Optimization of Trauma Care: A Two‑tiered Inhospital Trauma Team Response System

Document Type: Original Article

Authors

Departments of Trauma Surgery and 1Emergency Medicine, VU University Medical Center, Amsterdam, The Netherlands

Abstract

Background: To improve utilization of resources and reduce overtriage, two‑tiered trauma team activation (TTA) system was implemented.
The system activates a complete or selective trauma team (CTT, STT). Activation is based on the mechanism of injury (MOI), prehospital vital
signs and injuries. Objectives: The objective was to evaluate the feasibility, effectiveness and safety of the implementation of a two‑tiered
system and whether the triage is done according to the TTA criteria. Methods: A prospective observational study was performed at the
emergency department (ED) of a Level I trauma center. Data were collected on TTA criteria, patient demographics, MOI, prehospital vital
signs, imaging modalities and blood gas analysis in the ED and inhospital data. Results: In 3 months, 186 patients were presented to the trauma
resuscitation room. Thirty‑four patients were excluded, 152 patients were included for analysis. Median age was 48 years (range 1–93), 64%
were males. In 73%, the CTT was activated, in 27% the STT, the STT was upgraded three times. Seventy‑nine patients had to be admitted,
the median length of stay was 5 days (range 1–62). Thirty‑eight patients needed Intensive Care Unit (ICU) admission; the median ICU stay
was 3 days (range 1–33). Three patients died in the resuscitation room, in total, nine patients died. Overtriage was 29% and undertriage 7%.
No significant difference was found for mortality, duration of hospital admission or ICU admission across the four groups (correct activation
STT, undertriage, overtriage, and correct activation CTT). Conclusions: This TTA system identifies those patients in need of a CTT adequately
with an undertriage percentage of 7%, indicative of improved care for the severely injured and a more appropriate use of resources. With this
model, the overtriage is set to an acceptable percentage of 29%.

Keywords


1. Government of the Netherlands, the Ministry of Health, Welfare

and Sport. Policy Vision Traumacare 2006‑2010; 2010. Available

from: http://www.rijksoverheid.nl/documenten‑en‑publicaties/

kamerstukken/2006/04/19/beleidsvisie‑traumazorg‑2006‑2010.html.

[Last accessed on 2016 Nov 14].

2. Fung Kon Jin PH, van Olffen TB, Goslings JC, Luitse JS, Ponsen KJ.

In‑hospital downgrading of the trauma team: Validation of the academic

medical center downgrading criteria. Injury 2006;37:33‑40.

3. Savitsky E, Eastridge B, Katz D, Cooper R. Combat Casualty Care:

Lessons Learned from OEF and OIF. Fort Sam Houston: The Office of

the Surgeon General Borden Institute; 2011.

4. Giannakopoulos GF, Unal Y, Bloemers FW, Bakker FC. Overtriage, a

problem in handeling the prehospital triage model in the trauma region

North‑West Netherlands. Ned Tijdschr Trauma 2009;17:3‑7.

5. American College of Surgeons, Committee on Trauma. Recourses for

Optimal Care of the Injured Patient; 2014. Available from: https://www.

facs.org/~/media/files/quality%20programs/trauma/vrcresources.ashx.

[Last accessed on 2016 Nov 10].

6. Boyle MJ, Smith EC, Archer F. Is mechanism of injury alone a useful

predictor of major trauma? Injury 2008;39:986‑92.

7. Tiel Groenestege‑Kreb D, van Maarseveen O, Leenen L. Trauma team.

Br J Anaesth 2014;113:258‑65.

8. Cherry RA, King TS, Carney DE, Bryant P, Cooney RN. Trauma team

activation and the impact on mortality. J Trauma 2007;63:326‑30.

9. Kouzminova N, Shatney C, Palm E, McCullough M, Sherck J. The

efficacy of a two‑tiered trauma activation system at a level I trauma

center. J Trauma 2009;67:829‑33.

10. Esposito TJ, Offner PJ, Jurkovich GJ, Griffith J, Maier RV. Do

prehospital trauma center triage criteria identify major trauma victims?

Arch Surg 1995;130:171‑6.

11. Bevan C, Officer C, Crameri J, Palmer C, Babl FE. Reducing

“cry wolf” – Changing trauma team activation at a pediatric trauma

centre. J Trauma 2009;66:698‑702.

12. Driscoll PA, Vincent CA. Organizing an efficient trauma team. Injury

1992;23:107‑10.

13. Eastes LS, Norton R, Brand D, Pearson S, Mullins RJ. Outcomes

of patients using a tiered trauma response protocol. J Trauma

2001;50:908‑13.

14. Kohn MA, Hammel JM, Bretz SW, Stangby A. Trauma team activation

criteria as predictors of patient disposition from the emergency

department. Acad Emerg Med 2004;11:1‑9.

15. Nuss KE, Dietrich AM, Smith GA. Effectiveness of a pediatric trauma

team protocol. Pediatr Emerg Care 2001;17:96‑100.

16. Ochsner MG, Schmidt JA, Rozycki GS, Champion HR. The evaluation

of a two‑tier trauma response system at a major trauma center: Is it cost

effective and safe? J Trauma 1995;39:971‑7.

17. Tinkoff GH, O’Connor RE, Fulda GJ. Impact of a two‑tiered trauma

response in the emergency department: Promoting efficient resource

utilization. J Trauma 1996;41:735‑40.

18. Kaplan LJ, Santora TA, Blank‑Reid CA, Trooskin SZ. Improved

emergency department efficiency with a three‑tier trauma triage system.

Injury 1997;28:449‑53.

19. Qazi K, Wright MS, Kippes C. Stable pediatric blunt trauma patients: Is

trauma team activation always necessary? J Trauma 1998;45:562‑4.

20. Wong K, Petchell J. Paediatric trauma teams in Australia. ANZ J Surg

2004;74:992‑6.

21. Dowd MD, McAneney C, Lacher M, Ruddy RM. Maximizing the

sensitivity and specificity of pediatric trauma team activation criteria.

Acad Emerg Med 2000;7:1119‑25.