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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 29-33

Factors associated with undertriage of trauma patients at level 1 trauma center


1 Department of Surgery, Ministry of the National Guard-Health Affairs; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
2 King Abdullah International Medical Research Center; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Date of Submission29-Oct-2021
Date of Acceptance10-Dec-2021
Date of Web Publication12-May-2022

Correspondence Address:
Sahar Hammad Alomar
King Saud Bin Abdulaziz University for Health Sciences, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_88_21

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  Abstract 


Background: Applying American College of Surgeons Trauma Team Activation (TTA) criteria could improve trauma system outcomes and minimize both overtriage and undertriage of trauma patients. However, a percentage of trauma patients might slip through the system and become undertriaged.
Objective: The objective of the study is to investigate factors related to undertriage of trauma patients at level 1 trauma center.
Design: This was a retrospective cohort study.
Setting and Subjects: We included all trauma patients at a level 1 trauma center from January 1, 2016, to December 31, 2019.
Methods and Main Outcome Measures: We compared those who received TTA after 5 min of their arrival to emergency department (ED) (undertriaged cohort) to those who received no TTA (properly triaged cohort) in terms of demographic, anatomical, and physiological factors as well as injury severity assessment.
Results: A total of 3740 trauma patients were included; 3330 (89%) were appropriately triaged and needed no TTA while 410 (10.9%) were undertriaged. In multivariate logistic regression model, the following factors were significantly associated with undertriage: arriving to ED in weekends (odd ratio, 1.417, confidence interval [CI] 95%, 1.047–1.916), motorcycle accidents (odds ratio, 3.709, 95% CI, 1.422–9.671), pedestrian victims (odds ratio, 7.477, 95% CI, 3.048–18.341), heart rate <60 (odds ratio, 2.657, 95% CI, 1.083–6.522), systolic blood pressure 76–89 (odds ratio, 4.235, 95% CI, 1.596–11.235), and Glasgow coma scale 9–12 (odds ratio, 4.365, 95% CI, 2.747–6.936).
Conclusion: This study displayed different factors predictive of delayed TTA. Recognizing these factors could improve patient outcomes.
Limitations: Poor prehospital documentation and communication from emergency medical services and a large number of missing data.

Keywords: Trauma patients, trauma team activation criteria, undertriage


How to cite this article:
Al Babtain I, Alnasser M, Dohaim AB, Alomar SH. Factors associated with undertriage of trauma patients at level 1 trauma center. Saudi Surg J 2021;9:29-33

How to cite this URL:
Al Babtain I, Alnasser M, Dohaim AB, Alomar SH. Factors associated with undertriage of trauma patients at level 1 trauma center. Saudi Surg J [serial online] 2021 [cited 2022 Jun 25];9:29-33. Available from: https://www.saudisurgj.org/text.asp?2021/9/2/29/345195




  Introduction Top


Trauma triage system is designed to recognize patients who need trauma team activation (TTA) within a prehospital setting.[1],[2] The American College of Surgeons (ACS) Committee on Trauma has devised minimum criteria for full TTA, which include physiological and anatomical aspects, mechanism of injury, and logistical elements.[2] Accurate triage reduces trauma mortality and improves utilization of resources.[3],[4] Undertriage of trauma patients is associated with delayed diagnosis and intervention and poor outcomes.[5] A study that utilized the American 2010 Nationwide Emergency Department Sample had found that 34.0% of major trauma patients were undertriaged in the US emergency departments (EDs).[6] The aim of this study was to identify factors associated with undertriage of trauma patients at a level 1 trauma center in Riyadh, Saudi Arabia. The results of this study could determine causes of trauma undertriage and consequently optimize trauma system and TTA, improve practice, prevent disability, and decrease mortality among trauma patients.


  Methods Top


Study design, setting, and subjects

A retrospective cohort study conducted on trauma patients at a level 1 trauma center that provides comprehensive trauma care 24 h daily for complex injuries by specialized teams of emergency physicians and general and orthopedic surgeons. After obtaining an approval from the institutional review board (protocol number RC19/429/R), we extracted data of all trauma patients from January 1, 2016, to December 31, 2019, from trauma data registry. This registry was established in 2001 by the department of surgery to document all data related to the admitted trauma patients. A total of 5012 trauma patients were found and divided into two groups; the first group included 1004 patients who received TTA. 559 patients were excluded from the first group as they received TTA within 5 min of their arrival. The remaining 445 patients were included as they received delayed TTA for 5 min. After exclusion of 35 patients for incomplete data, the first cohort (undertraiged) accounted for 410 patients. The second group included 4008 patients who did not receive TTA, who were trauma patients who were managed properly upon their arrival, and who did not meet the TTA criteria at any point of their hospitalization. A total of 595 patients were excluded for incomplete data and 83 were pronounced dead on arrival. The remaining 3330 patients were included as the second cohort (properly triaged). In total, 3740 trauma patients were included [Diagram 1]. We investigated factors that might lead to deterioration and delayed TTA of patients in cohort 1 as compared to cohort 2.



