The Triage of Injured Patients: Mechanism of Injury, Regardless of Injury Severity, Determines Hospital Destination

The target rate for trauma undertriage is <5 per cent, but rates are as high as 30 to 40 per cent in many trauma systems. Wehypothesized that high undertriage rates were duetothe tendencyto undertriage injured elderly patients and a growing elderly population. We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database over a 5-year period. All hospital admissions and emergency department visits associated with injury were longitudinally linked. The primary outcome was triage pattern. Triage patterns were stratified across three dimensions: age, mechanism of injury, and access to care. A total of 60,182 severely injured patients were included in the analysis. Fall-related injuries were frequently undertriaged compared with injuries from motor vehicle collisions (MVCs) and penetrating trauma (52% vs 12% and 10%, respectively). This pattern was true for all age groups. Conversely, MVCs and penetrating traumas were associated with high rates of overtriage (>70% for both). In conclusion, in contrast to our hypothesis, we found that triage is largely determined by mechanism of injury regardless of injury severity. High rates of undertriage are largely due to the undertriage of fall-related injuries, which occurs in both younger and older adults. Patients injured after MVCs and penetrating trauma victims are brought to trauma centers regardless of injury severity, resulting in high rates of overtriage. These findings suggest an opportunity to improve trauma system performance.

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Initial Approach to the Management of Multisystem Trauma

Mayo Clinic Critical and Neurocritical Care Board Review ◽

10.1093/med/9780190862923.003.0062 ◽

2019 ◽

pp. 397-401

Author(s):

David S. Morris

Keyword(s):

Trauma Center ◽

Injury Severity ◽

Hospital Admissions ◽

The United States ◽

Emergency Department Visits ◽

Severely Injured ◽

Level Ii ◽

Level I ◽

Nonfatal Injuries ◽

Injured Patients

Nearly 200,000 people die of injury-related causes in the United States each year, and injury is the leading cause of death for all patients aged 1 to 44 years. Approximately 30 million people sustain nonfatal injuries each year, which results in about 29 million emergency department visits and 3 million hospital admissions. Management of severely injured patients, typically defined as having an Injury Severity Score greater than 15 is best managed in a level I or level II trauma center. Any physician who provides care for critically ill patients should have a basic familiarity with the fundamentals of trauma care.

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Impact of COVID-19 pandemic on injury prevalence and pattern in the Washington, DC Metropolitan Region: a multicenter study by the American College of Surgeons Committee on Trauma, Washington, DC

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000659 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000659

Author(s):

Marc Chodos ◽

Babak Sarani ◽

Andrew Sparks ◽

Brandon Bruns ◽

Shailvi Gupta ◽

...

Keyword(s):

Multicenter Study ◽

Trauma Center ◽

Injury Severity ◽

Motor Vehicle ◽

Penetrating Trauma ◽

Motor Vehicle Crash ◽

Metropolitan Region ◽

Washington Dc ◽

Mechanism Of Injury ◽

The Impact

BackgroundThe COVID-19 pandemic has had far-reaching effects on healthcare systems and society with resultant impact on trauma systems worldwide. This study evaluates the impact the pandemic has had in the Washington, DC Metropolitan Region as compared with similar months in 2019.DesignA retrospective multicenter study of all adult trauma centers in the Washington, DC region was conducted using trauma registry data between January 1, 2019 and May 31, 2020. March 1, 2020 through May 31, 2020 was defined as COVID-19, and January 1, 2019 through February 28, 2020 was defined as pre-COVID-19. Variables examined include number of trauma contacts, trauma admissions, mechanism of injury, Injury Severity Score, trauma center location (urban vs. suburban), and patient demographics.ResultsThere was a 22.4% decrease in the overall incidence of trauma during COVID-19 compared with a 3.4% increase in trauma during pre-COVID-19. Blunt mechanism of injury decreased significantly during COVID-19 (77.4% vs. 84.9%, p<0.001). There was no change in the specific mechanisms of fall from standing, blunt assault, and motor vehicle crash. The proportion of trauma evaluations for penetrating trauma increased significantly during COVID-19 (22.6% vs. 15.1%, p<0.001). Firearm-related and stabbing injury mechanisms both increased significantly during COVID-19 (11.8% vs. 6.8%, p<0.001; 9.2%, 6.9%, p=0.002, respectively).Conclusions and relevanceThe overall incidence of trauma has decreased since the arrival of COVID-19. However, there has been a significant rise in penetrating trauma. Preparation for future pandemic response should include planning for an increase in trauma center resource utilization from penetrating trauma.Level of evidenceEpidemiological, level III.

