The trade-offs in field trauma triage: A multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies

Craig Newgard, Renee Y. Hsia, N. Clay Mann, Terri Schmidt, Ritu Sahni, Eileen M. Bulger, N. Ewen Wang, James F. Holmes, Ross Fleischman, Dana Zive, Kristan Staudenmayer, Jason S. Haukoos, Nathan Kuppermann

Research output: Contribution to journalArticle

23 Citations (Scopus)

Abstract

Background: National benchmarks for trauma triage sensitivity (≥95%) and specificity (≥50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices. Methods: This was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity. Results: A total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4%) had ISS of 16 or greater. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4%). Conclusion: Reaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in overtriage). A 90% sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm. Level Of Evidence: Diagnostic test, level II.

Original languageEnglish (US)
Pages (from-to)1298-1306
Number of pages9
JournalJournal of Trauma and Acute Care Surgery
Volume74
Issue number5
DOIs
StatePublished - May 2013

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Triage
Wounds and Injuries
Emergency Medical Services
Benchmarking
Injury Severity Score
Databases
Sensitivity and Specificity
Decision Trees
Glasgow Coma Scale
Routine Diagnostic Tests
Medical Records
Registries
Hospital Emergency Service
Cohort Studies
Retrospective Studies
Regression Analysis

Keywords

  • emergency medical services
  • serious injury
  • trauma systems
  • Triage

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Surgery

Cite this

The trade-offs in field trauma triage : A multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies. / Newgard, Craig; Hsia, Renee Y.; Mann, N. Clay; Schmidt, Terri; Sahni, Ritu; Bulger, Eileen M.; Wang, N. Ewen; Holmes, James F.; Fleischman, Ross; Zive, Dana; Staudenmayer, Kristan; Haukoos, Jason S.; Kuppermann, Nathan.

In: Journal of Trauma and Acute Care Surgery, Vol. 74, No. 5, 05.2013, p. 1298-1306.

Research output: Contribution to journalArticle

Newgard, C, Hsia, RY, Mann, NC, Schmidt, T, Sahni, R, Bulger, EM, Wang, NE, Holmes, JF, Fleischman, R, Zive, D, Staudenmayer, K, Haukoos, JS & Kuppermann, N 2013, 'The trade-offs in field trauma triage: A multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies', Journal of Trauma and Acute Care Surgery, vol. 74, no. 5, pp. 1298-1306. https://doi.org/10.1097/TA.0b013e31828b7848
Newgard, Craig ; Hsia, Renee Y. ; Mann, N. Clay ; Schmidt, Terri ; Sahni, Ritu ; Bulger, Eileen M. ; Wang, N. Ewen ; Holmes, James F. ; Fleischman, Ross ; Zive, Dana ; Staudenmayer, Kristan ; Haukoos, Jason S. ; Kuppermann, Nathan. / The trade-offs in field trauma triage : A multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies. In: Journal of Trauma and Acute Care Surgery. 2013 ; Vol. 74, No. 5. pp. 1298-1306.
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abstract = "Background: National benchmarks for trauma triage sensitivity (≥95{\%}) and specificity (≥50{\%}) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices. Methods: This was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity. Results: A total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4{\%}) had ISS of 16 or greater. As the 95{\%} sensitivity target for triage was approached (from the current value of 87.5{\%}), decision tree complexity increased, specificity decreased (from 62.8{\%} to 18.7{\%}), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4{\%}). Conclusion: Reaching the field triage sensitivity benchmark of 95{\%} would require a large decrease in specificity (increase in overtriage). A 90{\%} sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm. Level Of Evidence: Diagnostic test, level II.",
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AU - Schmidt, Terri

AU - Sahni, Ritu

AU - Bulger, Eileen M.

AU - Wang, N. Ewen

AU - Holmes, James F.

AU - Fleischman, Ross

AU - Zive, Dana

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N2 - Background: National benchmarks for trauma triage sensitivity (≥95%) and specificity (≥50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices. Methods: This was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity. Results: A total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4%) had ISS of 16 or greater. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4%). Conclusion: Reaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in overtriage). A 90% sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm. Level Of Evidence: Diagnostic test, level II.

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