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Defining the representativeness heuristic in trauma triage: A retrospective observational cohort study.

ABSTRACT: BACKGROUND:Under-triage of severely injured patients presenting to non-trauma centers (failure to transfer to a trauma center) remains problematic despite quality improvement efforts. Insights from the behavioral science literature suggest that physician heuristics (intuitive judgments), and in particular the representativeness heuristic (pattern recognition), may contribute to under-triage. However, little is known about how the representativeness heuristic is instantiated in practice. METHODS:A multi-disciplinary group of experts identified candidate characteristics of "representative" severe trauma cases (e.g., hypotension). We then reviewed the charts of patients with moderate-to-severe injuries who presented to nine non-trauma centers in western Pennsylvania from 2010-2014 to assess the association between the presence of those characteristics and triage decisions. We tested bivariate associations using ?2 and Fisher's Exact method and multivariate associations using random effects logistic regression. RESULTS:We identified 235,605 injured patients with 3,199 patients (1%) having moderate-to-severe injuries. Patients had a median age of 78 years (SD 20.1) and mean Injury Severity Score of 10.9 (SD 3.3). Only 759 of these patients (24%) were transferred to a trauma center as recommended by the American College of Surgeons clinical practice guidelines. Representative characteristics occurred in 704 patients (22%). The adjusted odds of transfer were higher in the presence of representative characteristics compared to when they were absent (aOR 1.7, 95% CI: 1.4-2.0, p < 0.001). CONCLUSIONS:Most moderate-to-severely injured patients present without the characteristics representative of severe trauma. Presence of these characteristics is associated with appropriate transfer, suggesting that modifying physicians' heuristics in trauma may improve triage patterns.

SUBMITTER: Kulkarni SS

PROVIDER: S-EPMC6368323 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Defining the representativeness heuristic in trauma triage: A retrospective observational cohort study.

Kulkarni Shreyus S SS Dewitt Barry B Fischhoff Baruch B Rosengart Matthew R MR Angus Derek C DC Saul Melissa M Yealy Donald M DM Mohan Deepika D

PloS one 20190208 2

<h4>Background</h4>Under-triage of severely injured patients presenting to non-trauma centers (failure to transfer to a trauma center) remains problematic despite quality improvement efforts. Insights from the behavioral science literature suggest that physician heuristics (intuitive judgments), and in particular the representativeness heuristic (pattern recognition), may contribute to under-triage. However, little is known about how the representativeness heuristic is instantiated in practice.< ...[more]

PMID: 30735553

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Project description:IntroductionRetrospective trauma scores are often used to categorise trauma, however, they have little utility in the prehospital or hyper-acute setting and do not define major trauma to non-specialists. This study employed a Delphi process in order to gauge degrees of consensus/disagreement amongst expert panel members to define major trauma.MethodA two round modified Delphi technique was used to explore subject-expert consensus and identify variables to define major trauma through systematically collating questionnaire responses. After initial descriptive analysis of variables, Kruskal-Wallis tests were used to determine statistically significant differences (p < 0.05) in response to the Delphi statements between professional groups. A hierarchical cluster analysis was undertaken to identify patterns of similarity/difference of response. A grounded theory approach to qualitative analysis of data allowed for potentially multiple iterations of the Delphi process to be influenced by identified themes.ResultsOf 55 expert panel members invited to participate, round 1 had 43 participants (Doctor n = 20, Paramedic n = 20, Nurse n = 5, other n = 2). No consistent patterns of opinion emerged with regards to professional group. Cluster analysis identified three patterns of similar responses and coded as trauma minimisers, the middle ground and the risk averse. Round 2 had 35 respondents with minimum change in opinion between rounds. Consensus of > 70% was achieved on many variables which included the identification of life/limb threatening injuries, deranged physiology, need for intensive care interventions and that extremes of age need special consideration. It was also acknowledged that retrospective injury severity scoring has a role to play but is not the only method of defining major trauma. Various factors had a majority of agreement/disagreement but did not meet the pre-set criteria of 70% agreement. These included the topics of burns, spinal immobilisation and whether a major trauma centre is the only place where major trauma can be managed.ConclusionBased upon the output of this Delphi study, major trauma may be defined as: "Significant injury or injuries that have potential to be life-threatening or life-changing sustained from either high energy mechanisms or low energy mechanisms in those rendered vulnerable by extremes of age".

