Downloaded from http://emj.bmj.com/ on November 16, 2015 - Published by group.bmj.com
Original article
Establishing a standard for assessing the appropriateness of trauma team activation: a retrospective evaluation of two outcome measures Silvia Bressan,1,2,3 Katherine L Franklin,1 Helen E Jowett,1 Sebastian K King,1,2,4 Ed Oakley,1,2,4 Cameron S Palmer1,5 1 The Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia 2 Murdoch Children’s Research Institute, Victoria, Australia 3 Department of Woman’s and Child’s Health, University of Padova, Padova, Italy 4 Department of Paediatrics, University of Melbourne, Melbourne, Australia 5 Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
Correspondence to Dr Silvia Bressan, Trauma Service, The Royal Children’s Hospital, Melbourne, 50 Flemington Road, Parkville, VIC 3052, Australia; [email protected] Received 13 May 2014 Revised 24 November 2014 Accepted 27 November 2014 Published Online First 18 December 2014
ABSTRACT Background Trauma team activation (TTA) is a wellrecognised standard of care to provide rapid stabilisation of patients with time-critical, life-threatening injuries. TTA is associated with a substantial use of valuable hospital resources that may adversely impact upon the care of other patients if not carefully balanced. This study aimed to determine which of the two outcome measures would be a better standard for assessing the appropriateness of TTA at a paediatric centre: retrospective major trauma classification as defined within our state, and the use of emergency department high-level resources as recently published by Falcone et al (Falcone Interventions; FI). Methods Trauma registry data and patients’ charts between February 2011 and June 2013 were reviewed. Over-triage and under-triage rates for TTA, using both major trauma and FIs as outcome measures, were compared. Results Totallly, 280 patients received TTA, 243 met major trauma definition and 102 received one or more FIs. The rates of over-triage and under-triage were 39.7% (95% CI 35.0 to 44.6%) and 30.5% (95% CI 26.2 to 35.2%), when the major trauma definition was used as the outcome measure, and 67.5% (95% CI 62.2 to 72.5%) and 10.8% (95% CI 7.9 to 14.8%) when FI was used. Only 17.1% (95% CI 11.4% to 24.7%) of the under-triaged patients using the major trauma definition received one or more FIs. Conclusions Assessment of TTA appropriateness varied significantly based on the outcome measure used. FIs better reflected the use of acute-care TTA-related resources compared with the major trauma definition, and it should be used as the gold standard to prospectively assess and refine TTA criteria.
BACKGROUND
To cite: Bressan S, Franklin KL, Jowett HE, et al. Emerg Med J 2015;32: 716–721. 716
The activation of a dedicated trauma team is a wellrecognised standard of care for initial in-hospital treatment of patients with major trauma.1 The presence of a trauma resuscitation team has been shown to decrease both time to definitive treatment and mortality in children with life-threatening injuries, by providing rapid, systematic assessment and stabilisation.2–6 Trauma team activation (TTA) is associated with substantial use of valuable hospital resources. Unnecessary attendances by non-emergency department (ED)-based team members, such as surgical specialists, may affect ongoing clinical activities in the operating theatre (OT), wards and clinics, potentially
Key messages What is already known on this subject? ▸ Trauma centres must evaluate the appropriateness of their trauma team activations (TTA) to balance the acute resuscitation needs of potentially injured patients and resource usage by the hospital. ▸ Retrospective measures, such as an Injury Severity Score-based ‘major trauma’ definitions, are still widely used for this purpose. Such measures do not necessarily reflect the actual need for TTA in the emergency department (ED). What this study adds? ▸ An expert consensus list of high-level trauma ED resuscitation resources resulted in a superior measure to assess TTA appropriateness than the major trauma classification used in our state. ▸ We propose that this measure should be used as the gold standard to prospectively assess and refine the diagnostic accuracy of TTA criteria. This will lead to improved internal resource allocation and facilitate benchmarking across different trauma centres.
