Differences in trauma team activation criteria among Norwegian hospitals
© Larsen et al; licensee BioMed Central Ltd. 2010
Received: 18 January 2010
Accepted: 20 April 2010
Published: 20 April 2010
To ensure the rapid and correct triage of patients in potential need of specialized treatment, Norwegian hospitals are expected to establish trauma teams with predefined criteria for their activation. The objective of this study was to map and describe the criteria currently in use.
We undertook a cross-sectional survey in the summer of 2008, using structured telephone interviews to all Norwegian hospitals that might admit severely injured patients.
Forty-nine hospitals were included, of which 48 (98%) had a trauma team and 20 had a hospital-based trauma registry. Criteria for trauma team activation were found at 46 (94%) hospitals. No single criterion was common to all hospitals. The median number of criteria per hospital was 23 (range 8-40), with a total number of 156 and wide variation with respect to physiological "cut-off" values. The mechanism of injury was commonly in use despite a well-known, large over-triage rate.
In recent years, Norwegian hospitals have gradually established trauma teams and criteria for their activation. These criteria show considerable variation, including physiological "cut-off" values.
Traumatic injury is well recognized as one of the main challenges in modern health care . Worldwide, approximately 11.9 million people die annually as a result of trauma and thousands more are temporarily and permanently disabled . Based on the lessons of war, civilian trauma systems have developed substantially within the last 50 years .
The first civilian trauma centers in the US (established in San Francisco and Chicago in 1966) and the landmark paper "Optimal hospital resources for care of the seriously injured," published in 1976 by the American College of Surgeons Committee on trauma (ACS-COT), marked a new era of structured trauma care [3, 4]. Subsequent revisions of the paper by ACS-COT have followed as new knowledge evolves through systematic research, practical lessons learned, and technological developments [5–10].
Every injured patient should be treated as soon as possible at the right level of care. Organized trauma care systems, encompassing medical treatment from pre-hospital involvement to completed rehabilitation, significantly reduce injury-related mortality and morbidity in patients with moderate to severe injury [11–13].
The ideal system has been debated but should ensure appropriate patient care from resuscitation to rehabilitation. This includes triage guidelines in the field, adequate emergency medical services, and regional classification of hospitals according to the level of care [4, 14].
At the scene of an accident, it may be difficult to identify patients with potentially serious injuries due to the diversity of patients, injuries, and the degree of physiological derangement. In 1986, the American College of Surgeons published a "Field Triage Decision Scheme" which was intended to guide pre-hospital care providers to transport injured patients to the most appropriate medical facility [2, 5]. Initial experience led to recognition of inadequate triage, resulting in under- and over-triage at many trauma center facilities .
Many of these criteria have since been partially adopted for in-hospital use to perform trauma team activation (TTA). TTA shortens the time from when the patient arrives at the hospital until he or she is prepared in the operating room and improves the survival of severely injured patients . Ideal criteria should be both 100% sensitive (identifying all seriously injured patients, i.e., yielding no under-triage) and 100% specific (yielding no over-triage). Over-triage rates up to 50% have been accepted to minimize unfavorable under-triage . However, over-triage may result in an inadequate use of resources, increased workload, and longer out-of-hospital times . In 2006, an expert panel published the report "Trauma system in Norway - Suggestions for organizing the treatment of severely injured patients" . They concluded that a lack of systematic registration and national guidelines potentially cause suboptimal trauma care .
The aims of the present study were to investigate and compare the current use of TTA criteria in Norwegian hospitals.
Type of hospital
Local, Central, or Regional
Does the hospital have acute surgical function?
Yes or No
Has the hospital performed trauma team training according to the BEST1 guidelines?
Yes or No
If yes, when was the first training?
Have you been training during the last 12 months?
Yes or No
Does the hospital have a trauma manual or other written guidelines for trauma treatment?
Yes or No
Does the hospital have a defined trauma team?
Yes or No
If yes, does the hospital have predefined criteria concerning when to perform TTA?
If yes, which criteria does the hospital use today?
How were these criteria developed?
Have the criteria been revised?
If yes, when was the last revision?
If you do not have written criteria for TTA, how do you decide whether to activate the trauma team?
Does the hospital have a trauma registry and/or an injury registry?
Yes or No
If yes: trauma registry and/or injury registry
Do you perform regular trauma meetings discussing trauma patients treated by the hospital?
