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Research
JAMA Surgery | Original Investigation
Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients Frank J. Voskens, MD; Eveline A. J. van Rein, BSc; Rogier van der Sluijs, BSc; Roderick M. Houwert, MD, PhD; Robert Anton Lichtveld, MD, PhD; Egbert J. Verleisdonk, MD, PhD; Michiel Segers, MD; Ger van Olden, MD, PhD; Marcel Dijkgraaf, PhD; Luke P. H. Leenen, MD, PhD; Mark van Heijl, MD, PhD
Invited Commentary IMPORTANCE A major component of trauma care is adequate prehospital triage. To optimize
the prehospital triage system, it is essential to gain insight in the quality of prehospital triage of the entire trauma system. OBJECTIVE To prospectively evaluate the quality of the field triage system to identify severely injured adult trauma patients. DESIGN, SETTING, AND PARTICIPANTS Prehospital and hospital data of all adult trauma patients during 2012 to 2014 transported with the highest priority by emergency medical services professionals to 10 hospitals in Central Netherlands were prospectively collected. Prehospital data collected by the emergency medical services professionals were matched to hospital data collected in the trauma registry. An Injury Severity Score of 16 or more was used to determine severe injury. MAIN OUTCOMES AND MEASURES The quality and diagnostic accuracy of the field triage protocol and compliance of emergency medical services professionals to the protocol. RESULTS A total of 4950 trauma patients were evaluated of which 436 (8.8%) patients were severely injured. The undertriage rate based on actual destination facility was 21.6% (95% CI, 18.0-25.7) with an overtriage rate of 30.6% (95% CI, 29.3-32.0). Analysis of the protocol itself, regardless of destination facility, resulted in an undertriage of 63.8% (95% CI, 59.2-68.1) and overtriage of 7.4% (95% CI, 6.7-8.2). The compliance to the field triage trauma protocol was 73% for patients with a level 1 indication. CONCLUSIONS AND RELEVANCE More than 20% of the patients with severe injuries were not transported to a level I trauma center. These patients are at risk for preventable morbidity and mortality. This finding indicates the need for improvement of the prehospital triage protocol. JAMA Surg. doi:10.1001/jamasurg.2017.4472 Published online November 1, 2017.
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dequate prehospital trauma triage of injured patients is imperative for optimal trauma care. In an inclusive trauma system, it is essential to transport patients with severe injuries to a level I trauma center and patients without severe injuries to lower-level hospitals. 1,2 Previous studies have clearly shown lower mortality rates in patients with severe injuries treated at a level I trauma center compared with patients treated at a lower-level hospitals.1-6 Management of care of the injured trauma patient on the scene of injury remains challenging, and situations can be chaotic. After a rapid trauma assessment of clinical and physiological parameters, emergency medical services (EMS) professionals must identify patients at risk for severe injury and select the jamasurgery.com
Author Affiliations: Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands (Voskens, van Rein, van der Sluijs, Houwert, Leenen, van Heijl); Utrecht Trauma Center, Utrecht, the Netherlands (Houwert); Regional Ambulance Facility Utrecht, Regionale Ambulance Voorziening Utrecht, Utrecht, the Netherlands (Lichtveld); Department of Surgery, Diakonessenhuis Utrecht/Zeist/ Doorn, Utrecht, the Netherlands (Verleisdonk); Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands (Segers); Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands (van Olden); Clinical Research Unit, Academic Medical Center, Amsterdam, the Netherlands (Dijkgraaf). Corresponding Author: Frank J. Voskens, MD, Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands (
[email protected]).
proper destination. Prehospital triage protocols are used to help define the patient destination. However, triage of patients without evident abnormality and instability at presentation remains challenging given the limited facilities on scene. In the Netherlands, allocation of trauma patients to the appropriate level of trauma care is guided by the Dutch Field Triage Protocol (version 7.1, National Protocol of Ambulance Services),7 for EMS professionals (Figure 1). This protocol is based on the Field Triage Decision Scheme established by the American College of Surgeons Committee on Trauma (ACS-COT).8,9 Quality of prehospital triage can be determined by rates of undertriage and overtriage. Undertriage is defined as the pro(Reprinted) JAMA Surgery Published online November 1, 2017
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Research Original Investigation
Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients
portion of patients with severe injuries not transported to a level I trauma center. Overtriage is defined as the proportion of patients without severe injuries transported to a level I trauma center. Undertriage results in higher mortality and delay of adequate care, whereas overtriage limits the available level I resources for patients without severe injuries.2,8 To optimize the prehospital triage system, it is essential to gain insight in the quality of prehospital triage of the entire trauma system or region. The benchmark level in the ACS-COT guidelines is a maximum undertriage rate of 5%, allowing for an overtriage rate of up to 50%.8 In a Dutch population consisting of high-energy trauma patients only, the undertriage rate was 11%.10 The quality of triage in the complete trauma population is unknown. This present study aims to evaluate the quality of the Dutch field triage protocol for identifying severely injured trauma patients in a population consisting of adult trauma patients transported by EMS professionals with the highest priority in the Central Netherlands region.
Methods Study Design and Setting The present study was performed in the Central Netherlands region using prospectively collected prehospital and hospital data of all adult trauma patients transported with the highest priority by the Regional Ambulance Service Utrecht to 1 of the 10 hospitals in Central Netherlands between January 2012 and
Key Points Question What is the quality of the field triage system to identify severely injured adult trauma patients? Findings This study included 4950 trauma patients and shows that more than 20% of the patients with severe injuries were not transported to a level I trauma center. Meaning A significant group of severely injured trauma patients does not receive the appropriate level I trauma care, putting these patients at risk for increased morbidity and mortality; improvement of prehospital triage is necessary.
July 2014. The region Central Netherlands consists of 9 level II and level III hospitals and 1 level I trauma center in a 2418km2 region with a population of 1.2 million people. The University Medical Center Utrecht is designated as a level I trauma center, offering trauma care at the highest level for severely injured patients. The 9 surrounding level II and III hospitals are designed to treat patients without severe injuries. This regional trauma network is based on an inclusive and integrated trauma system.8 The ambulance care system is nursebased. Ambulance nurses are licensed to administer medical treatment at advanced life support level, and ambulance drivers are qualified to provide medical assistance to the ambulance nurses. The present study protocol was reviewed and approved by the local medical ethical committee, and patient consent was waived. Analyses began in 2016.
Figure 1. The Field Triage Protocol for the Distribution of Trauma Patients Over Different Hospitals ABC unstable RTS 32 km/h Vehicle deformity, >50 cm Vehicle intrusion passenger compartment >30 cm Vehicle rollover Passenger ejection from vehicle Fatality in same vehicle Car-pedestrian or car-bicycle impact at >8 km/h Pregnancy at >13 wk
No Level I or II
No Level I, II, or III
JAMA Surgery Published online November 1, 2017 (Reprinted)
© 2017 American Medical Association. All rights reserved.
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ABC indicates airway, breathing, and circulation; GCS, Glasgow Coma Scale; PTS, Pediatric Trauma Score; RTS, Revised Trauma Score. jamasurgery.com
Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients
Patients All trauma patients 16 years and older transported by EMS professionals with the highest priority were included in the study. Patients transported to a hospital outside Central Netherlands and patients transported by helicopter were excluded. Patients were also excluded if insufficient data were available in the receiving hospital to properly calculate the Injury Severity Score (ISS).
Original Investigation Research
Figure 2. Flowchart of Patient Enrollment 6581 Trauma patients transported with the highest emergency between 2012 and 2014
1631 Excluded 873 Transferred to a hospital outside the region 695 Aged 65 y) Prehospital GCS score
