Background: Under-triaged trauma patients have worse clinical outcomes. We evaluated the capability of four pre-hospital variables to identify this population at the lowest level trauma activation (level 3). Methods: A retrospective review of adult trauma activations from 2004 to 2014 was completed. Pre-hospital vital signs and Glasgow Coma Scale were converted to categorical variables. Patients were under-triaged based on meeting current level 1 or 2 criteria, or requiring a pre-defined critical intervention. Logistic regression was used to determine the association between the pre-hospital variables and under-triaged patients. Odds ratios and 95% confidence intervals were calculated for a comprehensive model, grouping all causes of under-triage as a single unit, and 16 individual models, one for each under-triage criterion. A new level 2 criterion was generated and internally validated. Results: In total, 12,332 activations occurred during the study period. Four hundred and sixty-six (5.9%) patients were under-triaged. Compared to patients with a normal respiratory rate (RR), tachypneic patients were more likely to be under-triaged for any reason, OR 1.7 [1.3–2.1], p < 0.001. In the individual event analysis, tachypneic patients were more likely to have flail chest, OR 22 [2.9–168.3], p = 0.003; require a chest tube, OR 3 [1.8–4.9], p < 0.001; or require emergent intubation, OR 1.6 [1.1–2.8], p = 0.04, compared to patients with a normal RR. The data-driven triage modification was tachypnea with suspected thoracic injury which reduced the under-triage rate by 1.2%. Conclusion: Tachypnea with suspected thoracic injury is the strongest level 2 triage modification to reduce level 3 under-triage.
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