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Using a multidisciplinary and evidence-based approach to decrease undertriage and overtriage of pediatric trauma
Mauricio A Escobar1, Carolynn J Morris1
1Mary Bridge Children's, Tacoma, WA.
Insights
Improving trauma team activation (TTA) criteria in pediatric trauma care significantly reduced undertriage to 5%, meeting American College of Surgeons Committee on Trauma standards. This enhanced patient identification and resource allocation.
Area of Science:
- Trauma Surgery
- Pediatric Emergency Medicine
- Quality Improvement
Background:
- The American College of Surgeons Committee on Trauma (ACS-COT) uses undertriage and overtriage rates as quality indicators for trauma patient care.
- Current ACS-COT recommendations suggest undertriage rates below 5% and overtriage rates between 25-35%.
- This study addresses outdated trauma team activation (TTA) criteria at a Level II Pediatric Trauma Center to improve patient identification and resource utilization.
Purpose of the Study:
- To enhance the accuracy of trauma patient identification by revising TTA criteria.
- To decrease undertriage and overtriage rates in a pediatric trauma population.
- To improve adherence to evidence-based TTA criteria for better patient outcomes.
Main Methods:
- A prospective Process Improvement Patient Safety (PIPS) project conducted in two phases.
- Phase I focused on revising TTA criteria and improving adherence using a modified Base Station report.
- Phase II shifted TTA responsibility to nursing staff, incorporating inter-facility transfer criteria, and calculated triage rates using the Cribari method.
Main Results:
- Baseline undertriage was 15% and overtriage was 75%.
- Following revised TTA criteria and improved adherence, undertriage decreased to 4.7% and overtriage fluctuated between 20% and 54%.
- Appropriate triage correlated with appropriate resource utilization, with shifts in patient disposition from the ER to the OR, PICU, or Med-Surg.
Conclusions:
- Standardizing TTA processes led to improved and sustainable undertriage and overtriage rates, meeting ACS-COT standards for undertriage.
- Evidence-based TTA criteria and process standardization are crucial for accurate pediatric trauma patient identification.
- Appropriate triage decisions positively impact the efficient utilization of trauma center resources.
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.
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