CURRENT OPINION
A consensus-based criterion standard for trauma center need E. Brooke Lerner, PhD, Brian D. Willenbring, BA, EMT-B, Ronald G. Pirrallo, MD, MHSA, Karen J. Brasel, MD, MPH, Charles E. Cady, MD, M. Riccardo Colella, DO, MPH, Arthur Cooper, MD, MS, Jeremy T. Cushman, MD, MS, EMT-P, David M. Gourlay, MD, Gregory J. Jurkovich, MD, Craig D. Newgard, MD, MPH, Jeffrey P. Salomone, MD, NREMT-P, Scott M. Sasser, MD, Manish N. Shah, MD, MPH, Robert A. Swor, DO, and Stewart C. Wang, MD, PhD
BACKGROUND: In civilian trauma care, field triage is the process applied by prehospital care providers to identify patients who are likely to have severe injuries and immediately need the resources of a trauma center. Studies of the efficacy of field triage have used various measures to define trauma center need because no ‘‘criterion standard’’ exists, making cross-study comparisons difficult. This study aimed to develop a consensus-based functional criterion standard definition of trauma center need. METHODS: Local and national experts were recruited for participation. Blinded key informant interviews were conducted in order of availability until no new themes emerged. Themes identified during the interviews were used to develop a Modified Delphi survey, which was electronically delivered via Survey Monkey. The trauma center need criteria were refined iteratively based on participant responses. Participants completed additional surveys until there was at least 80% agreement for each criterion. RESULTS: Fourteen experts were recruited. Five participated in key informant interviews. A Modified Delphi survey was administered five times (four modifications based on the expert’s responses). After the fifth round, there was at least 82% agreement on each criterion. The final definition included 10 time-specific indicators: major surgery, advanced airway, blood products, admission for spinal cord injury, thoracotomy, pericardiocentesis, cesarean delivery, intracranial pressure monitoring, interventional radiology, and in-hospital death. CONCLUSION: We developed a consensus-based functional criterion standard definition of needing the resources of a trauma center, which may help to standardize field triage research and quality assurance in trauma systems as well as allow for cross study comparisons. (J Trauma Acute Care Surg. 2014;76: 1157Y1163. Copyright * 2014 by Lippincott Williams & Wilkins) KEY WORDS: Wounds and injury; triage; emergency medical services; emergency medical technicians; trauma centers; Delphi method.
A
n estimated 41% of people in the United States transported to emergency departments (EDs) by ambulance have an injury-related chief complaint.1 For these patients, prehospital care providers must make a rapid assessment using the limited
Submitted: November 30, 2013, Revised: January 2, 2014, Accepted: January 2, 2014. From the Department of Emergency Medicine (E.B.L., R.G.P., C.E.C., M.R.C.), Department of Surgery, Division of Trauma/Critical Care (K.J.B.), Department of Surgery, Division of Pediatric Surgery (D.M.G.), Medical College of Wisconsin (B.D.W.) Milwaukee, Wisconsin; Division of Pediatric Surgery, Department of Surgery, Columbia University Medical Center Affiliation at Harlem Hospital (A.C.), New York; and Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, University of Rochester (J.T.C., M.N.S.), Rochester, New York; Department of Surgery, Denver Health Medical Center (G.J.J.), Denver, Colorado; Department of Emergency Medicine, Oregon Health & Science University (C.D.N.), Portland, Oregon; Department of Surgery, Maricopa Medical Center (J.P.S.), Phoenix, Arizona; Department of Emergency Medicine, Emory University School of Medicine (S.M.S.), Atlanta, Georgia; Department of Emergency Medicine, William Beaumont Hospital (R.A.S.), Royal Oak; and Department of Surgery, Section of Acute Care Surgery, University of Michigan Health Systems (S.C.W.), Ann Arbor, Michigan. This study was p resented at the Society for Academic Emergency Medicine Annual Meeting, May 2013, in Atlanta, Georgia. Address for reprints: E. Brooke Lerner, PhD, Department of Emergency Medicine, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226; email: [email protected]. DOI: 10.1097/TA.0000000000000189
resources that are available in the out-of-hospital setting and determine if the patient is likely to have severe injuries requiring immediate transport to the highest-level trauma center in the area. In the 1980s, the American College of Surgeons’ Committee on Trauma (ACS COT) began to develop Field Triage Guidelines to assist prehospital providers in determining which injured patients are likely to have severe injuries and require the resources of a trauma center.2,3 These guidelines have been revised several times, with the most recent update being released in January 2012.4 Revisions of the Field Triage Guidelines have been based on a critical evaluation of the most recent research and augmented by consensus opinion.4 In general, these revisions have attempted to improve the Field Triage Guidelines to meet the ACS COT recommendation that systems strive for an undertriage rate that is less than 5% and limit the overtriage rate to between 25% and 50%.5 This goal is supported by the findings of the National Study on the Costs and Outcomes of Trauma Care, which demonstrated that when patients with an Injury Severity Score (ISS) greater than 15 were treated at a Level 1 trauma center, mortality decreased by 25%.6 Efforts to incorporate research findings into improving the Field Triage Guidelines have been hampered by the lack of an accepted measure for determining which patients needed the resources of a trauma center.4,7 No accepted criterion standard exists for determining trauma center need that can be used by researchers to evaluate the accuracy of prehospital findings that
