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Deaths and high-risk trauma patients missed by standard trauma data sources

Newgard, Craig D. MD, MPH; Fu, Rongwei PhD; Lerner, E. Brooke PhD; Daya, Mohamud MD, MS; Wright, Dagan PhD; Jui, Jonathan MD, MPH; Mann, N. Clay PhD; Bulger, Eileen MD; Hedges, Jerris MD, MMM; Wittwer, Lynn MD; Lehrfeld, David MD; Rea, Thomas MD, MPH

Journal of Trauma and Acute Care Surgery: September 2017 - Volume 83 - Issue 3 - p 427–437
doi: 10.1097/TA.0000000000001616
Original Articles

BACKGROUND Trauma registries are used to evaluate and improve trauma care, yet potentially miss certain trauma deaths and high-risk patients. We estimated the number of missed deaths and high-risk trauma patients using commonly available sources of trauma data and resulting bias in quality metrics for field trauma triage.

METHODS This was a preplanned secondary analysis of a population-based prospective cohort of injured patients transported by 44 emergency medical services agencies to 28 hospitals in seven Northwest counties from January 1, 2011 to December 31, 2011 and followed through hospitalization. We used a stratified probability sampling design for 17,633 patients, weighted to represent all 53,487 injured patients transported by emergency medical services. We compared patients meeting National Trauma Data Bank (NTDB) criteria (weighted n = 5,883), all injured patients presenting to major trauma centers (weighted n = 16,859), and all admitted patients (weighted n = 18,433), to the full sample. Outcomes included in-hospital mortality, Injury Severity Score (ISS) of 16 or higher, and critical resource use within 24 hours.

RESULTS Among 53,487 injured patients, there were 520 emergency department and in-hospital deaths, 1,745 with ISS of 16 or higher, and 923 requiring early critical resources. Compared to the full cohort, the NTDB cohort missed 62.1% of deaths, 39.2% of patients with ISS of 16 or higher, and 23.8% requiring early critical resources, especially older adults injured by falls and admitted to nontrauma hospitals. The admission cohort missed the fewest patients—23.3% of deaths, 10.5% with an ISS of 16 or higher, and 13.1% requiring early resources. Compared to triage sensitivity in the full cohort (66.2%), sensitivity estimates ranged from 63.6% (all admissions) to 93.4% (NTDB). Compared to triage specificity in the full cohort (87.8%), estimates ranged from 36.4% (NTDB) to 77.3% (all admissions).

CONCLUSION Common sources of trauma data miss substantial numbers of trauma deaths and high-risk trauma patients and can generate biased estimates for trauma system quality metrics.

LEVEL OF EVIDENCE Epidemiologic, level III.

From the Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine (C.D.N., M.D., J.J.), Oregon Health & Science University Portland, Oregon; Department of Public Health and Preventive Medicine (R.F., D.W.), Oregon Health & Science University, Portland, Oregon; Department of Emergency Medicine (E.B.L.), Medical College of Wisconsin, Milwaukee, Wisconsin; Tualatin Valley Fire & Rescue (M.D.), Tualatin, Oregon; Injury and Violence Prevention Section Oregon Health Authority (D.W.), Portland, Oregon; Emergency Medical Services & Trauma Systems (D.W., D.L.), Oregon Health Authority, Portland Oregon; Multnomah County Emergency Medical Services (J.J.), Portland, Oregon; Intermountain Injury Control Research Center, Department of Pediatrics (N.C.M.), University of Utah, Salt Lake City, Utah; Department of Surgery (E.B.), University of Washington, Seattle, Washington; Department of Medicine (J.H.), John A. Burns School of Medicine, University of Hawaii-Manoa, Honolulu, Hawaii; Clark Regional Emergency Services Agency (L.W.), Vancouver, Washington; PeaceHealth Southwest Medical Center (L.W.), Vancouver, Washington; Department of Internal Medicine (T.R.), University of Washington; King County Emergency Medical Services (T.R.), Seattle, Washington.

Submitted: April 14, 2017, Accepted: May 14, 2017, Published online: June 9, 2017.

Findings from this study have not been presented at any national or regional meetings.

Address for reprints: Craig D. Newgard, MD, MPH, Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code CR-114, Portland, Oregon 97239–3098; email:

© 2017 Lippincott Williams & Wilkins, Inc.