Dataset Information

Cost-Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services.

ABSTRACT: The American College of Surgeons Committee on Trauma sets national targets for the accuracy of field trauma triage at ?95% sensitivity and ?65% specificity, yet the cost-effectiveness of realizing these goals is unknown. We evaluated the cost-effectiveness of current field trauma triage practices compared with triage strategies consistent with the national targets.This was a cost-effectiveness analysis using data from 79,937 injured adults transported by 48 emergency medical services agencies to 105 trauma and nontrauma hospitals in 6 regions of the western United States from 2006 through 2008. Incremental differences in survival, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio (costs per QALY gained) were estimated for each triage strategy during a 1-year and lifetime horizon using a decision analytic Markov model. We considered an incremental cost-effectiveness ratio threshold of <$100,000 to be cost-effective.For these 6 regions, a high-sensitivity triage strategy consistent with national trauma policy (sensitivity 98.6%, specificity 17.1%) would cost $1,317,333 per QALY gained, and current triage practices (sensitivity 87.2%, specificity 64.0%) cost $88,000 per QALY gained, compared with a moderate sensitivity strategy (sensitivity 71.2%, specificity 66.5%). Refining emergency medical services transport patterns by triage status improved cost-effectiveness. At the trauma-system level, a high-sensitivity triage strategy would save 3.7 additional lives per year at a 1-year cost of $8.78 million, and a moderate sensitivity approach would cost 5.2 additional lives and save $781,616 each year.A high-sensitivity approach to field triage consistent with national trauma policy is not cost-effective. The most cost-effective approach to field triage appears closely tied to triage specificity and adherence to triage-based emergency medical services transport practices.

SUBMITTER: Newgard CD

PROVIDER: S-EPMC4975576 | biostudies-literature | 2016 Jun

REPOSITORIES: biostudies-literature

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Cost-Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services.

Newgard Craig D CD Yang Zhuo Z Nishijima Daniel D McConnell K John KJ Trent Stacy A SA Holmes James F JF Daya Mohamud M Mann N Clay NC Hsia Renee Y RY Rea Tom D TD Wang N Ewen NE Staudenmayer Kristan K Delgado M Kit MK

Journal of the American College of Surgeons 20160303 6

<h4>Background</h4>The American College of Surgeons Committee on Trauma sets national targets for the accuracy of field trauma triage at ≥95% sensitivity and ≥65% specificity, yet the cost-effectiveness of realizing these goals is unknown. We evaluated the cost-effectiveness of current field trauma triage practices compared with triage strategies consistent with the national targets.<h4>Study design</h4>This was a cost-effectiveness analysis using data from 79,937 injured adults transported by 4 ...[more]

PMID: 27178369

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Project description:BackgroundThe National Field Triage Guidelines were created to inform triage decisions by emergency medical services (EMS) providers and include eight anatomic injuries that prompt transportation to a Level I/II trauma center. It is unclear how accurately EMS providers recognize these injuries. Our objective was to compare EMS-identified anatomic triage criteria with International Classification of Diseases-10th revision (ICD-10) coding of these criteria, as well as their association with trauma center need (TCN).MethodsScene patients 16 years and older in the NTDB during 2017 were included. National Field Triage Guidelines anatomic criteria were classified based on EMS documentation and ICD-10 diagnosis codes. The primary outcome was TCN, a composite of Injury Severity Score greater than 15, intensive care unit admission, urgent surgery, or emergency department death. Prevalence of anatomic criteria and their association with TCN was compared in EMS-identified versus ICD-10-coded criteria. Diagnostic performance to predict TCN was compared.ResultsThere were 669,795 patients analyzed. The ICD-10 coding demonstrated a greater prevalence of injury detection. Emergency medical service-identified versus ICD-10-coded anatomic criteria were less sensitive (31% vs. 59%), but more specific (91% vs. 73%) and accurate (71% vs. 68%) for predicting TCN. Emergency medical service providers demonstrated a marked reduction in false positives (9% vs. 27%) but higher rates of false negatives (69% vs. 42%) in predicting TCN from anatomic criteria. Odds of TCN were significantly greater for EMS-identified criteria (adjusted odds ratio, 4.5; 95% confidence interval, 4.46-4.58) versus ICD-10 coding (adjusted odds ratio 3.7; 95% confidence interval, 3.71-3.79). Of EMS-identified injuries, penetrating injury, flail chest, and two or more proximal long bone fractures were associated with greater TCN than ICD-10 coding.ConclusionWhen evaluating the anatomic criteria, EMS demonstrate greater specificity and accuracy in predicting TCN, as well as reduced false positives compared with ICD-10 coding. Emergency medical services identification is less sensitive for anatomic criteria; however, EMS identify the most clinically significant injuries. Further study is warranted to identify the most clinically important anatomic triage criteria to improve our triage protocols.Level of evidenceCare management, Level IV; Prognostic, Level III.

