Do emergency medical dispatchers choose the same response to serious injury in men and women - a qualitative study.

BACKGROUND: Recent research has indicated that sex is an important determinant of emergency medical response in patients with possible serious injuries. Men were found to receive more advanced prehospital treatment and more helicopter transportation and trauma centre destinations and were more often received by an activated trauma team, even when adjusted for injury mechanism. Emergency medical dispatchers choose initial resources when serious injury is suspected after a call to the emergency medical communication centre. This study aimed to assess how dispatchers evaluate primary responses in trauma victims, with a special focus on the sex of the victim. METHODS: Emergency medical dispatchers were interviewed using focus groups and a semistructured interview guide developed specifically for this study. Two vignettes describing typical and realistic injury scenarios were discussed. Verbatim transcripts of the conversations were analysed via systematic text condensation. The findings were reported in accordance with the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist. RESULTS: The analysis resulted in the main category "Tailoring the right response to the patient", supported by three categories "Get an overview of location and scene safety", "Patient condition" and "Injury mechanism and special concerns". The informants consistently maintained that sex was not a relevant variable when deciding emergency medical response during dispatch and claimed that they rarely knew the sex of the patient before a response was implemented. Some of the participants also raised the question of whether the Norwegian trauma criteria reliably detect serious injury in women. CONCLUSIONS: The results indicate that the emergency medical response is largely based on the national trauma criteria and that sex is of little or no importance during dispatch. The observed sex differences in the emergency medical response seems to be caused by other factors during the emergency medical response phase.

Does mortality after trauma team activation peak at shift change?

BACKGROUND: Prior institutional data have demonstrated trauma mortality to be highest between 06:00-07:59 at our center, which is also when providers change shifts (07:00-07:30). The objective was definition of patient, provider, and systems variables associated with trauma mortality at shift change among patients arriving as trauma team activations (TTA). METHODS: All TTA patients at our ACS-verified Level I trauma center were included (01/2008-07/2019), excluding those with undocumented arrival time. Study groups were defined by arrival time: shift change (SC) (06:00-07:59) vs. non-shift change (NSC) (all other times). Univariable/multivariable analyses compared key variables. Propensity score analysis compared outcomes after matching. RESULTS: After exclusions, 6020 patients remained: 229 (4%) SC and 5791 (96%) NSC. SC mortality was 25% vs. 16% during NSC (p < 0.001). More SC patients arrived with SBP <90 (19% vs. 11%, p < 0.001) or GCS <9 (35% vs. 24%, p < 0.001). ISS was higher during SC (43[32-50] vs. 34[27-50], p < 0.001). Time to CT scan (36[23-66] vs. 38[23-61] minutes, p = 0.638) and emergent surgery (94[35-141] vs. 63[34-107] minutes, p = 0.071) were comparable. Older age (p < 0.001), SBP <90 (p < 0.001), GCS <9 (p < 0.001), need for emergent operative intervention (p = 0.044), and higher ISS (p < 0.001) were independently associated with mortality. After propensity score matching, mortality was no different between SC and NSC (p = 0.764). CONCLUSIONS: Early morning is a low-volume, high-mortality time for TTAs. Increased mortality at shift change was independently associated with patient/injury factors but not provider/systems factors. Ensuring ample clinical resource allocation during this high acuity time may be prudent to streamline patient care at shift change.

Prehospital Narrow Pulse Pressure Predicts Need for Resuscitative Thoracotomy and Emergent Intervention After Trauma.

BACKGROUND: The pulse pressure (PP) is the difference between systolic and diastolic blood pressures. Narrow PP in the Emergency Department (ED) has recently been shown to predict hemorrhagic shock after trauma. This study examined the impact of prehospital narrow PP on outcomes after trauma. METHODS: Patients presenting to our ACS-verified Level I trauma center (2008-2020) were retrospectively screened. Exclusions were unrecorded prehospital/ED vitals, age <16 or >60, transfers, on-scene cardiac arrest, and missing discharge disposition. Prehospital blood pressure defined study groups: Narrow PP (<30 mmHg) vs. Hypotensive (SBP<90 mmHg) vs. Others (herein referred to as Normotensive). Univariable/multivariable analyses compared outcomes and determined independent predictors of mortality; resuscitative thoracotomy; emergent intervention; and need for trauma intervention (NFTI), a contemporary measure of major trauma. RESULTS: In total, 39,144 patients met inclusion/exclusion criteria: 5% (n=1,834) Narrow PP, 3% (n=1,062) Hypotensive, and 92% (n=36,248) Normotensive. Penetrating trauma was more frequent among Narrow PP and Hypotensive patients (23% vs. 32% vs. 14%, p<0.001). ISS was higher among Narrow PP and Hypotensive patients (5[1-14] vs. 10[2-21] vs. 4[1-9], p<0.001). Mortality was highest among the Hypotensive (n=130, 12%) followed by Narrow PP (n=92, 5%) and Normotensive patients (n=502, 1%) (p<0.001). On multivariable analysis, prehospital narrow PP was independently associated with resuscitative thoracotomy (OR 1.609, p=0.009), emergent intervention (OR 1.356, p=0.001), and NFTI (OR 1.237, p=0.009). CONCLUSION: Prehospital narrow PP independently predicts severe trauma, resuscitative thoracotomy, and emergent intervention. Although prehospital narrow PP is not currently a TTA criterion, these patients have a mortality rate and ISS intermediate to those of hypotensive and normotensive patients. Prehospital narrow PP should be recognized as a proxy for major trauma in patients with heightened surgical and interventional needs so that appropriate in-hospital preparations may be made prior to patient arrival.

