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Precision of field triage in patients brought to a trauma centre after introducing trauma team activation guidelines
Marius Rehn, Torsten Eken, Andreas Krüger, Petter Steen, Nils Skaga, Hans Lossius
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 2009, DOI: 10.1186/1757-7241-17-1
Abstract: Retrospective analysis of 7 years (2001–07) of prospectively collected trauma registry data for all patients with TTA or severe injury, defined as at least one of the following: Injury Severity Score (ISS) > 15, proximal penetrating injury, admitted ICU > 2 days, transferred intubated to another hospital within 2 days, dead from trauma within 30 days. Interhospital transfers to UUH and patients admitted by non-healthcare personnel were excluded. Overtriage is the fraction of TTA where patients are not severely injured (1-positive predictive value); undertriage is the fraction of severely injured admitted without TTA (1-sensitivity).Of the 4 659 patients included in the study, 2 221 (48%) were severely injured. TTA occurred 4 440 times, only 2 002 of which for severely injured (overtriage 55%). Overall undertriage was 10%. Mechanism of injury was TTA criterion in 1 508 cases (34%), of which only 392 were severely injured (overtriage 74%). Paramedic-manned prehospital services provided 66% overtriage and 17% undertriage, anaesthetist-manned services 35% overtriage and 2% undertriage. Falls, high age and admittance by paramedics were significantly associated with undertriage. A Triage-Revised Trauma Score (RTS) < 12 in the emergency department reduced the risk for undertriage compared to RTS = 12 (normal value). Field RTS was documented by anaesthetists in 64% of the patients compared to 33% among paramedics.Patients subject to undertriage had an ISS-adjusted Odds Ratio for 30-day mortality of 2.34 (95% CI 1.6–3.4, p < 0.001) compared to those correctly triaged to TTA.Triage precision had not improved after TTA guideline introduction. Anaesthetists perform precise trauma triage, whereas paramedics have potential for improvement. Skewed mission profiles makes comparison of differences in triage precision difficult, but criteria or the use of them may contribute. Massive undertriage among paramedics is of grave concern as patients exposed to undertriage had increased ris
Adoption of the 2006 Field Triage Decision Scheme for Injured Patients  [cached]
Sasser, Scott,Ossmann, Eric,Wald, Marlena,Lerner, E. Brooke
Western Journal of Emergency Medicine : Integrating Emergency Care with Population Health , 2011,
Abstract: Background: When emergency medical services (EMS) providers respond to the scene of an injury, they must decide where to transport the injured patients for further evaluation and treatment. This is done through a process known as “field triage”, whereby a patient’s injuries are matched to the most appropriate hospital. In 2005-2006 the National Expert Panel on Field Triage, convened by the Centers for Disease Control and Prevention and the National Highway Traffic Safety Administration, revised the 1999 American College of Surgeons Committee on Trauma Field Triage Decision Scheme. This revision, the 2006 Field Triage Decision Scheme, was published in 2006.Methods: State Public Health departments’ and EMS’ external websites were evaluated to ascertain the current status of implementation of the 2006 Field Triage Decision Scheme.Results: Information regarding field triage was located for 41 states. In nine states no information regarding field triage was available on their websites. Of the 41 states where information was located, seven were classified as “full adopters” of the 2006 Field Triage Decision Scheme; nine were considered “partial adopters”; 17 states were found to be using a full version or modification of the 1999 Field Triage Decision Scheme; and eight states were considered to be using a different protocol or scheme for field triage.Conclusion: Many states have adopted the 2006 Decision Scheme (full or partial). Further investigation is needed to determine the reasons why some states do not adopt the guidelines. [West J Emerg Med. 2011;12(3):275-283.]
RE: Field triage in trauma – do the data really justify the conclusions?