If yes, how often?
Does the hospital have predefined criteria for transfer of trauma patients to higher level treatment facilities?
If yes, which criteria?
Do you plan to change your practice?
If yes, how and when?
Marked questions are presented as results
The criteria were classified by subject matter or substantial interpretation by the author collecting and processing the data. If two criteria had different wording but only one interpretation, they were combined into one criterion. For instance "Penetrating injury" was specified by different hospitals as truncal, central, proximal to ankles and wrists, indicated by specific body parts, or unspecified. To allow a comparison of the criteria sets, these criteria were either classified as "centrally penetrating injury" or simply "penetrating injury". Criteria were assumed to relate to adults unless otherwise specified.
The regional ethics committee was informed about the study and decided that formal ethical approval was not required.
Norway is a narrow but long country covering 324,000 km2, with a straight-line distance from north to south of 1,800 km and a population of 4.8 million . The scattered population (16 per km2) leads to challenges regarding patient transport and availability of specialized treatment [16, 19].
The emergency medical service is well developed, with a combined ground and air ambulance service. Ambulance paramedics and general practitioners provide basic pre-hospital care, and the air ambulance service (with an anesthesiologist/paramedic crew) delivers advanced pre-hospital care. The latter responds separately when needed [16, 20]. Hospitals are organized in a three-level system of local, central, and regional university hospitals . Populations covered by local and central hospitals range from 13,000 to 400,000. University hospitals serve as trauma referral centers and cover populations varying in size from 250,000 to 2,500,000 .
"Penetrating injury" was the most frequent anatomic criterion, as reported by 43 hospitals. This was often specified as a gunshot wound or stab wound to the torso. "Burn injury" was the second most frequent criterion, but it was unspecified or referred to a variable percentage of the affected body surface: 10, 15, and 20% were all in use. "Inhalation injury" was often included. "Two large fractures", "crush injury", "pelvic injury", and "flail chest" were also frequently used. "Injury to at least two body sections", "impression fracture and "voltage injury" were other criteria used. "Thoracic pain after trauma", "pneumothorax", and "suspected femur fracture" each occurred at only one hospital.
Mechanism of injury
Five hospitals reported simultaneous admission of "more than one trauma patient" as a criterion for TTA. Another hospital operated with "more than two trauma patients" and one with "more than three trauma patients" received at the same time. Seven hospitals also had "transfer of a trauma or unstable patient from lower treatment level" as a TTA criterion. "Drowning" was used as criterion at seven hospitals, while three hospitals would activate their trauma team "when air ambulance physician requests TTA".
Pediatric cut-off values
"Pediatric trauma" was found as an independent criterion for TTA in two hospitals. Otherwise, specific cut-off values for children were applied to the criteria "burn injury" (> 10% of the body surface), "hit by motor vehicle" (speed > 30 km/h), and "fall injury" (height > 3 m or > 2-3 times the child's body length).
In most hospitals, the presence of a single criterion results in TTA, although in some, they consider the use of "relative" or additional criteria for TTA. These are mainly based on MOI, age, pregnancy, and patient co-morbidity. Some hospitals used these as "absolute" criteria; others used them to simply lower the threshold. Three hospitals had criteria based on MOI that were to be considered "in combination with identified symptoms or injuries and clinical aggravation of vital parameters". One hospital used relative criteria implicating that the surgeon on call decided activation or not. Another hospital required at least two relative criteria for TTA. Here, the MOI criteria were not valid if some time had passed, and the patient remained almost unaffected.
Two hospitals used relative criteria for the activation of a modified (limited) trauma team. Another hospital reported separate criteria for calling the team leader, who was informed about the accident and then decided whether to activate the full or modified trauma team. Thus, at least three hospitals in Norway operated with tiered trauma team activation. One hospital also used separate criteria for calling other medical specialists beyond the ordinary team members.
The main finding in this survey was a conglomerate of criteria for trauma team activation, as well as widely different physiological cut-off values.
A limitation of this study is that the collected information is based on a single eligible contact person. Verification of the answers given in the performed interviews was not attempted, e.g., by interviewing other persons within the same hospitals.