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are used for field triage decision making. In fact, the literature on the Field Triage Guidelines has used a variety of criterion standard measures to indicate trauma center need (Table 1). The lack of standardization in criterion standard measures makes it difficult to compare findings across studies and to further advance trauma triage decision making since no accepted criterion standard definition exists for determining which patients need a trauma center.8,9 ISS is currently the most common measure used for determining trauma center need.2,5,10 ISS is easy to obtain through medical record review, but it does not account for resource needs and has been found to be an ineffective proxy for trauma center need.9,11 Recently, researchers have attempted to use measures that more closely approximate actual resource use.9,12 An example of a resource-based approach is a composite measure that incorporates in-hospital death, intensive care unit (ICU) admission, or nonorthopedic surgery within 24 hours of arrival at the ED.13 However, some argue that ICU admission criteria are not uniform across the spectrum of hospitals, and as a result, this criterion is likely not consistent between providers or institutions. Studies published by the US Army have used a different resource-based approach, the lifesaving interventions model, to evaluate the trauma center need of patients based on a list of predetermined interventions (i.e., intubation, transfusion of blood, pericardiocentesis).14 Length of stay (LOS) at the hospital has also been used as an indicator for trauma center need, with a LOS greater than 2 days to 3 days typically accepted as indicative of trauma center need.9,15,16 However, since LOS can vary widely based on physician discretion, efficiency of the treating facility, availability of and access to discharge facilities, comorbidities, and insurance status of the patient, it is not ideal for determining trauma center need. Thus, there is a need for a concise, reproducible, and accurate criterion standard definition of which injured patients need the resources of a trauma center. It is important to note that this definition would not be used clinically but would be used by researchers to evaluate and potentially modify the field triage guidelines that are used clinically by prehospital care providers. A consensus-based criterion standard definition for trauma center need may help to standardize field triage research by enabling researchers to more easily compare results between studies. Therefore, the objective of this project was to develop a consensus-based functional criterion standard definition of trauma center need that could be used to study the Field Triage Guidelines.
PATIENTS AND METHODS Local and national experts in emergency medicine and trauma care were recruited to participate. The expert panel included participants from across the country, some of whom were members of the expert panel that revised the Field Triage Guidelines, researchers who have studied the Field Triage Guidelines, and local emergency medical service (EMS) medical directors, and hospital care providers (Table 2). Recruited experts were interviewed by the same two investigators (E.B.L., B.D.W.) in order of convenience to determine their respective opinions of previously used measures of trauma center need and to identify additional measures they thought should be considered in a 1158
criterion standard definition of trauma center need. During the interview, participants were presented with a list of possible indicators of trauma center need that had been used in previously published studies of the Field Triage Guidelines (Table 1) and asked which criteria they thought indicated trauma center need. Participants were also asked to provide any additional indicators that should be added to the list. Time frames (i.e., the time interval from ED presentation within which the given procedure or intervention was performed) for each of the indicators were also discussed and whether the standard should change if the patient was pediatric or geriatric. The interviewees were blinded to the response of previous participants. Newly recommended indicators were added to the list before the next interview; no indicators were removed. Interviews were conducted until no new indicators were identified in subsequent interviews. A modified Delphi process was then used.17 The indicators identified during the interviews were used to develop an electronic survey where all participants were asked to determine which indicators signify trauma center need and in what time frame. A Web-based survey tool (SurveyMonkey) was used to deliver the survey to the participants. After the surveys were complete, indicators were added, modified, or dropped based on the responses, and the survey process was repeated until a minimum consensus of 80% agreement was reached for each criterion.
RESULTS A total of 14 local and national experts were recruited (Table 2). Five informant interviews were conducted, and 26 potential indicators were identified. The participants completed five voting rounds before consensus was reached. The fifth round was conducted by e-mail since only one criterion was discussed. Seven participants responded to the initial round, 10 to the second, 11 to the third, 12 to the fourth, and 13 to the fifth round. After the fifth voting round, at least 82% agreement was reached among the experts for each of the 10 proposed criterion standard criteria (Table 3). The percent agreement was calculated based on the number of participants who participated in the survey. Table 3 provides a list of the indicators that were identified. The 10 indicators are intended to be used independently, and the presence of any one indicates trauma center need, with one exception, injured patients who arrived in the ED in traumatic cardiac arrest. Patients who arrived in the ED in traumatic cardiac arrest were determined not to require the resources of a trauma center, even if they met one of the other indicators (e.g., intubation by a prehospital care provider in the field or receiving a blood transfusion in an air ambulance).
