Research
Effectiveness of prehospital trauma triage guidelines for the identification of major trauma in elderly motor vehicle crash victims*,**,

https://doi.org/10.1067/men.2003.59Get rights and content

Abstract

Introduction: Undertriage of older trauma victims has been a persistent and serious problem. Because of physiologic changes and pre-existing disease, blunt trauma in older persons is often covert. Prehospital trauma triage guidelines developed for use with a general adult population may not be sensitive enough to detect covert injuries in elderly trauma patients. This study examined the sensitivity and specificity of one state's prehospital trauma triage guidelines for adults, with a particular focus on the triage of elderly persons. Methods: This retrospective study used patient discharge data to examine the sensitivity (a measure of undertriage) and specificity (a measure of overtriage) of the adult prehospital trauma triage guidelines in 3 counties with level I trauma centers. Sensitivity and specificity of young and middle-aged adults was compared with that of older adults. Results: Undertriage was 8% for young and middle-aged men, 12% for young and middle-aged women, 18% for older men, and 15% for older women. Overtriage was present in all age groups, indicating that many motor vehicle crash victims who were admitted to trauma centers could have been admitted to nontrauma center hospitals. Discussion: Low sensitivity and specificity of trauma triage guidelines results in undertriage and overtriage. These guidelines should include age as a decision point to avoid placing older persons at risk for undertriage. Although some degree of overtriage is unavoidable without increasing undertriage, efforts should be made to minimize this costly occurrence.

Section snippets

Prehospital trauma triage

The clinical effectiveness of any trauma triage process lies in its ability to differentiate persons who have and have not sustained major trauma. Thus, when we think in terms of clinical effectiveness, we are actually referring to the validity, or accuracy, of the process, expressed as sensitivity and specificity. In epidemiologic terms,8 sensitivity is the probability of a positive test when disease is present, whereas specificity is the probability of a negative test when the disease is

Methods

This retrospective database study used information from the New Jersey Department of Health and Senior Services UB-92 Patient Discharge Data for 2000, the most recent year for which data were available. This statewide database includes multiple data elements for all persons discharged from acute care hospitals in any specified year.

Sample

The final sample included 2063 male and female MVC victims whose ages ranged from 25 to 97 years. Group 1, men and women ages 25 to 64 years, included 1600 persons (77.6%). Group 2, men and women ages 65 to 97 years, included 463 persons (22.4%). Additional demographic information regarding the sample is presented in Table 3.

. Demographic characteristics of study sample (N = 2063)

GroupGenderNo. (%)Age range (y)Mean age (y)Age SDISS rangeMean ISSISS SD
Group 1 (ages 25-64 y)Male980 (47.50)25-6440.58

Discussion

The goal of trauma triage is rapid differentiation of major and minor trauma victims and transportation to the appropriate level of care. Trauma triage guidelines were developed by states to facilitate such differentiation. Although there is no widely held standard for acceptable degrees of undertriage and overtriage, Phillips et al3 recommended that undertriage not exceed 5% and overtriage not exceed 20%. Comparison of undertriage rates in this study to Phillips' recommendation indicates that

Recommendations for future research

This study did not intend to identify the causes of undertriage and overtriage or methods to prevent it from occurring. Moreover, further research is warranted to examine the sensitivity and specificity of the prehospital trauma triage guidelines throughout the entire state with a focus on age, gender differences, and the influence of selected preexisting diseases, particularly among older adults. Studies to examine “what went wrong” when under- and overtriage occur are also needed.

Moreover,

Limitations

The study sample was drawn from MVC victims who were admitted to acute care hospitals for treatment of their injuries. Excluded from the study were persons who died at the scene, en route to the hospital, or in the emergency department, as well as persons who were treated and released from the emergency department.

Implications for practice

Prehospital trauma triage guidelines have the potential to reduce preventable deaths, disability, and health care costs. In 1999 the ACS-COT11 recommended that age, as well as the existence of selected pre-existing diseases, be considered during prehospital triage of trauma victims. In light of the findings from this study and the 1999 ACS-COT recommendations, New Jersey and other states with similar guidelines should strongly consider adopting all of the Committee's prehospital triage

Acknowledgements

I acknowledge the valued contributions of Joanne Stevenson, RN, PhD, FAAN, professor emeritus, Rutgers University, who critiqued the proposal during the development process and edited the manuscript, and Howard Bondell, MS, PhD(c), Rutgers University, Department of Statistics, who performed the statistical analyses and assisted with manuscript editing.

References (11)

  • D McMahon et al.

    The injured elderly in the trauma intensive care unit

    Surg Clin North Am

    (2000)
  • American College of Surgeons. National trauma data bank

  • S Phillips et al.

    The failure of triage criteria to identify geriatric patients with trauma: Results from the Florida trauma triage study

    J Trauma Injury Infection Crit Care

    (1996)
  • M Zimmer-Gembeck et al.

    Triage in an established trauma system

    J Trauma Injury Infection Crit Care

    (1995)
  • M Huei-Ming et al.

    Compliance with prehospital triage protocols for major trauma patients

    J Trauma Injury Infection Crit Care

    (1999)
There are more references available in the full text version of this article.

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*

Funding for this study was provided by a combined grant from the Emergency Nurses Association Foundation and Sigma Theta Tau International and grants from the Rutgers University College of Nursing, Office of Research and Grants, and the Rutgers University College of Nursing Faculty Development Award Program.

**

For reprints, write: Linda J. Scheetz, EdD, APRN, BC, CEN, Assistant Professor, College of Nursing, Rutgers, The State University of NJ, 180 University Ave, Newark, NJ 07102-1897; E-mail: [email protected] .

J Emerg Nurs 2003;29:109-15.

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