Isolated Intracranial Hemorrhage in Elderly Patients With Pre-Injury Anticoagulation: Is Full Trauma Team Activation Necessary?

BACKGROUND: Traumatic intracranial hemorrhage (ICH) is a highly morbid injury, particularly among elderly patients on preinjury anticoagulants (AC). Many trauma centers initiate full trauma team activation (FTTA) for these high-risk patients. We sought to determine if FTTA was superior compared with those who were evaluated as a trauma consultation (CON). METHODS: Patients aged ≥55 on preinjury AC who presented from January 2015 to December 2019 with blunt isolated head injury (non-head AIS ≤2) and confirmed ICH were identified. CON patients and FTTA patients were matched by age and head AIS. Cox proportional hazard model was used to assess patient and injury characteristics with mortality and survivor discharge disposition. REASULTS: There were 45 CON patients and 45 FTTA patients. Mean age was 80 years in both groups. Fall was the most common mechanism (98% CON vs. 92% FTTA). Glasgow Coma Score (GCS) was lower in FTTA (14 vs. 15, p<0.01). CON had a significantly longer time from arrival to CT scan (1.3 vs. 0.4 hrs, p<0.01). Hospital days were similar (CON: 3.9 vs. FTTA: 3.7 days). However, CON had increased ventilator use (p=0.03). Lower admission GCS was the only factor associated with increased risk of death. Among survivors, only head AIS increased the risk of discharge to a level of care higher than that of preinjury (p=0.01). CONCLUSION: There was no difference in mortality or adverse discharge disposition between FTTA and CON, although FTTA was associated with a more rapid evaluation and diagnosis. Any alteration in GCS was strongly associated with mortality and should prompt evaluation by FTTA.

[Emergency intervention rate in the emergency room depending on the alerting criteria : Prospective data analysis of a supraregional trauma center]. / Notfallinterventionsrate bei Schockraumpatienten in Abhängigkeit von den Alarmierungskriterien : Prospektive Datenanalyse eines überregionalen Traumazentrums.

Trauma team alert (TTA) to the emergency room (ER) takes place in the event of disturbed vital signs or serious injuries (A criteria) or after a dangerous accident (B criteria). Due to low specificity and limited personnel resources, TTA is questioned for B criteria. The consequences would be an increase in undertriage and thus endangering patients. Due to the lack of data it is unclear whether adapted ER teams would be a solution to the problem.The aim of the study was to describe ER patients according to the TTA criteria and to collect the corresponding emergency intervention rates in ER.Over 1 year, all TTAs of a supraregional trauma center were prospectively recorded, categorized according to TTA criteria (A, B and NULL criteria) and compared descriptively. NULL criteria were TTAs for which neither A nor B criteria were met. Treatment data were documented according to the TraumaRegister DGU® standard form. Emergency interventions were intubation, chest tube, cardiopulmonary resuscitation, transfusion, coagulation substitution, external pelvic stabilization and surgical hemostasis.The TTA due to A, B and NULL criteria were performed in 19.5%, 51.2% and 29.3%, respectively. The mean injury severity (ISS ± standard deviation) was 20.6 ± 21.3 for A criteria, significantly higher than for B criteria (8.0 ± 7.1) and NULL criteria (5.6 ± 8.2). The emergency intervention rate for A , B and NULL criteria was 75%, 6% and 2.1%, respectively.Differentiation according to the TTA criteria results in patient collectives with different injury severity and emergency intervention rates. This result justifies considerations to adjust team composition based on TTA criteria, as long as it is ensured that critical conditions can be identified and remedied by adapted teams.

Old Age With a Traumatic Mechanism of Injury Should Be a Trauma Team Activation Criterion.