DISCUSSION The indicators identified in this study are anticipated to standardize the outcome measures used by researchers studying the Field Triage Guidelines and represent an initial step in developing a consensus-based, criterion standard definition of trauma center need. It is our hope that these findings will initiate a national discussion of what factors indicate trauma center need and lead to uniform definitions for future research. * 2014 Lippincott Williams & Wilkins
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ACS COT2 Knopp18 Baxt11 Esposito19 Norcorss20 Simmons21 Henry15 Henry22 Wuerz23 O’Keefe24* Engum25 Potoka26 Meldon16 Taylor27 Baez28 Holcomb14** MacKenzie6 Eastridge29 Burd30 Newgard31 Newgard9 Cancio32 Newgard33 Lehmann34 Newgard35 Newgard8 Beekley36† Brown37 Lerner12 Lerner13 Nakamura38
1986 1988 1990 1995 1995 1995 1996 1996 1996 1999 2000 2000 2002 2002 2003 2005 2006 2006 2007 2007 2008 2008 2009 2009 2010 2010 2010 2011 2011 2011 2012
In-Hospital Death
X
X
X
X
X
X
X
X
X
X
X X
X
X
X X X
X
X
X
X X
X
X
X
ED Death
X
X
DOA to ED
X
X
DOA to EMS
X X X
ISS Q16
X
X
X
X
X X
ISS 9 15
X
X X
X
X
X
X
Death
X X
ED Disposition
X X X
X
X X X
X X
X
X X X
ICU Admission/ LOS
X
Admission
X
Transfer to Another Facility
X X
X
X
X
X
X X
X
Nonorthopedic Surgery
*O’Keefe also used cost as an outcome measure. Death was included in the table; however, O’Keefe looked at the case-fatality rate. **Holcomb did not specify what procedures they used as life-saving interventions; however, in their article, they did additionally state that they used insertion of a chest tube, defibrillation, and arteriograms as outcome measures. †Beekley also used the application of tourniquets and hemostatic dressings as an outcome measure. ‡It is important to note that generalizations were sometimes made in including outcome measures in the table. For instance, major surgery within 6 hours of hospital arrival is included under the ‘‘major surgery’’ column without a time qualifier. CPR, cardiopulmonary resuscitation; DOA, dead on arrival.
First Author
Previously Used Measures of Trauma Center Need
Year
TABLE 1.
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1986 ACS COT2 1988 Knopp18 1990 Baxt11 1995 Esposito19 1995 Norcorss20 1995 Simmons21 1996 Henry15 1996 Henry22 1996 Wuerz23 1999 O’Keefe24* 2000 Engum25 2000 Potoka26 2002 Meldon16 2002 Taylor27 2003 Baez28 2005 Holcomb14** 2006 MacKenzie6 2006 Eastridge29 2007 Burd30 2007 Newgard31 2008 Newgard9 2008 Cancio32 2009 Newgard33 2009 Lehmann34 2010 Newgard35 2010 Newgard8 2010 Beekley36† 2011 Brown37 2011 Lerner12 2011 Lerner13 2012 Nakamura38
X X
X
X
X X
X
X
X
X
X
X
X
X
X
X
X
X X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Major LOS LOS Total 91 L of Blood Needle Cardioversion Invasive CNS /Pacing CPR Pericardiocentesis Monitoring Year First Author Surgery 9 2 d 9 3 d LOS Fluid Transfusion Ventilator Intubation Thoracostomy Cricothyrotomy Thoracotomy
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TABLE 2. Local and National Experts Participation in the Delphi Process Name
Institution
Karen J. Brasel, MD, MPH Charles E. Cady, MD M. Riccardo Colella, DO, MPH Arthur Cooper, MD, MS Jeremy T. Cushman, MD, MS, EMT-P David M. Gourlay, MD Gregory J. Jurkovich, MD Craig D. Newgard, MD, MPH Ronald G. Pirrallo, MD, MHSA Jeffrey P. Salomone, MD Scott M. Sasser, MD Manish N. Shah, MD, MPH Robert A. Swor, DO Stewart C. Wang, MD
Medical College of Wisconsin Medical College of Wisconsin Medical College of Wisconsin Columbia University Medical Center Affiliation at Harlem Hospital University of Rochester Medical Center Medical College of Wisconsin Denver Health and Hospital Authority Oregon Health & Science University Medical College of Wisconsin Emory University School of Medicine Emory University School of Medicine University of Rochester Medical Center Beaumont Health System University of Michigan Health System
Uniform definitions will facilitate comparisons between studies and ultimately lead to improved destination decision making in the prehospital setting. It is important to emphasize that these indicators are not intended to guide prehospital clinical care but were instead developed as a tool for researchers to use in the evaluation of prehospital decision making. Sensitivity, specificity, positive predictive value, and other measures used to evaluate screening tools and other medical tests require a reference standard. Thus, it is not possible to conduct research without a criterion standard definition for the condition the test is intended to identify, in this case an injured patient who requires the services of a trauma center.
