patient and team safety. Team members should be mindful of all communications, even when things are winding down. Try to spare patient clothing if possible. Use adequate analgesia and judicious sedation. And always remember to communicate clearly!

Related post:

Why did the trauma team cut off my clothes?

Reference: Patient experiences of trauma resuscitation. JAMA Surg 152(9):843-850, 2017.

Mechanism, Trauma Center

Trauma Activation For Strangulation: Yes or No?

February 6, 2017 The Trauma Pro Leave a comment

I received a request to discuss this topic from a reader in Salina, KS. Thanks!

Trauma activation criteria generally fall into four broad categories: physiology, anatomy, mechanism of injury, and co-factors. Of these, the first two are the best predictors of patients who actually need to be assessed by the full trauma team. Many trauma centers include a number of mechanistic criteria, usually much to their chagrin. They typically end up with frequent team activations and the patient usually ends up have trivial injuries.

However, there are some mechanisms that just seem like they demand additional attention. Death of another occupant in the vehicle. Fall from a significant height. But what about a patient who has been strangled?

Unfortunately, the published literature gives us little guidance. This usually means that trauma centers will then just do what seems to “make sense.” And unfortunately, this frequently results in significant overtriage, with many patients going home from the emergency department.

Since there is little to know research to show us the way, I’d like to share my thoughts:

As a guiding principle, the trauma team should be activated when the patient will derive significant benefit from it. And the benefit that the team really provides is speed. The team approach results in quicker diagnosis from physical exam and FAST. It gets patients to diagnostic imaging quicker, if appropriate. And gets them to the OR faster when it’s not appropriate to go to CT.
Activating for a strangulation mechanism alone is probably a waste of time.
Look at the patient’s physiology first. Are the vital signs normal? What is the GCS? If either are abnormal, activate.
Then check out the anatomy. If the patient has any voice changes, or has obvious discoloration from bruising, crepitus, or subcutaneous emphysema, call the team. They may suffer a deteriorating airway at any moment.

If physiologic and anatomic findings don’t trigger an activation, then standard evaluation is in order. Here are some things to think about:

A complete physical exam is mandatory. This not only includes the neck, but the rest of the body. Strangulation is a common injury from domestic violence, and other injuries are frequently present.
If there are any marks on the neck, CT evaluation is required. This includes soft tissue, CT angiography, and cervical spine evaluation. All three can be done with a single contrast-enhanced scan. The incidence of spine injury is extremely low with strangulation, but the spine images are part of the set anyway.
CT of the chest is never indicated. There is no possibility of aortic injury with this mechanism, and all the other stuff will show up on the chest x-ray, if significant enough for treatment.
Even if there are no abnormalities, your patient may need admission while social services arranges a safe place for their discharge. Don’t forget the social and forensic aspects of this injury. Law enforcement may need photographic evidence or statements from the patient so this event can’t happen again.

Next post: Trauma Activation for Hanging: Yes or No?

Reference: Strangulation forensic examination: best practice for health care providers. Adv Emerg Nurs J 35(4):314-327, 2013.

Trauma Center

EAST 2017 #13: An Extra Trauma Activation Tier For Geriatric Trauma

January 13, 2017 The Trauma Pro Leave a comment

Our elderly population is growing rapidly, and the average age of the patients on the trauma service is escalating. These patients offer a number of challenges throughout their presentation to the hospital and the rest of their stay. Some trauma centers are now organizing special teams or response types to deal with the unique needs of this population. A few have adopted a separate response type when injured elderly patients present to the ED.

The group at Reading Hospital implemented a separate trauma activation tier, “Tier 3”, driven by emergency physicians, to manage these patients. Tier 3 was designed to identify patients > 65 years of age with the potential for occult blunt injury to the head and torso. The normal activation criteria at this center would not have necessarily identified these patients. This study retrospectively looked at demographics and outcomes for two separate three year periods, one before and one after implementation of Tier 3.

