Geographic Variation in Operative Management of Adhesive Small Bowel Obstruction.

INTRODUCTION: Variation in surgical management exists nationally. We hypothesize that geographic variation exists in adhesive small bowel obstruction (aSBO) management. MATERIALS AND METHODS: A retrospective analysis of a national commercial insurance claims database (MarketScan) sample (2017-2019) was performed in adults with hospital admission due to aSBO. Geographic variation in rates of surgical intervention for aSBO was evaluated by state and compared to a risk-adjusted national baseline using a Bayesian spatial rates Poisson regression model. For individual-level analysis, patients were identified in 2018, with 365-d look back and follow-up periods. Logistic regression was performed for individual-level predictors of operative intervention for aSBO. RESULTS: Two thousand one hundred forty-five patients were included. State-level analysis revealed rates of operative intervention for aSBO were significantly higher in Missouri and lower in Florida. On individual-level analysis, age (P < 0.01) and male sex (P < 0.03) but not comorbidity profile or prior aSBO, were negatively associated with undergoing operative management for aSBO. Patients presenting in 2018 with a history of admission for aSBO the year prior experienced a five-fold increase in odds of representation (odds ratio: 5.4, 95% confidence interval: 3.1-9.6) in 2019. Patients who received an operation for aSBO in 2018 reduced the odds of readmission in the next year by 77% (odds ratio: 0.23, 95% confidence interval: 0.1-0.5). The volume of operations performed within a state did not influence readmission. CONCLUSIONS: Surgical management of aSBO varies across the continental USA. Operative intervention is associated with decreased rates of representation in the following year. These data highlight a critical need for standardized guidelines for emergency general surgery patients.

Inguinal Hernia Repairs on the Chief's Service: A Safe Educational Model in Resident Entrustment.

OBJECTIVE: We hypothesized that a Chief Resident Service educational model provides safe care for patients compared to that received on standard academic services where rotating residents adopt the practices and preferences of their attending. DESIGN: We retrospectively identified patients undergoing inguinal hernia repairs from July 2016 through June 2019 and matched Chief's service patients to standard academic service patients 1:1 on CPT, sex and age. We compared patient characteristics, recurrence rates, outcomes and complications. SETTING: Tertiary care center, single institution. PARTICIPANTS: Overall, 77 patients undergoing inguinal hernia repairs (66% open and 34% laparoscopic) on the Chief's service matched successfully to 77 standard academic service patients during the study period. RESULTS: Age, BMI and ASA were similar between the services, but Chief's service patients were less likely to be current smokers (1.3% vs. 24.7%) and more likely to be former smokers (59.7% vs. 26.0%) than standard academic service patients (p < 0.01). Patients presenting with incarcerated hernias (5.2% vs. 9.1%), recurrent (10.4% vs. 5.2%) and bilateral hernias (19.5% vs. 10.4%) were similar between the Chief's service and standard academic services, respectively (all p > 0.05). Operative times were longer for the Chief's service for open (123 min vs. 67, p < 0.01) and laparoscopic (112 min vs. 79, p = 0.02) repairs. Recurrence rates (6.5% vs. 3.9%, p = 0.47) and complications including infection, seroma or hematoma requiring evacuation and need for reoperation were similarly low (p > 0.05) between the Chief's and standard academic services, respectively. Despite low complication rates, Chief's service patients were more likely to present to the ED post-op (14.3% vs. 1.3%; p = 0.001), but readmission rates were similarly low (2.6% vs. 0%, p = 0.09). CONCLUSIONS: Providing general surgery chief residents with a supervised opportunity to direct, plan and provide surgical care in clinic and the operating room, as a transition to independent practice following graduation, is safe for patients presenting with inguinal hernias. Concerns about patient safety should not be a barrier to maximizing entrustment for the evaluation and operative management of select core general surgery diagnoses and operations.

Advanced Automatic Crash Notification Algorithm for Children.