BACKGROUND: Age is not a standard trauma team activation (TTA) criteria recommended by the Committee on Trauma. However, there is concern that vital signs in elderly patients are often unreliable. In addition, elderly patients are at risk after moderate trauma. At our institution, age ≥ 70 years with traumatic mechanisms of injury has been a TTA criterion for more than 15 years. OBJECTIVE: Our aim was to determine whether age ≥70 years as a TTA criterion appropriately identifies patients in need of additional resources without significantly impacting overtriage rates. METHODS: We conducted a retrospective trauma registry study of TTAs for age ≥ 70 years from January 2012-December 2016. Demographics, injury data, Injury Severity Score (ISS), procedures, emergency department (ED) disposition, and hospital data were collected. Primary outcome was mortality, secondary outcomes were intensive care unit (ICU) and hospital lengths of stay. Patients were stratified into meeting standard criteria (TTA-S) or activated based on age alone (TTA-A). TTA patients with ISS > 15, ED intubation, ICU admission, immediate operating room or catheter-based intervention, and mortalities were appropriately triaged. RESULTS: During the study, there were 5436 total TTAs. Seven hundred and thirty-nine TTAs in patients aged ≥ 70 years, of which 198 (26.8%) were TTA-S and 541 (73.2%) were TTA-A. In the TTA-A group, 49 (9%) patients died, 149 (27.5%) had ISS > 15, 65 (12%) underwent immediate intervention, 72 (13%) had ED intubations, and 306 (56.6%) required admission to the ICU. The overtriage rate in the TTA-A group was 39.6%. CONCLUSIONS: Elderly patients with severe trauma patients often do not meet the standard TTA criteria, resulting in potentially dangerous undertriage. Addition of age (≥70 years) criterion for TTA reduces undertriage and does not result in excessive overtriage.

Role of trauma team activation in poor outcomes of elderly patients.

INTRODUCTION: Elderly trauma patients suffer worse outcomes than younger patients. Trauma team activation (TTA) improves outcomes in younger patients. It is unclear whether decreased TTA effectiveness or under-activation in elderly patients could contribute to their poor outcomes. MATERIAL AND METHODS: This retrospective registry study examined all adult trauma patients admitted to a level 1 trauma center over 2 y. Analyses tested (1) whether age modifies the effect of TTA on poor outcomes, (2) whether elderly patients with severe injury were less likely to receive TTA than younger patients, and (3) which early variables were associated with poor outcomes among elderly patients who did not receive TTA. RESULTS: The study included 10,033 patients. The adjusted relative risk from TTA for all ages was 0.48 (95% confidence interval (CI) = 0.34-0.68, P < 0.001), and there was no effect modification by age (interaction term P value, 0.171). The adjusted odds ratio for the young was 0.49 (95% CI = 0.26-0.91, P = 0.024) and for the elderly was 0.80 (95% CI = 0.53-1.20, P = 0.282). The adjusted odds ratio for lack of TTA associated with old age was 1.37 (95% CI = 1.12-1.69, P = 0.003). The strongest associations with poor outcomes were seen with low heart rate, low minimum blood pressure, high injury severity score, and high Glasgow coma score. CONCLUSIONS: Lack of TTA could contribute to elderly patients' poor outcomes. Clinicians should not be reassured by normal heart rates and should be wary of even transiently lower blood pressures in the elderly. A large cohort study is needed to identify which additional elderly patients could benefit from TTA.

An evaluation of the use of a two-tiered trauma team activation system in a UK major trauma centre.

OBJECTIVES AND BACKGROUND: Appropriate activation of multidisciplinary trauma teams improves outcome for severely injured patients but can disrupt normal service in the rest of the hospital. Derriford Hospital uses a two-tiered trauma team activation system. The emergency department trauma team (EDTT) is activated in response to a significant traumatic mechanism; the hospital trauma team (HTT) is activated when this mechanism coexists with physiological abnormality or specific anatomical injury. The aim of this study was to compare characteristics, process measures and outcomes between patients treated by EDTTs or HTTs to evaluate the approach in a UK setting. METHODS: A retrospective database review was performed using Trauma Audit Research Network (TARN) and the local source trauma database. Patients who activated a trauma team between 1 April and 30 September 2012 were included. Patients were categorised according to the type of trauma team activated. Data included time to X-rays, time to CT, time to intubation, numbers discharged from ED, intensive care unit admission, injury severity score and mortality. RESULTS: During the study period, 456 patients activated a trauma team with 358 EDTT and 98 HTT activations. Patients seen by the ED team were significantly less likely to have severe injury or require hospital admission, intubation, emergency operation or blood transfusion. Differences in time taken to key investigations were statistically but not clinically significant. CONCLUSIONS: A two-tiered trauma team activation system is an efficient and cost-effective way of dealing with trauma patients presenting to a major trauma centre in the UK.