Project description:Importance:Despite a large rural US population, there are potential differences between rural and urban regions in the processes and outcomes following trauma. Objectives:To describe and evaluate rural vs urban processes of care, injury severity, and mortality among injured patients served by 9-1-1 emergency medical services (EMS). Design, Setting, and Participants:This was a preplanned secondary analysis of a prospective cohort enrolled from January 1 through December 31, 2011, and followed up through hospitalization. The study included 44 EMS agencies transporting to 28 hospitals in 2 rural and 5 urban counties in Oregon and Washington. A population-based, consecutive sample of 67?047 injured children and adults served by EMS (1971 rural and 65?076 urban) was enrolled. Among the 53?487 patients transported by EMS, a stratified probability sample of 17?633 patients (1438 rural and 16?195 urban) was created to track hospital outcomes (78.9% with in-hospital follow-up). Data analysis was performed from June 12, 2015, to May 20, 2016. Exposures:Rural was defined at the county level by 60 minutes or more driving proximity to the nearest level I or II trauma center and/or rural designation in the Centers for Medicare & Medicaid Services ambulance fee schedule by zip code. Main Outcomes and Measures:Mortality (out-of-hospital and in-hospital), need for early critical resources, and transfer rates. Results:Of the 53?487 injured patients transported by EMS (17?633 patients in the probability sample), 27?535 were women (51.5%); mean (SD) age was 51.6 (26.1) years. Rural vs urban sensitivity of field triage for identifying patients requiring early critical resources was 65.2% vs 80.5%, and only 29.4% of rural patients needing critical resources were initially transported to major trauma centers vs 88.7% of urban patients. After accounting for transfers, 39.8% of rural patients requiring critical resources were cared for in major trauma centers vs 88.7% of urban patients. Overall mortality did not differ between rural and urban regions (1.44% vs 0.89%; P?=?.09); however, 89.6% of rural deaths occurred within 24 hours compared with 64% of urban deaths. Rural regions had higher transfer rates (3.2% vs 2.7%) and longer transfer distances (median, 97.4 km; interquartile range [IQR], 51.7-394.5 km; range, 47.8-398.6 km vs 22.5 km; IQR, 11.6-24.6 km; range, 3.5-97.4 km). Conclusions and Relevance:Most high-risk trauma patients injured in rural areas were cared for outside of major trauma centers and most rural trauma deaths occurred early, although overall mortality did not differ between regions. There are opportunities for improved timeliness and access to major trauma care among patients injured in rural regions.

Project description:BackgroundIn Sweden, the rapid emergency triage and treatment system (RETTS-A) is used in the pre-hospital setting. With RETTS-A, patients triaged to the lowest level could safely be referred to a lower level of care. The national early warning score (NEWS) has also shown promising results internationally. However, a knowledge gap in optimal triage in the pre-hospital setting persists. This study aimed to evaluate RETTS-A performance, compare RETTS-A with NEWS and NEWS 2, and evaluate the emergency medical service (EMS) nurse's field assessment with the physician's final hospital diagnosis.MethodsA prospective, observational study including patients (≥16 years old) transported to hospital by the Gothenburg EMS in 2016. Three comparisons were made: 1) Combined RETTS-A levels orange and red (high acuity) compared to a predefined reference emergency, 2) RETTS-A high acuity compared to NEWS and NEWS 2 score ≥ 5, and 3) Classification of pre-hospital nurse's field assessment compared to hospital physician's diagnosis. Outcomes of the time-sensitive conditions, mortality and hospitalisation were examined. The statistical tests included Mann-Whitney U test and Fisher's exact test, and several binary classification tests were determined.ResultsOverall, 4465 patients were included (median age 69 years; 52% women). High acuity RETTS-A triage showed a sensitivity of 81% in prediction of the reference patient with a specificity of 64%. Sensitivity in detecting a time-sensitive condition was highest with RETTS-A (73%), compared with NEWS (37%) and NEWS 2 (35%), and specificity was highest with NEWS 2 (83%) when compared with RETTS-A (54%). The negative predictive value was higher in RETTS-A (94%) compared to NEWS (91%) and NEWS 2 (92%). Eleven per cent of the final diagnoses were classified as time-sensitive while the nurse's field assessment was appropriate in 84% of these cases.ConclusionsIn the pre-hospital triage of EMS patients, RETTS-A showed sensitivity that was twice as high as that of both NEWS and NEWS 2 in detecting time-sensitive conditions, at the expense of lower specificity. However, the proportion of correctly classified low risk triaged patients (green/yellow) was higher in RETTS-A. The nurse's field assessment of time-sensitive conditions was appropriate in the majority of cases.