Here are the factoids:

Geriatric volume increased significantly from 1715 to 3688 patients (!!), and more received expedited workup as either a trauma activation or Tier 3
There were statistically significant decreases in time to CT (102 vs 128 minutes) and ED length of stay (361 vs 432 minutes) (see my comments)
Mortality decreased from 8% to 5% overall, and from 19% to 11% in patients with head AIS > 3, both of which were significant
Regression analysis showed that implementation of the Tier 3 response was an independent predictor of improved survival

Bottom line: This poster shows results that suggest having a specific response for select elderly patients who don’t meet trauma activation criteria can be beneficial. However, the devil is in the details. Each center must develop criteria for the Tier 3 response that mesh with their own activation criteria. And the details of that response need to be clinically significantly better than the usual consult response.

Questions and comments for the authors/presenters:

Be careful not to confuse statistical significance with clinical significance. Decreasing mean time to CT from 2:08 to 1:42 is not that big of a deal. The same applies to 7 hours in the ED vs 6.
Please share the Tier 3 criteria and details of the ED response.
Have you modified your Tier 3 criteria and/or response since inception, and if so, how and why?

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference: “Tier 3”: Long term experience with a novel addition to a two-tiered triage system to expedite care of geriatric trauma patients.. Poster #34, EAST 2017.

Trauma Center

When Should You Activate Your Backup Trauma Surgeon?

November 16, 2016 The Trauma Pro Leave a comment

The American College of Surgeons requires all US Trauma Centers to publish a call schedule that includes a backup trauma surgeon. This is important for several reasons:

It maintains a high level of care when the on-call surgeon is encumbered with multiple critical patients, or has other on-call responsibilities such as acute care surgery
It reduces the need to place the entire trauma center on divert due to surgeon issues

However, the ACS does not provide any guidance regarding the criteria for and logistics of mobilizing the backup surgeon. In my mind, the guiding principle is a simple one:

The backup should be called any time a patient is occupying the on-call surgeon’s time to the extent that they cannot manage the care of a newly arrived (or expected to arrive) patient with critical needs that only the surgeon can provide.

There’s a lot of meat in that sentence, so let’s go over it in detail.

First, the on-call surgeon must already be busy. This means that they are actively managing one or more patients. Depending on the structure of the call system, they may be involved with trauma patients, general/acute care surgery patients, ICU patients, or a combination thereof. Busy means tied up to the point that they cannot meaningfully manage another patient.

Note that I did not say “evaluate another patient.” Frequently, it is possible to have a resident (at an appropriate training level) or advanced practice provider (APP) see the new patient while the surgeon is tied up, say in the operating room. They can report back, and the surgeon can then weigh his or her choices regarding the level of management that will be needed. Or if operating with a chief resident, it may be possible for the surgeon to briefly leave the OR to see the second patient or quickly check in on the trauma resuscitation. Remember, our emergency medicine colleagues can easily run a trauma activation and provide initial care for major trauma patients. They just can’t operate on them.

What if the surgeon is in the OR? Should they call the backup every time they are doing a case at night? Or every time a trauma activation is called while they are doing one? In my opinion, no. The chance of having a highest level trauma activation called is not that high, and as above, the surgeon, resident, or APP may be able to assess how much attention the new patient is likely to need. But recognize that the surgeon may not meet the 15 minute trauma activation attendance requirement set forth by the ACS.

However, once such a patient does arrive (or there is notification that one of these patients is on the way), call in the backup surgeon. These would include patients that are known to, or are highly suspected of needing immediate operative management. Good examples are penetrating injuries to the torso with hemodynamic problems, or those with known uncontrolled bleeding (e.g. mangled extremity).

If two or more patients are being managed by the surgeon, and they believe that they would not be able to manage another, it’s a good idea to notify the backup that they may be needed. This lets them plan their evening better to ensure rapid availability.

Finally, what is the expected time for the backup to respond and arrive at the hospital to help? There is no firm guideline, but remember, your partner and the patient are asking for your assistance! In my opinion, total time should be no more than 30 minutes. If it takes longer, then the trauma program should look at its backup structure and come up with a way to meet this time frame.

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