Study variables

The following subject parameters were used; gender, age, day and time of arrival, ED length of stay, ED disposition, hospital length of stay, site and mechanism of injury, injury severity score (ISS), initial vital signs (heart rate [HR], respiratory rate [RR], and systolic blood pressure [SBP]), Glasgow come scale (GCS), revised trauma score (RTS), modes of transportation, prehospital communication, and documentation by emergency medical services (EMSs). We categorized date and time of arrival into weekdays (Sunday–Thursday), weekends (Friday and Saturday), day (00:00–11:59), and night (12:00–23:59). Type of injury was categorized into blunt penetrating gunshot, penetrating stab, and burn/scald injuries. However, the mechanism of injury was classified into motor vehicle accidents (MVAs), motorcycle, fall, pedestrian, burn, homicide, suicide, and others. The classification of GCS, SBP, and RR used for calculating RTS was used to categorize GCS, SBP, and RR. There were three means of transportation (BLS ambulance, private vehicle, or helicopter), five ED dispositions (operating room [OR], intensive care unit [ICU], burn unit, ward, or morgue), and three hospital dispositions (home, death in hospital, or transfer to other hospital).

Analyses

Data analysis was performed using Statistical Package for the Social Sciences, SPSS 23rd version from IBM corporation, NY, USA. Frequency and percentages were used to describe categorical variables (gender, age, day of ED arrival, time of ED arrival, transportation method, ED disposition, hospital disposition, HR, RR, SBP, GCS, and ISS). Mean and standard deviation were used to describe continuous variables (ED and hospital length of stay). Independent t-test and analysis of variance test were used to assess the presence of association between TTA and ED deposition, ED length of stay, hospital disposition, and hospital length of stay. Level of significance was set at 0.05. Bivariate and multivariate logistic regression analyses were performed to determine adjusted and unadjusted predictability of undertriage of trauma patients based on the study variables. Level of significance was set at 0.05.


  Results Top


A total of 5012 trauma patients were included in the study between 2016 and 2019. Patients with missing data and TTA within 5 min upon arrival to the ED were excluded. Finally, 3740 trauma patients were included; 3330 (89%) were appropriately triaged and needed no TTA while 410 (10.9%) were undertriaged, deteriorated at the ED, and needed TTA after 5 min of their arrival.

[Table 1] shows the demographical characteristics and injury severity assessment of trauma patients. In the undertriaged cohort, 375 (91.4%) were males, and 149 (36.3%) were aged between 15 and 24 years. The mean HR was 103.46 (25.35). The mean RR was 24.18 (7.45). The mean SBP was 128.89 (28.24). The mean GCS was 10.36 (4.36). The mean RTS was 10.10 (2.48). The mean ISS was 18.86 (10.86).
Table 1: Demographical characteristics and injury severity assessment of trauma patients

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[Table 2] displays the bivariate logistic regression to predict delayed TTA. The following characteristics were significantly more likely to have delayed TTA: all age groups below 55–64, arriving to ED in weekend, MVA, motorcycle accidents, pedestrian, homicide, suicide, SBP 50–75, SBP 76–89, and GCS 4–5, 6–8, and 9–12. The following characteristics were significantly less likely to have delayed TTA: females, PM time of arrival (between afternoon and before midnight), HR 60–100, and ISS 1–8.
Table 2: Association between patient characteristics, severity of injury and delayed trauma team activation; bivariate logistic regression model

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In multivariate logistic regression model, the following characteristics were significantly more likely to have delayed TTA: all age groups below 55–64, arriving to ED in weekend, motorcycle accidents, pedestrians, HR <60, SBP 76–89, and GCS 4–5, 6–8, and 9–12. The following characteristics were significantly less likely to have delayed TTA: PM time of arrival (between afternoon and before midnight), HR 60–100, RR 10–29, and ISS 1–8 [Table 3].
Table 3: Factors predicting delayed trauma team activation; multivariate logistic regression analysis

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A significant difference (P < 0.001) was observed in the ED length of stay between undertriaged cohort and properly triaged cohort (33.3 [79.7] h vs. 6.2 [6.1] h) and hospital length of stay (33.2 [79.7] days vs. 13.85 [33.2] days). Moreover, a considerable number of patients from the undertriaged cohort were disposed to OR (26.5%) and ICU (47.5%) compared to 4.9% and 5.9% in patients from the properly triaged cohort, respectively. Higher rates of death and referral were seen in patients from the undertriaged cohort (10.9% and 5.1%) compared to 0.7% and 0.9% in patients from the properly triaged cohort, respectively [Table 4].
Table 4: Emergency department deposition, emergency department length of stay, hospital disposition, and hospital length of stay in the two cohorts