Project description:The emergency medical services (EMS) cover initiatives and services established to provide essential medical assistance in situations of acute illness. Triage-methods for systematic prioritizing of patients according to how urgent patients need care, including triage of requests of acute medical treatment, are adopted in hospitals as well as in the pre-hospital settings. This systematic review searched to identify available research on the effects of validated triage systems for use in the pre-hospital EMS on health outcomes, patient safety, patient satisfaction, user-friendliness, resource use, goal achievement, and the quality on the information exchange between the different settings of the EMS (for example the quality of documentation). The specific research questions were: 1) are pre-hospital triage systems effective, 2) is one triage system more effective than others, and 3) is it effective to use the same triage system in two or more settings of the EMS-chain? We conducted a systematic literature search in nine databases up to June 2012. We searched for systematic reviews (SRs), randomized controlled trials (RCTs), non-randomized controlled trials (non-RCTs), controlled before and after studies (CBAs) and interrupted time series analyses (ITSs). Two persons independently reviewed titles and abstracts, and the same persons read all possibly relevant full text articles and rated the methodological quality where relevant. The literature search identified 11011 unique references. A total of 120 publications were read in full text. None of the identified articles fulfilled our inclusion criteria, thus our question on the effects of pre-hospital triage systems, if one system is better than other systems, and the question on effects of using the same triage system in two or more settings of the EMS, remain unanswered. We conclude that there is an evidence gap regarding the effects of pre-hospital triage systems and the effects of using the same triage system in two or more settings of the EMS. The finding does not mean that pre-hospital triage systems are ineffective, but that we lack knowledge about potential effects. When introducing a new assessment tool in the EMS, it is timely to conduct well-planned studies aimed to assess the effect.

Project description:IntroductionA proposed Diagnostic AI System for Robot-Assisted Triage ("DAISY") is under development to support Emergency Department ("ED") triage following increasing reports of overcrowding and shortage of staff in ED care experienced within National Health Service, England ("NHS") but also globally. DAISY aims to reduce ED patient wait times and medical practitioner overload. The objective of this study was to explore NHS health practitioners' perspectives and attitudes towards the future use of AI-supported technologies in ED triage.MethodsBetween July and August 2022 a qualitative-exploratory research study was conducted to collect and capture the perceptions and attitudes of nine NHS healthcare practitioners to better understand the challenges and benefits of a DAISY deployment. The study was based on a thematic analysis of semi-structured interviews. The study involved qualitative data analysis of the interviewees' responses. Audio-recordings were transcribed verbatim, and notes included into data documents. The transcripts were coded line-by-line, and data were organised into themes and sub-themes. Both inductive and deductive approaches to thematic analysis were used to analyse such data.ResultsBased on a qualitative analysis of coded interviews with the practitioners, responses were categorised into broad main thematic-types, namely: trust; current practice; social, legal, ethical, and cultural concerns; and empathetic practice. Sub-themes were identified for each main theme. Further quantitative analyses explored the vocabulary and sentiments of the participants when talking generally about NHS ED practices compared to discussing DAISY. Limitations include a small sample size and the requirement that research participants imagine a prototype AI-supported system still under development. The expectation is that such a system would work alongside the practitioner. Findings can be generalisable to other healthcare AI-supported systems and to other domains.DiscussionThis study highlights the benefits and challenges for an AI-supported triage healthcare solution. The study shows that most NHS ED practitioners interviewed were positive about such adoption. Benefits cited were a reduction in patient wait times in the ED, assistance in the streamlining of the triage process, support in calling for appropriate diagnostics and for further patient examination, and identification of those very unwell and requiring more immediate and urgent attention. Words used to describe the system were that DAISY is a "good idea", "help", helpful, "easier", "value", and "accurate". Our study demonstrates that trust in the system is a significant driver of use and a potential barrier to adoption. Participants emphasised social, legal, ethical, and cultural considerations and barriers to DAISY adoption and the importance of empathy and non-verbal cues in patient interactions. Findings demonstrate how DAISY might support and augment human medical performance in ED care, and provide an understanding of attitudinal barriers and considerations for the development and implementation of future triage AI-supported systems.

Dataset Information

Cost-Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services.

Publications

Cost-Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services.

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