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      Accuracy of Pediatric Trauma Field Triage : A Systematic Review

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          Abstract

          Field triage of pediatric patients with trauma is critical for transporting the right patient to the right hospital. Mortality and lifelong disabilities are potentially attributable to erroneously transporting a patient in need of specialized care to a lower-level trauma center.

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          A national evaluation of the effect of trauma-center care on mortality.

          Ellen J MacKenzie, Frederick Rivara, Gregory Jurkovich … (2006)
          Hospitals have difficulty justifying the expense of maintaining trauma centers without strong evidence of their effectiveness. To address this gap, we examined differences in mortality between level 1 trauma centers and hospitals without a trauma center (non-trauma centers). Mortality outcomes were compared among patients treated in 18 hospitals with a level 1 trauma center and 51 hospitals non-trauma centers located in 14 states. Patients 18 to 84 years old with a moderate-to-severe injury were eligible. Complete data were obtained for 1104 patients who died in the hospital and 4087 patients who were discharged alive. We used propensity-score weighting to adjust for observable differences between patients treated at trauma centers and those treated at non-trauma centers. After adjustment for differences in the case mix, the in-hospital mortality rate was significantly lower at trauma centers than at non-trauma centers (7.6 percent vs. 9.5 percent; relative risk, 0.80; 95 percent confidence interval, 0.66 to 0.98), as was the one-year mortality rate (10.4 percent vs. 13.8 percent; relative risk, 0.75; 95 percent confidence interval, 0.60 to 0.95). The effects of treatment at a trauma center varied according to the severity of injury, with evidence to suggest that differences in mortality rates were primarily confined to patients with more severe injuries. Our findings show that the risk of death is significantly lower when care is provided in a trauma center than in a non-trauma center and argue for continued efforts at regionalization. Copyright 2006 Massachusetts Medical Society.
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            Diagnostic test accuracy may vary with prevalence: implications for evidence-based diagnosis.

            Patrick Bossuyt, Les Irwig, Mariska Leeflang (2008)
            Several studies and systematic reviews have reported results that indicate that sensitivity and specificity may vary with prevalence. We identify and explore mechanisms that may be responsible for sensitivity and specificity varying with prevalence and illustrate them with examples from the literature. Clinical and artefactual variability may be responsible for changes in prevalence and accompanying changes in sensitivity and specificity. Clinical variability refers to differences in the clinical situation that may cause sensitivity and specificity to vary with prevalence. For example, a patient population with a higher disease prevalence may include more severely diseased patients, therefore, the test performs better in this population. Artefactual variability refers to effects on prevalence and accuracy associated with study design, for example, the verification of index test results by a reference standard. Changes in prevalence influence the extent of overestimation due to imperfect reference standard classification. Sensitivity and specificity may vary in different clinical populations, and prevalence is a marker for such differences. Clinicians are advised to base their decisions on studies that most closely match their own clinical situation, using prevalence to guide the detection of differences in study population or study design.
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              The cost of overtriage: more than one-third of low-risk injured patients were taken to major trauma centers.

              Craig Newgard, Kristan L. Staudenmayer, Renee Hsia … (2013)
              Regionalized trauma care has been widely implemented in the United States, with field triage by emergency medical services (EMS) playing an important role in identifying seriously injured patients for transport to major trauma centers. In this study we estimated hospital-level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury severity. Among 301,214 patients, the average adjusted per episode cost of care was $5,590 higher in a level 1 trauma center than in a nontrauma hospital. We found hospital-level differences in cost among patients with minor, moderate, and serious injuries. Of the 248,342 low-risk patients-those who did not meet field triage guidelines for transport to trauma centers-85,155 (34.3 percent) were still transported to major trauma centers, accounting for up to 40 percent of acute injury costs. Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions we studied.
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                Author and article information

                Journal
                Title: JAMA Surgery
                Abbreviated Title: JAMA Surg
                Publisher: American Medical Association (AMA)
                ISSN (Print): 2168-6254
                Publication date Created: July 01 2018
                Publication date (Print): July 01 2018
                Volume: 153
                Issue: 7
                Page: 671
                Affiliations
                [1 ]Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
                [2 ]Department of Surgery, Diakonessenhuis Utrecht-Zeist-Doorn, Utrecht, the Netherlands
                Article
                DOI: 10.1001/jamasurg.2018.1050
                PubMed ID: 29799916
                SO-VID: e7a82fda-6305-4673-97b0-73a028d02873
                Copyright © © 2018
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