Undertriage in trauma: an ignored quality indicator?

Abstract

Background: Early identification of life-threatening injuries is essential to reduce morbidity and mortality in trauma patients. Failure to detect severe injury may cause delayed diagnosis and therapeutic interventions and is associated with increased morbidity. A national trauma system will contribute to ensure the optimal care for seriously injured patients throughout the treatment chain by, among other things, defining a sensitive triage tool for identifying severe injury and contribute to correct treatment destination. In 2017, a National trauma plan was implemented in Norway and several quality indicators were recommended to ensure an evaluation of potential gaps between achieved and desired quality, and thereby highlighting areas with potential for quality improvement. With this commentary, we want to draw attention to, what we believe is, an ignoring of an important quality indicator: undertriage in trauma. Main body: Severely injured patients not met by a trauma team is commonly referred to as undertriage. An undertriage rate below 5 % is an internationally recognized quality indicator in trauma care and is emphasized in the Norwegian national trauma plan. However, whether hospitals measure and report data about undertriage, have received little attention. Therefore, a national survey was performed among Norwegian hospitals, where thirty-seven of forty trauma receiving hospitals contributed. The results of the survey showed that only half of Norwegian trauma hospitals were capable of providing these data. The results of this survey show that currently the national trauma system is not equipped to obtain important data on an important and specific quality indicator. An ongoing discussion at a national level is how to define severe injury, which may alter future definitions on undertriage. Conclusions: Knowledge of undertriage in trauma is important to enhance patient safety, increase the precision of the triage tool and provide valuable learning information to individual hospitals and prehospital services. Currently only half of Norwegian hospitals who receive trauma patients report undertriage rates and unfortunately, only few hospital administrators request these data.

Epidemiology of geriatric trauma patients in Norway: A nationwide analysis of Norwegian Trauma Registry data, 2015–2018. A retrospective cohort study

“…According to the sensitivity of the national triage criteria we were able to include patients with NISS ≥9 due to the low threshold for trauma team activation, but patients not meeting inclusion criteria with a NISS between 9 and 12 might be underrepresented in the material. Undertriage, defined as no TTA for patients with Injury Severity Score > 15, is a nationally defined benchmark [33] , but despite this, only half of Norwegian hospitals identified and reported undertriaged patients [38] . Mainly these are hospitals with small patient volumes and the risk of bias is therefore limited.…”

“…Patients declared dead before hospital arrival after initiation of prehospital management do also meet the inclusion criteria, but because of inadequate information, the registry has low coverage of those who die at the injury site. Fifty percent of the hospitals identified undertriaged patients, and among these are all the largest hospitals, covering the majority of patient volume [34,38] .…”

The impact of regionalized trauma care on the distribution of severely injured patients in the Netherlands

“…However, about 30% of these patients are still transported to NTCs in the Netherlands. Similar percentages are seen in other countries, such as Norway and the United States [17][18][19][20][21]. According to the American College of Surgeons Committee on Trauma, an under-triage rate above 5% is unacceptable, as under-triage increases the risk of mortality and morbidity due to patients not being managed at the best-equipped hospital [22].…”

Validation of Dutch Obstetric Telephone Triage System: A Prospective Validation Study

“…Every single case involving undertriage can indicate factors, which can be used to consider improvement of quality in future. 23,24 In addition to a good assessment of medical urgency, a telephone triage system is also intended to provide a good distribution of resources and to avoid unnecessary consultations. With a 49% level of specificity (95% CI 44-53) it can be said that DOTTS does not provide sufficient differentiation in the "intermediate urgency" category.…”

“…Every single case involving undertriage can indicate factors, which can be used to consider improvement of quality in future. 23 , 24 …”