Evaluation and improvement of prehospital trauma triage

Abstract

Worldwide, every five seconds a life is cut short as a result of an injury. Additionally, many more lives are affected by injury-related disabilities. In first world countries, systems of trauma care have been shown to substantially reduce the mortality associated with injury. In these trauma systems, different levels of trauma centers exist. In general, two levels of trauma centers can be distinguished; higher-level and lower-level trauma centers. Ensuring transport of severely injured patients to higher-level trauma center has a profound impact on these patients’ survival. At the same time, transport of patients without severe injuries to lower-level trauma centers should be warranted, in order to lower the preventable burden on higher-level trauma centers and unnecessary high costs. Every single day, emergency medical services (EMS) providers assess and make decisions for each individual patient: they have to start initial care, decide whether treatment at a trauma center is necessary, and if so, transport that patient to the most appropriate trauma center. This process of prehospital trauma triage plays a central role in every trauma system. The goal is to identify the at-risk patients and to timely transport them to the most appropriate trauma center. However, identification of severely injured patients is a challenging task. Prehospital trauma triage protocols have been developed to aid EMS providers in identifying severely injured patients. This thesis showed that currently used prehospital trauma triage protocols and triage quality are falling short and desperately need improvement. Evaluation of the prehospital trauma triage in different regions of the Netherlands showed that the triage protocol in use functioned so poorly; even flipping a coin had a higher chance of correctly identifying a severely injured patient. Fortunately, the EMS providers also rely on their clinical judgment and experience to assess the patient. Consequently, a large proportion of the severely injured patients are transported to higher-level trauma centers. Yet, work remains to be done, since 22%-27% of the severely injured patients were not transported to a higher-level trauma center. The newly developed and validated prediction model, as described in this thesis, could identify about 90% of the severely injured patients. This triage prediction model could aid EMS providers in their transport decisions. Furthermore, addition of EMS provider judgment could enhance the accuracy even more. The current trauma system is well designed; however, it can be improved substantially by accurate prehospital trauma triage. Inadequate prehospital trauma triage has a negative impact on the whole trauma system chain, such as a decreased functional outcome for the patient and relatively higher trauma care costs. Innovation, education, and regional collaboration are the three pillars on which this improvement is based. A newly developed triage tool serves as an important first step on the road ahead to optimize prehospital trauma triage. This road will lead to an improvement of the entire trauma care chain and provide future patients with the care they deserve.