Should we still use motor vehicle intrusion as a sole triage criterion for the use of trauma center resources?

Abstract

Background

Motor vehicle intrusion (MVI) is one of the field triage criteria recommended by the American College of Surgeons Committee of Trauma (ACS-COT) and Centers for Disease Control and Prevention (CDC). However, the evidence supporting its validity is scarce. The purpose of this study was to evaluate the validity of this criterion and assess its impact on overtriage or undertriage.

Patients and methods

This was a retrospective study based on the Los Angeles County Trauma and Emergency Medicine Information System (TEMIS) Trauma database. Included in the analysis were patients with MVI as the sole criterion for trauma center triage. Physiological characteristics, severity of injury, and outcomes of the MVI patients were compared between different age groups. Further, a logistic regression model was used to identify factors significantly associated with the need for trauma center resources.

Results

During the period 2002–2012, a total of 10,554 trauma patients involved in motor vehicle crashes had documentation of MVI. A subgroup of 3998 patients (37.9%) did not meet any other criteria that require immediate transportation to a designated trauma center. Only 0.7% of these patients had hypotension and 0.1% had deterioration of the Glasgow Coma Scale on admission to the emergency room. Overall, 18.8% of patients required trauma center resources defined as intubation in the emergency room, certain surgical procedures, in-hospital death, or intensive care unit admission. Age ≥65 years, male gender, prehospital heart rate >100/min, and systolic blood pressure <110 mmHg were significantly associated with the need for trauma center resources.

Conclusions

The MVI itself did not appear to be a strong indicator for the use of trauma center resources and is associated with excessive overtriage. However, age >65 years, systolic blood pressure <110 mmHg, and heart rate >100/min were significant predictors for the need of trauma center resources. The MVI criterion should be refined for better utilization of trauma center resources.

Introduction

 ^–1Unintentional injury is one of the leading causes of death, particularly in younger age groups, in the USA [1]. In 2008, 5.4 million injured patients were transferred by the emergency medical services (EMS) to emergency rooms (ER) [2]. As such a large number of trauma patients need to be triaged to the appropriate destination, including designated trauma centers. Optimal utilization of trauma center resources is important for good outcomes and cost effectiveness. The American College of Surgeons Committee on Trauma (ACS-COT) and the Centers for Disease Control and Prevention (CDC) have proposed a field triage process to be used by the EMS providers in the prehospital setting [3]. The field triage process is based on physiologic, anatomic, mechanism of injury, and special consideration factors [4]. While some of the criteria are supported by scientific evidence, some other criteria are based on expert anecdotal recommendations [5], [6], [7], [8]. There is a concern that unproven criteria could potentially lead to either overtriage or undertriage and suboptimal care [9].

Motor vehicle intrusion (MVI: >12 in at the occupant site or >18 in at any site) is one of the field triage criteria, mainly based on expert anecdotal opinion [3]. To date, several small studies have been conducted with contradictory results [10], [11], [12], [13], [5]. Thus, we sought to evaluate the validity of the MVI in a large, mature trauma system, as a predictor of the need for trauma centers resources. The purpose of this study was to assess the validity of MVI with no other criterion in field triage following motor vehicle collision. We hypothesized that the overall, MVI is a crude field triage criterion but other associated factors could be valuable in improving its performance.