BACKGROUND: Advanced automatic crash notification (AACN) can improve triage decision-making by using vehicle telemetry to alert first responders of a motor vehicle crash and estimate an occupant's likelihood of injury. The objective was to develop an AACN algorithm to predict the risk that a pediatric occupant is seriously injured and requires treatment at a Level I or II trauma center. METHODS: Based on 3 injury facets (severity; time sensitivity; predictability), a list of Target Injuries associated with a child's need for Level I/II trauma center treatment was determined. Multivariable logistic regression of motor vehicle crash occupants was performed creating the pediatric-specific AACN algorithm to predict risk of sustaining a Target Injury. Algorithm inputs included: delta-v, rollover quarter-turns, belt status, multiple impacts, airbag deployment, and age. The algorithm was optimized to achieve under-triage ≤5% and over-triage ≤50%. Societal benefits were assessed by comparing correctly triaged motor vehicle crash occupants using the AACN algorithm against real-world decisions. RESULTS: The pediatric AACN algorithm achieved 25% to 49% over-triage across crash modes, and under-triage rates of 2% for far-side, 3% for frontal and near-side, 8% for rear, and 14% for rollover crashes. Applied to real-world motor vehicle crashes, improvements of 59% in under-triage and 45% in over-triage are estimated: more appropriate triage of 32,320 pediatric occupants annually. CONCLUSIONS: This AACN algorithm accounts for pediatric developmental stage and will aid emergency personnel in correctly triaging pediatric occupants after a motor vehicle crash. Once incorporated into the trauma triage network, it will increase triage efficiency and improve patient outcomes.

Professionalism of Admitting and Consulting Services and Trauma Patient Outcomes.

OBJECTIVE: To determine whether trauma patients managed by an admitting or consulting service with a high proportion of physicians exhibiting patterns of unprofessional behaviors are at greater risk of complications or death. SUMMARY BACKGROUND DATA: Trauma care requires high-functioning interdisciplinary teams where professionalism, particularly modeling respect and communicating effectively, is essential. METHODS: This retrospective cohort study used data from 9 level I trauma centers that participated in a national trauma registry linked with data from a national database of unsolicited patient complaints. The cohort included trauma patients admitted January 1, 2012 through December 31, 2017. The exposure of interest was care by 1 or more high-risk services, defined as teams with a greater proportion of physicians with high numbers of patient complaints. The study outcome was death or complications within 30 days. RESULTS: Among the 71,046 patients in the cohort, 9553 (13.4%) experienced the primary outcome of complications or death, including 1875 of 16,107 patients (11.6%) with 0 high-risk services, 3788 of 28,085 patients (13.5%) with 1 high-risk service, and 3890 of 26,854 patients (14.5%) with 2+ highrisk services (P < 0.001). In logistic regression models adjusting for relevant patient, injury, and site characteristics, patients who received care from 1 or more high-risk services were at 24.1% (95% confidence interval 17.2% to 31.3%; P < 0.001) greater risk of experiencing the primary study outcome. CONCLUSIONS: Trauma patients who received care from at least 1 service with a high proportion of physicians modeling unprofessional behavior were at an increased risk of death or complications.

Immunoneutralization of human angiotensin-(1-12) with a monoclonal antibody in a humanized model of hypertension.

We engineered a monoclonal antibody (mAb) against the human C-terminus of angiotensin-(1-12) [h-Ang-(1-12)] and performed a biochemical characterization in concert with direct in vivo and ex vivo (carotid artery strips) assessments of h-Ang-(1-12) vasoconstrictor activity in 78 (36 females) transgenic rats expressing the human angiotensinogen gene [TGR(hAGT)L1623] and 26 (10 female) Sprague Dawley (SD) controls. The mAb shows high specificity in neutralizing angiotensin II formation from h-Ang-(1-12) and did not cross-react with human and rat angiotensins. Changes in arterial pressure and heart rate in Inactin® hydrate anesthetized rats were measured before and after h-Ang-(1-12) injections [dose range: 75-300 pmol/kg i.v.] prior to and 30-60 minutes after administration of the h-Ang-(1-12) mAb. Neutralization of circulating Ang-(1-12) inhibited the pressor action of h-Ang-(1-12), prevented Ang-(1-12) constrictor responses in carotid artery rings in both SD and TGR(hAGT)L1623 rats, and caused a fall in the arterial pressure of male and female transgenic rats. The Ang-(1-12) mAb did not affect the response of comparable dose-related pressor responses to Ang II, pre-immune IgG, or the rat sequence of Ang-(1-12). This h-Ang-(1-12) mAb can effectively suppress the pressor actions of the substrate in the circulation of hypertensive rats or in carotid artery strips from both SD and transgenic rats. The demonstration that this Ang-(1-12) mAb by itself, induced a fall in arterial pressure in transgenic hypertensive rats supports further exploring the potential abilities of Ang-(1-12) mAb in the treatment of hypertension.