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  Discussion Top


Applying ACS TTA criteria could improve trauma system outcomes and minimize both overtriage and undertriage of trauma patients. However, a percentage of trauma patients might slip through the system and become undertriaged for unknown factors. Understanding the characteristics and risk factors associated with undertriaged patients may help identify the gaps of the current TTA criteria and prevent delayed treatment and poor outcomes. In this retrospective cohort study, we investigated factors related to undertriage of trauma patients at a level 1 trauma center. Although advancing age has been reported as one of the most common factors related to undertriage of trauma patients,[7],[8],[9],[10] our data showed that no specific age group was underassessed and any trauma patient below 64 years can also be missed. We found a significant association between undertriage and presenting to the ED in weekends; this could be related to shortage of staffing which was more noticed during weekends and the threshold of TTA was higher than in weekdays. Connolly et al. found that there was no statistical difference in terms of what time of day that the patient arrived to the ED; our data showed similar findings. Although motorcycle accidents were considered as high-energy mechanism of injury and often taken into account in almost all TTA protocols as a top priority mechanism of injury, there was still a percentage of those victims whom vital signs were reassuring when triaged, but their condition deteriorated and was severe enough to activate trauma team.

Physiological profiles of those undertriaged patients were similar to those in previously published data, vast majority of those patients were hemodynamically stable upon their arrival to the ED.[1],[3],[7] This might be attributed to the fact that some injuries such as pelvic or head injuries were difficult to identify initially and usually have an insidious presentation with progressive worsening of the patient's vital signs. Nakahara et al. suggested that isolated head injuries with slow-growing intracranial hematomas were linked with higher risk of undertriage as they present with a good level of consciousness and later deteriorate.[3] This was equivalent to stable pelvic fractures with expanding hematomas where patients experience slow drop in their SBP and hemoglobin level.

Several scoring systems were designed to ensure that both physiological and anatomical profiles were taken into consideration as well as mechanisms and types of injury to detect patients who actually need TTA. Underestimation of scores within normal range could increase the rate of undertriage in trauma patients. The mean ISS and GCS of our study were similar to those in published evidence.[8],[9] Modification of the cutoff points of these scoring systems might be needed to decrease the percentage of undertriaged trauma patients. Delayed TTA was linked to longer ED and hospital stay and higher rate of ICU admission in our study, which could therefore increase the mortality rate in patients with potentially higher complications. Staudenmayer et al. concluded that undertriage was associated with high cost, and it was even higher in older patients.[10]

The study was limited due to several factors. The trauma registry did not include data on EMS prehospital communication and documentation. A total of 630 patients were excluded from the study; 35 from the undertriaged cohort and 595 from the properly triaged cohort due to incomplete variables from the registry. Effect of prehospital documentation and communication by EMS on trauma undertriage needs to be evaluated by further studies.


  Conclusion Top


This study displayed different factors predictive of delayed TTA. Recognizing these factors could improve patient outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schellenberg M, Benjamin E, Bardes JM, Inaba K, Demetriades D. Undertriaged trauma patients: Who are we missing? J Trauma Acute Care Surg 2019;87:865-9.  Back to cited text no. 1
    
2.
American College of Surgeons. Committee on Trauma. Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons; 1990.  Back to cited text no. 2
    
3.
Nakahara S, Matsuoka T, Ueno M, Mizushima Y, Ichikawa M, Yokota J, et al. Predictive factors for undertriage among severe blunt trauma patients: What enables them to slip through an established trauma triage protocol? J Trauma 2010;68:1044-51.  Back to cited text no. 3
    
4.
Tignanelli CJ, Vander Kolk WE, Mikhail JN, Delano MJ, Hemmila MR. Noncompliance with American College of Surgeons Committee on Trauma recommended criteria for full trauma team activation is associated with undertriage deaths. J Trauma Acute Care Surg 2018;84:287-94.  Back to cited text no. 4
    
5.
Haas B, Gomez D, Zagorski B, Stukel TA, Rubenfeld GD, Nathens AB. Survival of the fittest: The hidden cost of undertriage of major trauma. J Am Coll Surg 2010;211:804-11.  Back to cited text no. 5
    
6.
Xiang H, Wheeler KK, Groner JI, Shi J, Haley KJ. Undertriage of major trauma patients in the US emergency departments. Am J Emerg Med 2014;32:997-1004.  Back to cited text no. 6
    
7.
Connolly R, Woo MY, Lampron J, Perry JJ. Factors associated with delay in trauma team activation and impact on patient outcomes. CJEM 2018;20:606-13.  Back to cited text no. 7
    
8.
Ryb GE, Cooper C, Waak SM. Delayed trauma team activation: Patient characteristics and outcomes. J Trauma Acute Care Surg 2012;73:695-8.  Back to cited text no. 8
    
9.
Chang DC, Bass RR, Cornwell EE, Mackenzie EJ. Undertriage of elderly trauma patients to state-designated trauma centers. Arch Surg 2008;143:776-81.  Back to cited text no. 9
    
10.
Staudenmayer KL, Hsia RY, Mann NC, Spain DA, Newgard CD. Triage of elderly trauma patients: A population-based perspective. J Am Coll Surg 2013;217:569-76.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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