Study objective We evaluate trauma undertriage by age group, the association between age and serious injury after accounting for other field triage criteria and confounders, and the potential effect ...of a mandatory age triage criterion for field triage. Methods This was a retrospective cohort study of injured children and adults transported by 48 emergency medical services (EMS) agencies to 105 hospitals in 6 regions of the western United States from 2006 through 2008. We used probabilistic linkage to match EMS records to hospital records, including trauma registries, state discharge databases, and emergency department databases. The primary outcome measure was serious injury, as measured by an Injury Severity Score greater than or equal to 16. We assessed undertriage (Injury Severity Score ≥16 and triage-negative or transport to a nontrauma center) by age decile and used multivariable logistic regression models to estimate the association (linear and nonlinear) between age and Injury Severity Score greater than or equal to 16, adjusted for important confounders. We also evaluated the potential influence of age on triage efficiency and trauma center volume. Results Injured patients (260,027) were evaluated and transported by EMS during the 3-year study period. Undertriage increased for patients older than 60 years, reaching approximately 60% for those older than 90 years. There was a strong nonlinear association between age and Injury Severity Score greater than or equal to 16. For patients not meeting other triage criteria, the probability of serious injury was most notable after 60 years. A mandatory age triage criterion would have decreased undertriage at the expense of overtriage, with 1 patient with Injury Severity Score greater than or equal to 16 identified for every 60 to 65 additional patients transported to major trauma centers. Conclusion Trauma undertriage increases in patients older than 60 years. Although the probability of serious injury increases among triage-negative patients with increasing age, the use of a mandatory age triage criterion appears inefficient for improving field triage.
Background The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains ...unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score ISS ≥ 16) in a large and diverse multisite cohort. Study Design This was a retrospective cohort study of injured children and adults transported by 94 emergency medical services (EMS) agencies to 122 hospitals in 7 regions of the Western US from 2006 through 2008. Patients who met any of the field trauma triage criteria (per EMS personnel) were considered triage positive. Hospital outcomes measures were probabilistically linked to EMS records through trauma registries, state discharge data, and emergency department data. The primary outcome defining a “major trauma patient” was ISS ≥ 16. Results There were 122,345 injured patients evaluated and transported by EMS over the 3-year period, 34.5% of whom met at least 1 triage criterion and 5.8% had ISS ≥ 16. The overall sensitivity and specificity of the criteria for identifying major trauma patients were 85.8% (95% CI 85.0% to 86.6%) and 68.7% (95% CI 68.4% to 68.9%), respectively. Triage sensitivity and specificity, respectively, differed by age: 84.1% and 66.4% (0 to 17 years); 89.5% and 64.3% (18 to 54 years); and 79.9% and 75.4% (≥55 years). Evaluating the diagnostic value of triage by hospital destination (transport to Level I/II trauma centers) did not substantially improve these findings. Conclusions The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.