Outcomes Following Cholecystectomy on a Service Designed to Maximize Chief Resident Entrustment.

BACKGROUND: The chief resident service provides surgical trainees in their final year of training the opportunity to maximize responsibility, continuity, and decision-making. Although supervised, chief residents operate according to personal preferences instead of adapting to their attendings' preferences. We hypothesized that outcomes following cholecystectomy are equivalent between the chief resident service and standard academic services. METHODS: We matched adults undergoing cholecystectomy from 07/2016-06/2019 on the chief resident service to two standard academic service patients based on operative indication and age. We compared demographics, operative details, and 30-d complications. RESULTS: This study included 186 patients undergoing cholecystectomy. Body mass index (32.4 versus 32.0, P = 0.49) and Charlson comorbidity index (0.9 versus 1.4, P = 0.16) were similar between chief resident and standard academic services, respectively. Operative approach was similar (95.2% laparoscopic on chief resident service versus 94.4% on standard service), but residents on the chief resident service performed cholangiograms more often (48.4% versus 22.6%, P < 0.01) and averaged longer operative times during laparoscopic cholecystectomy with cholangiogram (146±28 versus 85±22 min, P < 0.01) and without (94±31 versus 76±35 min, P < 0.01) compared with standard academic services, respectively. 30-d complication rates were similar (5.2% chief resident versus 5.0% standard, P = 0.95). No patients suffered bile leak, bile duct injury, or reoperation. Emergency Department visits were similar (12.1% chief resident versus 7.4% standard, P = 0.32); readmissions were less frequent on the chief resident service (0.0% versus 5.0% standard, P = 0.03). CONCLUSIONS: With appropriate supervision, chief residents provide safe care for patients undergoing cholecystectomy while directing medical decisions and practicing according to their preferences.

Automated Frailty Screening At-Scale for Pre-Operative Risk Stratification Using the Electronic Frailty Index.

BACKGROUND: Frailty is associated with numerous post-operative adverse outcomes in older adults. Current pre-operative frailty screening tools require additional data collection or objective assessments, adding expense and limiting large-scale implementation. OBJECTIVE: To evaluate the association of an automated measure of frailty integrated within the Electronic Health Record (EHR) with post-operative outcomes for nonemergency surgeries. DESIGN: Retrospective cohort study. SETTING: Academic Medical Center. PARTICIPANTS: Patients 65 years or older that underwent nonemergency surgery with an inpatient stay 24 hours or more between October 8th, 2017 and June 1st, 2019. EXPOSURES: Frailty as measured by a 54-item electronic frailty index (eFI). OUTCOMES AND MEASUREMENTS: Inpatient length of stay, requirements for post-acute care, 30-day readmission, and 6-month all-cause mortality. RESULTS: Of 4,831 unique patients (2,281 females (47.3%); mean (SD) age, 73.2 (5.9) years), 4,143 (85.7%) had sufficient EHR data to calculate the eFI, with 15.1% categorized as frail (eFI > 0.21) and 50.9% pre-frail (0.10 < eFI ≤ 0.21). For all outcomes, there was a generally a gradation of risk with higher eFI scores. For example, adjusting for age, sex, race/ethnicity, and American Society of Anesthesiologists class, and accounting for variability by service line, patients identified as frail based on the eFI, compared to fit patients, had greater needs for post-acute care (odds ratio (OR) = 1.68; 95% confidence interval (CI) = 1.36-2.08), higher rates of 30-day readmission (hazard ratio (HR) = 2.46; 95%CI = 1.72-3.52) and higher all-cause mortality (HR = 2.86; 95%CI = 1.84-4.44) over 6 months' follow-up. CONCLUSIONS: The eFI, an automated digital marker for frailty integrated within the EHR, can facilitate pre-operative frailty screening at scale.

Predicting Pediatric Patients Who Require Care at a Trauma Center: Analysis of Injuries and Other Factors.