Marius Rehn, Torsten Eken, Andreas Krüger, Petter Steen, Nils Skaga, Hans Lossius
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 2009, DOI: 10.1186/1757-7241-17-25
Abstract: Thank you for your interest in our article; "Precision of field triage in patients brought to a trauma centre after introducing trauma team activation guidelines" [1], which gives us the opportunity for expounding some conclusions that could be open for misinterpretation.We agree with Dr. Sandberg that paramedics and anaesthetists conduct missions with very skewed profiles. We suspect that this mission-selection bias applies to all anaesthetists-manned services, regardless of transport method. The differences in task profile may be beyond the scope of statistical adjustment contributing to a contra-comparison line of argumentation. This is a problem in most epidemiologic studies. What is found is an association between factors; a good starting point for prospective intervention studies. In this case possibly testing changes in one or more of the links in the triage chain. Hopefully, readers agree with us in our statement "skewed mission profiles make comparison of differences in triage precision difficult".Dr. Sandberg correctly states that the formal decision to activate the trauma team is not made in-field, but in-hospital by the ED nurse. We still used the term field triage, in an attempt to differentiate the study from those that describe traditional ED triage algorithms. Regardless of where the formal decision is made, triage decisions made before the patient arrives in the ED are based upon information gathered in-field and the triage decision have in-field consequences.We agree with Dr. Sandberg that it is difficult to isolate the aetiology of over- and undertriage. Over- and undertriage rates reflect a chain of events. We did not attempt to identify the link in this chain with most potential for improvement. This is reflected in our recommended improvement initiatives that address every major link in the trauma triage chain: improved on-scene patient evaluation, better routines in communicating patient data from EMS units to the nurse coordinator in the ED,
Sources of non-compliance with clinical practice guidelines in trauma triage: a decision science study
Mohan Deepika,Rosengart Matthew R,Farris Coreen,Fischhoff Baruch
Implementation Science , 2012, DOI: 10.1186/1748-5908-7-103
Abstract: Background United States trauma system guidelines specify when to triage patients to specialty centers. Nonetheless, many eligible patients are not transferred as per guidelines. One possible reason is emergency physician decision-making. The objective of the study was to characterize sensory and decisional determinants of emergency physician trauma triage decision-making. Methods We conducted a decision science study using a signal detection theory-informed approach to analyze physician responses to a web-based survey of 30 clinical vignettes of trauma cases. We recruited a national convenience sample of emergency medicine physicians who worked at hospitals without level I/II trauma center certification. Using trauma triage guidelines as our reference standard, we estimated physicians’ perceptual sensitivity (ability to discriminate between patients who did and did not meet guidelines for transfer) and decisional threshold (tolerance for false positive or false negative decisions). Results We recruited 280 physicians: 210 logged in to the website (response rate 74%) and 168 (80%) completed the survey. The regression coefficient on American College of Surgeons – Committee on Trauma (ACS-COT) guidelines for transfer (perceptual sensitivity) was 0.77 (p<0.01, 95% CI 0.68 – 0.87) indicating that the probability of transfer weakly increased as the ACS-COT guidelines would recommend transfer. The intercept (decision threshold) was 1.45 (p<0.01, 95% CI 1.27 – 1.63), indicating that participants had a conservative threshold for transfer, erring on the side of not transferring patients. There was significant between-physician variability in perceptual sensitivity and decisional thresholds. No physician demographic characteristics correlated with perceptual sensitivity, but men and physicians working at non-trauma centers without a trauma-center affiliation had higher decisional thresholds. Conclusions On a case vignette-based questionnaire, both sensory and decisional elements in emergency physicians’ cognitive processes contributed to the under-triage of trauma patients.
Can a course modify the quality of triage in ER?
Nicola Parenti,Andrea Zardi,Roberta Manfredi,Diego Sangiorgi
Emergency Care Journal , 2009, DOI: 10.4081/ecj.2009.3.16
Abstract: All international Societies of Emergency Medicine have developed and promote courses on triage methods and guidelines, given their fundamental role in improving initial evaluation of patients in Emergency Department settings. However, as far as we know, few studies analyse the effect of triage courses on the allocation of priority codes. Since 2001, the Intra-Hospital Triage Guidelines have been implemented in Imola, where they are disseminated and illustrated in two-day courses. In this study, we analysed the effect of a two-day triage course on the quality of priority code allocation to patients evaluated at our ER. The Triage Guidelines course appears to improve two of the quality indicators analysed: observance of documentation standards and compliance with Triage Guidelines.
Field triage in trauma – do the data really justify the conclusions?