Interviewed
First Round
Second Round
Third Round
Fourth Round
Fifth Round
X X
X
X
X X
X X X
X
X X X X
X
X
X
X
X
X
X X
X X
X X
X X
X X
X
X X X
X X X
X
X
X
X X
X
X
X
X
X
X
X
X
X
X
X
X
X X
X X
The consensus process included agreeing on time frames for each of the identified indicators. The goal in selecting these times was to make them long enough for a patient who was treated at a nontrauma center to still meet the indication either following an interfacility transfer or after necessary staff were called in to the nontrauma center hospital but not so long that the indication was due to a secondary event or was a nonurgent procedure. In general, the panel members considered whether a given indicator warranted the potential increased risks associated with bypassing closer hospitals and travelling with lights and sirens or by a helicopter to the highest level of care within the defined trauma system. Thus, the longest time frame associated with a proposed criterion in the consensus-based
TABLE 3. Proposed Consensus-Based Criterion Standard Definition of Trauma Center Need for the Injured Patient Who Requires the Highest Level of Care Within the Defined Trauma System Indicator
Time Frame
Received 91 U of a blood product. Admitted to the hospital for a spinal cord injury. Received any advanced airway management (e.g., surgical airway, intubation, LMA, King LT). This excludes intubation solely for surgical procedures. Did not meet the NAEMSP/ACS COT criteria for termination of resuscitation39 for traumatic cardiopulmonary arrest and received a thoracotomy for treatment of their initial injury. Did not meet the NAEMSP/ACS COT criteria for termination39 of resuscitation for traumatic cardiopulmonary arrest and received a pericardiocentesis for treatment of their initial injury. Received an emergency cesarean delivery because of their injuries. Received intracranial pressure monitoring. Received interventional radiology for interventional or diagnostic purposes related to their injury. Received vascular, neurologic, abdominal, thoracic, pelvic, spine, or limb-conserving surgery (i.e., on a limb that was found to be pulseless distal to the injury before surgery). Patients who had an injury that typically required any of the treatments listed above as needing a trauma center and arrived at the hospital not in cardiac arrest but ultimately died of their injury in the ED or before hospital discharge.
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4 h of hospital arrival None 4 h of hospital arrival 48 h of hospital arrival 24 h of hospital arrival 24 h of hospital arrival 48 h of hospital arrival 4 h of hospital arrival 24 h of hospital arrival None
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standard is 48 hours. While a minority of injured patients will meet some of the criteria beyond 48 hours, it was reasoned that they could be effectively transferred to the highest level of care within the defined trauma system by a nonemergent ground ambulance if they required the resources of a trauma center. This study is limited because it represents the consensus opinion of 14 experts and may not be representative of researchers and clinicians nationally. It is important to note that to limit the influence of panel members on each other, no group discussions were held either by telephone or face to face. Each participant voted independently and without access to other members’ votes. If clarifications were needed, only one author (E.B.L.), who did not vote on the criteria, contacted the participant to discuss the vote and clarify any modifications that were recommended. Ideally, these indicators should be validated using clinical data. Before a clinical validation study can be conducted, the logical next step is to receive feedback from national stakeholders and to operationalize these indicators. Once the indicators are operationalized, it will be important to determine the validity, feasibility, as well as the intrarater and interrater reliability of identifying them through a medical record review. AUTHORSHIP E.B.L. and B.D.W. designed the study, conducted all data collection and analysis, and developed an initial draft of the manuscript. All of the remaining authors participated in the data collection phase and reviewed and critically revised the manuscript.
DISCLOSURE B.D.W. was awarded a Wisconsin Medical Society Foundation Fellowship in Government and Community Service to fund his work on this project during the summer of 2012. In addition, B.D.W. was awarded a travel stipend from the Friends of the Medical College of Wisconsin to offset the costs of presenting this project at a national meeting in Atlanta, Georgia. No other external support was received for this project. The authors have no relevant financial conflicts of interest to report.
