A multisite assessment of the American College of Surgeons Committee on Trauma field triage decision scheme for identifying seriously injured children and adults

Abstract

Background: The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ≥ 16) in a large and diverse multisite cohort.

Study design: This was a retrospective cohort study of injured children and adults transported by 94 emergency medical services (EMS) agencies to 122 hospitals in 7 regions of the Western US from 2006 through 2008. Patients who met any of the field trauma triage criteria (per EMS personnel) were considered triage positive. Hospital outcomes measures were probabilistically linked to EMS records through trauma registries, state discharge data, and emergency department data. The primary outcome defining a "major trauma patient" was ISS ≥ 16.

Results: There were 122,345 injured patients evaluated and transported by EMS over the 3-year period, 34.5% of whom met at least 1 triage criterion and 5.8% had ISS ≥ 16. The overall sensitivity and specificity of the criteria for identifying major trauma patients were 85.8% (95% CI 85.0% to 86.6%) and 68.7% (95% CI 68.4% to 68.9%), respectively. Triage sensitivity and specificity, respectively, differed by age: 84.1% and 66.4% (0 to 17 years); 89.5% and 64.3% (18 to 54 years); and 79.9% and 75.4% (≥55 years). Evaluating the diagnostic value of triage by hospital destination (transport to Level I/II trauma centers) did not substantially improve these findings.

Conclusions: The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.

Figure 1

The 2006 ACSCOT Field Triage Decision Scheme. (Reprinted with permission from: Resources for the Optimal Care of the Injured Patient. Chicago, IL, American College of Surgeons, 2006.)

Figure 2

Diagnostic metrics and receiver operating characteristic curve for identifying major trauma patients (ISS ≥ 16) using each “step” of the Field Triage Decision Scheme among 6 sites (n = 89,441). *Data were restricted to 6 sites, as the 7^th site did not collect adequate information necessary to categorize the triage steps. Diagnostic metrics for the “Cumulative Steps” section includes patients from each of the previous incremental steps in the triage algorithm, while metrics for the “Independent Steps” section assesses each of the triage steps independently. There were 36,230 (40.5%) patients in the 6-site sample that met field triage criteria and 5,720 (6.4%) with ISS ≥ 16. The overall ROC value for the Field Triage Decision Scheme using the 6-site sample is 0.75. *Triage steps include: 1 (physiologic), 2 (anatomic), 3 (mechanism of injury) and 4 (special considerations). ^†The number of patients in each triage step is based on the total number of patients meeting triage criteria for each independent step. As patients can meet criteria from multiple different triage steps, the column totals for number of triage-positive patients and number of patients with ISS ≥ 16 will be greater than the actual number of patients (ie, the triage steps are not mutually exclusive). EMS, emergency medical services; ISS, Injury Severity Score; sens, sensitivity; spec, specificity; CI, confidence interval; PPV, positive predictive value; NPV, negative predictive value; +LR, positive likelihood ratio; −LR, negative likelihood ratio; AUC, area under the curve.