BACKGROUND: Triage decision correctness for children in motor vehicle crashes can be affected by occult injuries. There is a need to develop a transfer score (TS) metric for children that can help quantify the likelihood that an injury is present that would require transfer to a trauma center (TC) from a non-TC, and improve triage decision making. Ultimately, the TS metric might be useful in an advanced automatic crash notification algorithm, which uses vehicle telemetry data to predict the risk of serious injury after a motor vehicle crash using an approach that includes metrics to describe injury severity, time sensitivity, and predictability. STUDY DESIGN: Transfer score metrics were calculated in 4 pediatric age groups (0 to 4, 5 to 9, 10 to 14, 15 to 18 years) for the most frequent motor vehicle crash injuries using the proportions of children transferred to a TC or managed at a non-TC using the National Inpatient Sample years 1998 to 2007. To account for the maximum Abbreviated Injury Scale (MAIS) injury, a co-injury adjusted transfer score (TSMAIS) was calculated. The TS and TSMAIS range from 0 to 1, with 1 indicating highly transferred injuries. RESULTS: Injuries in younger patients were more likely to be transferred (median TS 0.48, 0.35, 0.25, and 0.23 for 0 to 4, 5 to 9, 10 to 14, and 15 to 18 years, respectively). Injuries more likely to be transferred in younger children occurred in the thorax and abdomen. Regardless of age, spine (median TSMAIS 0.59), head (median TSMAIS 0.48), and thorax (median TSMAIS 0.46) injuries had the highest frequency for transfer. CONCLUSIONS: The TS metrics quantitatively describe age-specific transfer practices for children with particular injuries. This information can be useful in advanced automatic crash notification systems to alert first responders to the possibility of occult injuries and reduce undertriage of commonly missed injuries.

Predicting Mortality and Independence at Discharge in the Aging Traumatic Brain Injury Population Using Data Available at Admission.

BACKGROUND: Aging worsens outcome in traumatic brain injury (TBI), but available studies may not provide accurate outcomes predictions due to confounding associated injuries. Our goal was to develop a predictive tool using variables available at admission to predict outcomes related to severity of brain injury in aging patients. STUDY DESIGN: Characteristics and outcomes of blunt trauma patients, aged 50 or older, with isolated TBI, in the National Trauma Data Bank (NTDB), were evaluated. Equations predicting survival and independence at discharge (IDC) were developed and validated using patients from our trauma registry, comparing predicted with actual outcomes. RESULTS: Logistic regression for survival and IDC was performed in 57,588 patients using age, sex, Glasgow Coma Scale score (GCS), and Revised Trauma Score (RTS). All variables were independent predictors of outcome. Two models were developed using these data. The first included age, sex, and GCS. The second substituted RTS for GCS. C statistics from the models for survival and IDC were 0.90 and 0.82 in the GCS model. In the RTS model, C statistics were 0.80 and 0.67. The use of GCS provided better discrimination and was chosen for further examination. Using a predictive equation derived from the logistic regression model, outcome probabilities were calculated for 894 similar patients from our trauma registry (January 2012 to March 2016). The survival and IDC models both showed excellent discrimination (p < 0.0001). Survival and IDC generally decreased by decade: age 50 to 59 (80% IDC, 6.5% mortality), 60 to 69 (82% IDC, 7.0% mortality), 70 to 79 (76% IDC, 8.9% mortality), and 80 to 89 (67% IDC, 13.4% mortality). CONCLUSIONS: These models can assist in predicting the probability of survival and IDC for aging patients with TBI. This provides important data for loved ones of these patients when addressing goals of care.

Use of Unsolicited Patient Observations to Identify Surgeons With Increased Risk for Postoperative Complications.

