Prevalence and Predictors of Under-Diversion in the Primary Trauma Diversion System in Hong Kong

Abstract

Introduction Primary trauma diversion (PTD) enables direct transfer of major trauma patients to trauma centres for definitive care. This study aimed to evaluate the performance of PTD in the New Territories West Cluster (NTWC) of Hospital Authority and to identify the predictors for under-diversion. Methods A cross-sectional study based on local trauma registry. All major trauma patients (defined as ISS>15 or requiring trauma team activation) in the catchment area of the local hospital from September 2007 to December 2011 were included. The appropriateness of diversion decision was independently evaluated by an expert team (a trauma nurse coordinator and an emergency medicine practitioner). The sensitivity, specificity, predictive values, agreement, over-diversion and under-diversion rates were calculated. Potential predictors for under-diversion including age, Glasgow Coma Scale, mechanism of injury, injured body part, and the distance from scene to the trauma centre/local hospital were employed for logistic regression analysis. Results There were 141 eligible cases identified. The sensitivity and specificity for PTD were 59.5% and 96.5% respectively. The over-diversion rate was 3.5% and the under-diversion rate was 40.5%. The overall accuracy was around 74.5%. Non-motor vehicle accident (OR 13, 95% confidence interval [CI]=3.5-48.0, p<0.01) and isolated head injury (OR 5.35, 95% CI=1.5-19.5, p=0.01) were 2 independent predictors for under-diversion in PTD. Conclusions The overall field triage compliance by the paramedics is satisfactory. Under-diversion rate in NTWC is high. Non-motor vehicle accident mechanism and isolated head injury are 2 significant predictors for under-diversion. Reinforcement in training to avoid potential pitfalls would improve the paramedics' trauma triage performance.

Over‐Triage in Casevac Categorisation is Common in Hong Kong

“…Moreover, the PTD criteria are represented by a simple step-by-step protocol that allows easy following. On the other hand, the existing CASEVAC guidelines are less robust and only give general recommendations and practical examples, and hence interpretation by different doctors may vary (as shown by the 20% inter-rater disagreement in our study vs 2.1% as reported by Wong et al 10 ). Pizzola JL, in his article "MEDEVAC Miscategorisation", found that the over-categorisation rate was 49% over a 6-week period from end of December 2008 through January 2009, in Regional Command-South, during militar y missions of the North Atlantic Treaty Organization (NATO) forces in Afghanistan.…”

“…74.5% and 74% respectively. 10,11 However, Wong et al reported a small over-diversion rate of 3.5% while Suen et al reported a high over-triage rate of 44.8%. The vast difference could be explained by different definitions of over-diversion being adopted in the two studies.…”

A Comparison Between Differently Skilled Prehospital Emergency Care Providers in Major-Incident Triage in South Africa

“…Similar findings of protocol non-adherence were reported by Wong, et al in their Hong Kong study assessing appropriate diversion of 141 major trauma cases by paramedics. Over-diversion rate was 3.5% with under-diversion at 40.5%; overall accuracy was 74.5% 15 …”

“…[11][12][13] An important reason for triage errors is the lack of adherence to the triage algorithm, occurring up to 26.0% of the time. 11,14,15 Fitzharris, et al found variations in triage performance across different training levels of prehospital personnel where the highest adherence rates (77.0%) occurred among the lowest-level trained personnel. 14 Selecting the most appropriate responder to perform triage during a major incident might help to reduce these errors.…”

Traumatic Brain Injury Rehabilitation in Hong Kong: A Review of Practice and Research

“…In the past, trauma casualties were brought to the nearest public hospital regardless of the severity of their injuries. With the pilot implementation of the Primary Trauma Diversion Policy in 2003, trauma casualties are transported from the scene to these trauma centers directly if necessary, as determined by the ambulance crew according to a standardized protocol [ 29 ]. Alternatively, the crew may decide to transport the casualty to a regional hospital for initial resuscitation before transferring to a trauma center, that is, a Secondary Trauma Diversion [ 30 ].…”