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Trauma Team Activation at a Level I Trauma Center in Southern California: Time of Day Matters

The American Surgeon ◽

10.1177/000313481908501014 ◽

2019 ◽

Vol 85 (10) ◽

pp. 1142-1145

Author(s):

Morgan Schellenberg ◽

Kenji Inaba ◽

Bryan E. Love ◽

Zachary Warriner ◽

Matthew J. Forestiere ◽

...

Keyword(s):

Injury Severity ◽

Motor Vehicle ◽

Penetrating Trauma ◽

Trauma Team ◽

Time Of Day ◽

Operative Intervention ◽

Trauma Patients ◽

Mechanism Of Injury ◽

Trauma Team Activation ◽

Level I

The ACS Committee on Trauma specifies prehospital criteria that trigger trauma team activation (TTA). The study aims to define the relationship between TTA and time of day, mechanism of injury, and need for operative intervention. All trauma patients presenting to LAC1USC (January 2008–July 2018) after triggering TTA were screened. Patients were excluded if time of ED arrival was undocumented. Demographics, injury data, and outcomes were analyzed. After exclusions (<1%), 54,826 patients were enrolled. The median age was 35 [IQR 23–53]. The median Injury Severity Score was 4 [1–10]. The most common mechanisms of injury were falls (n = 14,166; 31%), auto versus pedestrian collisions (n = 11,921; 26%), and motor vehicle collisions (n = 11,024; 24%). Penetrating trauma comprised 16 per cent (n = 8,686). The busiest hour for TTAs was 19:00 to 20:00, although penetrating trauma was most common between 23:00 and 01:00. Emergent surgical intervention in absolute numbers was most frequent between 20:00 and 01:00. As a proportion of the number of TTAs per hour, emergent operative intervention was most frequent between 23:00 and 06:00. In conclusion, the volume of TTAs and the triggering mechanism of injury vary significantly by time of day. The need for operative intervention is highest overnight. This information can be used to help increase hospital preparedness and allocate resources accordingly.

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Trauma in pregnancy: A review of the Pennsylvania Trauma Systems Foundation database

Trauma ◽

10.1177/1460408617703677 ◽

2017 ◽

Vol 20 (1) ◽

pp. 30-37 ◽

Cited By ~ 3

Author(s):

Meike Schuster ◽

Natasha Becker ◽

Amanda Young ◽

Michael J Paglia ◽

A Dhanya Mackeen

Keyword(s):

Blunt Trauma ◽

Motor Vehicle ◽

Penetrating Trauma ◽

Blunt Injury ◽

Trauma Patients ◽

Severely Injured ◽

Trauma Systems ◽

Severely Injured Patients ◽

Vaginal Deliveries ◽

Injured Patients

Objective The goal of this study is to determine if injury severity score (ISS) of ≥9 and systolic blood pressure (SBP) predict poor maternal/pregnancy outcomes in blunt and penetrating trauma, respectively. Methods The Pennsylvania Trauma Systems Foundation database was used to identify pregnant trauma patients. Blunt trauma patients were analyzed with regard to ISS, while penetrating trauma patients were analyzed to determine whether SBP < 90 mmHg was predictive of poor maternal outcome. Results Patients with severe blunt injury (ISS ≥ 9) due to motor vehicle accident were less likely to wear seatbelts (51% vs. 63%, p = 0.005), and delivery was required in 17% of these patients as compared to 6% of the less severely injured, and only 6% of those were vaginal deliveries. Severely injured patients were discharged home 68% of the time and 6% died compared to less severely injured patients of which 83% were discharged home and <1% died; all other patients required discharge to a rehabilitation facility. Patients with penetrating trauma and SBP < 90 mmHg on arrival were more likely to require delivery (35% vs. 5%, p < 0.001) and were 14 times more likely to die (58% vs. 4%, p < 0.001) when compared to the normotensive group. Conclusion ISS ≥ 9 and SBP < 90 mmHg are predictors for poor outcomes after trauma during pregnancy. Severely injured blunt trauma patients often require surgery and delivery. Patients who present with SBP < 90 after penetrating trauma are more likely to deliver and are 14 times more likely to die.