M?rten Sandberg
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 2009, DOI: 10.1186/1757-7241-17-24
Abstract: I read with interest the recently published paper by Rehn and coworkers about field triage in trauma [1]. The topic is interesting and improved quality of the work and information flow from the scene-of-the-accident to the emergency department can save lives. However, some of the conclusions drawn by the authors can be challenged.First, the authors compared undertriage and overtriage of the traumatized patients and found 2% and 17% undertriage and 35% and 66% overtriage for anaesthetists and paramedics, respectively. They conclude that "anaesthetists perform precise trauma triage, whereas paramedics have potential for improvement" although the authors themselves state that "skewed mission profiles make comparison of differences in triage precision difficult" [1]. The ground ambulances staffed with paramedics are used locally while the helicopters staffed with anaesthetists are a regional resource. The helicopters are dispatched when major trauma is suspected while ground ambulances are dispatched to any sort of incidence. In Oslo, an anaesthetist-staffed ground ambulance operates alongside ordinary ambulances and the patients transported with this service are a subgroup of the patients transported by anaesthetists. If the triage precision between paramedics and anaesthetists is to be compared, data from ground ambulances in Oslo (with or without anaesthetist) should be used and the data from patients brought to the hospital by helicopter or other services should be excluded. Such a comparison would give a good indication about the real difference in triage precision between the two groups of prehospital care providers. Unfortunately, that subgroup analysis has not been performed. That is sad, because the numbers that is provided in the article is of little interest since the services that are compared are too different.Second, in the system described, the paramedics or the anaesthetists examine the patient and investigate the mechanism of the accident before reporti
Clinical Applications of Heart Rate Variability in the Triage and Assessment of Traumatically Injured Patients  [PDF]
Mark L. Ryan,Chad M. Thorson,Christian A. Otero,Thai Vu,Kenneth G. Proctor
Anesthesiology Research and Practice , 2011, DOI: 10.1155/2011/416590
Abstract: Heart rate variability (HRV) is a method of physiologic assessment which uses fluctuations in the RR intervals to evaluate modulation of the heart rate by the autonomic nervous system (ANS). Decreased variability has been studied as a marker of increased pathology and a predictor of morbidity and mortality in multiple medical disciplines. HRV is potentially useful in trauma as a tool for prehospital triage, initial patient assessment, and continuous monitoring of critically injured patients. However, several technical limitations and a lack of standardized values have inhibited its clinical implementation in trauma. The purpose of this paper is to describe the three analytical methods (time domain, frequency domain, and entropy) and specific clinical populations that have been evaluated in trauma patients and to identify key issues regarding HRV that must be explored if it is to be widely adopted for the assessment of trauma patients. 1. Introduction Heart rate variability (HRV) is defined by the fluctuating time between normal sinus beats (RR intervals) [1] and indicates modulation of the heart rate by the autonomic nervous system (ANS) [2]. Afferent inputs from sensory and baroreceptors within the heart and great vessels, respiratory changes, vasomotor regulation, the thermoregulatory system, and alterations in endocrine function determine ANS influence on the heart [1]. In 1997, a consensus panel issued a set of guidelines regarding the measurement and interpretation of HRV [3]. Changes in HRV are now an accepted method of assessing autonomic dysfunction in patients in several pathologic states, with and without structural heart disease. In the 14 years since that report, there have been major technological advances and hundreds of publications in various patient populations, but there has been no comprehensive review specifically directed at trauma. This paper attempts to fill that gap. It is now well established that absence of HRV is an early predictor of brain death [4, 5] and that low HRV correlates with increased mortality and morbidity after trauma [6–13]. Abnormal HRV is associated with increased intracranial pressure and decreased cerebral perfusion pressure [5, 9, 10, 14, 15]. Recently, it was suggested that HRV is a “new vital sign” and could be used as a trauma triage tool [7, 8, 11, 16, 17]. However, the mechanisms responsible for these associations are not clearly established, and no specific therapy is currently available to treat patients with abnormal HRV. Furthermore, there is no consensus on exactly how to measure HRV. Typically,
Benefit of a Tiered-Trauma Activation System for Triaging Dead-on-Arrival Patients
Omar K. Danner,Kenneth L. Wilson,Sheryl Heron,Yusuf Ahmed
Western Journal of Emergency Medicine : Integrating Emergency Care with Population Health , 2012,
Abstract: Introduction: Although national guidelines have been published for the management of critically injured traumatic cardiopulmonary arrest (TCPA) patients, many hospital systems have not implemented in-hospital triage guidelines. The objective of this study was to determine if hospital resources could be preserved by implementation of an in-hospital tiered triage system for patients in TCPA with prolonged resuscitation who would likely be declared dead on arrival (DOA).Method: We conducted a retrospective analysis of 4,618 severely injured patients, admitted to our Level I trauma center from December 2000 to December 2008 for evaluation. All of the identified patients had sustained life-threatening penetrating and blunt injuries with pre-hospital TCPA. Patients who received cardiopulmonary resuscitation (CPR) for 10 minutes were assessed for survival rate, neurologic outcome, and charge-for-activation (COA) for our hospital trauma system.Results: We evaluated 4,618 charts, which consisted of patients seen by the MSM trauma service from December 2001 through December 2008. We identified 140 patients with severe, life-threatening traumatic injuries,who sustained pre-hospitalTCPArequiring prolongedCPRin the field andwere brought to the emergency department (ED).Group I was comprised of 108 patients sustaining TCPA (53 blunt, 55penetrating), who died after receiving, 45 minutes of ACLS after arrival. Group II, which consisted of 32 patients (25 blunt, 7 penetrating), had resuscitative efforts in the EDlasting.45 minutes, but all ultimately died prior to discharge. Estimated hospital charge-for-activation for Group I was approximately $540,000, based on standard charges of $5000 per full-scale trauma system activation (TSA).Conclusion: Full-scale trauma system activation for patients sustaining greater than 10 minutes of prehospital TCPA in the field is futile and economically depleting. [West J Emerg Med. 2012;13(3):225–229.]