Importance: Unsolicited patient observations are associated with risk of medical malpractice claims. Because lawsuits may be triggered by an unexpected adverse outcome superimposed on a strained patient-physician relationship, a question remains as to whether behaviors that generate patient dissatisfaction might also contribute to the genesis of adverse outcomes themselves. Objective: To examine whether patients of surgeons with a history of higher numbers of unsolicited patient observations are at greater risk for postoperative complications than patients whose surgeons generate fewer such unsolicited patient observations. Design, Setting, and Participants: This retrospective cohort study used data from 7 academic medical centers participating in the National Surgical Quality Improvement Program and the Vanderbilt Patient Advocacy Reporting System from January 1, 2011, to December 31, 2013. Patients older than 18 years included in the National Surgical Quality Improvement Program who underwent inpatient or outpatient operations at 1 of the participating sites during the study period were included. Patients were excluded if the attending surgeon had less than 24 months of data in the Vanderbilt Patient Advocacy Reporting System preceding the date of the operation. Data analysis was conducted from June 1, 2015, to October 20, 2016. Exposures: Unsolicited patient observations for the patient's surgeon in the 24 months preceding the date of the operation. Main Outcomes and Measures: Postoperative surgical or medical complications as defined by the National Surgical Quality Improvement Program within 30 days of the operation of interest. Results: Among the 32 125 patients in the cohort (13 230 men, 18 895 women; mean [SD] age, 55.8 [15.8] years), 3501 (10.9%) experienced a complication, including 1754 (5.5%) surgical and 2422 (7.5%) medical complications. Prior unsolicited patient observations for a surgeon were significantly associated with the risk of a patient having any complication (odds ratio, 1.0063; 95% CI, 1.0004-1.0123; P = .03), any surgical complication (odds ratio, 1.0104; 95% CI, 1.0022-1.0186; P = .01), any medical complication (odds ratio, 1.0079; 95% CI, 1.0009-1.0148; P = .03), and being readmitted (odds ratio, 1.0088, 95% CI, 1.0024-1.0151; P = .007). The adjusted rate of complications was 13.9% higher for patients whose surgeon was in the highest quartile of unsolicited patient observations compared with patients whose surgeon was in the lowest quartile. Conclusions and Relevance: Patients whose surgeons have large numbers of unsolicited patient observations in the 24 months prior to the patient's operation are at increased risk of surgical and medical complications. Efforts to promote patient safety and address risk of malpractice claims should continue to focus on surgeons' ability to communicate respectfully and effectively with patients and other medical professionals.

Expert Perspectives on Time Sensitivity and a Related Metric for Children Involved in Motor Vehicle Crashes.

OBJECTIVE: Advanced Automatic Crash Notification (AACN) uses vehicle telemetry data to predict risk of serious injury among motor vehicle crash occupants and can thus improve the accuracy with which injured children are triaged by first responders. To better define serious injury for AACN systems (which typically use Abbreviated Injury Scale [AIS] metrics), an age-specific approach evaluating severity, time sensitivity (TS), and predictability of injury has been developed. This study outlines the development of the TS score. METHODS: The 95% most frequent AIS 2+ injuries in a national motor vehicle crash data set spanning 2000 to 2011 were determined for the following age groups: 0 to 4, 5 to 9, 10 to 14, and 15 to 18 years. For each age-specific injury, clinicians with pediatric trauma expertise were asked if treatment at a trauma center was required and were asked about the urgency of treatment. A TS score (range 0-1) was calculated by combining the mean trauma center decision and urgency scores. RESULTS: A total of 30 to 32 responses were obtained for each age-specific injury. The most frequent motor vehicle crash-induced injuries in the younger groups received significantly higher scores than those in the older groups (median TS score 0 to 4 years: 0.89, 5-9 years: 0.87, 10-14 years: 0.82, 15-18 years: 0.72, P < .001). Large variations in TS existed within each AIS severity level; for example, scores among AIS 2 injuries in 0- to 4-year-olds ranged from 0.12 to 0.98. CONCLUSIONS: The TS of common pediatric injuries varies on the basis of age and may not be accurately reflected by AIS metrics. AIS may not capture all aspects of injury that should be considered by AACN systems.

An Injury Severity-, Time Sensitivity-, and Predictability-Based Advanced Automatic Crash Notification Algorithm Improves Motor Vehicle Crash Occupant Triage.

BACKGROUND: Advanced Automatic Crash Notification algorithms use vehicle telemetry measurements to predict risk of serious motor vehicle crash injury. The objective of the study was to develop an Advanced Automatic Crash Notification algorithm to reduce response time, increase triage efficiency, and improve patient outcomes by minimizing undertriage (<5%) and overtriage (<50%), as recommended by the American College of Surgeons. STUDY DESIGN: A list of injuries associated with a patient's need for Level I/II trauma center treatment known as the Target Injury List was determined using an approach based on 3 facets of injury: severity, time sensitivity, and predictability. Multivariable logistic regression was used to predict an occupant's risk of sustaining an injury on the Target Injury List based on crash severity and restraint factors for occupants in the National Automotive Sampling System - Crashworthiness Data System 2000-2011. The Advanced Automatic Crash Notification algorithm was optimized and evaluated to minimize triage rates, per American College of Surgeons recommendations. RESULTS: The following rates were achieved: <50% overtriage and <5% undertriage in side impacts and 6% to 16% undertriage in other crash modes. Nationwide implementation of our algorithm is estimated to improve triage decisions for 44% of undertriaged and 38% of overtriaged occupants. Annually, this translates to more appropriate care for >2,700 seriously injured occupants and reduces unnecessary use of trauma center resources for >162,000 minimally injured occupants. CONCLUSIONS: The algorithm could be incorporated into vehicles to inform emergency personnel of recommended motor vehicle crash triage decisions. Lower under- and overtriage was achieved, and nationwide implementation of the algorithm would yield improved triage decision making for an estimated 165,000 occupants annually.