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31. Newgard CD, Cudnik M, Warden CR, Hedges JR. The predictive value and appropriate ranges of prehospital physiological parameters for high-risk injured children. Pediatr Emerg Care. 2007;23(7):450Y456. 32. Cancio LC, Batchinsky AI, Salinas J, Kuusela T, Convertino VA, Wade CE, Holcomb JB. Heart-rate complexity for prediction of prehospital lifesaving interventions in trauma patients. J Trauma. 2008;65(4): 813Y819. 33. Newgard CD, Rudser K, Atkins DL, Berg R, Osmond MH, Bulger EM, Davis DP, Schreiber MA, Warden C, Rea TD, et al.; ROC Investigators. The availability and use of out-of-hospital physiologic information to identify high-risk injured children in a multisite, population-based cohort. Prehosp Emerg Care. 2009;13(4):420Y431. 34. Lehmann R, Beekley A, Casey L, Salim A, Martin M. The impact of advanced age on trauma triage decisions and outcomes: a statewide analysis. Am J Surg. 2009;197(5):571Y574; discussion 574Y575. 35. Newgard CD, Rudser K, Hedges JR, Kerby JD, Stiell IG, Davis DP, Morrison LJ, Bulger E, Terndrup T, Minei JP, Bardarson B, Emerson S; ROC Investigators. A critical assessment of the out-of-hospital trauma triage guidelines for physiologic abnormality. J Trauma. 2010;68(2):452Y462.
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A consensus-based criterion standard for trauma center need E. Brooke Lerner, PhD, Brian D. Willenbring, BA, EMT-B, Ronald G. Pirrallo, MD, MHSA, Karen J. Brasel, MD, MPH, Charles E. Cady, MD, M. Riccardo Colella, DO, MPH, Arthur Cooper, MD, MS, Jeremy T. Cushman, MD, MS, EMT-P, David M. Gourlay, MD, Gregory J. Jurkovich, MD, Craig D. Newgard, MD, MPH, Jeffrey P. Salomone, MD, NREMT-P, Scott M. Sasser, MD, Manish N. Shah, MD, MPH, Robert A. Swor, DO, and Stewart C. Wang, MD, PhD
BACKGROUND: In civilian trauma care, field triage is the process applied by prehospital care providers to identify patients who are likely to have severe injuries and immediately need the resources of a trauma center. Studies of the efficacy of field triage have used various measures to define trauma center need because no ‘‘criterion standard’’ exists, making cross-study comparisons difficult. This study aimed to develop a consensus-based functional criterion standard definition of trauma center need. METHODS: Local and national experts were recruited for participation. Blinded key informant interviews were conducted in order of availability until no new themes emerged. Themes identified during the interviews were used to develop a Modified Delphi survey, which was electronically delivered via Survey Monkey. The trauma center need criteria were refined iteratively based on participant responses. Participants completed additional surveys until there was at least 80% agreement for each criterion. RESULTS: Fourteen experts were recruited. Five participated in key informant interviews. A Modified Delphi survey was administered five times (four modifications based on the expert’s responses). After the fifth round, there was at least 82% agreement on each criterion. The final definition included 10 time-specific indicators: major surgery, advanced airway, blood products, admission for spinal cord injury, thoracotomy, pericardiocentesis, cesarean delivery, intracranial pressure monitoring, interventional radiology, and in-hospital death. CONCLUSION: We developed a consensus-based functional criterion standard definition of needing the resources of a trauma center, which may help to standardize field triage research and quality assurance in trauma systems as well as allow for cross study comparisons. (J Trauma Acute Care Surg. 2014;76: 1157Y1163. Copyright * 2014 by Lippincott Williams & Wilkins) KEY WORDS: Wounds and injury; triage; emergency medical services; emergency medical technicians; trauma centers; Delphi method.
A
n estimated 41% of people in the United States transported to emergency departments (EDs) by ambulance have an injury-related chief complaint.1 For these patients, prehospital care providers must make a rapid assessment using the limited
Submitted: November 30, 2013, Revised: January 2, 2014, Accepted: January 2, 2014. From the Department of Emergency Medicine (E.B.L., R.G.P., C.E.C., M.R.C.), Department of Surgery, Division of Trauma/Critical Care (K.J.B.), Department of Surgery, Division of Pediatric Surgery (D.M.G.), Medical College of Wisconsin (B.D.W.) Milwaukee, Wisconsin; Division of Pediatric Surgery, Department of Surgery, Columbia University Medical Center Affiliation at Harlem Hospital (A.C.), New York; and Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, University of Rochester (J.T.C., M.N.S.), Rochester, New York; Department of Surgery, Denver Health Medical Center (G.J.J.), Denver, Colorado; Department of Emergency Medicine, Oregon Health & Science University (C.D.N.), Portland, Oregon; Department of Surgery, Maricopa Medical Center (J.P.S.), Phoenix, Arizona; Department of Emergency Medicine, Emory University School of Medicine (S.M.S.), Atlanta, Georgia; Department of Emergency Medicine, William Beaumont Hospital (R.A.S.), Royal Oak; and Department of Surgery, Section of Acute Care Surgery, University of Michigan Health Systems (S.C.W.), Ann Arbor, Michigan. This study was p resented at the Society for Academic Emergency Medicine Annual Meeting, May 2013, in Atlanta, Georgia. Address for reprints: E. Brooke Lerner, PhD, Department of Emergency Medicine, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226; email: [email protected]. DOI: 10.1097/TA.0000000000000189