Time Delay in Motor Vehicle Accident Arrival: A Critical Analysis of Trauma Team Activation.

Introduction This research aims to investigate the role of time since trauma (TST) in refining trauma team activation (TTA) criteria within a level I trauma center. We analyze the association between TST and post-emergency department (ED) disposition, proposing new insights for the enhancement of TTA criteria. Methods A retrospective analysis was conducted on a dataset comprising 3,693 patients presenting to a level I trauma center following motor vehicle accidents (MVAs) from 2016 to 2021. Data from a trauma registry, encompassing time of injury, time of ED arrival, TTA status, and post-ED disposition, were utilized. TST was calculated as the difference between the time of injury and the time of ED arrival. Patients that received TTA, full or partial, were categorized based on TST (less than one hour, one to two hours, and two or more hours). Statistical analyses, including chi-square tests, were performed using the Statistical Analysis System (SAS) (version 3.8, SAS Institute Inc., Cary, NC). Results Of the 1,261 patients meeting the criteria, 98.3% received TTA, with decreasing TTA rates observed with increasing TST (p = 0.0076). A significant association was found between TST and post-ED disposition for patients who received TTA (p = 0.0007). Compared to the other TST groups, a higher proportion of patients with a TST of two or more hours were admitted, sent to the intensive care unit (ICU), and sent to the operating room (OR).  Conclusion The study indicates a statistically significant relationship between TST and TTA rates, challenging our assumptions about the decreased need for TTA over time. While a longer TST was associated with a lower percentage of TTA, patients with a TST of two or more hours demonstrated increased rates of admission, ICU utilization, and surgical interventions. This suggests that TTA criteria may benefit from refinement to include patients with longer TST. Acknowledging study limitations, such as a small sample size and retrospective design, this research contributes valuable insights into potential considerations for optimizing trauma care protocols.

Evaluation of Prehospital Undertriage in Relation to Trauma Team Activation-Results from a Prospective Study in 12 Level one German Trauma Centers.

Background/Objective: This prospective, multicenter observational cohort study was carried out in 12 trauma centers in Germany and Switzerland. Its purpose was to evaluate the rate of undertriage, as well as potential consequences, and relate these with different Trauma Team Activation Protocols (TTA-Protocols), as this has not been done before in Germany. Methods: Each trauma center collected the data during a three-month period between December 2019 and February 2021. All 12 participating hospitals are certified as supra-regional trauma centers. Here, we report a subgroup analysis of undertriaged patients. Those included in the study were all consecutive adult patients (age ≥ 18 years) with acute trauma admitted to the emergency department of one of the participating hospitals by the prehospital emergency medical service (EMS) within 6 h after trauma. The data contained information on age, sex, trauma mechanism, pre- and in-hospital physiology, emergency interventions, emergency surgical interventions, intensive care unit (ICU) stay, and death within 48 h. Trauma team activation (TTA) was initiated by the emergency medical services. This should follow the national guidelines for severe trauma using established field triage criteria. We used various denominators, such as ISS, and criteria for the appropriateness of TTA to evaluate the undertriage in four groups. Results: This study included a total of 3754 patients. The average injury severity score was 5.1 points, and 7.0% of cases (n = 261) presented with an injury severity score (ISS) of 16+. TTA was initiated for a total of 974 (26%) patients. In group 1, we evaluated how successful the actual practice in the EMS was in identifying patients with ISS 16+. The undertriage rate was 15.3%, but mortality was lower in the undertriage cohort compared to those with a TTA (5% vs. 10%). In group 2, we evaluated the actual practice of EMS in terms of identifying patients meeting the appropriateness of TTA criteria; this showed a higher undertriage rate of 35.9%, but as seen in group 1, the mortality was lower (5.9% vs. 3.3%). In group 3, we showed that, if the EMS were to strictly follow guideline criteria, the rate of undertriage would be even higher (26.2%) regarding ISS 16+. Using the appropriateness of TTA criteria to define the gold standard for TTA (group 4), 764 cases (20.4%) fulfilled at least one condition for retrospective definition of TTA requirement. Conclusions: Regarding ISS 16+, the rate of undertriage in actual practice was 15.3%, but those patients did not have a higher mortality.

Pediatric Trauma Management in Switzerland: Insights from a Nationwide Survey.