Study objective Patients with minor traumatic intracranial hemorrhage are frequently admitted to the ICU, although many never require critical care interventions. To describe ICU resource use in ...minor traumatic intracranial hemorrhage, we assess (1) the variability of ICU use in a cohort of patients with minor traumatic intracranial hemorrhage across multiple trauma centers, and (2) the proportion of adult patients with traumatic intracranial hemorrhage who are admitted to the ICU and never receive a critical care intervention during hospitalization. In addition, we evaluate the association between ICU admission and key independent variables. Methods A structured, historical cohort study of adult patients (aged 18 years and older) with minor traumatic intracranial hemorrhage was conducted within a consortium of 8 Level I trauma centers in the western United States from January 2005 to June 2010. The study population included patients with minor traumatic intracranial hemorrhage, defined as an emergency department (ED) Glasgow Coma Scale (GCS) score of 15 (normal mental status) and an Injury Severity Score less than 16 (no other major organ injury). The primary outcome measure was initial ICU admission. The secondary outcome measure was a critical care intervention during hospitalization. Critical care interventions included mechanical ventilation, neurosurgical intervention, transfusion of blood products, vasopressor or inotrope administration, and invasive hemodynamic monitoring. ED disposition and the proportion of ICU patients not receiving a critical care intervention were compared across sites with descriptive statistics. The association between ICU admission and predetermined independent variables was analyzed with multivariable regression. Results Among 11,240 adult patients with traumatic intracranial hemorrhage, 1,412 (13%) had minor traumatic intracranial hemorrhage and complete ED disposition data (mean age 48 years; SD 20 years). ICU use within this cohort across sites ranged from 50% to 97%. Overall, 847 of 888 patients (95%) with minor traumatic intracranial hemorrhage who were admitted to the ICU did not receive a critical care intervention during hospitalization (range between sites 80% to 100%). Three of 524 (0.6%) patients discharged home or admitted to the observation unit or ward received a critical care intervention. After controlling for severity of injury (age, blood pressure, and Injury Severity Score), study site was independently associated with ICU admission (odds ratios ranged from 1.5 to 30; overall effect P <.001). Conclusion Across a consortium of trauma centers in the western United States, there was wide variability in ICU use within a cohort of patients with minor traumatic intracranial hemorrhage. Moreover, a large proportion of patients admitted to the ICU never required a critical care intervention, indicating the potential to improve use of critical care resources in patients with minor traumatic intracranial hemorrhage.
Background Elderly patients are frequently undertriaged. However, the associations between triage patterns and outcomes from a population perspective are unknown. We hypothesized that triage patterns ...would be associated with differences in outcomes. Study Design This is a population-based, retrospective, cohort study of all injured adults aged 55 years or older, from 3 counties in California and 4 in Utah (2006 to 2007). Prehospital data were linked to trauma registry data, state-level discharge data, emergency department records, and death files. The primary outcome was 60-day mortality. Patients treated at trauma centers were compared with those treated at nontrauma centers. Undertriage was defined as an Injury Severity Score (ISS) >15, with transport to a nontrauma center. Results There were 6,015 patients in the analysis. Patients who were taken to nontrauma centers were, on average, older (79.4 vs 70.7 years, p < 0.001), more often female (68.6% vs 50.2%, p < 0.01), and less often had an ISS >15 (2.2% vs 6.7%, p < 0.01). There were 244 patients with an ISS >15 and the undertriage rate was 32.8% (n = 80). Overall 60-day mortality for patients with an ISS >15 was 17%, with no difference between trauma and nontrauma centers in unadjusted or adjusted analyses. However, the median per-patient costs were $21,000 higher for severely injured patients taken to trauma centers. Conclusions This is the first population-based analysis of triage patterns and outcomes in the elderly. We have shown high rates of undertriage that are not associated with higher mortality, but are associated with higher costs. Future work should focus on determining how to improve outcomes for this population.
Abstract Objectives Although the emergency department (ED) provides essential care for severely ill or injured children, past research has shown that children often visit the ED for potentially ...preventable illnesses, including asthma. We sought to determine how children's rate of ED visits for asthma has changed over the last decade and to analyze what factors are associated with a child's potentially preventable ED visit for asthma. Methods We retrospectively analyzed ED visits by children aged 2 to 17 from 2001 to 2010 using data from the National Hospital Ambulatory Medical Care Survey. Visits were classified as potentially preventable asthma visits by mapping ICD-9-CM diagnosis codes to the Agency for Healthcare Research and Quality's asthma pediatric quality indicator. We examined trends in the annual rate of ED visits for asthma per 1000 children using a weighted linear regression model. Finally, we used multivariate logistic regression to determine what demographic, clinical, and structural factors were associated with a child's ED visit being for a potentially preventable asthma crisis. Results The rate of children's ED visits for asthma increased 13.3% between 2001 and 2010, from 8.2 to 9.3 visits per 1000 children ( P = .26). ED visits by children who were younger, male, racial or ethnic minorities, insured with Medicaid/Children's Health Insurance Program, and visiting between 11 pm and 7 am were more likely to be for potentially preventable asthma crises. Conclusions Although the overall rate of potentially preventable ED visits for asthma did not significantly change over the last decade, racial, insurance-based, and other demographic disparities in the likelihood of a preventable asthma-related ED visit persist.