Effectiveness of a physiotherapy-initiated telephone triage of orthopedic waitlist patients  [cached]
Morris J,Grimmer-Somers K,Kumar S,Murphy K
Patient Related Outcome Measures , 2011,
Abstract: Joanne Morris1, Karen Grimmer-Somers2, Saravana Kumar2, Karen Murphy3, Lisa Gilmore1, Bryan Ashman1, Chandima Perera1, Kathryn Vine1, Corinne Coulter11The Canberra Hospital, ACT Government Health Directorate, Canberra, ACT, Australia; 2International Centre for Allied Health Evidence, University of South Australia, Adelaide, SA, Australia; 3ACT Government Health Directorate, Canberra, ACT, AustraliaBackground: There is generally a lengthy wait on outpatient orthopedic waiting lists in Australian public hospitals to consult a specialist. Patients then wait again for surgery, if required. Patients with higher need are rarely prioritized, and there is the potential for increased morbidity for those who wait. There is generally no option of alternative care whilst waiting. This paper compares historical orthopedic outpatient clinic data with the outcomes of a physiotherapy-led initiative in one large Australian tertiary hospital.Methods: Two physiotherapists working within-scope conducted a telephone triage (October to December 2010) using a standard instrument for all new patients on the orthopedic waiting list. They were offered primary treatment options of retaining their appointment, being discharged, referral to a new model of assessment (multidisciplinary specialist clinic), or referral to physiotherapy. The outcomes were costs of the service, waiting time, and percentage of patients taking up management options. This was compared with a historical sample of new patients on the orthopedic waiting list (January to March 2009), whose treatment consumption was tracked longitudinally.Results: The telephone triage resulted in 16.4% patients being discharged directly (compared with 0.1% comparison sample). For approximately AU$17.00 per patient, the telephone triage process released 21 booked appointments on the outpatient clinic waiting list. Moreover, approximately 26% patients were referred directly to physiotherapy, which was not a primary management option in the comparison sample. The waiting time for an appointment, for those patients who remained on the waiting list, was significantly shorter for the telephone triage sample than the comparison sample. There were significantly higher rates of failure to attend appointments, and significantly lower rates of discharge, in the comparison sample, than the telephone triage sample.Conclusion: A physiotherapist-led intervention offering alternative management options whilst patients waited for an orthopedic outpatient clinic consultation appears to be cost-effective, and patient-centered.Keywords: extended s
Implementing a structured triage system at a community health centre using Kaizen
AA Isaacs, DA Hellenberg
South African Family Practice , 2009,
Abstract: Background: More than 100 unbooked patients present daily to the Mitchell’s Plain Community Health Centre (MPCHC), and are triaged by a doctor, with the assistance of a staff nurse. The quality of the triage assessments has been found to be variable, with patients often being deferred without their vital signs being recorded. This leads to frustration, and a resultant increased workload for doctors; management is concerned with the medicolegal risk of deferring patients who have not been triaged in accordance with the guidelines; and patients are unhappy with the quality of service they receive. Aim: We set out to standardise the triage process and to manage unbooked patients presenting to the community health centre (CHC) in a manner that is medico-legally safe, cost efficient and patient friendly, using the Kaizen method. Methods: The principles of Kaizen were used to observe and identify inefficiencies in the existing triage process at the MPCHC. Findings were analysed and interventions introduced to improve outcomes. The new processes were, in turn, validated and standardised. Results: The majority of patients presenting to Triage were those needing reissuing of prescriptions for their chronic medication, and this prevented practitioners from timeously attending to other patients waiting to be seen. Reorganising of the process was needed; it was necessary to separate the patients needing triage from those requiring only prescriptions to be reissued. After the intervention, triage was performed by a staff nurse only, using the Cape Triage Score (CTS) method. Subsequent to the implementation of interventions, no patients have been deferred, and all patients are now assessed according to a standardised protocol. The reasons for patients requiring reissuing of prescriptions were numerous, and implementing countermeasures to the main causes thereof decreased the number of reissues by 50%. Conclusion: The Kaizen method can be used to improve the triage process for unbooked patients at the MPCHC, thereby improving the quality of services delivered to these patients. As the needs of the various CHCs differ quite widely across the service platform, the model needs to be adapted to suit local conditions.
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