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The found down patient: A Western Trauma Association multicenter study

Howard, Benjamin M. MD, MPH; Kornblith, Lucy Z. MD; Conroy, Amanda S.; Burlew, Clay Cothren MD; Wagenaar, Amy E.; Chouliaras, Konstantinos MD; Hill, J. Ryan; Carrick, Matthew M. MD; Mallory, Gina R. RN, CCRC; Watkins, Jeffrey R. MD; Truitt, Michael S. MD; Ciesla, David J. MD; Davis, Jaime A.; Vail, Christopher J. PA-C, MMCi; Kemp Bohan, Phillip M.; Nelson, Mary F. RN, MPA; Callcut, Rachael A. MD, MSPH; Cohen, Mitchell Jay MDWestern Trauma Association Multicenter Study Group

Journal of Trauma and Acute Care Surgery: December 2015 - Volume 79 - Issue 6 - p 976–982
doi: 10.1097/TA.0000000000000862
WTA Plenary Papers

BACKGROUND Unconscious patients who present after being “found down” represent a unique triage challenge. These patients are selected for either trauma or medical evaluation based on limited information and have been shown in a single-center study to have significant occult injuries and/or missed medical diagnoses. We sought to further characterize this population in a multicenter study and to identify predictors of mistriage.

METHODS The Western Trauma Association Multicenter Trials Committee conducted a retrospective study of patients categorized as found down by emergency department triage diagnosis at seven major trauma centers. Demographic, clinical, and outcome data were collected. Mistriage was defined as patients being admitted to a non–triage-activated service. Logistic regression was used to assess predictors of specified outcomes.

RESULTS Of 661 patients, 33% were triaged to trauma evaluations, and 67% were triaged to medical evaluations; 56% of all patients had traumatic injuries. Trauma-triaged patients had significantly higher rates of combined injury and a medical diagnosis and underwent more computed tomographic imaging; they had lower rates of intoxication and homelessness. Among the 432 admitted patients, 17% of them were initially mistriaged. Even among properly triaged patients, 23% required cross-consultation from the non–triage-activated service after admission. Age was an independent predictor of mistriage, with a doubling of the rate for groups older than 70 years. Combined medical diagnosis and injury was also predictive of mistriage. Mistriaged patients had a trend toward increased late-identified injuries, but mistriage was not associated with increased length of stay or mortality.

CONCLUSION Patients who are found down experience significant rates of mistriage and triage discordance requiring cross-consultation. Although the majority of found down patients are triaged to nontrauma evaluation, more than half have traumatic injuries. Characteristics associated with increased rates of mistriage, including advanced age, may be used to improve resource use and minimize missed injury in this vulnerable patient population.

LEVEL OF EVIDENCE Epidemiologic study, level III.

Supplemental digital content is available in the text.

From the Department of Surgery (B.M.H., L.Z.K., A.S.C., M.F.N., R.A.C., M.J.C.), San Francisco General Hospital, University of California San Francisco, San Francisco; and Division of Trauma Surgery and Surgical Critical Care (K.C., J.R.H.), University of Southern California, Los Angeles, California; Department of Surgery (C.C.B., A.E.W.), Denver Health Medical Center, University of Colorado, Denver, Colorado; Acute Care Surgery Specialty (M.M.C., G.R.M.), Medical Center of Plano, Plano; and Methodist Dallas Medical Center (J.R.W., M.S.T.), Dallas, Texas; Department of Surgery (D.J.C., J.A.D.), University of South Florida College of Medicine, Tampa, Florida; Duke University Medical Center (C.J.V., P.M.K.B.), Durham, North Carolina.

Submitted: March 10, 2015, Revised: July 28, 2015, Accepted: August 19, 2015, Published online: October 19, 2015.

The Western Trauma Association Multicenter Study Group members include Kenji Inaba, MD, Peter J. Rappa, MD, Nimesh H. Patel, MD, Mark L. Shapiro, MD, Kimen S. Balhotra, Jeremy M. Crane, Melissa R. Forde, Kaitlin Z. Gee, Eric K. Hong, Robert E. Lew, and Caitlin K. Robinson.

This study was presented at the 45th annual meeting of the Western Trauma Association, March 1–6, 2015, in Telluride, Colorado.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Address for reprints: Mitchell Jay Cohen, MD, Department of Surgery, Ward 3A, San Francisco General Hospital, 1001 Potrero Ave, Room 3C-38, San Francisco, CA 94110; email:

© 2015 Lippincott Williams & Wilkins, Inc.