BACKGROUND
Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS.
METHODS
Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS).
RESULTS
The NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios [99.5% confidence interval]: NFTI = 9.44 [8.46–10.53]; ISS = 5.94 [5.36–6.60], RTS = 4.79 [4.29–5.34]; LOS incidence rate ratios (99.5% confidence interval): NFTI = 3.15 [3.08–3.22], ISS = 2.87 [2.80–2.94], RTS = 2.37 [2.30–2.45]). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk [99.5% confidence interval]: NFTI = 2.59 [2.52–2.66], ISS = 2.51 [2.44–2.59], RTS = 2.37 [2.28–2.46]). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS greater than 15 or RTS less than 7.84.
CONCLUSION
In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments.
LEVEL OF EVIDENCE
Prognostic, level IV.
Many existing metrics, such as Injury Severity Score (ISS), cannot fully describe many trauma patients because of comorbidities. This study developed and evaluated the Need For Trauma Intervention (NFTI) metric as a novel indicator of major trauma. The NFTI metric was developed from an analysis of 2,396 trauma patients at a Level I trauma center. Six commonly recorded registry variables were found to be indicative of major trauma and comprised the NFTI criteria: receiving packed red blood cells within 4 hr; discharge from the emergency department (ED) to the operating room within 90 min; discharge from the ED to interventional radiology; discharge from the ED to the intensive care unit (ICU) with an ICU length of stay (LOS) of 3 or more days; mechanical ventilation outside of procedural anesthesia within 3 days; or death within 60 hr. Patients meeting any NFTI criteria are classified as having major traumas and, therefore, needing trauma activations (NFTI+). Need For Trauma Intervention was tested in an overlapping sample of 9,737 patients. Being NFTI+ was associated with higher trauma activation levels, older age, higher ISS, worse ED vitals, longer hospital LOS, and mortality. Only 13 of 561 deaths were not NFTI+ and all were in patients with do not resuscitate (DNR) orders; using ISS greater than 15 missed 73 mortalities, 46 with DNR orders. Results suggest that NFTI provides a comprehensive view of both anatomy and physiology in a manner that self-adjusts for age, frailty, and comorbidities as long as care teams adjust their treatments. Need For Trauma Intervention appears to be a unique, simple, and effective tool to retrospectively identify major trauma, regardless of ISS.
Trauma centers manage an active Trauma Registry from which research, quality improvement, and epidemiologic information are extracted to ensure optimal care of the trauma patient. We evaluated coding procedures using the Relational Trauma Scoring System to determine the relative accuracy of the Relational Trauma Scoring System for coding diagnoses in comparison to the standard retrospective chart-based format. Charts from 150 patients admitted to a level I trauma service were abstracted using standard methods. These charts were then randomized and abstracted by trauma nurse clinicians with coding software aide. For charts scored pre-training, percent correct for the trauma nurse clinicians ranged from 52 to 64 percent, while the registrars scored 51 percent correct. After training, percentage correct for the trauma nurse clinicians increased to a range of 80-86 percent. Our research has demonstrated implementable changes that can significantly increase the accuracy of data from trauma centers.
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