Using a multidisciplinary and evidence-based approach to decrease undertriage and overtriage of pediatric trauma patients

Abstract

Background: The American College of Surgeons Committee on Trauma (ACS-COT) view over- and undertriage rates based on trauma team activation (TTA) criteria as surrogate markers for quality trauma patient care. Undertriage occurs when classifying patients as not needing a TTA when they do. Over-triage occurs when a TTA is unnecessarily activated. ACS-COT recommends undertriage <5% and overtriage 25-35%. We sought to improve the under-triage and over-triage rates at our Level II Pediatric Trauma Center by updating our outdated trauma team activation criteria in an evidence-based fashion to better identify severely injured children and improving adherance to following established trauma team activation criteria.

Methods: This study was designed prospectively as a Process Improvement Patient Safety (PIPS) project in two phases. Data was obtained from our trauma registry. Prior to the initiation of Phase I, the TTA was modified using the best available evidence at the time. A Base Station report was modified to include elements of the TTA to be checked when EMS called prior to arrival to guide in activation. Phase I of the study (April 1-June 30, 2011) involved improving adherence to activating a trauma according to our newly revised TTA criteria. Phase II of the study (July 1, 2011-June 30, 2012) moved the trauma team activation responsibility primarily to nursing (collaborating with MDs) and including activation criteria regarding transfers-in from outside hospitals. Triage rates were calculated using the Cribari method: undertriage=patients with an ISS >15 for which a major or modified was not activated, and overtriage=patients with an ISS <16 for which a major was activated.

Results: 2011 Q1 YTD data was used as a baseline comparison. Baseline undertriage was 15% and overtriage was 75%. Phase I demonstrated 90% use of the redesigned Base Station report reflecting the new TTA criteria and was validated by RN/MD signatures. This resulted in an undertriage rate of 10% (12/118) and an overtriage rate of 20% (1/5). During Phase II, there was 100% use of the newly redesigned Base Station report. Phase IIa (concluding the data collection for 2011) demonstrated an undertriage rate of 8.4% (19/226) and an overtriage rate of 38% (5/13). Data during Phase IIb indicated an undertriage rate of 4.7% (12/251 pts) and overtriage rate of 54% (7/13). During baseline phase of the study, 50% of major patients went to the OR from the ER. During Phase I all major activations required admission to the PICU (4) or the OR (1). Finally, during Q2 2012 (the last quarter of Phase II), 25% of majors went to OR (2/8), 50% to ICU (4/8), 12.5% to Med-Surg (1/8), and 12.5% to home (1/8).

Conclusions: Standardization of process resulted in improved, sustainable under-/overtriage rates. Undertriage rates dropped from 15% to 5% undertriage, the ACS-recommended standard. Appropriate triage appears to have correlated with appropriate utilization of resources.

Keywords: Pediatric trauma; Process improvement; Trauma triage.