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Evaluation of the performance of French physician-staffed emergency medical service in the triage of major trauma patients

Hamada, Sophie Rym MD; Gauss, Tobias MD; Duchateau, François-Xavier MD; Truchot, Jennifer MD; Harrois, Anatole MD; Raux, Mathieu MD, PHD; Duranteau, Jacques MD, PHD; Mantz, Jean MD, PHD; Paugam-Burtz, Catherine MD, PHD

Journal of Trauma and Acute Care Surgery: June 2014 - Volume 76 - Issue 6 - p 1476–1483
doi: 10.1097/TA.0000000000000239
Original Articles
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Background Proper prehospital triage of trauma patients is a cornerstone for the process of care of trauma patients. In France, emergency physicians perform this process according to a national triage algorithm called Vittel Triage Criteria (VTC), introduced in 2002 to help the triage decision-making process. The aim of this two-center study was to evaluate the performance of the triage process based on the VTC to identify major trauma patients in the Paris area.

Methods This was a retrospective analysis of two cohorts. The first cohort consisted of all patients admitted between January 2011 and September 2012 in two trauma referral centers in the region of Paris (Ile de France) and allowed estimation of overtriage. Undertriage was assessed in a second cohort made up of all prehospital trauma interventions from one emergency medicine sector during the same period. Adequate triage was defined by a direct admission of patients with an Injury Severity Score (ISS) greater than 15 into one of the regional trauma centers, and undertriage was defined as an initial nonadmission to a trauma center. Overtriage was defined by an admission of patients with an ISS of 15 or lower to a trauma center. The performance of the VTC was evaluated according to a strict to-the-letter application of the VTC and termed as theoretical triage. Logistic regression was performed to identify VTC criteria able to predict major trauma.

Results Among 998 admitted patients of the first cohort, 173 patients (17%) were excluded because they were not directly admitted in the first 24 hours. In the first cohort (n = 825), adequate triage was 58% and overtriage was 42%. In the second cohort (n = 190), adequate triage was 40%, overtriage was 60%, and undertriage was less than 1%. Theoretical triage generated a nonsignificantly lower overtriage and a higher undertriage compared with observed triage. The most powerful predictors of major trauma were paralysis (odds ratio [OR,] 0.09; 95% confidence interval [CI], 0.03–0.22), flail chest (OR, 0.1; 95% CI, 0.01–0.03), and Glasgow Coma Scale (GCS) score of less than 13 (OR, 0.28; 95% CI, 0.17–0.45), whereas global assessments of speed and mechanism alone were poor predictors (positive likelihood ratio, 0.92–1.4).

Conclusion In the Paris area, the French physician-based prehospital triage system for patients with suspicion of major trauma showed a high rate of overtriage and a low rate of undertriage. Criteria of global assessment of speed and mechanism alone were poor predictors of major trauma.

Critical Care & Anesthesiology Department (S.R.H.), AP-HP, Hôpital Beaujon, 100 boulevard du général Leclerc, 92110 Clichy, Hôpitaux Universitaires Paris Nord Val de Seine, F-75018, Paris, France; Critical Care & Anesthesiology Department (S.R.H.), AP-HP, Hôpital Bicêtre, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, Hôpitaux Universitaires Paris Sud, F-94275, Le Kremlin Bicêtre, France; University Paris Diderot (T.G.), Sorbonne Paris Cité, F-75018, Paris, France; Critical Care & Anesthesiology Department, AP-HP, Hôpital Beaujon, 100 boulevard du général Leclerc, 92110 Clichy, Hôpitaux Universitaires Paris Nord Val de Seine, F-75018, Paris, France; SMUR (F.X.D.), AP-HP, Hôpital Beaujon, 100 boulevard du général Leclerc, 92110 Clichy, Hôpitaux Universitaires Paris Nord Val de Seine, F-75018, Paris, France; Urgences - SMUR department (J.T.), Hôpital Lariboisière, 2 rue Ambroise Paré, 75475 Paris, Hôpitaux Universitaires Paris Nord Val de Seine, F-75018, Paris, France; University Paris Sud (A.H.), F-94275, Le Kremlin Bicêtre, France; Critical Care & Anesthesiology Department, AP-HP, Hôpital Bicêtre, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, Hôpitaux Universitaires Paris Sud, F-94275, Le Kremlin Bicêtre, France; University Pierre Marie Curie (M.R.), F 75013, Paris France; UR 10 UPMC, Paris VI, Critical Care & Anesthesiology Department, AP-HP, Hôpital Pitie Salpétrière, 47-83 Boulevard de l’Hôpital, 75013 Paris, Hôpitaux Universitaires Pitié Salpétrière, F 75013, Paris, France; University Paris Sud (J.D.), F-94275, Le Kremlin Bicêtre, France; Equipe universitaire 3509 Paris VII, Paris XI, Paris XIII; Critical Care & Anesthesiology Department, AP-HP, Hôpital Bicêtre, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, Hôpitaux Universitaires Paris Sud, F-94275, Le Kremlin Bicêtre, France; University Paris Diderot (J.M.), Sorbonne Paris Cité, F-75018, Paris, France; Critical Care & Anesthesiology Department, AP-HP, Hôpital Beaujon, 100 boulevard du général Leclerc, 92110 Clichy, Hôpitaux Universitaires Paris Nord Val de Seine, F-75018, Paris, France; University Paris Diderot (C.P.-B.), Sorbonne Paris Cité, F-75018, Paris, France; Critical Care & Anesthesiology Department, AP-HP, Hôpital Beaujon, 100 boulevard du général Leclerc, 92110 Clichy, Hôpitaux Universitaires Paris Nord Val de Seine, F-75018, Paris, France.

Submitted: March 6, 2013, Revised: February 13, 2014, Accepted: February 14, 2014.

Address for reprints: Sophie Rym Hamada, MD, Critical Care & Anesthesiology Department, AP-HP, Hôpital Beaujon, 100 boulevard du général Leclerc, 92110 Clichy, Hôpitaux Universitaires Paris Nord Val de Seine, F-75018, Paris, France & Critical Care & Anesthesiology Department, AP-HP, Hôpital Bicêtre 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, Hôpitaux Universitaires Paris Sud, F-94275, Le Kremlin Bicêtre, France; email: sophiehamada@hotmail.com.

© 2014 Lippincott Williams & Wilkins, Inc.