compromising other patients’ care and increasing hospital costs.7 8 Trauma centres must, therefore, find a balance between the mobilisation of scarce resources and the need for acute resuscitative measures in severely injured patients. This balance may be achieved by assessing the appropriateness of TTA as a part of quality improvement monitoring. The results of these assessments may be used to implement changes to improve the trauma activation and response system within each institution. Retrospective measures (such as Injury Severity Score (ISS), mortality, intensive care unit (ICU) admission and others), alone or in combination with acute interventions, have been widely used as proxy markers of morbidity. Assessment of underactivation and overactivation—also referred to as under-triage and over-triage—may be used to determine appropriateness of TTA.9–16 However, such definitions are retrospectively applied, and despite being of great value for epidemiological and funding purposes, are not easily available at the time of initial assessment, and do not necessarily reflect the actual need for activation of the trauma team within the ED.17 18
Bressan S, et al. Emerg Med J 2015;32:716–721. doi:10.1136/emermed-2014-203998
Downloaded from http://emj.bmj.com/ on November 16, 2015 - Published by group.bmj.com
Original article Study participants and data collection Box 1 Definition of major trauma and emergency department high-level resources Major trauma definition* ▸ Death after injury ▸ Injury Severity Score >12 ▸ Admission to intensive care unit >24 h requiring ventilation ▸ Urgent surgery (within 48 h of admission) for intracranial, intra-abdominal, thoracic injury or fixation of pelvic or spinal fracture Emergency department high-level resources (Falcone Interventions)† ▸ Intubation/reintubation ▸ Administration of blood ▸ Fluid bolus (≥40 mL/kg since time of arrival) ▸ Arrival time to operating theatre transfer
Original article
Establishing a standard for assessing the appropriateness of trauma team activation: a retrospective evaluation of two outcome measures Silvia Bressan,1,2,3 Katherine L Franklin,1 Helen E Jowett,1 Sebastian K King,1,2,4 Ed Oakley,1,2,4 Cameron S Palmer1,5 1 The Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia 2 Murdoch Children’s Research Institute, Victoria, Australia 3 Department of Woman’s and Child’s Health, University of Padova, Padova, Italy 4 Department of Paediatrics, University of Melbourne, Melbourne, Australia 5 Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
Correspondence to Dr Silvia Bressan, Trauma Service, The Royal Children’s Hospital, Melbourne, 50 Flemington Road, Parkville, VIC 3052, Australia; [email protected] Received 13 May 2014 Revised 24 November 2014 Accepted 27 November 2014 Published Online First 18 December 2014
ABSTRACT Background Trauma team activation (TTA) is a wellrecognised standard of care to provide rapid stabilisation of patients with time-critical, life-threatening injuries. TTA is associated with a substantial use of valuable hospital resources that may adversely impact upon the care of other patients if not carefully balanced. This study aimed to determine which of the two outcome measures would be a better standard for assessing the appropriateness of TTA at a paediatric centre: retrospective major trauma classification as defined within our state, and the use of emergency department high-level resources as recently published by Falcone et al (Falcone Interventions; FI). Methods Trauma registry data and patients’ charts between February 2011 and June 2013 were reviewed. Over-triage and under-triage rates for TTA, using both major trauma and FIs as outcome measures, were compared. Results Totallly, 280 patients received TTA, 243 met major trauma definition and 102 received one or more FIs. The rates of over-triage and under-triage were 39.7% (95% CI 35.0 to 44.6%) and 30.5% (95% CI 26.2 to 35.2%), when the major trauma definition was used as the outcome measure, and 67.5% (95% CI 62.2 to 72.5%) and 10.8% (95% CI 7.9 to 14.8%) when FI was used. Only 17.1% (95% CI 11.4% to 24.7%) of the under-triaged patients using the major trauma definition received one or more FIs. Conclusions Assessment of TTA appropriateness varied significantly based on the outcome measure used. FIs better reflected the use of acute-care TTA-related resources compared with the major trauma definition, and it should be used as the gold standard to prospectively assess and refine TTA criteria.
BACKGROUND
To cite: Bressan S, Franklin KL, Jowett HE, et al. Emerg Med J 2015;32: 716–721. 716
The activation of a dedicated trauma team is a wellrecognised standard of care for initial in-hospital treatment of patients with major trauma.1 The presence of a trauma resuscitation team has been shown to decrease both time to definitive treatment and mortality in children with life-threatening injuries, by providing rapid, systematic assessment and stabilisation.2–6 Trauma team activation (TTA) is associated with substantial use of valuable hospital resources. Unnecessary attendances by non-emergency department (ED)-based team members, such as surgical specialists, may affect ongoing clinical activities in the operating theatre (OT), wards and clinics, potentially
Key messages What is already known on this subject? ▸ Trauma centres must evaluate the appropriateness of their trauma team activations (TTA) to balance the acute resuscitation needs of potentially injured patients and resource usage by the hospital. ▸ Retrospective measures, such as an Injury Severity Score-based ‘major trauma’ definitions, are still widely used for this purpose. Such measures do not necessarily reflect the actual need for TTA in the emergency department (ED). What this study adds? ▸ An expert consensus list of high-level trauma ED resuscitation resources resulted in a superior measure to assess TTA appropriateness than the major trauma classification used in our state. ▸ We propose that this measure should be used as the gold standard to prospectively assess and refine the diagnostic accuracy of TTA criteria. This will lead to improved internal resource allocation and facilitate benchmarking across different trauma centres.
compromising other patients’ care and increasing hospital costs.7 8 Trauma centres must, therefore, find a balance between the mobilisation of scarce resources and the need for acute resuscitative measures in severely injured patients. This balance may be achieved by assessing the appropriateness of TTA as a part of quality improvement monitoring. The results of these assessments may be used to implement changes to improve the trauma activation and response system within each institution. Retrospective measures (such as Injury Severity Score (ISS), mortality, intensive care unit (ICU) admission and others), alone or in combination with acute interventions, have been widely used as proxy markers of morbidity. Assessment of underactivation and overactivation—also referred to as under-triage and over-triage—may be used to determine appropriateness of TTA.9–16 However, such definitions are retrospectively applied, and despite being of great value for epidemiological and funding purposes, are not easily available at the time of initial assessment, and do not necessarily reflect the actual need for activation of the trauma team within the ED.17 18
Bressan S, et al. Emerg Med J 2015;32:716–721. doi:10.1136/emermed-2014-203998
Downloaded from http://emj.bmj.com/ on November 16, 2015 - Published by group.bmj.com
Original article Study participants and data collection Box 1 Definition of major trauma and emergency department high-level resources Major trauma definition* ▸ Death after injury ▸ Injury Severity Score >12 ▸ Admission to intensive care unit >24 h requiring ventilation ▸ Urgent surgery (within 48 h of admission) for intracranial, intra-abdominal, thoracic injury or fixation of pelvic or spinal fracture Emergency department high-level resources (Falcone Interventions)† ▸ Intubation/reintubation ▸ Administration of blood ▸ Fluid bolus (≥40 mL/kg since time of arrival) ▸ Arrival time to operating theatre transfer