resources that are available in the out-of-hospital setting and determine if the patient is likely to have severe injuries requiring immediate transport to the highest-level trauma center in the area. In the 1980s, the American College of Surgeons’ Committee on Trauma (ACS COT) began to develop Field Triage Guidelines to assist prehospital providers in determining which injured patients are likely to have severe injuries and require the resources of a trauma center.2,3 These guidelines have been revised several times, with the most recent update being released in January 2012.4 Revisions of the Field Triage Guidelines have been based on a critical evaluation of the most recent research and augmented by consensus opinion.4 In general, these revisions have attempted to improve the Field Triage Guidelines to meet the ACS COT recommendation that systems strive for an undertriage rate that is less than 5% and limit the overtriage rate to between 25% and 50%.5 This goal is supported by the findings of the National Study on the Costs and Outcomes of Trauma Care, which demonstrated that when patients with an Injury Severity Score (ISS) greater than 15 were treated at a Level 1 trauma center, mortality decreased by 25%.6 Efforts to incorporate research findings into improving the Field Triage Guidelines have been hampered by the lack of an accepted measure for determining which patients needed the resources of a trauma center.4,7 No accepted criterion standard exists for determining trauma center need that can be used by researchers to evaluate the accuracy of prehospital findings that
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are used for field triage decision making. In fact, the literature on the Field Triage Guidelines has used a variety of criterion standard measures to indicate trauma center need (Table 1). The lack of standardization in criterion standard measures makes it difficult to compare findings across studies and to further advance trauma triage decision making since no accepted criterion standard definition exists for determining which patients need a trauma center.8,9 ISS is currently the most common measure used for determining trauma center need.2,5,10 ISS is easy to obtain through medical record review, but it does not account for resource needs and has been found to be an ineffective proxy for trauma center need.9,11 Recently, researchers have attempted to use measures that more closely approximate actual resource use.9,12 An example of a resource-based approach is a composite measure that incorporates in-hospital death, intensive care unit (ICU) admission, or nonorthopedic surgery within 24 hours of arrival at the ED.13 However, some argue that ICU admission criteria are not uniform across the spectrum of hospitals, and as a result, this criterion is likely not consistent between providers or institutions. Studies published by the US Army have used a different resource-based approach, the lifesaving interventions model, to evaluate the trauma center need of patients based on a list of predetermined interventions (i.e., intubation, transfusion of blood, pericardiocentesis).14 Length of stay (LOS) at the hospital has also been used as an indicator for trauma center need, with a LOS greater than 2 days to 3 days typically accepted as indicative of trauma center need.9,15,16 However, since LOS can vary widely based on physician discretion, efficiency of the treating facility, availability of and access to discharge facilities, comorbidities, and insurance status of the patient, it is not ideal for determining trauma center need. Thus, there is a need for a concise, reproducible, and accurate criterion standard definition of which injured patients need the resources of a trauma center. It is important to note that this definition would not be used clinically but would be used by researchers to evaluate and potentially modify the field triage guidelines that are used clinically by prehospital care providers. A consensus-based criterion standard definition for trauma center need may help to standardize field triage research by enabling researchers to more easily compare results between studies. Therefore, the objective of this project was to develop a consensus-based functional criterion standard definition of trauma center need that could be used to study the Field Triage Guidelines.
PATIENTS AND METHODS Local and national experts in emergency medicine and trauma care were recruited to participate. The expert panel included participants from across the country, some of whom were members of the expert panel that revised the Field Triage Guidelines, researchers who have studied the Field Triage Guidelines, and local emergency medical service (EMS) medical directors, and hospital care providers (Table 2). Recruited experts were interviewed by the same two investigators (E.B.L., B.D.W.) in order of convenience to determine their respective opinions of previously used measures of trauma center need and to identify additional measures they thought should be considered in a 1158
criterion standard definition of trauma center need. During the interview, participants were presented with a list of possible indicators of trauma center need that had been used in previously published studies of the Field Triage Guidelines (Table 1) and asked which criteria they thought indicated trauma center need. Participants were also asked to provide any additional indicators that should be added to the list. Time frames (i.e., the time interval from ED presentation within which the given procedure or intervention was performed) for each of the indicators were also discussed and whether the standard should change if the patient was pediatric or geriatric. The interviewees were blinded to the response of previous participants. Newly recommended indicators were added to the list before the next interview; no indicators were removed. Interviews were conducted until no new indicators were identified in subsequent interviews. A modified Delphi process was then used.17 The indicators identified during the interviews were used to develop an electronic survey where all participants were asked to determine which indicators signify trauma center need and in what time frame. A Web-based survey tool (SurveyMonkey) was used to deliver the survey to the participants. After the surveys were complete, indicators were added, modified, or dropped based on the responses, and the survey process was repeated until a minimum consensus of 80% agreement was reached for each criterion.