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Despite Trauma Center Closures, Trauma System Regionalization Reduces Mortality and Time to Definitive Care in Severely Injured Patients

The American Surgeon ◽

10.1177/000313481708300623 ◽

2017 ◽

Vol 83 (6) ◽

pp. 591-597 ◽

Cited By ~ 4

Author(s):

Jack C. He ◽

David Schechtman ◽

Debra L. Allen ◽

Jillian J. Cremona ◽

Jeffrey A. Claridge

Keyword(s):

Median Time ◽

Injury Severity ◽

Trauma System ◽

Relative Reduction ◽

Severely Injured ◽

Severely Injured Patients ◽

Trauma Outcomes ◽

Hospital Systems ◽

Injured Patients ◽

Patient Subgroups

The Northern Ohio Trauma System (NOTS), consisting of multiple hospital systems, was established in 2010 to improve trauma outcomes. This study assessed its impact on mortality and time to definitive care, focusing especially on the severely injured patients. NOTS trauma registry was queried for all trauma activations from 2008 to 2013. The years between 2008–2009 and 2011–2013 were designated as pre- and post-NOTS, respectively. Data from 2010 was excluded as a transitional year. Two trauma centers (TCs) closed in 2010. Predetermined patient subgroups were analyzed. A total of 27,843 patients were examined. Mean age was 46 and 64 per cent were male. Median Injury Severity Score (ISS) was five, and 87 per cent sustained blunt injuries. Of these, 10,641 patients were pre-NOTS and 17,202 were post-NOTS. Comparing the two groups, mortality decreased from 5 to 4 per cent post-NOTS (P < 0.001); median time to definitive care increased by 12 minutes post-NOTS. Multivariate logistic regression showed that NOTS implementation was an independent predictor for survival (P = 0.008), whereas time to definitive care was not. Subgroup analyses demonstrated mortality reductions post-NOTS for all subgroups except patients with penetrating injuries, where mortality remained the same despite an increase in ISS. Patients with ISS ≥15 had a 23 per cent relative reduction in mortality, and their median time to definitive care decreased by 12 minutes. Implementation of a collaborative, regional trauma system was associated with mortality reduction and shortened time to definitive care in the severely injured patients. These findings highlight the importance of collaboration in the future development of regional trauma systems.

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A Decade Evaluation of a State Trauma System: Has Access to Inpatient Trauma Care at Designated Trauma Centers Improved?

The American Surgeon ◽

10.1177/000313481708300736 ◽

2017 ◽

Vol 83 (7) ◽

pp. 769-777 ◽

Cited By ~ 2

Author(s):

◽

Dennis W. Ashley ◽

Etienne E. Pracht ◽

Regina S. Medeiros ◽

Elizabeth V. Atkins ◽

...