In 2000, 52 hospitals in Norway admitted potentially severely injured patients, and this number was reduced to 49 hospitals in 2008 [18, 23]. Isaksen et al. (2006) noted an increase in the implementation of predefined trauma teams (88% in 2004 vs. 52% in 2000) and predefined TTA criteria (29 of 44 hospitals in 2004 vs. 19 of 27 hospitals in 2000) [18, 23]. Although the qualitative contents of these developments was not assessed previously, we can now document a further increase of 98% of hospitals having a defined trauma team and 96% having TTA criteria in 2008.
To translate the significance of an injury identified in the field to in-hospital use, many systems use a variation of the ACS-COT field triage scheme as their TTA-decision scheme [4–10]. This scheme and subsequent revisions were initially intended to guide pre-hospital personnel to identify the most severely injured patients. Many criteria in the ACS-COT triage scheme, when used as a single criterion, lack high sensitivity for severe injuries . Indeed, several criteria have been deemed anecdotal or of unproven predictive ability .
Physiologic criteria possess significantly higher sensitivity and better positive predictive values (PPVs) in identifying those severely injured [24, 25]. PPV is understood as the percentage of severely injured patients among all patients who receive TTA. The classical concept of "specificity", defined as the probability of no TTA among those with minor injury, gives little information about "unnecessary" strain to the trauma team. This is because it takes into account the large number of patients with minor injuries for whom TTA is never considered . Over-triage rates of 25-50% and under-triage rates of 0-5% are seen as acceptable, but it is reasonable to attempt to reduce these rates further .
In our study, 83% of included hospitals used MOI as an independent criterion for full TTA, despite the substantial amount of evidence suggesting its low accuracy. Some studies indicate that it is useful to limit criteria to only those that are scientifically documented, thereby reducing over-triage without increasing under-triage [29, 30]. In a study by Cook et al., the number of criteria for full TTA was reduced to incorporate only physiological and anatomic variables. This resulted in less over-triage without compromised safety .
A core issue in the original ACS-COT scheme is a set up of weighted steps using physiologic (Step 1 - potential critical injury), anatomic (Step 2 - potential serious injury), MOI criteria (Step 3 - potentially severe but occult injury), and special considerations (Step 4 - underlying conditions and comorbidity) [4–10]. The motivation was to prevent under-triage of patients not showing vital derangement immediately following the accident. Our findings, however, revealed a non-differentiated use according to the nature of the criteria (physiologic, anatomic, and MOI), in which a single criterion was often used to activate the trauma team. A single criterion may cause low accuracy and should preferably be seen in conjunction with other criteria to increase triage accuracy . Additionally, vague or unspecific criteria (e.g., abnormal respiration and decreased consciousness) may be interpreted rather differently by the personnel involved.
Studies from Great Britain, Denmark, and Australia have shown wide variation with respect to TTA criteria within the same country and region, despite comparable trauma populations [32–34]. As evident in our study, it is not clear why hospitals choose different "cut-offs", but tradition rather than evidence was cited as a possible explanation [30, 31]. We found that hospitals in Norway mainly use TTA criteria based on a combination of experience from other hospitals, local adjustments, and expert opinions in their own trauma organization. Where the decision to perform TTA occurs and how different hospitals accommodate pre-hospital information was not investigated in our study.
Few hospitals possess trauma registries and are therefore unable to revise criteria according to their own actual experience. Furthermore, most hospitals admit too few trauma patients to develop evidence-based criteria on their own, suggesting the need for a national consensus. In 2006, the majority (78%) of Norwegian hospitals reported less than 150 annual trauma calls . Of course, over-triage may have positive effects (e.g., training for the trauma team) but is a challenge for hospitals with frequent TTA. Substantial over-triage rates are common in Norwegian referral centers [20, 35, 36]. While over-triage mainly causes negative system management effects, under-triage is of the greatest concern, as this may cause delayed diagnosis and/or treatment of potentially life-threatening injuries.
Tiered trauma response has evolved as many systems have struggled to cope with an increasing rate of over-triage. Using several response levels, multispecialty teams (when severe injuries and abnormal vital signs are identified), and smaller teams for stable trauma patients promote better resource utilization . In patients with minor to moderate injury, rapid trauma workup is still important, as occult injuries may exist, but it may still not mandate a full trauma team.
In recent years, Norwegian hospitals have gradually established trauma teams and criteria for the activation of these teams. These criteria show considerable variation, including physiological "cut-off" values.
