Increased mortality with undertriaged patients in a mature trauma center with an aggressive trauma team activation system

The American College of Surgeons Committee on Trauma (ACS-COT) has determined that a 5 % pre-hospital undertriage [UT; defined as Injury Severity Score (ISS) > 15 and not sent to a trauma center] is an acceptable rate for pre-hospital transfer to a non-trauma center. We sought to determine if this level of undertriage is acceptable within a mature Level II trauma center as a measure of the adequacy of its trauma activation system.

Our trauma activation system encompasses anatomic, physiologic, and mechanism of injury criteria. We defined UT as ISS > 15 and no trauma activation. All UT patients during the period 2000–2010 were compared to properly triaged patients (CT). The variables examined were mortality, emergency department (ED) length of stay (LOS), hospital LOS, complications, Coumadin use, and age >64 years.

There were 18,324 patients admitted, with 1,156 (6.3 %) UT. UT is associated with an increase in mortality [odds ratio (OR) 3.0; 95 % confidence interval (CI) 2.4–3.8; p < 0.001), longer ED LOS (OR 54.5; 95 % CI 45.5–63.5; p < 0.001), and longer hospital LOS (OR 1.7; 95 % CI 1.4–2.1; p < 0.001). In addition, UT patients had a two-fold increase in complications (OR 2.0; 95 % CI 1.6–2.5; p < 0.001). When controlling for age ≥65 years, Revised Trauma Score (RTS) > 7.0, and one or more co-morbidities, UT patients had 2.18 times higher odds of mortality than their CT counterparts (OR 2.18; 95 % CI 1.57–3.01; p < 0.001). Patients on pre-hospital Coumadin (OR 3.61; 95 % CI 3.04–4.30; p < 0.001) and age >64 years (OR 4.93; 95 % CI 4.36–5.58; p < 0.001) were significant predictors of being undertriaged. A p-value ≤ 0.05 was considered to be significant.

Standard trauma activation criteria may not be adequate to identify the at-risk severely injured trauma patient. Further refinement of in-house trauma triage protocols is necessary if trauma centers are to improve outcomes following trauma.