Trauma systems have been successful in saving lives and preventing disability. Making sure that the right patient gets the right treatment in the shortest possible time is integral to this success. Most trauma systems have not fully developed trauma triage to optimize outcomes. For trauma triage to be effective, there must be a well-developed pre-hospital system with an efficient dispatch system and adequately resourced ambulance system. Hospitals must have clear designations of the level of service provided and agreed protocols for reception of patients. The response within the hospital must be targeted to ensure the sickest patients get an immediate response. To enable the most appropriate response to trauma patients across the system, a well-developed monitoring programme must be in place to ensure constant refinement of the clinical response. This article gives a brief overview of the current approach to triaging trauma from time of dispatch to definitive treatment.

Triaging the right patient to the right place in the shortest time

BACKGROUND
Although injured persons presenting to nontertiary hospitals are routinely transferred for further care, it is unknown whether there is an outcome benefit associated with this practice. We sought to assess whether the transfer of injured patients from nontertiary hospital emergency departments (EDs) is associated with improved survival.


METHODS
This was a retrospective cohort analysis of all consecutive injured children and adults meeting state trauma criteria, presenting to 1 of 42 nontertiary hospital EDs (primarily rural) and requiring either admission or transfer (n = 10,176) from January 1998 through December 2003. Higher level of care transfer was defined as interhospital transfer from the ED to one of six Level I or II trauma centers. Propensity scores were used to adjust for the known nonrandom selection of patients for higher level of care transfer. The outcome measure was inhospital mortality.


RESULTS
There were 10,176 trauma patients who presented to nontertiary hospital EDs and were included in the analysis, of which 3,785 (37%) were transferred to a tertiary hospital from the ED. Transfer patients had higher unadjusted mortality (odds ratio [OR] 2.83, 95% confidence interval [CI] 2.06-3.89). After adjusting for the propensity to be transferred, transfer from the ED to a tertiary hospital was associated with a reduction in mortality (OR 0.67, 95% CI 0.48-0.94), which was strongest among patients transferred to Level I hospitals (OR 0.62, 95% CI 0.40-0.95). There was no measurable benefit for patients transferred to Level II hospitals (OR 0.82, 95% CI 0.47-1.43).


CONCLUSIONS
After adjusting for injury severity and the nonrandom selection of patients for transfer, trauma patients transferred from nontertiary EDs to major trauma centers had lower inhospital mortality than patients remaining in nontrauma hospitals. Recognition and early transfer of at-risk rural trauma patients may improve survival in a regionalized trauma system.

The Benefit of Higher Level of Care Transfer of Injured Patients from Nontertiary Hospital Emergency Departments

OBJECTIVE: To examine trends in mechanism and outcome of major traumatic injury in adults since the implementation of the New South Wales trauma monitoring program, and to identify factors associated with mortality. DESIGN AND SETTING: Retrospective review of NSW Trauma Registry data from 1 January 2003 to 31 December 2007, including patient demographics, year of injury, and level of trauma centre where definitive treatment was provided. PARTICIPANTS: 9769 people aged ≥ 15 years hospitalised for trauma, with an injury severity score (ISS) > 15. MAIN OUTCOME MEASURES: The NSW Trauma Registry outcome measures included were overall hospital length of stay, length of stay in an intensive care unit and inhospital mortality. RESULTS: There was a decreasing trend in severe trauma presentations in the age group 16-34 years, and an increasing trend in presentations of older people, particularly those aged ≥ 75 years. Road trauma and falls were consistently the commonest injury mechanisms. There were 1328 inhospital deaths (13.6%). Year of injury, level of trauma centre, ISS, head/neck injury and age were all independent predictors of mortality. The odds of mortality was significantly higher among patients receiving definitive care at regional trauma centres compared with Level I centres (odds ratio, 1.34; 95% CI, 1.10-1.63). CONCLUSIONS: Deaths from major trauma in NSW trauma centres have declined since 2003, and definitive care at a Level 1 trauma centre was associated with a survival benefit. More comprehensive trauma data collection with timely analysis will improve injury surveillance and better inform health policy in NSW. Language: en

/pdf/injury-trends-and-mortality-in-adult-patients-with-major-1ajmy6vncw.pdf

Injury trends and mortality in adult patients with major trauma in New South Wales.

The main objective was to compare the 30-day mortality rate of trauma patients treated at trauma centers as compared to non-trauma centers in Sweden. The secondary objective was to evaluate how injury severity influences the potential survival benefit of specialized care. This retrospective study included 29,864 patients from the national Swedish Trauma Registry (SweTrau) during the period 2013–2017. Three sampling exclusion criteria were applied: (1) Injury Severity Score (ISS) of zero; (2) missing data in any variable of interest; (3) data falling outside realistic values and duplicate registrations. University hospitals were classified as trauma centers; other hospitals as non-trauma centers. Logistic regression was used to analyze the effect of trauma center care on mortality rate, while adjusting for other factors potentially affecting the risk of death. Treatment at a trauma center in Sweden was associated with a 41% lower adjusted 30-day mortality (odds ratio 0.59 [0.50–0.70], p   70% mortality decrease for the most critically injured group (ISS ≥ 50). There exists a potentially substantial survival benefit for trauma patients treated at trauma centers in Sweden, especially for the most severely injured. This study motivates a critical review and possible reorganization of the national trauma system, and further research to identify the characteristics of patients in most need of specialized care.

