INTRODUCTION
According to the World Health Organization, death attributable to injury accounts for 9% of fatalities worldwide.(1) Approximately 90% of these deaths occur in low- and middle-income countries.(1) South Africa, a middle-income country, bears this trauma burden along with high mortality rates related to poor maternal and child health; non-communicable diseases such as heart disease, stroke and diabetes as well as HIV/AIDS – a “quadruple burden of disease”.(2)
The beneficial effects of a fully functional trauma system and a dedicated trauma team on patient survival rates are well-known.(3,4) However, appropriate utilisation of the trauma team is critical. If the trauma team is over-activated because of over-triage of patients this will result in unnecessarily assigning resources to a patient that does not require it.(5) Over-triage leads to overburdening of the system and higher trauma care costs.(6,7) Conversely, under-triage of trauma patients leading to under-activation can result in potential morbidity or mortality as a result of delays in diagnosis and treatment, missed injuries, and decreased patient functional outcomes.(5,7)
Various scoring systems have been developed to guide trauma team activation (TTA). To date, however, there is no standardised composition of criteria required for TTA.(8) Two such systems are the American College of Surgeons Committee on Trauma (ACS-COT) “guidelines for field triage of injured patients” and the “Loma Linda Rule”.(9–11) These scoring systems are designed to potentially identify which injured patients may require emergency surgical intervention and assist in guiding the triage of the injured patient to an appropriate hospital. TTA in South Africa is largely determined by the clinical judgement of either the prehospital or in-hospital Emergency Department (ED) healthcare provider team.
The aim of this study was to analyse the practice of clinical judgement TTA when compared to the ACS-COT TTA guideline and the Loma Linda Rule for TTA.
METHODS
This was a 1-year retrospective analysis of TTA from MediBank (the South African Trauma and Medical Resuscitation Registry) data from an accredited Level 1 trauma centre in a private hospital setting in South Africa.
Ethical clearance was obtained from the University of Witwatersrand's Human Research Ethics Committee (M170205).
The data for patients who received a TTA during the study period were extracted into an electronic spreadsheet Microsoft® Excel (Microsoft Office 2019, Microsoft Corporation). This information included basic demographic data (sex and age), mechanism of injury, prehospital and ED vital signs (Glasgow Coma Scale score, heart rate, systolic blood pressure) and patient disposition. Patients whose data were incomplete were excluded. Additionally, patients seen at other facilities initially who were then transferred to the ED as well as patients who were dead-on-arrival were ultimately excluded from analysis.
THE ACS-COT GUIDELINE (9,10)
In each of the four steps of the ACS-COT guideline algorithm, if one or more criteria are met for that specific step, then TTA is triggered – there is no need to proceed further down the algorithm. Step one is based on the patients’ Glasgow Coma Scale, respiratory rate and systolic blood pressure. Step two includes criteria based on whether the patient has a penetrating mechanism of injury; chest wall instability or deformity; two or more proximal long bone fractures; crushed, mangled, degloved or pulseless extremity; amputation proximal to the wrist or ankle; pelvic fractures; open or depressed skull fractures or paralysis. In Step three, activation is triggered if there is a height-specific fall; a high-risk motor vehicle collision; a motor vehicle–bicycle/pedestrian collision or a motorcycle collision. Step Four activation is triggered based on age-related criteria for adults and children; if a patient is on anticoagulation; has sustained burns; is pregnant more than 20 weeks of gestation or based on prehospital emergency care practitioner's discretion.
THE LOMA LINDA RULE (11)
Based on the Loma Linda Rule, the trauma team needs to be activated if any one of the following criteria are fulfilled: the patient has penetrating trauma as their mechanism of injury; the patient's systolic blood pressure is less than 100▒mmHg; or the patient's heart rate is greater than 100 beats per minute.
DATA ANALYSIS
The patient population for TTA was analysed using descriptive statistics. These patients were subjected to the criteria included in the ACS-COT guideline and the Loma Linda Rule to establish how many patients would have qualified for TTA based on each objective rule.
RESULTS
There were 9207 trauma patients that presented to the ED during the 1-year study period. Of these, 865 had TTA resulting in a 9.4% activation rate.
