The Accuracy of Alternative Triage Rules for Identification of Significant Traumatic Brain Injury: A Diagnostic Cohort Study

Abstract

Objectives & Background Traumatic brain injury (TBI) is a leading cause of death and disability in young adults. Reorganisation of trauma services with direct triage of suspected head injury patients to trauma centres may improve outcomes following TBI. This study aimed to determine the sensitivity of principal English triage tools for identifying significant TBI. Methods We performed a diagnostic cohort study using data prospectively collated from the Trauma Audit and Research Network database between 2005-2011. Adult head injury patients were retrospectively classified according to London Ambulance Service (LAS) and Head Injury Transportation Straight to Neurosurgery study (HITS-NS) triage criteria. Sensitivity and specificity were then calculated against a reference standard of significant TBI, comprising head region abbreviated injury score (AIS) ≥3 or neurosurgical operation. To investigate the determinants of triage rule sensitivity patient characteristics were compared between true positive and false negative groups using descriptive statistics and hypothesis testing. Additional analyses were conducted to explore the robustness of results to selection bias and examine the sensitivity of pre-hospital Glasgow Coma Score (GCS) for detecting significant TBI. Results 6,559 patients were included in complete case analyses. The LAS and HITS-NS triage tools demonstrated sensitivities of 44.5% (95% CI 43.2-45.9) and 32.6% (95% CI 31.4-33.9) respectively for identifying significant TBI patients. These results were not materially changed following multiple imputation of missing data under a missing at random assumption. False negative significant TBI cases were relatively older, more likely to be female, more frequently secondary to low-level falls, and were less likely to have very severe AIS 5 or 6 head injuries, p<0.01. Pre-hospital GCS did not appear to be a sensitive discriminator for identifying significant TBI, with 44.9% of patients classified as having significant TBI presenting with a PH GCS of ≥13. Conclusion considerable proportion of significant head injury patients may not to be triaged directly to trauma centres. Investment is therefore necessary to improve the accuracy of existing triage rules and maintain expertise in TBI diagnosis and management in non-specialist emergency departments. 876Emerg Med J 2013;30(10):866-880

Large-scale informatic analysis to algorithmically identify blood biomarkers of neurological damage

“…For example, it is well established that rapid and accurate diagnosis of acute neurological injuries such as stroke and traumatic brain injury during the early stages of care significantly reduces mortality and morbidity (2,3). However, the symptom-based assessments that are currently used for recognition of such injuries during triage have limited accuracy, and up to 35% of patients are misdiagnosed at initial clinician contact (4)(5)(6)(7)(8). In these acute conditions, the development of biomarker-based screening tools with the ability to accurately detect neurological damage could substantially reduce rates of mistriage, enable earlier access to intervention, and improve patient outcomes (9).…”

Diagnostic value of emergency medical services provider judgement in the identification of head injuries among trauma patients

“…Previous studies showed that the vital signs are often not affected and may change over time. Patients suffering a head injury from low‐risk mechanisms of injury might present to the EMS providers with minimal symptoms, but develop alarming symptoms hours or days later . In this study, most patients with a head injury had a Glasgow Coma Scale (GCS) score between 12 and 15.…”

“…Worldwide, 26-67% of patients with a severe head injury are not transported to a higher-level trauma centre [9][10][11]20,24]. The percentage depends greatly on the inclusion criteria, i.e.…”

The role of emergency medical service providers in the decision-making process of prehospital trauma triage

“…Previous studies have shown a lower compliance rate to the vital sign criteria [23,34,38]. This could be because the majority of the trauma patients have normal or near normal vital signs [39][40][41].…”