Evaluation of Prehospital Undertriage in Relation to Trauma Team Activation-Results from a Prospective Study in 12 Level one German Trauma Centers.
Helena Düsing, Paul Hagebusch, Markus Baacke, Dan Bieler, Michael Caspers, Valentin Clemens, Matthias Fröhlich, Lisa Hackenberg, Renè Hartensuer, Sebastian Imach, Kai Oliver Jensen, Annette Keß, Christian Kleber, Fabian Laue, Rolf Lefering, Mindaugas Maslauskas, Gerrit Matthes, André Nohl, Orkun Özkurtul, Thomas Paffrath, Vera Pedersen, Tristan Pfläging, Kai Sprengel, Philipp Störmann, Heiko Trentzsch, Christian Waydhas, Uwe Schweigkofler
Author Information
Helena Düsing: Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Muenster, Germany.
Paul Hagebusch: Department of Trauma Surgery and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt, 60389 Frankfurt am Main, Germany.
Markus Baacke: Department of Trauma Surgery, Hospital of the Merciful Brothers Trier, 54292 Trier, Germany.
Dan Bieler: Department for Trauma Surgery and Orthopedics, Reconstructive Surgery, Hand Surgery, Burn Medicine German Armed Forces Central Hospital Koblenz, 56072 Koblenz, Germany. ORCID
Michael Caspers: Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr. 200, 51109 Cologne, Germany.
Valentin Clemens: Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU Klinikum, 80336 München, Germany.
Matthias Fröhlich: Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr. 200, 51109 Cologne, Germany. ORCID
Lisa Hackenberg: Department for Trauma Surgery and Orthopedics, Reconstructive Surgery, Hand Surgery, Burn Medicine German Armed Forces Central Hospital Koblenz, 56072 Koblenz, Germany.
Renè Hartensuer: Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Muenster, Germany. ORCID
Sebastian Imach: Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimerstr. 200, 51109 Cologne, Germany.
Kai Oliver Jensen: Department of Trauma, University Hospital Zurich (USZ), Raemistr. 100, 8091 Zurich, Switzerland. ORCID
Annette Keß: Department of Orthopaedics, Trauma Surgery and Plastic Surgery, Leipzig University Hospital, Liebigstr. 16, 04103 Leipzig, Germany.
Christian Kleber: Department of Orthopaedics, Trauma Surgery and Plastic Surgery, Leipzig University Hospital, Liebigstr. 16, 04103 Leipzig, Germany.
Fabian Laue: Department of Trauma and Reconstructive Surgery, Ernst von Bergmann Klinikum Potsdam, 14467 Potsdam, Germany.
Rolf Lefering: Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, 51067 Köln, Germany.
Mindaugas Maslauskas: Department of Trauma Surgery, Hospital of the Merciful Brothers Trier, 54292 Trier, Germany.
Gerrit Matthes: Department of Trauma and Reconstructive Surgery, Ernst von Bergmann Klinikum Potsdam, 14467 Potsdam, Germany.
André Nohl: Center for Emergency Medicine, BG Klinikum Duisburg, 47249 Duisburg, Germany. ORCID
Orkun Özkurtul: Department of Orthopaedics, Trauma Surgery and Plastic Surgery, Leipzig University Hospital, Liebigstr. 16, 04103 Leipzig, Germany. ORCID
Thomas Paffrath: Department of Trauma and Hand Surgery, Cellitinnen-Severinsklösterchen, Augustinerinnen Hospital, 50678 Köln, Germany.
Vera Pedersen: Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), LMU Klinikum, 80336 München, Germany.
Tristan Pfläging: Department for Trauma Surgery and Orthopedics, Reconstructive Surgery, Hand Surgery, Burn Medicine German Armed Forces Central Hospital Koblenz, 56072 Koblenz, Germany.
Kai Sprengel: Hirslanden Clinic St. Anna, Faculty of Health Sciences and Medicine, University of Lucerne, 6006 Lucerne, Switzerland. ORCID
Philipp Störmann: Department of Trauma and Orthopedic Surgery, University Hospital Frankfurt, 60596 Frankfurt am Main, Germany.
Heiko Trentzsch: Institut für Notfallmedizin und Medizinmanagement (INM), LMU Klinikum, LMU München, 80336 Munich, Germany.
Christian Waydhas: Department of Trauma Surgery, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany. ORCID
Uwe Schweigkofler: Department of Trauma Surgery and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt, 60389 Frankfurt am Main, Germany.
This prospective, multicenter observational cohort study was carried out in 12 Trauma centers in Germany and Switzerland. Its purpose was to evaluate the rate of undertriage, as well as potential consequences, and relate these with different Trauma Team Activation Protocols (TTA-Protocols), as this has not been done before in Germany. : Each Trauma center collected the data during a three-month period between December 2019 and February 2021. All 12 participating hospitals are certified as supra-regional Trauma centers. Here, we report a subgroup analysis of undertriaged patients. Those included in the study were all consecutive adult patients (age ≥ 18 years) with acute Trauma admitted to the emergency department of one of the participating hospitals by the prehospital emergency medical service (EMS) within 6 h after Trauma. The data contained information on age, sex, Trauma mechanism, pre- and in-hospital physiology, emergency interventions, emergency surgical interventions, intensive care unit (ICU) stay, and death within 48 h. Trauma team activation (TTA) was initiated by the emergency medical services. This should follow the national guidelines for severeTrauma using established field triage criteria. We used various denominators, such as ISS, and criteria for the appropriateness of TTA to evaluate the undertriage in four groups. : This study included a total of 3754 patients. The average injury severity score was 5.1 points, and 7.0% of cases ( = 261) presented with an injury severity score (ISS) of 16+. TTA was initiated for a total of 974 (26%) patients. In group 1, we evaluated how successful the actual practice in the EMS was in identifying patients with ISS 16+. The undertriage rate was 15.3%, but mortality was lower in the undertriage cohort compared to those with a TTA (5% vs. 10%). In group 2, we evaluated the actual practice of EMS in terms of identifying patients meeting the appropriateness of TTA criteria; this showed a higher undertriage rate of 35.9%, but as seen in group 1, the mortality was lower (5.9% vs. 3.3%). In group 3, we showed that, if the EMS were to strictly follow guideline criteria, the rate of undertriage would be even higher (26.2%) regarding ISS 16+. Using the appropriateness of TTA criteria to define the gold standard for TTA (group 4), 764 cases (20.4%) fulfilled at least one condition for retrospective definition of TTA requirement. : Regarding ISS 16+, the rate of undertriage in actual practice was 15.3%, but those patients did not have a higher mortality.