Project description:BackgroundTrauma related deaths remain a relevant public health problem, in particular in the younger male population. A significant number of these deaths occur prehospitally without transfer to a hospital. These patients, sometimes termed "the forgotten cohort", are usually not included in clinical registries, resulting in a lack of information about prehospitally trauma deaths. The aim of the present study was to compare patients who died prehospital with those who sustained life-threatening injuries in order to analyze and potentially improve prehospital strategies.MethodsThis cohort study included all primary operations carried out by Switzerland's largest helicopter emergency medical service (HEMS) between January 1, 2011, and December 31, 2021. We included all adult trauma patients with life-threatening or fatal conditions. The outcome of this study is the vital status of the patient at the end of mission, i.e. fatal or life-threatening. Injury, rescue characteristics, and interventions of the forgotten trauma cohort, defined as patients with a fatal injury (NACA score of VII), were compared with life-threatening injuries (NACA score V and VI).ResultsOf 110,331 HEMS missions, 5534 primary operations were finally analyzed, including 5191 (93.8%) life-threatening and 343 (6.2%) fatal injuries. More than two-thirds of patients (n = 3772, 68.2%) had a traumatic brain injury without a significant difference between the two groups (p > 0.05). Thoracic trauma (44.6% vs. 28.7%, p < 0.001) and abdominal trauma (22.2% vs. 16.1%, p = 0.004) were more frequent in fatal missions whereas pelvic trauma was similar between the two groups (13.4% vs. 12.9%, p = 0.788). Pneumothorax decompression rate (17.2% vs. 3.7%, p < 0.001) was higher in the forgotten cohort group and measures for bleeding control (15.2% vs. 42.7%, p < 0.001) and pelvic belt application (2.9% vs. 13.1% p < 0.001) were more common in the life-threating injury group.ConclusionChest decompression rates and measures for early hemorrhage control are areas for potential improvement in prehospital care.

Project description:Recent studies have implicated the differences in the ABO blood system as a potential risk for various diseases, including hemostatic disorders and hemorrhage. In this study, we evaluated the impact of the difference in the ABO blood type on mortality in patients with severe trauma.A retrospective observational study was conducted in two tertiary emergency critical care medical centers in Japan. Patients with trauma with an Injury Severity Score (ISS)?>?15 were included. The association between the different blood types (type O versus other blood types) and the outcomes of all-cause mortality, cause-specific mortalities (exsanguination, traumatic brain injury, and others), ventilator-free days (VFD), and total transfusion volume were evaluated using univariate and multivariate competing-risk regression models. Moreover, the impact of blood type O on the outcomes was assessed using regression coefficients in the multivariate analysis adjusted for age, ISS, and the Revised Trauma Score (RTS).A total of 901 patients were included in this study. The study population was divided based on the ABO blood type: type O, 284 (32%); type A, 285 (32%); type B, 209 (23%); and type AB, 123 (13%). Blood type O was associated with high mortality (28% in patients with blood type O versus 11% in patients with other blood types; p?<? 0.001). Moreover, this association was observed in a multivariate model (adjusted odds ratio =?2.86, 95% confidence interval 1.84-4.46; p?<? 0.001). The impact of blood type O on all-cause in-hospital mortality was comparable to 12 increases in the ISS, 1.5 decreases in the RTS, and 26 increases in age. Furthermore, blood type O was significantly associated with higher cause-specific mortalities and shorter VFD compared with the other blood types; however, a significant difference was not observed in the transfusion volume between the two groups.Blood type O was significantly associated with high mortality in severe trauma patients and might have a great impact on outcomes. Further studies elucidating the mechanism underlying this association are warranted to develop the appropriate intervention.

Project description:Injury burden is highest in low-income and middle-income countries. To reduce avoidable deaths, it is necessary to identify health system deficiencies preventing timely, quality care. We developed criteria to use verbal autopsy (VA) data to identify avoidable deaths and associated health system deficiencies. Agincourt, a rural Bushbuckridge municipality, Mpumalanga Province, South Africa. Agincourt Health and Socio-Demographic Surveillance System and healthcare providers (HCPs) from local hospitals. A literature review to explore definitions of avoidable deaths after trauma and barriers to access to care using the 'three delays framework' (seeking, reaching and receiving care) was performed. Based on these definitions, this study developed criteria, applicable for use with VA data, for identifying avoidable death and which of the three delays contributed to avoidable deaths. These criteria were then applied retrospectively to the VA-defined category external injury deaths (EIDs-a subset of which are trauma deaths) from 2012 to 2015. The findings were validated by external expert review. Key informant interviews (KIIs) with HCPs were performed to further explore delays to care. Using VA data, avoidable death was defined with a focus on survivability, using level of consciousness at the scene and ability to seek care as indicators. Of 260 EIDs (189 trauma deaths), there were 104 (40%) avoidable EIDs and 78 (30%) avoidable trauma deaths (41% of trauma deaths). Delay in receiving care was the largest contributor to avoidable EIDs (61%) and trauma deaths (59%), followed by delay in seeking care (24% and 23%) and in reaching care (15% and 18%). KIIs revealed context-specific factors contributing to the third delay, including difficult referral systems. A substantial proportion of EIDs and trauma deaths were avoidable, mainly occurring due to facility-based delays in care. Interventions, including strengthening referral networks, may substantially reduce trauma deaths.

Dataset Information

Defining the representativeness heuristic in trauma triage: A retrospective observational cohort study.

Publications

Defining the representativeness heuristic in trauma triage: A retrospective observational cohort study.

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