Most trauma systems set certain prehospital criteria that, when met, direct that patient to a trauma center. It is now well-established that care of these patients results in improved survival if they are managed at those centers. Unfortunately, undertriage is still a problem, meaning that those patients may not always be taken to a hospital most appropriate to care for their injuries. What is the penalty that your patient pays if this happens?
The University of Toronto performed a nice, prospective study across a large region with both urban and rural areas. Database information was analyzed for all victims of motor vehicle crashes who had a severe injury (ISS>15) or who died. Over 6,000 crash victims’ data were analyzed.
Just under half of the victims (45%) were triaged to a trauma center. Of those who were taken to other hospitals, slightly more than half (58%) were transferred to one within 24 hours, but nearly 5% died in the non-trauma center ED. The overall mortality for severely injured patients who were taken to a nontrauma center was 8.7%. This was a 30% increase in adjusted mortality compared to those taken to a trauma center directly.
Bottom line: Follow the rules! EMS authorities and trauma systems should make it a priority to adopt the CDC protocol (see below) or create trauma guidelines based on them that ensure patients with significant injuries are taken directly to a trauma center. Going to the nearest hospital (if it is not a trauma center) or bending to the patient’s preference is not in their best interest (and may kill them)!
Click here to download the Centers For Disease Control and Prevention (CDC) National Trauma Triage Protocol. This should be used as a standard!
Reference: The mortality benefit of direct trauma center transport in a regional trauma system: a population-based analysis. AAST 2011 Annual Meeting, Paper 50.
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.
The cost of care in a trauma center is high. When anything is expensive, it is natural to wonder about its cost-effectiveness. A group of biostatisticians recently looked at the treatment costs and cost-effectiveness of treating trauma patients in a trauma center vs an nontrauma hospital. They were very comprehensive in looking at costs, including costs for transportation, treatment at a transferring hospital, rehospitalization for acute care if needed, inpatient rehab, stays in longterm care or skilled nursing care facilities, outpatient care and informal care given by family members.
Treatment at a trauma center saved 3.4 lives per 100 patients treated. The overall added cost for treatment at a trauma center was about $36,000 per life year gained. However, in order to gauge cost-effectiveness we need to know what a year of life is worth. As you can imagine, this is tough to figure out. A number of researchers have looked at this, and it typically ranges from $50,000 to $200,000 per year. Thus, trauma center care is overall cost-effective.
The data was more closely analyzed, and it appears that the cost-effectiveness is greater for patients with more severe injuries. Unfortunately, cost-effectiveness is not as clear for patients who are 55 years or older.
The bottom line: Trauma is a leading cause of death in this country. The concept of treating more severely injured patients at trauma centers is both effective and cost-effective. Trauma systems need to be fine-tuned so that they get the right patient to the right hospital and so care for elderly patients continue to improve.
Reference: Nathens et al. The Value of Trauma Care. J Trauma 69(1):1-10, 2010.