Increased Screening for Child Physical Abuse in Emergency Departments in a Regional Trauma System: Response to a Sentinel Event.

A pediatric patient was assaulted while being treated at a Level 1 pediatric trauma center, prompting a Centers for Medicare & Medicaid Services site visit. The process of screening for physical abuse and protection of patients was reevaluated and revised, and a new guideline was implemented and shared with referral hospitals. During this same time period, 13 referral hospitals participated in an unrelated federally funded study determining the impact of recognition and care of injured children in states with and without a pediatric emergency care facility recognition program. A pre-post study analysis revealed that screening for abuse doubled during this time period.

Defining the acute care surgery curriculum.

BACKGROUND: This study was designed to define the gaps in essential and desirable (E/D) case volumes that may prompt reevaluation of the acute care surgery (ACS) curriculum or restructuring of the training provided. METHODS: A review of the first 2 years of ACS case log entry (July 2011 to June 2013) was performed. Individual trainee logs were evaluated to determine how often they performed each case on the E/D list. Trainees described cases using current procedural terminology codes, which had been previously mapped to the E/D list. RESULTS: There were 29 trainees from 15 programs (Year 1) and 30 trainees from 13 programs (Year 2) who participated in case log entry, with some overlap between the years. There were a total of 487 fellow-months of data with an average of 14.6 current procedural terminology codes per month and 175.5 per year for cases on the E/D list versus 12 and 143.5 for cases not on the E/D list, respectively. Overall, the most common essential cases were laparotomy for trauma (1,463; 705 in Year 1, 758 in Year 2), tracheostomy (665; 372 in Year 1, 293 in Year 2) and gastrostomy tubes (566; 289 in Year 1, 277 in Year 2). There are a total of 73 types of essential operations and 45 types of desirable operations in the current curriculum. There were 16 distinct codes (13.6%) never used, of which 6 overlapped with other codes. Based on body region, the 10 E/D codes never used by any fellow were as follows: one head/face, lateral canthotomy; five neck; elective neck dissections; one thoracic, vascular trauma to chest; three pediatrics, inguinal hernia repair and small bowel obstruction treatments. CONCLUSION: The current ACS trainees lack adequate head/neck and pediatric experience as defined by the ACS curriculum. Restructuring rotations at individual institutions and a focus on novel educational modalities may be needed to augment the individual institutional exposure. Reevaluation of the curriculum may be warranted.

Development of a time sensitivity score for frequently occurring motor vehicle crash injuries.

BACKGROUND: Injury severity alone is a poor indicator of the time sensitivity of injuries. The purpose of the study was to quantify the urgency with which the most frequent motor vehicle crash injuries require treatment, according to expert physicians. STUDY DESIGN: The time sensitivity was quantified for the top 95% most frequently occurring Abbreviated Injury Scale (AIS) 2+ injuries in the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) 2000-2011. A Time Sensitivity Score was developed using expert physician survey data in which physicians were asked to determine whether a particular injury should go to a Level I/II trauma center and the urgency with which that injury required treatment. RESULTS: When stratifying by AIS severity, the mean Time Sensitivity Score increased with increasing AIS severity. The mean Time Sensitivity Scores by AIS severity were as follows: 0.50 (AIS 2); 0.78 (AIS 3); 0.92 (AIS 4); 0.97 (AIS 5); and 0.97 (AIS 6). When stratifying by anatomical region, the head, thorax, and abdomen were the most time sensitive. CONCLUSIONS: Appropriate triage depends on multiple factors, including the severity of an injury, the urgency with which it requires treatment, and the propensity of a significant injury to be missed. The Time Sensitivity Score did not correlate highly with the widely used AIS severity scores, which highlights the inability of AIS scores to capture all aspects of injury severity. The Time Sensitivity Score can be useful in Advanced Automatic Crash Notification systems for identifying highly time sensitive injuries in motor vehicle crashes requiring prompt treatment at a trauma center.