Keyword(s):

Trauma Care ◽

Injury Severity ◽

Trauma System ◽

Age Groups ◽

Trauma Centers ◽

Access To Treatment ◽

Score Method ◽

Severity Levels ◽

Injured Patients ◽

Discharge Database

Recently, the trauma center component of the Georgia trauma system was evaluated demonstrating a 10 per cent probability of increased survival for severely injured patients treated at designated trauma centers (DTCs) versus nontrauma centers. The purpose of this study was to determine the effectiveness of a state trauma system to provide access to inpatient trauma care at DTCs for its residents. We reviewed 371,786 patients from the state's discharge database and identified 255,657 treated at either a DTC or a nontrauma center between 2003 and 2012. Injury severity was assigned using the International Classification Injury Severity Score method. Injury was categorized as mild, moderate, or severe. Patients were also categorized by age and injury type. Access improved over time in all severity levels, age groups, and injury types. Although elderly had the largest improvement in access, still only 70 per cent were treated at a DTC. During the study period, increases were noted for all age groups, injury severity levels, and types of injury. A closer examination of the injured elderly population is needed to determine the cause of lower utilization by this age group. Overall, the state's trauma system continues to mature by providing patients with increased access to treatment at DTCs.

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Major trauma patients are not who you might think they are: a linked data study

Australasian Journal of Paramedicine ◽

10.33151/ajp.16.704 ◽

2019 ◽

Vol 16 ◽

Author(s):

Elizabeth Brown ◽

Hideo Tohira ◽

Paul Bailey ◽

Daniel Fatovich ◽

Judith Finn

Keyword(s):

Major Trauma ◽

Injury Severity ◽

Motor Vehicle ◽

High Energy ◽

Categorical Variables ◽

Common Mechanism ◽

Trauma Patients ◽

Continuous Variables ◽

Mechanism Of Injury ◽

Young Males

IntroductionMajor trauma patients are often perceived as being young males injured by high energy transfer mechanisms. The aim of this study was to describe the demographics of major trauma patients who were transported to hospital by ambulance.MethodsThis is a retrospective cohort study of adult major trauma (injury severity score >15) patients transported to hospital by St John Western Australia emergency ambulance in metropolitan Perth, between 1 January 2013 and 31 December 2016. To describe the cohort, median and interquartile range (IQR) were used for continuous variables and counts and percentages for categorical variables. Differences between mechanism of injury groups were assessed using the Kruskal-Wallis test. Trauma deaths were defined as early (declared deceased within 24 hours) or late (declared deceased within 30 days). ResultsA total of 1625 patients were included. The median age was 51 years (IQR 30-75) and 1158 (71%) were male. Falls from standing were the most common mechanism of injury (n=460, 28%) followed by motor vehicle crashes (n=259, 16%). Falls from standing were responsible for the majority of early (n=45/175, 26%) and late deaths (n=69/158, 44%). A large number of early deaths also resulted from motorbike crashes (n=32/175, 18%) with a median age of 34 years (IQR 21-46, p<0.001). ConclusionMajor trauma is not only a disease of the young. More than half of the cohort was more than 51 years of age and the most common cause was a fall from standing. Pre-hospital care must evolve to address the needs of a changing trauma patient demographic.

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Sports-related Injuries Among Adolescents: When Do They Occur, and How Can We Prevent Them?

Pediatrics in Review ◽

10.1542/pir.16.5.184 ◽

1995 ◽

Vol 16 (5) ◽

pp. 184-187

Author(s):

Ellen S. Rome

Keyword(s):

Emergency Department ◽

Hospital Admissions ◽

Motor Vehicle ◽

Sports Injuries ◽

Sports Injury ◽

Emergency Department Visits ◽

Mortality Data ◽

Seek Health Care ◽

Vehicle Accidents ◽

School Based Health Centers

Sports injuries, as causes of frequent morbidity but infrequent mortality among teens, receive less attention than do more dramatic motor vehicle accidents, homicides, and suicides. Injury to adolescents caused by both organized and informal athletics occurs commonly, yet the precise frequency, severity, and predisposing risk factors of such injuries have not been defined well. Unlike mortality data, which can be obtained readily from death certificates or through the National Center for Health Statistics, nonfatal sports injuries often go unrecognized among injury statistics because adolescents frequently do not seek health care or tell a coach or family member about the injury. Moreover, data on injuries can exist in a variety of places outside of physicians' offices, including emergency department or hospital records, school-based health centers, or trainers' logs. Different studies also have defined injury differently, with little standardization between studies and variances in sources used for data collection. Hospital or emergency department data may differ in the degree of severity of the injury from office-based data or data on those injuries treated solely by a coach or athletic trainer. Despite these difficulties, a plethora of data exists on the topic of sports injuries and their prevention. Common Causes of Sports Injury In a Massachusetts study by Gallagher and colleagues in the 1980s, sports injuries were found to be the most common cause of injury and, overall, the second leading cause of emergency department visits and hospital admissions in the 13- to 19- year-old age group.