Objective: To explore and analyze pediatric trauma care practices across designated pediatric trauma centers (PTCs) in Switzerland. The focus is on reception, trauma team activation (TTA), trauma team composition, patient volumes, and infrastructure. Methods: A national online survey was conducted among all eight PTCs in Switzerland with an 18- item questionnaire. The survey investigated organizational aspects, criteria for TTA, patient volume, and communication modalities in pediatric emergency departments (PEDs). Results: All PTCs responded, revealing varied methods of TTA, and with reception of major trauma either within PEDs or at adjacent adult trauma facilities. Trauma team composition and activation criteria also differ among centers, with nonsurgeons often leading the teams and anesthesia as a default for airway management. TTA criteria vary widely, with the most common being the request of prehospital crew (62.5%) and physician discretion (50%). Trauma resuscitation is predominantly led by PED attendings (75%). Conclusion: The survey provides insights into the state of pediatric trauma care in Switzerland and emphasizes the importance of multidisciplinary teams and the variability in trauma management practices, which are often tailored to local circumstances. Despite the limitations of self-reported data and the small sample size due to the country's size, the results suggest that a national trauma registry would help to evaluate and optimize pediatric trauma care protocols.

Trauma team activation for older patients with pelvic fractures: Are current criteria adequate?

OBJECTIVES: The present study aimed to identify the impact of age on current trauma team activation (TTA) processes and outcomes for patients with pelvic fractures. METHODS: Adult patients with moderate and/or severe pelvic fractures (Abbreviated Injury Scale ≥ 2) between 1 January 2016 and 31 December 2021 were included utilising major trauma hospital data in Queensland. Characteristics of older (age ≥ 65) and younger patients including TTA, interventions and outcomes were examined. Multivariate analysis was used to determine factors associated with TTA in older patients. RESULTS: Data from 637 patients was included. Despite comparable injury severity, a TTA was activated in fewer older people (older: 65% vs. younger: 79%, P < 0.001). Older patients had more falls leading to the trauma presentation (54.4% vs. 22.6%, P < 0.001), with higher initial systolic BP (131 vs. 125 mmHg, P = 0.04). Outcomes were worse for older people, with greater rates of in-hospital complications (27.2% vs. 16.4%, P = 0.004), and longer hospital stays (12 vs. 8 days, P = 0.04). Fewer older patients could be discharged independently to home (46.3% vs. 74.5%, P < 0.001). In older patients, falls and haemodynamic parameters were strongly associated with the reduced likelihood of TTA (fall mechanism [odds ratio (OR)] 0.33; 95% confidence interval [CI] 0.15-0.74; P = 0.01; systolic BP [OR 0.98; 95% CI 0.97-0.99; P = 0.03], heart rate [OR 0.97; 95% CI 0.95-0.99; P = 0.02]). CONCLUSION: Current TTA criteria based on higher energy mechanisms and traditional vital sign thresholds are inadequate for identifying injury in older patients. Sensitive triage criteria and increased clinician awareness are required to enhance injury recognition and improve outcomes in older trauma patients.

Effectiveness of a two-tiered trauma team activation system at a level I trauma center.

PURPOSE: Many trauma patients who are transported to our level I trauma center have minor injuries that do not require full trauma team activation (FTTA). Thus, we implemented a two-tiered TTA system categorizing patients into red and yellow code alerts, indicating FTTA and Limited TTA (LTTA) requirements, respectively. This study aimed to assess the effectiveness of this triage tool by evaluating its diagnostic parameters (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), undertriage and overtriage) and comparing injury severity between the two groups. METHODS: A retrospective cohort study of patients admitted to a Level I trauma center. Characteristics compared between the red and yellow code groups included demographics, injury severity, treatments, and hospital length of stay (LOS). Calculating the diagnostic parameters was based on Injury Severity Score (ISS) and the need for life-saving surgery or procedures. RESULTS: Significant differences in injury severity indicators were observed between the two groups. Patients in the red code group had a higher ISS and New Injury Severity Score (NISS), a lower Glasgow Coma Score (GCS), Revised Trauma Score (RTS), and probability of survival. They had a longer hospital LOS, a higher Intensive Care Unit (ICU) admission rate and required more emergency operations. The Sensitivity of the triage tool was 85.2%, specificity was 55.6%, PPV was 74.2%, NPV was 71.5%, undertriage was 14.7%, and overtriage was 25.7%. CONCLUSION: The two-tiered TTA system effectively distinguish between patients with major trauma who need FTTA and patients with minor trauma who can be managed by LTTA.

STRAUMA: A Novel Alert System for a Combined Stroke and Trauma.

