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The trade-offs in field trauma triage: a multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies.

ABSTRACT: National benchmarks for trauma triage sensitivity (?95%) and specificity (?50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices.This was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity.A total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4%) had ISS of 16 or greater. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4%).Reaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in overtriage). A 90% sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm.

SUBMITTER: Newgard CD

PROVIDER: S-EPMC3726266 | biostudies-literature | 2013 May

REPOSITORIES: biostudies-literature

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The trade-offs in field trauma triage: a multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies.

Newgard Craig D CD Hsia Renee Y RY Mann N Clay NC Schmidt Terri T Sahni Ritu R Bulger Eileen M EM Wang N Ewen NE Holmes James F JF Fleischman Ross R Zive Dana D Staudenmayer Kristan K Haukoos Jason S JS Kuppermann Nathan N

The journal of trauma and acute care surgery 20130501 5

<h4>Background</h4>National benchmarks for trauma triage sensitivity (≥95%) and specificity (≥50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices.<h4>Methods</h4>This was a retrospective cohort study ...[more]

PMID: 23609282

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Project description:The ability to dynamically and rapidly adjust task performance based on its outcome is fundamental to adaptive, flexible behavior. Over trials of a task, responses speed up until an error is committed and after the error responses slow down. These dynamic adjustments serve to optimize performance and are well-described by the speed-accuracy trade-off (SATO) function. We hypothesized that SATOs based on outcomes reflect reciprocal changes in the allocation of attention between the internal milieu and the task-at-hand, as indexed by reciprocal changes in activity between the default and dorsal attention brain networks. We tested this hypothesis using functional MRI to examine the pattern of network activation over a series of trials surrounding and including an error. We further hypothesized that these reciprocal changes in network activity are coordinated by the posterior cingulate cortex (PCC) and would rely on the structural integrity of its white matter connections. Using diffusion tensor imaging, we examined whether fractional anisotropy of the posterior cingulum bundle correlated with the magnitude of reciprocal changes in network activation around errors. As expected, reaction time (RT) in trials surrounding errors was consistent with predictions from the SATO function. Activation in the default network was: (i) inversely correlated with RT, (ii) greater on trials before than after an error and (iii) maximal at the error. In contrast, activation in the right intraparietal sulcus of the dorsal attention network was (i) positively correlated with RT and showed the opposite pattern: (ii) less activation before than after an error and (iii) the least activation on the error. Greater integrity of the posterior cingulum bundle was associated with greater reciprocity in network activation around errors. These findings suggest that dynamic changes in attention to the internal versus external milieu in response to errors underlie SATOs in RT and are mediated by the PCC.

Project description:Objective: Older adults make up a rapidly increasing proportion of motor vehicle occupants and previous studies have demonstrated that this population is more susceptible to traumatic injuries. The CDC recommends that patients anticipated to have severe injuries (Injury Severity Score [ISS] ≥ 16) be transported to a trauma center. The recommended target rate for undertriage is ≤ 5% and for overtriage is ≤ 50%. Several regression-based algorithms for injury prediction have been developed in order to predict severe injury in occupants involved in a motor vehicle collision (MVC). The objective of this study to was to determine if the accuracy of regression-based injury severity prediction algorithms decreases for older adults.Methods: Data were obtained from the National Automotive Sampling System - Crashworthiness Data System (NASS-CDS) from the years 2000-2015. Adult occupants involved in non-rollover MVCs were included. Regression-based injury risk models to predict severe injury (ISS ≥ 16) were developed using random split-samples with the following variables: age, delta-V, direction of impact, belt status, and number of impacts. Separate models were trained using data from the following age groups: (1) all adults, (2) 15-54 years, (3) ≥45 years, (4) ≥55 years, and (5) ≥65 years. The models were compared using the mean receiver operating characteristic area under curve (ROC-AUC) after 1,000 iterations of training and testing. The predicted rates of overtriage were then determined for each group in order to achieve an undertriage rate of 5%.Results: There were 24,577 occupants (6,863,306 weighted) included in this analysis. The injury prediction model trained using data from all adults did not perform as well when tested on older adults (ROC-AUC: 15-54 years: 0.874 [95% CI: [0.851-0.895]; 45+ years: 0.837 [95% CI: 0.802-869]; 55+ years: 0.821 [95% CI: 0.775-0.864]; and 65+ years: 0.813 [95% CI: 0.754-0.866]). The accuracy of this model decreased in each decade of life. The performance did not change significantly when age-specific data were used to train the prediction models (ROC-AUC: 18-54 years: 0.874 [95% CI: 0.851-0.896]; 45+ years: 0.836 [95% CI: 0.798-0.871]; 55+ years: 0.822 [95% CI: 0.779-0.864]; and 65+ years: 0.808 [95% CI: 0.748-0.868]). In order to achieve an undertriage rate of 5%, the predicted overtriage rate by these models were 50% for occupants 15-54 years, 61% for occupants ≥ 55 years, 70% for occupants ≥ 55 years, and 71% for occupants ≥ 65 years.Conclusion: The results of this study indicate that it is more difficult to accurately predict severe injury in older adults involved in MVCs, which has the potential to result in significant overtriage. This decreased accuracy is likely due to variations in fragility in older adults. These findings indicate that special care should be taken when using regression-based prediction models to determine the appropriate hospital destination for older occupants.

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Dataset Information

The trade-offs in field trauma triage: a multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies.

Publications

The trade-offs in field trauma triage: a multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies.

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