UNDERTRIAGE and OVERTRIAGE
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1 UNDERTRIAGE and OVERTRIAGE Alison Wilson, MD, FACS Professor Skewes Family Chair in Trauma Director, Critical Care and Trauma Institute
2 TRIAGE 18 TH century French: Trier = to separate out Minimal use until 1970 s Assign degrees of urgency to wounds/illness to decide order of treatment in large group Rations treatment efficiently when resources are insufficient to treat all Sorting based on need or likely benefit
3 Over Triage and Under Triage Overestimating injuries Goal: 25-30% Discharge w/in 24/48 h No Surgery No ICU No Blood ISS less 15 Underestimating degree or urgency of injuries Goal: less 5% Needed Resources but didn t get them
4 For the TPMs Chap 16: The ORANGE Book Tracking and PI Variable Definitions Cribari Method
5 CRIBARI METHOD ISS 1-15 ISS TOTAL FTTA A B C PTTA D E F No TTA G H I TOTAL TRAUMA Undertriage: (E + H) / (F + I) x 100 Overtriage: (A/C x 100) J
6 UNIFORM CRITERIA BETTER State wide adoption of uniform criteria No change in mortality, but more pts. direct to higher level WV Brice. PreHospital Emergency Care activations based on physiology (9.8% vs 14.5%, p<.0001) Activations AFTER ED arrival: 20% (p<.0039) transported from scene Level 1/2 vs ¾ (p<.0061) Statewide mortality decreased by 6% (p<.03)
7 SCORING SYSTEMS GCSm 5 vs GCS 13 GCSm 5 better assoc. w TC need (Odd ratio: 3.37) Brown JB. J Trauma Acute Care Surg Jul; 77: MGAP: Mechanism, GCS, Age, Art. Press Vs RTS, triage RTS Point value to ranges for each criteria More specific, accurate Low risk (23-29 pts), intermediate (18-22 pts), high <18 Mortality 2.8%, 15%, 48% Sartorius. Crit Care Med Mar 38:831-7
8 SHOCK INDEX What Is It? Bad: > 1 HR/SBP Compared to SBP < 90 More sensitive, less specific for: ISS > 15, emergent operation, ICU >1d, ED death undertriage (5.9%) overtriage (1.3%) Haider. J Trauma Acute Care Surg Dec. 81:
9 LACTATE ED Lactate vs. SBP (pre-hosp. or ED ) Better predicting > 6 UpRBC (p<.0001) Better predicting mortality (p<.0001) Vandromme. J Am Coll Surg May 210:861-7 Lactate 2.5 vs PH SBP <100 Better predictor of: Bld transfusion > 5U, operation, IR, death Guyette J Trauma Acute Care Surg Mar 78:600-6.
10 LACTATE Lactate + ACS criteria Improved: PPV, NPV, accuracy Over-triage decreased 7.2% Under-triage increased 0.7% Brown J Trauma Acute Care Surg :445-52
11 KIDS?? Standardized Criteria Escobar. J Ped Surg : Pre-hospital Lactate For all - Requiring critical care Median 2.1 mmol/l (CC) vs 1.7 mmol/l (p=.01) Subgroup: Nl VS + Nl GCS Median 2.6 mmol/l (CC) vs 1.7 mmol/l (p=.01) Shah Pediatr Em Care :715-9
12 KIDS SIPA (Shock Index, Ped Age-adjusted) SI > 1.22 (4-6 yo), > 1.0 (7-12yo), >.9 (13-16) SBP <90 (4-6 yo), SBP <100 (7-16 yo) Emergency Operation Need for ETT Need for Transfusion SIPA outperforms (p<.001) Acker. Surgery. 2017: Downside More Math
13 GERIATRIC 65 yo +: 30-45% of Total Trauma admissions Less likely to be transported to Trauma Center Less likely to be transferred to TC Kozar. J Trauma Acute Care Surg : More likely to be UNDER TRIAGED : % vs 17.8%, (p<.001) Chang. Arch Surg.2008;143:776-81
14 GERIATRIC SPECIFIC CRITERIA Age alone: 70+ mandates FTTA ED LOS, mortality Hammer J Trauma Acute Care Surg :162-7 Age alone: 70+ mandates EMS transport to TC Overall No mortality or DC to home ISS less 10: mortality (2.5% vs 3.0%) Caterino JAGS :
15 GERIATRIC + PHYSIOLOGY SBP 110 vs 90 Undertriage by 4.4% Sensitivity for need for intervention Brown J Trauma Acute Care Surg :352-9 Shock Index SI > 1 Require Blood Transfusion (p=.0001) Ex Lap (p=.01) Complications (p=.02) Predictor of Mortality (OR 3.1) Pandit J Trauma Acute Care Surg. 2014; 76:1111-5
16 SECONDARY OVERTRIAGE Seen at 1 facility Transfer to Trauma Center Home from ED, w/in 24 hr No Interventions 26% total - almost double if Peds Head/neck injuries (56%) Skin/soft tissue (41%) Sorensen. JAMA. 2013; 148: % total, Mean ISS 4 Ext Fx (31%); Head (23%); Soft tissue (13%) Tang J Trauma Acute Care Surg.2014 dec; 77:
17 SECONDARY OVERTRIAGE Rural Areas: Factors Need for Consultants: Face, Ortho, Spine Night Shift hospital resources Con JSR 2015 Mar 462-7
18 SECONDARY OVERTRIAGE - KIDS NTDB age 15 yrs or younger 144,420 transfers evaluated Secondary overtriage if ALL 4 criteria met: ISS less 9, No surgical procedure needed, No CC admission, LOS less 24 hr 22.4 % (32,318 kids) met definition 37.5% DISCHARGED directly from ED Goldstein J Ped Surg :
19 SECONDARY OVERTRIAGE - KIDS Reasons: Night shift Scene GCS less 15 Need for consultation w Neurosurgeon Followed by Spine, Face Younger much higher rate of transfer (0-2 yrs) Leung Am Surg 2016; 763-7
20 SUMMARY Stick to the Criteria Physiologic Additions SHOCK INDEX, Lactate Specific Geriatric Kids Overtriage, Old Folks Undertriage Secondary Overtriage opportunity???
21 THANK YOU
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