/pdf/mortality-of-trauma-patients-treated-at-trauma-centers-4o7x5aoc74.pdf

Mortality of trauma patients treated at trauma centers compared to non-trauma centers in Sweden: a retrospective study

Emergency trauma care in rural and remote settings: Challenges and patient outcomes.

Trauma centers are designated to provide systematized multidisciplinary care to injured patients. Effective trauma systems reduce patient mortality by facilitating the treatment of injured patients at appropriately resourced hospitals. Several U.S. studies report reduced mortality among patients admitted directly to a level I trauma center compared with those admitted to hospitals with less resources. It has yet to be shown whether there is an outcome benefit associated with the “level of hospital” initially treating severely injured trauma patients in Australia. This study was designed to determine whether the level of trauma center providing treatment impacts mortality and/or hospital length of stay. Outcomes were evaluated for severely injured trauma patients with an Injury Severity Score (ISS) > 15 using NSW Institute of Trauma and Injury Management data from 2002–2007 for our regional health service. To assess the association between trauma centers and binary outcomes, a logistic regression model was used. To assess the association between trauma centers and continuous outcomes, a multivariable linear regression model was used. Sex, age, and ISS were included as covariates in all models. There were 1,986 trauma presentations during the 6-year period. Patients presenting to a level III trauma center had a significantly higher risk of death than those presenting to the level I center, regardless of age, sex, ISS, or prehospital time. Peer review of deaths at the level III center identified problems in care delivery in 15 cases associated with technical errors, delay in decision making, or errors of judgement. Severely injured patients treated at a level III center had a higher mortality rate than those treated at a level I center. Most problems identified occurred in the emergency department and were related to delays in care provision. This research highlights the importance of efficient prehospital, in-hospital, and regional trauma systems, performance monitoring, peer review, and adherence to protocols and guidelines.

Outcomes of Severely Injured Adult Trauma Patients in an Australian Health Service: Does Trauma Center Level Make a Difference?

In NSW Australia, a formal trauma system including the use of helicopter emergency medical services (HEMS) has existed for over 20 years. Despite providing many advantages in NSW, HEMS patients are frequently over-triaged; leading to financial implications for major trauma centres that receive HEMS patients. The aim of this study was to investigate the financial implications of HEMS over-triage from the perspective of major trauma centres in NSW. The study sample included all trauma patients transported via HEMS to 12 major trauma centres in NSW during the period: 1 July 2008 to 30 June 2009. Clinical data were gathered from individual hospital trauma registries and merged with financial information obtained from casemix units at respective hospitals. HEMS over-triage was estimated based on the local definition of minor to moderate trauma (ISS≤12) and hospital length of stay of less than 24 hrs. The actual treatment costs were determined and compared to state-wide peer group averages to obtain estimates of potential funding discrepancies. A total of 707 patients transported by HEMS were identified, including 72% pre-hospital (PH; n=507) and 28% inter-hospital (IH; n=200) transports. Over-triage was estimated at 51% for PH patients and 29% for IH patients. Compared to PH patients, IH patients were more costly to treat on average (IH: $42,604; PH: $25,162), however PH patients were more costly overall ($12,329,618 [PH]; $8,265,152 [IH]). When comparing actual treatment costs to peer group averages we found potential funding discrepancies ranging between 4% and 32% across patient groups. Using a sensitivity analysis, the potential funding discrepancy increased with increasing levels of over-triage. HEMS patients are frequently over-triaged in NSW, leading to funding implications for major trauma centres. In general, HEMS patient treatment costs are higher than the peer group average and the potential funding discrepancy varies by injury severity and the type of transport performed. Although severely injured HEMS patients are more costly to treat, HEMS patients with minor injuries make up the majority of HEMS transports and have larger relative potential funding discrepancies. Future episode funding models need to account for the variability of trauma patients and the proportion of patients transported via HEMS.

/pdf/helicopter-emergency-medical-services-hems-over-triage-and-31vd4zx6w0.pdf

Helicopter emergency medical services (HEMS) over-triage and the financial implications for major trauma centres in NSW, Australia

Outcomes of severely injured adult trauma patients in an Australian health service. Does trauma centre level make a difference

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Outcomes of Severely Injured Adult Trauma Patients in an Australian Health Service: Does Trauma Center Level Make a Difference?

Helicopter emergency medical services (HEMS) over-triage and the financial implications for major trauma centres in NSW, Australia

Outcomes of severely injured adult trauma patients in an Australian health service. Does trauma centre level make a difference