The authors thank Torben Wisborg and Sven Erik Gisvold for valuable comments.
- World Health Organization: The global burden of disease: 2004 update. Geneva. 2004Google Scholar
- Mackersie RC: History of trauma field triage development and the American College of Surgeons Criteria. Prehosp Emerg Care. 2006, 10: 287-94. 10.1080/10903120600721636.View ArticlePubMedGoogle Scholar
- Freeark RJ: The trauma centres - its hospitals, head injuries, helicopters, and heroes. J Trauma. 1983, 23: 173-83. 10.1097/00005373-198303000-00001.View ArticlePubMedGoogle Scholar
- American College of Surgeons: Optimal hospital resources for care of the seriously injured. Bull Am Coll Surg. 1976, 61: 15-22.Google Scholar
- American College of Surgeons: Hospital and prehospital resources for the optimal care of the injured patient. 1986, Chicago, IL: American College of SurgeonsGoogle Scholar
- American College of Surgeons: Resources for the optimal care of the injured patient. 1990, Chicago, IL: American College of SurgeonsGoogle Scholar
- American College of Surgeons: Resources for the optimal care of the injured patient. 1993, Chicago, IL: American College of SurgeonsGoogle Scholar
- American College of Surgeons: Resources for the optimal care of the injured patient. 1999, Chicago, IL: American College of SurgeonsGoogle Scholar
- American College of Surgeons: Resources for the optimal care of the injured patient. 2006, Chicago, IL: American College of SurgeonsGoogle Scholar
- Sasser SM, Hunt RC, Sullivent EE, Wald MM, Mitchko J, Jurkovich GJ, Henry MC, Salomone JP, Wang SC, Galli RL, Cooper A, Brown LH, Sattin RW, National Expert Panel on Field Triage, Centers for Disease Control and Prevention (CDC): Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep. 2009, 58: 1-35.PubMedGoogle Scholar
- Utter GH, Maier RV, Rivara FP, Mock CN, Jurkovich GJ, Nathens AB: Inclusive trauma systems: do they improve triage or outcomes of the severely injured?. J Trauma. 2006, 60: 529-35. 10.1097/01.ta.0000204022.36214.9e. discussion 535-37View ArticlePubMedGoogle Scholar
- MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, Salkever DS, Scharfstein DO: A national evaluation of the effect of trauma-centre care on mortality. New Engl J Med. 2006, 354: 366-378. 10.1056/NEJMsa052049.View ArticlePubMedGoogle Scholar
- Petrie D, Lane P, Stewart TC: An evaluation of patient outcomes comparing trauma team activation versus trauma team not activated using TRISS analysis. J Trauma. 1996, 41: 870-5. 10.1097/00005373-199611000-00020.View ArticlePubMedGoogle Scholar
- Gwinnutt CL, Driscoll PA, Whittaker J: Trauma systems - state of the art. Resuscitation. 2001, 48: 17-23. 10.1016/S0300-9572(00)00314-2.View ArticlePubMedGoogle Scholar
- Henry MC, Alicandro JM, Hollander JE, Moldashel JG, Cassara G, Thode HC: Evaluation of American College of Surgeons trauma triage criteria in a suburban and rural setting. Am J Emerg Med. 1996, 14: 124-9. 10.1016/S0735-6757(96)90117-5.View ArticlePubMedGoogle Scholar
- National report by Committee appointed by the Norwegian health authorities: Trauma system in Norway - Suggestions for organizing the treatment of severely injured patients. Oslo. 2007Google Scholar
- The BEST Foundation - Better and Systematic Trauma care. [http://www.bestnet.no]
- Brattebo G, Wisborg T, Hoylo T: Organization of trauma admissions at Norwegian hospitals. Tidsskr Nor Laegeforen. 2001, 121: 2364-7.PubMedGoogle Scholar
- Statistics Norway - Minifacts about Norway 2009. Cited 2009, [http://www.ssb.no/english/subjects/00/minifakta_en/en/]
- Uleberg O, Vinjevoll OP, Eriksson U, Aadahl P, Skogvoll E: Overtriage in trauma - what are the causes?. Acta Anaesthesiol Scand. 2007, 51: 1178-1183.PubMedGoogle Scholar
- Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ: Trauma score. Crit Care Med. 1981, 9: 672-6. 10.1097/00003246-198109000-00015.View ArticlePubMedGoogle Scholar
- Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME: A revision of the Trauma Score. J Trauma. 1989, 29: 623-9. 10.1097/00005373-198905000-00017.View ArticlePubMedGoogle Scholar
- Isaksen MI, Wisborg T, Brattebo G: Organization of trauma services - major improvements over four years. Tidsskr Nor Laegeforen. 2006, 126: 145-7.PubMedGoogle Scholar
- Esposito TJ, Offner PJ, Jurkovich GJ, Griffith J, Maier RV: Do prehospital trauma center triage criteria identify major trauma victims?. Arch Surg. 1995, 130: 171-6.View ArticlePubMedGoogle Scholar
- Kohn MA, Hammel JM, Bretz SW, Stangby A: Trauma team activation criteria as predictors of patient disposition from the emergency department. Acad Emerg Med. 2004, 11: 1-9. 10.1111/j.1553-2712.2004.tb01364.x.View ArticlePubMedGoogle Scholar
- Boyle MJ, Smith EC, Archer F: Is mechanism of injury alone a useful predictor of major trauma?. Injury. 2008, 39: 986-92. 10.1016/j.injury.2008.03.015.View ArticlePubMedGoogle Scholar
- Kann SH, Hougaard K, Christensen EF: Evaluation of pre-hospital trauma triage criteria: a prospective study at a Danish level I trauma centre. Acta Anaesthesiol Scand. 2007, 51: 1172-7.PubMedGoogle Scholar
- Cooper ME, Yarbrough DR, Zone-Smith L, Byrne TK, Norcross ED: Application of field triage guidelines by pre-hospital personnel: is mechanism of injury a valid guideline for patient triage?. Am Surg. 1995, 61: 363-7.PubMedGoogle Scholar
- Purtill MA, Benedict K, Hernandez-Boussard T, Brundage SI, Kritayakirana K, Sherck JP, Garland A, Spain DA: Validation of a prehospital trauma triage tool: A 10-year perspective. J Trauma. 2008, 65: 1253-7. 10.1097/TA.0b013e31818bbfc2.View ArticlePubMedGoogle Scholar
- Lehmann RK, Arthurs ZM, Cuadrado DG, Casey LE, Beekley AC, Martin MJ: Trauma team activation: simplified criteria safely reduces overtriage. Am J Surg. 2007, 193: 630-4. 10.1016/j.amjsurg.2007.01.017. discussion 4-5View ArticlePubMedGoogle Scholar
- Cook CH, Muscarella P, Praba AC, Melvin WS, Martin LC: Reducing overtriage without compromising outcomes in trauma patients. Arch Surg. 2001, 136: 752-6. 10.1001/archsurg.136.7.752.View ArticlePubMedGoogle Scholar
- Smith J, Caldwell E, Sugrue M: Difference in trauma team activation criteria between hospitals within the same region. Emerg Med Australas. 2005, 17: 480-7. 10.1111/j.1742-6723.2005.00780.x.View ArticlePubMedGoogle Scholar
- Clemmesen ML, Rytter S, Birch K, Lindholt JS, Jensen SS, Troelsen S: Should high-energy traumas always result in a trauma team call?. Ugeskr Laeger. 2006, 168: 2916-20.PubMedGoogle Scholar
- Pitchford L, Smith J: Differences in trauma team activation criteria used by hospitals in the South West Peninsula. Emerg Med J. 2007, 24: 372-3. 10.1136/emj.2007.047134.PubMed CentralView ArticlePubMedGoogle Scholar
- Krueger AJ, Hesselberg N, Abrahamsen GT, Bartnes K: When should the trauma team be activated?. Tidsskr Nor Laegeforen. 2006, 126: 1335-7.Google Scholar
- Rehn M, Eken T, Krüger AJ, Steen PA, Skaga NO, Lossius HM: Precision of field triage in patients brought to a trauma centre after introducing trauma team activation guidelines. Scand J Trauma Resusc Emerg Med. 2009, 9 (17): 1-10.1186/1757-7241-17-1.View ArticleGoogle Scholar
- Eastes LS, Norton R, Brand D, Pearson S, Mullins RJ: Outcomes of patients using a tiered trauma response protocol. J Trauma. 2001, 50: 908-13. 10.1097/00005373-200105000-00022.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.