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The cost and compensability of trauma patients

Australian Health Review ◽

10.1071/ah090084 ◽

2009 ◽

Vol 33 (1) ◽

pp. 84 ◽

Cited By ~ 10

Author(s):

Kate Curtis ◽

Cara Dickson ◽

Deborah Black ◽

Thomas Nau

Keyword(s):

Health Insurance ◽

Injury Severity ◽

Motor Vehicle ◽

Direct Costs ◽

Trauma Centre ◽

Third Party ◽

Workers Compensation ◽

Trauma Patients ◽

Mechanism Of Injury ◽

Insurance Cover

Injury in Australia was responsible for 400 000 hospitalisations in 2002. This study aimed to examine the direct costs of trauma patients in a Level 1 trauma centre and determine the compensability of those patients. Data on all admitted patients (206) filling trauma criteria were collected prospectively over a 3-month period (November 2006 to January 2007). A 10-question survey was completed on each patient to record mechanism of injury, third party private health insurance or workers compensation, and direct costs were also obtained. 30% of trauma admissions had an injury severity score (ISS)> 15 (n = 62; median ISS =9; range, 1?56). Median length of stay was 3 days (range, 1?126). Almost half (47%) of the patients were involved in road trauma, and 29% in falls. More than half (53.4%) were eligible for compensation (21.8% of patients had full hospital health insurance cover, 21.4% third party insurance and 9.2% workers compensation). The mechanism of injury with the highest median cost per patient was assault, followed by pedal cyclists, pedestrians then motor vehicle collisions.

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Association of mechanism of injury with overtriage of injured youth patients as trauma alerts

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2019-000300 ◽

2019 ◽

Vol 4 (1) ◽

pp. e000300 ◽

Cited By ~ 1

Author(s):

Jessica Lynn Ryan ◽

Etienne Pracht ◽

Barbara Langland-Orban ◽

Marie Crandall

Keyword(s):

Injury Severity ◽

Motor Vehicle ◽

Pediatric Trauma ◽

International Classification Of Diseases ◽

Mechanism Of Injury ◽

Level Of Evidence ◽

Severe Injuries ◽

Firearm Injuries ◽

Field Triage ◽

Classification Of Diseases

BackgroundTrauma alert criteria include physiologic and anatomic criteria, although field triage based on injury mechanism is common. This analysis evaluates injury mechanisms associated with pediatric trauma alert overtriage and estimates the effect of overtriage on patient care costs.MethodsFlorida’s Agency for Health Care Administration inpatient and financial data for 2012–2014 were used. The study population included mildly and moderately injured patients aged 5–15 years brought to a trauma center and had an International Classification of Diseases-based Injury Severity Score survival probability ≥0.90, a recorded mechanism of injury, no surgery, a hospital stay less than 24 hours, and discharged to home. Overtriaged patients were those who had a trauma alert. Logistic regression was used to analyze the odds of overtriage relative to mechanism of injury and multivariable linear regression was used to analyze cost of overtriage.ResultsTwenty percent of patients were overtriaged; yet these patients accounted for 37.2% of total costs. The mechanisms of injury related to firearms (OR 11.99) and motor vehicle traffic (2.25) were positively associated with overtriage as a trauma alert. Inpatient costs were 131.8% higher for overtriaged patients.DiscussionFirearm injuries and motor vehicle injuries can be associated with severe injuries. However, in this sample, a proportion of patients with this mechanism suffered minimal injuries. It is possible that further identifying relevant anatomic and physiologic criteria in youth may help decrease overtriage without compromising outcomes.Level of evidenceEconomic, level IV.

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