Study objective Hospitalizations that occur shortly after emergency department (ED) discharge may reveal opportunities to improve ED or follow-up care. There currently is limited, population-level ...information about such events. We identify hospital- and visit-level predictors of bounce-back admissions, defined as 7-day unscheduled hospital admissions after ED discharge. Methods Using the California Office of Statewide Health Planning and Development files, we conducted a retrospective cohort analysis of adult (aged >18 years) ED visits resulting in discharge in 2007. Candidate predictors included index hospital structural characteristics such as ownership, teaching affiliation, trauma status, and index ED size, along with index visit patient characteristics of demographic information, day of service, against medical advice or eloped disposition, insurance, and ED primary discharge diagnosis. We fit a multivariable, hierarchic logistic regression to account for clustering of ED visits by hospitals. Results The study cohort contained a total of 5,035,833 visits to 288 facilities in 2007. Bounce-back admission within 7 days occurred in 130,526 (2.6%) visits and was associated with Medicaid (odds ratio OR 1.42; 95% confidence interval CI 1.40 to 1.45) or Medicare insurance (OR 1.53; 95% CI 1.50 to 1.55) and a disposition of leaving against medical advice or before the evaluation was complete (OR 1.90; 95% CI 1.89 to 2.0). The 3 most common age-adjusted index ED discharge diagnoses associated with a bounce-back admission were chronic renal disease, not end stage (OR 3.3; 95% CI 2.8 to 3.8), end-stage renal disease (OR 2.9; 95% CI 2.4 to 3.6), and congestive heart failure (OR 2.5; 95% CI 2.3 to 2.6). Hospital characteristics associated with a higher bounce-back admission rate were for-profit status (OR 1.2; 95% CI 1.1 to 1.3) and teaching affiliation (OR 1.2; 95% CI 1.0 to 1.3). Conclusion We found 2.6% of discharged patients from California EDs to have a bounce-back admission within 7 days. We identified vulnerable populations, such as the very old and the use of Medicaid insurance, and chronic or end-stage renal disease as being especially at risk. Our findings suggest that quality improvement efforts focus on high-risk individuals and that the disposition plan of patients consider vulnerable populations.
Background The American College of Surgeons Committee on Trauma sets national targets for the accuracy of field trauma triage at ≥95% sensitivity and ≥65% specificity, yet the cost-effectiveness of ...realizing these goals is unknown. We evaluated the cost-effectiveness of current field trauma triage practices compared with triage strategies consistent with the national targets. Study Design This was a cost-effectiveness analysis using data from 79,937 injured adults transported by 48 emergency medical services agencies to 105 trauma and nontrauma hospitals in 6 regions of the western United States from 2006 through 2008. Incremental differences in survival, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio (costs per QALY gained) were estimated for each triage strategy during a 1-year and lifetime horizon using a decision analytic Markov model. We considered an incremental cost-effectiveness ratio threshold of <$100,000 to be cost-effective. Results For these 6 regions, a high-sensitivity triage strategy consistent with national trauma policy (sensitivity 98.6%, specificity 17.1%) would cost $1,317,333 per QALY gained, and current triage practices (sensitivity 87.2%, specificity 64.0%) cost $88,000 per QALY gained, compared with a moderate sensitivity strategy (sensitivity 71.2%, specificity 66.5%). Refining emergency medical services transport patterns by triage status improved cost-effectiveness. At the trauma-system level, a high-sensitivity triage strategy would save 3.7 additional lives per year at a 1-year cost of $8.78 million, and a moderate sensitivity approach would cost 5.2 additional lives and save $781,616 each year. Conclusions A high-sensitivity approach to field triage consistent with national trauma policy is not cost-effective. The most cost-effective approach to field triage appears closely tied to triage specificity and adherence to triage-based emergency medical services transport practices.