INTRODUCTION: Cerebrovascular accident (CVA) can lead to traumatic injury. While timely administration of tissue plasminogen activator (tPA) can be lifesaving in CVAs, it is contraindicated with active bleeding. A STRAUMA is a combined stroke and highest-level trauma activation for patients with suspected CVA and signs of trauma. The purpose of this study is to evaluate the impact of the STRAUMA activation on time to CT and patient outcomes. METHODS: A retrospective review was conducted on adult patients presenting to a Level 1 trauma and comprehensive stroke center with signs of CVA between 01/2019 and 09/2020. Patients who had a STRAUMA activation were compared to patients who had a stroke alert. RESULTS: Five hundred and eighty patients met the inclusion criteria. Of these, 111 had STRAUMA activations and 469 had stroke alerts. There were no differences in age, gender, or anticoagulation use. The STRAUMA group had a higher NIH stroke scale (NIHSS) (11 vs 5, P<.0001). The STRAUMA group had a longer time to CT (23.1 min vs 16.9 min, P<.0001) and a lower rate of tPA (13.5% vs 27.9%, P = .001). Time to tPA and thrombectomy were similar. The STRAUMA group had a 15% rate of traumatic injury with a median injury severity score of 9. Mortality was higher in the STRAUMA group (14.4% vs 6.0%, P = .003). Multivariable logistic regression identified NIHSS and time to CT as predictors of mortality. STRAUMA did not predict mortality. CONCLUSION: The novel STRAUMA activation allows for an evaluation of both stroke and trauma to facilitate safe and timely administration of lifesaving interventions.

Evaluating the impact of pre-hospital trauma team activation criteria.

BACKGROUND: Little evidence exists studying the benefits of pre-hospital trauma team activation. Our study measured the impact of pre-hospital trauma team activation on 24-h survival. Our secondary objectives assessed the effects of pre-hospital trauma team activation on time to emergency procedure, computed tomography, blood transfusion, and critical administration threshold, as well as emergency department length of stay. METHODS: We conducted a 40-month health records review on all trauma team activations at The Ottawa Hospital, a Level 1 Trauma Center. Outcomes were compared between pre-hospital and in-hospital trauma team activations. We used logistic and linear regression models to assess outcomes, while controlling for injury severity score, age, systolic blood pressure, and anti-coagulation use. A P value < 0.05 was considered statistically significant. A sensitivity analysis was also used to validate the primary outcome results. RESULTS: Of the 1013 trauma team activations occurring during the study period, 762 patients were included. The mean age (41.3 vs. 43.8) and percentage of males (79.4% vs. 77.5%) for pre-hospital activations were similar to their counterparts. Pre-hospital activations did not have a statistically significant effect on 24-h mortality (14.4% vs. 4.5%; P = 0.30). However, pre-hospital activations did demonstrate a statistically significant reduction in time (minutes) to emergency procedure (18.0 vs. 27.0; P < 0.001), computed tomography (37.0 vs 42.0; P = 0.009), and blood transfusion (14.0 vs. 28.0; P < 0.001), as well as emergency department length of stay (101.0 vs. 171.0; P < 0.001). CONCLUSION: When controlling for key covariates, pre-hospital trauma team activation did not have a significant effect on 24-h mortality, but did result in a significant reduction in time to emergency procedure, computed tomography, and blood transfusion, as well as emergency department length of stay. Our study demonstrates that pre-hospital trauma team activation can expedite patient intervention and disposition.

RéSUMé: CONTEXTE: Il existe peu de données sur les avantages de l'activation de l'équipe de traumatologie préhospitalière. Notre étude a mesuré l'impact de l'activation de l'équipe de traumatologie pré-hospitalière sur la survie à 24 heures. Nos objectifs secondaires ont évalué les effets de l'activation de l'équipe de traumatologie préhospitalière sur le délai de la procédure d'urgence, de la tomodensitométrie, de la transfusion sanguine et du seuil d'administration critique, ainsi que sur la durée du séjour dans les services d'urgence. MéTHODES: Nous avons procédé à un examen des dossiers médicaux sur 40 mois pour toutes les activations de l'équipe de traumatologie à l'Hôpital d'Ottawa, un centre de traumatologie de niveau 1. Les résultats ont été comparés entre les activations des équipes de traumatologie pré-hospitalières et intra-hospitalières. Nous avons utilisé des modèles de régression logistique et linéaire pour évaluer les résultats, tout en contrôlant le score de gravité des blessures, l'âge, la pression artérielle systolique et l'utilisation d'anticoagulants. Une valeur P < 0.05 a été considérée comme statistiquement significative. Une analyse de sensibilité a également été utilisée pour valider les résultats primaires. RéSULTATS: Sur les 1013 activations d'équipes de traumatologie survenues pendant la période de l'étude, 762 patients ont été inclus. L'âge moyen (41.3 contre 43.8) et le pourcentage d'hommes (79.4% contre 77.5%) pour les activations préhospitalières étaient similaires à ceux de leurs homologues. Les activations préhospitalières n'ont pas eu d'effet statistiquement significatif sur la mortalité à 24 heures (14.4% contre 4.5%; P = 0.30). Cependant, les activations préhospitalières ont démontré une réduction statistiquement significative du temps (minutes) nécessaire à la procédure d'urgence (18.0 contre 27.0; P < 0.001), à la tomodensitométrie (37.0 contre 42.0; P = 0.009) et à la transfusion sanguine (14.0 contre 0.009). 28.0; P < 0.001), ainsi que la durée du séjour aux urgences (101.0 contre 171.0; P < 0.001). CONCLUSION: En tenant compte des principales covariables, l'activation de l'équipe de traumatologie préhospitalière n'a pas eu d'effet significatif sur la mortalité à 24 heures, mais a entraîné une réduction significative du temps nécessaire à l'intervention d'urgence, à la tomodensitométrie et à la transfusion sanguine, ainsi que de la durée de séjour dans les services d'urgence.