RESULTS A total of 14 local and national experts were recruited (Table 2). Five informant interviews were conducted, and 26 potential indicators were identified. The participants completed five voting rounds before consensus was reached. The fifth round was conducted by e-mail since only one criterion was discussed. Seven participants responded to the initial round, 10 to the second, 11 to the third, 12 to the fourth, and 13 to the fifth round. After the fifth voting round, at least 82% agreement was reached among the experts for each of the 10 proposed criterion standard criteria (Table 3). The percent agreement was calculated based on the number of participants who participated in the survey. Table 3 provides a list of the indicators that were identified. The 10 indicators are intended to be used independently, and the presence of any one indicates trauma center need, with one exception, injured patients who arrived in the ED in traumatic cardiac arrest. Patients who arrived in the ED in traumatic cardiac arrest were determined not to require the resources of a trauma center, even if they met one of the other indicators (e.g., intubation by a prehospital care provider in the field or receiving a blood transfusion in an air ambulance).
DISCUSSION The indicators identified in this study are anticipated to standardize the outcome measures used by researchers studying the Field Triage Guidelines and represent an initial step in developing a consensus-based, criterion standard definition of trauma center need. It is our hope that these findings will initiate a national discussion of what factors indicate trauma center need and lead to uniform definitions for future research. * 2014 Lippincott Williams & Wilkins
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ACS COT2 Knopp18 Baxt11 Esposito19 Norcorss20 Simmons21 Henry15 Henry22 Wuerz23 O’Keefe24* Engum25 Potoka26 Meldon16 Taylor27 Baez28 Holcomb14** MacKenzie6 Eastridge29 Burd30 Newgard31 Newgard9 Cancio32 Newgard33 Lehmann34 Newgard35 Newgard8 Beekley36† Brown37 Lerner12 Lerner13 Nakamura38
1986 1988 1990 1995 1995 1995 1996 1996 1996 1999 2000 2000 2002 2002 2003 2005 2006 2006 2007 2007 2008 2008 2009 2009 2010 2010 2010 2011 2011 2011 2012
In-Hospital Death
X
X
X
X
X
X
X
X
X
X
X X
X
X
X X X
X
X
X
X X
X
X
X
ED Death
X
X
DOA to ED
X
X
DOA to EMS
X X X
ISS Q16
X
X
X
X
X X
ISS 9 15
X
X X
X
X
X
X
Death
X X
ED Disposition
X X X
X
X X X
X X
X
X X X
ICU Admission/ LOS
X
Admission
X
Transfer to Another Facility
X X
X
X
X
X
X X
X
Nonorthopedic Surgery
*O’Keefe also used cost as an outcome measure. Death was included in the table; however, O’Keefe looked at the case-fatality rate. **Holcomb did not specify what procedures they used as life-saving interventions; however, in their article, they did additionally state that they used insertion of a chest tube, defibrillation, and arteriograms as outcome measures. †Beekley also used the application of tourniquets and hemostatic dressings as an outcome measure. ‡It is important to note that generalizations were sometimes made in including outcome measures in the table. For instance, major surgery within 6 hours of hospital arrival is included under the ‘‘major surgery’’ column without a time qualifier. CPR, cardiopulmonary resuscitation; DOA, dead on arrival.
First Author
Previously Used Measures of Trauma Center Need
Year
TABLE 1.
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1986 ACS COT2 1988 Knopp18 1990 Baxt11 1995 Esposito19 1995 Norcorss20 1995 Simmons21 1996 Henry15 1996 Henry22 1996 Wuerz23 1999 O’Keefe24* 2000 Engum25 2000 Potoka26 2002 Meldon16 2002 Taylor27 2003 Baez28 2005 Holcomb14** 2006 MacKenzie6 2006 Eastridge29 2007 Burd30 2007 Newgard31 2008 Newgard9 2008 Cancio32 2009 Newgard33 2009 Lehmann34 2010 Newgard35 2010 Newgard8 2010 Beekley36† 2011 Brown37 2011 Lerner12 2011 Lerner13 2012 Nakamura38
X X
X
X
X X
X
X
X
X
X
X
X
X
X
X
X
X X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Major LOS LOS Total 91 L of Blood Needle Cardioversion Invasive CNS /Pacing CPR Pericardiocentesis Monitoring Year First Author Surgery 9 2 d 9 3 d LOS Fluid Transfusion Ventilator Intubation Thoracostomy Cricothyrotomy Thoracotomy
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TABLE 2. Local and National Experts Participation in the Delphi Process Name
Institution
Karen J. Brasel, MD, MPH Charles E. Cady, MD M. Riccardo Colella, DO, MPH Arthur Cooper, MD, MS Jeremy T. Cushman, MD, MS, EMT-P David M. Gourlay, MD Gregory J. Jurkovich, MD Craig D. Newgard, MD, MPH Ronald G. Pirrallo, MD, MHSA Jeffrey P. Salomone, MD Scott M. Sasser, MD Manish N. Shah, MD, MPH Robert A. Swor, DO Stewart C. Wang, MD
Medical College of Wisconsin Medical College of Wisconsin Medical College of Wisconsin Columbia University Medical Center Affiliation at Harlem Hospital University of Rochester Medical Center Medical College of Wisconsin Denver Health and Hospital Authority Oregon Health & Science University Medical College of Wisconsin Emory University School of Medicine Emory University School of Medicine University of Rochester Medical Center Beaumont Health System University of Michigan Health System
Uniform definitions will facilitate comparisons between studies and ultimately lead to improved destination decision making in the prehospital setting. It is important to emphasize that these indicators are not intended to guide prehospital clinical care but were instead developed as a tool for researchers to use in the evaluation of prehospital decision making. Sensitivity, specificity, positive predictive value, and other measures used to evaluate screening tools and other medical tests require a reference standard. Thus, it is not possible to conduct research without a criterion standard definition for the condition the test is intended to identify, in this case an injured patient who requires the services of a trauma center.
