Emergency physician and nurse discretion accurately triage high-risk trauma patients.
Morgan Schellenberg, Stephen Docherty, Natthida Owattanapanich, Brent Emigh, Paige Lutterman, Lindsey Karavites, Emily Switzer, Matthew Wiepking, Carl Chudnofsky, Kenji Inaba
Author Information
Morgan Schellenberg: Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angele, CA, 90033, USA. morgan.schellenberg@med.usc.edu.
Stephen Docherty: Department of Emergency Medicine, LAC+USC Medical Center, University Of Southern California, Los Angeles, CA, USA.
Natthida Owattanapanich: Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angele, CA, 90033, USA.
Brent Emigh: Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angele, CA, 90033, USA.
Paige Lutterman: Department of Emergency Medicine, LAC+USC Medical Center, University Of Southern California, Los Angeles, CA, USA.
Lindsey Karavites: Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angele, CA, 90033, USA.
Emily Switzer: Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angele, CA, 90033, USA.
Matthew Wiepking: Department of Emergency Medicine, LAC+USC Medical Center, University Of Southern California, Los Angeles, CA, USA.
Carl Chudnofsky: Department of Emergency Medicine, LAC+USC Medical Center, University Of Southern California, Los Angeles, CA, USA.
Kenji Inaba: Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angele, CA, 90033, USA.
PURPOSE: Prehospital trauma team activation (TTA) criteria allow for early identification of severely injured trauma patients. Although most TTA criteria are objective, one TTA criterion is subjective: emergency provider discretion. The study objective was to define the ability of emergency department physician and nurse discretion to accurately perform prehospital triage of high risk trauma patients. METHODS: All highest level TTAs arriving to our American College of Surgeons (ACS)-verified Level 1 trauma center (06/2015-08/2020) were included. Exclusions were undocumented prehospital vitals or discharge disposition. At our institution, TTAs are triggered for standard ACS TTA criteria and age > 70 with traumatic mechanism other than ground level fall. Patients meeting ≥ 1 criterion apart from "Emergency Provider Discretion" were defined as Standard TTAs and patients meeting only "Emergency Provider Discretion" were defined as Discretion TTAs. Univariable/multivariable analyses compared injury data and outcomes. RESULTS: 4540 patients met inclusion/exclusion criteria: 3330 (73%) Standard TTAs and 1210 (27%) Discretion TTAs. Discretion TTAs were younger (34 vs. 37 years, p < 0.001) and more frequently injured by penetrating trauma (38% vs. 33%, p = 0.008), particularly stab wounds (64% vs. 29%). Overtriage rates were comparable after Discretion vs. Standard TTAs (33% vs. 31%, p = 0.141). Blood transfusion < 4 h (31% vs. 32%, p = 0.503) and ICU admission ≥ 3 days (25% vs. 27%, p = 0.058) were comparable between groups. Discretion TTA was independently associated with increased need for emergent surgery (OR 1.316, p = 0.005). CONCLUSIONS: Emergency provider discretion accurately identifies major trauma, with comparable rates of overtriage as standard TTA criteria. Discretion TTAs were as likely as Standard TTAs to require early blood transfusion and prolonged ICU stay. After controlling for confounders, Discretion TTAs were significantly more likely to require emergent surgical intervention. Emergency provider discretion should be recognized as a valid method of identifying major trauma patients at high risk of need for intervention.
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