All about the Benjamins: Efficacy of a modified triage protocol for trauma activation in geriatric patients.

BACKGROUND: The geriatric triage protocol at the study institution was modified from SBP <90 mmHg to SBP <110 mmHg and then to SBP <100 mmHg. The purpose of this study is to evaluate the impact of adjusting geriatric triage protocols on patient outcomes. METHODS: A single-center retrospective review was conducted on trauma patients 65 years or older. Three study periods with different geriatric specific trauma team activation (TTA) protocols (Group 1-SBP<90 mmHg; Group 2-SBP<110 mmHg; Group 3-SBP<100 mmHg) were compared. RESULTS: 2016 patients were included. There were no differences in mortality rates or need for trauma intervention (NFTI) rates among the three groups. The SBP <100 mmHg and SBP <110 mmHg groups had similar under-triage rates. The NFTI over-triage rate in the SBP <100 mmHg group was lower than the SBP <110 mmHg group. CONCLUSION: Using SBP <100 mmHg threshold for TTA criteria in geriatric trauma patients improves over-triage without leading to under-triage.

Emergency physician and nurse discretion accurately triage high-risk trauma patients.

PURPOSE: Prehospital trauma team activation (TTA) criteria allow for early identification of severely injured trauma patients. Although most TTA criteria are objective, one TTA criterion is subjective: emergency provider discretion. The study objective was to define the ability of emergency department physician and nurse discretion to accurately perform prehospital triage of high risk trauma patients. METHODS: All highest level TTAs arriving to our American College of Surgeons (ACS)-verified Level 1 trauma center (06/2015-08/2020) were included. Exclusions were undocumented prehospital vitals or discharge disposition. At our institution, TTAs are triggered for standard ACS TTA criteria and age > 70 with traumatic mechanism other than ground level fall. Patients meeting ≥ 1 criterion apart from "Emergency Provider Discretion" were defined as Standard TTAs and patients meeting only "Emergency Provider Discretion" were defined as Discretion TTAs. Univariable/multivariable analyses compared injury data and outcomes. RESULTS: 4540 patients met inclusion/exclusion criteria: 3330 (73%) Standard TTAs and 1210 (27%) Discretion TTAs. Discretion TTAs were younger (34 vs. 37 years, p < 0.001) and more frequently injured by penetrating trauma (38% vs. 33%, p = 0.008), particularly stab wounds (64% vs. 29%). Overtriage rates were comparable after Discretion vs. Standard TTAs (33% vs. 31%, p = 0.141). Blood transfusion < 4 h (31% vs. 32%, p = 0.503) and ICU admission ≥ 3 days (25% vs. 27%, p = 0.058) were comparable between groups. Discretion TTA was independently associated with increased need for emergent surgery (OR 1.316, p = 0.005). CONCLUSIONS: Emergency provider discretion accurately identifies major trauma, with comparable rates of overtriage as standard TTA criteria. Discretion TTAs were as likely as Standard TTAs to require early blood transfusion and prolonged ICU stay. After controlling for confounders, Discretion TTAs were significantly more likely to require emergent surgical intervention. Emergency provider discretion should be recognized as a valid method of identifying major trauma patients at high risk of need for intervention.

Pediatric Trauma and Trauma Team Activation in a Swiss Pediatric Emergency Department: An Observational Cohort Study.

