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?
- Survival of the fittest: the hidden cost of undertriage of major trauma. J Amer Col Surgeons, 211:804-811, Dec 2010.
- Outcome assessment of blunt trauma patients who are undertriaged. Surgery 148(2): 239-245, Aug 2010.
TCAA Trauma Marketing For TMD/TPM
This handout contains the slides for the presentation on trauma marketing given at the TCAA Trauma Medical Director Conference on November 12, 2010 in San Diego. It’s focus is on marketing from the perspective of the trauma program (TMD/TPM)
TCAA Trauma Marketing For Hospital Leadership
This handout contains the slides for the presentation on trauma marketing given at the TCAA Trauma Leadership Conference on November 12, 2010 in San Diego. It’s focus is on marketing from the perspective of hospital administration and marketing departments.
Emergency Medicine & Trauma Update – Bloomington, MN 10/28/10
“Torso Trauma Update” presented at 8:40AM.
For a copy of the slideset, click here.
- What is the utility of focused assessment with sonography in trauma (FAST) exam in penetrating torso trauma? Injury, in press, 2010.
- CT of blunt abdominal and pelvic vascular injury. Emerg Radiology 17:21-29, 2010
- More operations, more deaths? Relationship between operative intervention and risk-adjusted mortality at trauma centers. J Trauma 69(1):70-77, 2010
Scoop and run vs stay and play are traditionally EMS concepts. Do I stay at the scene to perform invasive procedures, or do I perform the minimum I can and get to the nearest hospital?
For trauma patients time is the enemy and there is a different flavor of scoop and run vs stay and play. Do I take the patient to a nearby hospital that is not a high level trauma center to stay and play, or do I scoop and run to the nearest Level I or II center?
Admissions to a group of 8 trauma centers were analyzed over a 3 year period. A total of 1112 patients were studied. Patients were divided into two groups: those who were taken directly to a Level I trauma center (76%), and those who were transferred from another hospital (24%).
Patients who were taken to a non-trauma center first received 3 times more IV crystalloid, 12 times more blood, and were nearly 4 times more likely to die!
Obviously, the cause of this increased mortality cannot be determined from the data. The authors speculate that patients may undergo more aggressive resuscitation with crystalloid and blood at the outside hospital making them look better than they really are, and then they die. Alternatively, they may have been under-resuscitated at the outside hospital, making it more difficult to ensure survival at the trauma center.
Bottom line: this is an interesting paper, but there are a number of flaws that prevent us from mandating that all trauma patients should go directly to the trauma center. The authors never really define a “nontrauma hospital.” Does a Level III or IV center count? How did patients who stayed at the outside hospital do?
A lot of work needs to be done to add detail to this work. In the meantime, we have to trust our experienced prehospital providers to determine who really needs to go to the closest appropriate center, and what that really is.
Reference: Scoop and run to the trauma center or stay and play at the local hospital: hospital transfer’s effect on mortality. J Trauma 69(3):595-601, 2010.