There were 18 TTAs excluded from further analysis due to missing data (13 patients were dead-on-arrival and 5 patients had incomplete data). Data from 847 TTA patients were analysed.
Male patients accounted for 71% of TTAs (602 patients). The median (interquartile range) age for activation was 36 years (26–49). The prehospital and ED vital signs are shown in Table 1 and the mechanisms of injury in Figure 1. The ultimate outcomes of the TTA patients is highlighted in Table 2.
Vital signs of TTA patients prehospital and in the ED
| VITAL SIGNS | Prehospital Median (IQR) | ED Median (IQR) |
|---|---|---|
| Systolic blood pressure (mmHg) | 129* (109;141) | 132 (115;147) |
| Heart Rate (beats per minute) | 90* (77;106) | 87 (74;100) |
| Respiratory Rate (breaths per minute) | 18* (16;21) | 19 (15;22) |
| Glasgow Coma Scale | 15 (14;15) | 15 (14;15) |
22 patients did not have a recordable blood pressure; 9 patients did not have a recordable heart rate; and 4 patients did not have a recordable respiratory rate.
ED Emergency Department IQR interquartile range
THE ACS-COT GUIDELINE
Table 3 shows the breakdown of patients who fulfilled the ACS-COT guideline at each step. There were 407 patients (48%) who fulfilled the ACS-COT guidelines for TTA.
ACS-COT guideline step-by-step breakdown of patients fulfilling TTA criteria
| N (%) | |
|---|---|
| STEP 1 | 152 (37.3%) |
| Systolic Blood Pressure | 46 (30.3%) |
| Respiratory Rate | 30 (19.7%) |
| Glasgow Coma Scale | 76 (50%) |
| STEP 2 | 78 (19.2%) |
| Penetrating injury | 39 (50%) |
| Chest trauma | 1 (1.3%) |
| Extremity injury | 6 (7.7%) |
| Amputation | 2 (2.6%) |
| Pelvic fracture | 17 (21.8%) |
| Skull fracture | 12 (15.4%) |
| Paralysis | 1 (1.3%) |
| Penetrating injury | 39 (50%) |
| Chest trauma | 1 (1.3%) |
| Extremity injury | 6 (7.7%) |
| Amputation | 2 (2.6%) |
| Pelvic fracture | 17 (21.8%) |
| Skull fracture | 12 (15.4%) |
| Paralysis | 1 (1.3%) |
| STEP 3 | 73 (17.9%) |
| Motor vehicle accident | 49 (67.1%) |
| Pedestrian vehicle accident | 17 (23.3%) |
| Bicycle – vehicle accident | 4 (5.5%) |
| Fall from height | 3 (4.1%) |
| STEP 4 | 104 (25.6%) |
| Age specific | 99 (95.2%) |
| Burns | 5 (4.8%) |
THE LOMA LINDA RULE
Using the Loma Linda Rule, 456 patients (53.8%) fulfilled TTA criteria. Penetrating injuries were present in 98 patients (21.5%); 116 patients (25.4%) had a systolic blood pressures of less than 100▒mmHg; and 242 patients (53.1%) had a heart rate of greater than 100 beats per minute.
DISCUSSION
In the most recent burden of diseases study for South Africa, a decline in mortality related to injury was noted compared to prior years.(2) However, trauma is still an epidemic in South Africa.(12) It is therefore critical that trauma resources are utilised correctly, and that activation of the trauma team occurs appropriately, in order to ensure that patients who need it most can benefit from it.
