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Noncompliance with American College of Surgeons Committee on Trauma recommended criteria for full trauma team activation is associated with undertriage deaths

Tignanelli, Christopher, J., MD; Vander Kolk, Wayne, E., MD; Mikhail, Judy, N., PhD; Delano, Matthew, J., MD, PhD; Hemmila, Mark, R., MD

Journal of Trauma and Acute Care Surgery: February 2018 - Volume 84 - Issue 2 - p 287–294
doi: 10.1097/TA.0000000000001745
AAST 2017 Podium Paper
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CME

BACKGROUND The appropriate triage of acutely injured patients within a trauma system is associated with improved rates of mortality and optimal resource utilization. The American College of Surgeons Committee on Trauma (ACS-COT) put forward six minimum criteria (ACS-6) for full trauma team activation (TTA). We hypothesized that ACS-COT–verified trauma center compliance with these criteria is associated with low undertriage rates and improved overall mortality.

METHODS Data from a state-wide collaborative quality initiative was used. We used data collected from 2014 through 2016 at 29 ACS verified Level I and II trauma centers. Inclusion criteria are: adult patients (≥16 years) and Injury Severity Score of 5 or less. Quantitative data existed to analyze four of the ACS-6 criteria (emergency department systolic blood pressure ≤ 90 mm Hg, respiratory compromise/intubation, central gunshot wound, and Glasgow Coma Scale score < 9). Patients were considered to be undertriaged if they had major trauma (Injury Severity Score > 15) and did not receive a full TTA.

RESULTS 51,792 patients were included in the study. Compliance with ACS-6 minimum criteria for full TTA varied from 51% to 82%. The presence of any ACS-6 criteria was associated with a high intervention rate and significant risk of mortality (odds ratio, 16.7; 95% confidence interval, 15.2–18.3; p < 0.001). Of the 1,004 deaths that were not a full activation, 433 (43%) were classified as undertriaged, and 301 (30%) had at least one ACS-6 criterion present. Undertriaged patients with any ACS-6 criteria were more likely to die than those who were not undertriaged (30% vs. 21%, p = 0.001). Glasgow Coma Scale score less than 9 and need for emergent intubation were the ACS-6 criteria most frequently associated with undertriage mortality.

CONCLUSION Compliance with ACS-COT minimum criteria for full TTA remains suboptimal and undertriage is associated with increased mortality. These data suggest that the most efficient quality improvement measure around triage should be ensuring compliance with the ACS-6 criteria. This study suggests that practice pattern modification to more strictly adhere to the minimum ACS-COT criteria for full TTA will save lives.

LEVEL OF EVIDENCE Care management, level III.

Fom the Department of Surgery (C.J.T.), University of Minnesota, Minneapolis, Minnesota; Department of Surgery (W.E.V.K.), Mercy Health, Grand Rapids, Michigan; Department of Surgery (J.N.M., M.J.D., M.R.H.), University of Michigan, Ann Arbor, Michigan.

Submitted: August 31, 2017, Revised: November 3, 2017, Accepted: November 9, 2017, Published online: November 21, 2017.

This study was presented at the 76th annual meeting of American Association for the Surgery of Trauma Meeting, September 14–17, 2017, in Baltimore, Maryland.

Address for reprints: Christopher J. Tignanelli, MD, University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN 55455; email: ctignane@med.umich.edu.

© 2018 Lippincott Williams & Wilkins, Inc.