BACKGROUND: Trauma is one of the most common causes of death in childhood, but data on severely injured Swiss children are absent from existing national registries. Our aim was to analyze trauma activations and the profiles of critically injured children at a tertiary, non-academic Swiss pediatric emergency department (PED). In the absence of a national pediatric trauma database, this information may help to guide the design of infrastructure, processes within organizations, training, and policies. METHODS: A retrospective analysis of pediatric trauma patients in a prospective resuscitation database over a 2-year period. Critically injured trauma patients under the age of 16 years were included. Patients were described with established triage and injury severity scales. Statistical evaluation included logistic regression analysis. RESULTS: A total of 82 patients matched one or more of the study inclusion criteria. The most frequent age group was 12-15 years, and 27% were female. Trauma team activation (TTA) occurred with 49 patients (59.8%). Falls were the most frequent mechanism of injury, both overall and for major trauma. Road-traffic-related injuries had the highest relative risk of major trauma. In the multivariate analysis, patients receiving medicalized transport were more likely to trigger a TTA, but there was no association between TTA and age, gender, or Injury Severity Score (ISS). Nineteen patients (23.2%) sustained major trauma with an ISS > 15. Injuries of Abbreviated Injury Scale severity 3 or greater were most frequent to the head, followed by abdomen, chest, and extremities. The overall mortality rate in the cohort was 2.4%. Conclusions: Major trauma presentations only comprise a small proportion of the total patient load in the PED, and trauma team activation does not correlate with injury severity. Low exposure to high-acuity patients highlights the importance of deliberate learning and simulation for all professionals in the PED. Our findings indicate that high priority should be given to training in the management of severely injured children in the PED. The leading major trauma mechanisms were preventable, which should prompt further efforts in injury prevention.

Trauma-team-activation in Germany: how do emergency service professionals use the activation due to trauma mechanism? Results from a nationwide survey.

BACKGROUND: Trauma team activation (TTA) requires significant human and financial resources. The implemented German guidelines reduced the mortality of severe injured patients significantly over the last decade. Up to now there is no two-tier trauma team activation protocol in Germany. A two-tier TTA [often activated due to trauma mechanism (TM)] is thought to be a reasonable way to maintain patient safety while increasing cost efficiency. METHODS: We created an online survey addressed at the Emergency Medical Service in Germany to conduct a cross-sectional study. Both physicians and rescue service professionals (RSPs) were included. A minimum of 1550 participants answered questions in 4 different categories concerning the aspects of limited-TTA (L-TTA). Case studies were presented to evaluate the usage of TTA due to TM in the daily routine. RESULTS: Eighty percent (n:1233) of the respondents wish for a possibility to activate a limited trauma team. Seventy-two percent (n: 1109) of the participants consider a L-TTA due to TM to be adequate. There were significant differences (p < 0.05) in the assessment and opinion on L-TTA among physicians and RSPs as well as different medical professions. The evaluated case studies showed diverse answers: depending on the profession, the same patient was ranked as severely injured by 54% and as minorly injured by 46% of the 1550 participants. CONCLUSIONS: Members of the German Emergency Medical Service call for a two-tier TTA-protocol. Up to now we cannot fully recommend an automatic reduction of the trauma team when activated due to TM in Germany with the guidelines implemented. The profession might affect the L-TTA-behavior. Criteria for a L-TTA in Germany have to be defined and evaluated. LEVEL OF EVIDENCE: IV, cross-sectional study.

A "GAP" in Activation: A Better Way to Manage Geriatric and Anticoagulated Patients with Head Trauma.

BACKGROUND: Older age and anticoagulant use have been associated with worse outcomes in trauma. At the study institution, elderly and anticoagulated patients with suspected traumatic brain injury (TBI) were previously triaged as a second tier trauma team activation (TTA) with a high rate of over-triage. A novel "GAP" (Geriatric or Anticoagulated Pathway) alert was created to streamline care delivery to these patients. The purpose of the study is to assess the efficacy and outcomes of the GAP alert. METHODS: A retrospective review was conducted on adult patients presenting to a level-1 trauma center from 1/2018-12/2020. The GAP alert was implemented in 2/2018. The GAP alert group was compared to the second tier TTA group. RESULTS: 1743 patients were identified. 504 (29%) received a GAP alert. GAP alert patients were older (79 years vs 47 years, P < .0001), had a lower injury severity score (ISS) (8.6 vs 9.9, P = .006), and had a higher rate of pre-injury anticoagulant use (28.4% vs 2.5%, P < .0001). The in-hospital mortality was higher in the GAP group (2.4% vs .7%, P = .004). On multivariable logistic regression, GAP alert was not identified as a predictor of mortality. Age, ISS, and pre-injury anticoagulant use predicted mortality. During the study period, the number of GAP alerts increased (B = .15, P = .003) and the number of second tier TTAs decreased (B = -.33, P < .0001). CONCLUSION: Implementation of the GAP alert led to a decrease in trauma resource utilization while providing timely diagnosis and treatment of geriatric patients or those on anticoagulation medication with suspected TBI.