Interviewed
First Round
Second Round
Third Round
Fourth Round
Fifth Round
X X
X
X
X X
X X X
X
X X X X
X
X
X
X
X
X
X X
X X
X X
X X
X X
X
X X X
X X X
X
X
X
X X
X
X
X
X
X
X
X
X
X
X
X
X
X X
X X
The consensus process included agreeing on time frames for each of the identified indicators. The goal in selecting these times was to make them long enough for a patient who was treated at a nontrauma center to still meet the indication either following an interfacility transfer or after necessary staff were called in to the nontrauma center hospital but not so long that the indication was due to a secondary event or was a nonurgent procedure. In general, the panel members considered whether a given indicator warranted the potential increased risks associated with bypassing closer hospitals and travelling with lights and sirens or by a helicopter to the highest level of care within the defined trauma system. Thus, the longest time frame associated with a proposed criterion in the consensus-based
TABLE 3. Proposed Consensus-Based Criterion Standard Definition of Trauma Center Need for the Injured Patient Who Requires the Highest Level of Care Within the Defined Trauma System Indicator
Time Frame
Received 91 U of a blood product. Admitted to the hospital for a spinal cord injury. Received any advanced airway management (e.g., surgical airway, intubation, LMA, King LT). This excludes intubation solely for surgical procedures. Did not meet the NAEMSP/ACS COT criteria for termination of resuscitation39 for traumatic cardiopulmonary arrest and received a thoracotomy for treatment of their initial injury. Did not meet the NAEMSP/ACS COT criteria for termination39 of resuscitation for traumatic cardiopulmonary arrest and received a pericardiocentesis for treatment of their initial injury. Received an emergency cesarean delivery because of their injuries. Received intracranial pressure monitoring. Received interventional radiology for interventional or diagnostic purposes related to their injury. Received vascular, neurologic, abdominal, thoracic, pelvic, spine, or limb-conserving surgery (i.e., on a limb that was found to be pulseless distal to the injury before surgery). Patients who had an injury that typically required any of the treatments listed above as needing a trauma center and arrived at the hospital not in cardiac arrest but ultimately died of their injury in the ED or before hospital discharge.
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4 h of hospital arrival None 4 h of hospital arrival 48 h of hospital arrival 24 h of hospital arrival 24 h of hospital arrival 48 h of hospital arrival 4 h of hospital arrival 24 h of hospital arrival None
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standard is 48 hours. While a minority of injured patients will meet some of the criteria beyond 48 hours, it was reasoned that they could be effectively transferred to the highest level of care within the defined trauma system by a nonemergent ground ambulance if they required the resources of a trauma center. This study is limited because it represents the consensus opinion of 14 experts and may not be representative of researchers and clinicians nationally. It is important to note that to limit the influence of panel members on each other, no group discussions were held either by telephone or face to face. Each participant voted independently and without access to other members’ votes. If clarifications were needed, only one author (E.B.L.), who did not vote on the criteria, contacted the participant to discuss the vote and clarify any modifications that were recommended. Ideally, these indicators should be validated using clinical data. Before a clinical validation study can be conducted, the logical next step is to receive feedback from national stakeholders and to operationalize these indicators. Once the indicators are operationalized, it will be important to determine the validity, feasibility, as well as the intrarater and interrater reliability of identifying them through a medical record review. AUTHORSHIP E.B.L. and B.D.W. designed the study, conducted all data collection and analysis, and developed an initial draft of the manuscript. All of the remaining authors participated in the data collection phase and reviewed and critically revised the manuscript.
DISCLOSURE B.D.W. was awarded a Wisconsin Medical Society Foundation Fellowship in Government and Community Service to fund his work on this project during the summer of 2012. In addition, B.D.W. was awarded a travel stipend from the Friends of the Medical College of Wisconsin to offset the costs of presenting this project at a national meeting in Atlanta, Georgia. No other external support was received for this project. The authors have no relevant financial conflicts of interest to report.
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