Study objective The location of a patient’s residence is often used for emergency medical services (EMS) system planning. Our objective is to evaluate the association between patient residence and ...emergency incident zip codes for 911 calls. Methods We used data from the 2013 National Emergency Medical Services Information System (NEMSIS) Public-Release Research Dataset. We studied all 911 calls with a valid complaint by dispatch, identifying zip codes for both the residence and incident locations (n=12,376,784). The primary outcomes were geographic and distance discordances between patient residence and incident zip codes. We used a multivariate logistic regression model to determine geographic discordance between residence and incident zip codes by dispatch complaint, age, and sex. We also measured distances between locations with geospatial processing. Results The overall proportion of geographic discordance for all 911 calls was 27.7% (95% confidence interval CI 27.7% to 27.8%) and the median distance discordance was 11.5 miles (95% CI 11.5 to 11.5 miles). Lower geographic discordance rates were found among patients aged 65 to 79 years (20.2%; 95% CI 20.1% to 20.2%) and 80 years and older (14.5%; 95% CI 14.5% to 14.6%). Motor vehicle crashes (63.5%; 95% CI 63.5% to 63.6%), industrial accidents (59.3%; 95% CI 58.0% to 60.6%), and mass casualty incidents (50.6%; 95% CI 49.6% to 51.5%) were more likely to occur outside a patient’s residence zip code. Median network distance between home and incident zip centroid codes ranged from 8.6 to 23.5 miles. Conclusion In NEMSIS, there was geographic discordance between patient residence zip code and call location zip code in slightly more than one quarter of EMS responses records. The geographic discordance rates between residence and incident zip codes were associated with dispatch complaints and age. Although a patient’s residence might be a valid proxy for incident location for elderly patients, this relationship holds less true for other age groups and among different complaints. Our findings have important implications for EMS system planning, resource allocation, and injury surveillance.
Study objective We examine differences in inpatient mortality and hospitalization costs at trauma and nontrauma centers for injuries of minor and moderate severity. Methods Inpatient data sets from ...the California Office of Statewide Health Planning and Development were analyzed for 2009 to 2011. The study population included patients younger than 85 years and admitted to general, acute care hospitals with a primary diagnosis of a minor or moderate injury. Minor injuries were defined as having a New Injury Severity Score less than 5 and moderate injuries as having a score of 5 to 15. Multivariate logistic regression and generalized linear model with log-link and γ distribution were used to estimate differences in adjusted inpatient mortality and costs. Results A total of 126,103 admissions with minor or moderate injury were included in the study population. The unadjusted mortality rate was 6.4 per 1,000 admissions (95% confidence interval CI 5.9 to 6.8). There was no significant difference found in mortality between trauma and nontrauma centers in unadjusted (odds ratio 1.2; 95% CI 0.97 to 1.48) or adjusted models (odds ratio 1.1; 95% CI 0.79 to 1.57). The average cost of a hospitalization was $13,465 (95% CI $12,733 to $14,198) and, after adjustment, was 33.1% higher at trauma centers compared with nontrauma centers (95% CI 16.9% to 51.6%). Conclusion For patients admitted to hospitals for minor and moderate injuries, hospitalization costs in this study population were higher at trauma centers than nontrauma centers, after adjustments for patient clinical-, demographic-, and hospital-level characteristics. Mortality was a rare event in the study population and did not significantly differ between trauma and nontrauma centers.
Abstract Objective Timely transport to designated trauma centers impacts mortality following serious injury. We examined whether the distribution of trauma centers in Chicago has created disparities ...in access to trauma care. Methods Using the Illinois State Trauma Registry, locations of Chicago-area gunshot wounds (GSWs) from 1999-2009 were geocoded and transport times were analyzed for pediatric (age ≤15) and adult (age ≥16) GSWs. Results A total of 11,744 included pediatric and adult GSWs were analyzed. Adults experienced longer mean transport times (11.3 vs 10.2 minutes, p<0.001). Disproportionate numbers of adult GSW victims experienced over 30-minute transport times on Chicago’s south side. Pediatric GSWs demonstrated no such disparity, likely attributable to the presence of a pediatric trauma center on the southeast side. Conclusions Geographic disparities in access to trauma care exist even within urban trauma systems. The absence of an adult trauma center on Chicago’s southeast side has contributed to these disparities.
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