Similar to evaluations of trauma patient populations elsewhere in South Africa and in other middle-income countries, our resuscitation population had a young, male adult preponderance with the main mechanism of injury being blunt trauma.(13–15) The relatively high incidence of penetrating injuries (10%) is concerning and a reminder of the country's tumultuous history of violence-related deaths from penetrating injuries.(16) However, there are trauma centres in high-income countries such as the Harborview Medical Center in Seattle, in the United States of America who have a very similar incidence of penetrating trauma.(17) However, the mean age of the trauma populations in high-income countries tends to be much older.(17–19)
Clinical judgement or “eyeball triage” method for determining TTA, has previously been found to be superior to a formalised triage system with respect to mortality prediction in some settings.(20) The findings of this study, however, showed this not to be applicable as clinical judgement resulted in almost double the number of patients having the trauma team activated as there would have been compared to either the ACS-COT guideline or the Loma Linda Rule. This is a very concerning finding and suggests that over-triage was highly likely. This over-triage tendency in trauma resuscitation patients is potentially a trauma-related phenomenon. It has previously been shown that even less injured trauma patients were more likely to be incorrectly promoted to higher triage categories.(5) This may be related to healthcare providers being able to directly visualise the patient's presenting problem i.e. bleeding, which leads them to rather err on the side of caution and ultimately upgrade the trauma patients’ level of care.
Both the over- and under-triage rates are important quality indicators of a trauma system.(21) The so-called gold standard for calculating trauma over- and under-triage is comparing a trauma unit's own trauma activation criteria to each patient admission and to evaluate whether criteria for the TTA were met.(22) This is a big drawback of a clinical judgement system – the inability to adjudicate the validity of the TTA. Construction of a Cribari Matrix is a surrogate method of trauma mis-triage calculation.(9,21) Unfortunately, as only data from TTA are collected by the MediBank registry and not data from all trauma patients presenting to the ED, we were unable to utilise this method. This analysis was therefore devised as a proxy by comparing TTA via clinical judgement to the ACS-COT guideline and the Loma Linda Rule.
The ACS-COT guidelines stipulate a preference towards over-triage in order to avoid high under-triage rates and deaths from potentially preventable causes.(9) ACS-COT consider over-triage rates of 25 to 35% and under-triage rates of up to 5% as acceptable.(9) However, over-triage consumes valuable resources and potentially endangers those patients who actually need TTA.(8) As with any form of triage, over-triage or trauma team over-activation unnecessarily assigns resources to a patient, and under-triage, or under-activation, may lead to potential morbidity or mortality for more critical patients as a result of delays in management.(5)
Over-activation of the trauma team not only impacts on the resources of the ED, but this also extends to the hospital resources and therefore increases overall costs. Almost two-thirds of the TTA patients in the present study were admitted to the intensive care or high care units. This is a very high admission rate to high acuity beds in the hospital considering that it was likely that almost half of the patients should not have had the trauma team activated in the first place. Intensive care admissions in other trauma centres worldwide does vary, ranging from 15.8% to 51.7%.(17–19,23) The fact that the study centre was in a private hospital may have influenced the outcomes of patients to some degree. A higher availability of ICU and high care beds and a heightened concern for medico-legal jeopardies, when compared to similar trauma centres in public hospitals, could have accounted for this difference in admission rates. It would be valuable to explore this apparent mismatch between patient severity of injury and the pattern of admission in future studies.
Similar to other ED triage systems, there is currently no agreement regarding a benchmark for TTA.(8,20,24) A systematic review of mis-triage in trauma patients by Najafi et al. echoed this lack of standardisation.(25) Waydhas et al. have recently tried to overcome this deficit with a survey that they performed to determine TTA requirements, however, this is yet to be globally adopted.(8)
A limitation of our study is not having compared the clinical judgement assessment to the patients’ injury severity score (ISS). It is unlikely to have changed the findings substantially however, as many of the criteria for the ACS-COT and the Loma Linda scoring systems overlap with ISS criteria. A further limitation is, since there was no data available of patients in whom the trauma team was not activated, the study only reported on over-triage and was unable to report on under-triage. This study was limited to a single centre. It was a retrospective study largely dependent on the accuracy of the data input into the registry itself.
CONCLUSIONS
This study showed that activation of a trauma team using the initial healthcare provider clinical judgement assessment resulted in trauma team over-activation when compared to the ACS-COT guideline and the Loma Linda Rule. Over-activation of the trauma team consumes valuable resources and potentially endangers those patients who actually need TTA and cannot receive it due to a misassignment of those resources. Implementation of a standardised TTA tool could potentially aid in the optimisation of patient care and appropriate resource utilisation. This needs to be coupled with regular self-evaluation in order to assess adequacy of function. This study has echoed the need for further research and consensus in this arena.
