Trauma Triage and Trauma System Performance

Trauma systems seek to provide complex medical care at the correct time and the correct place. During the past four decades numerous articles have been published that validate trauma systems from many points of view. Achievements of trauma systems include improvement in mortality and morbidity, efficiencies of care, and economic outcomes. Prehospital policy execution is intrinsic to trauma system performance. Trauma system criteria are relatively standardized. However, flexibility in emergency medical service (EMS) decision-making is commonly allowed. These decisions have major impacts on resource allocation, trauma center utilization, and patient outcome. In this edition, Holst, et al1 reviewed adult emergency department (ED) trauma deaths as reported in the 2010 National Emergency Department Sample. They recorded the association of these deaths to trauma or non-trauma center designation, as well as geographic and patient demographics including rural vs urban site, gender, and patient income data. They found that one half of all trauma ED deaths nationally and one third of ED urban trauma patients died in non-trauma centers. Both elderly trauma deaths and deaths due to falls more frequently occurred in non-trauma centers. Like most studies describing trauma system performance, this is a retrospective review taken from a large database. Therefore, causation of outcome cannot be directly attributed to undertriage. However, the magnitude of the non-trauma center death rate merits further investigation. Trauma system literature often describes the undertriage of trauma patients with regard to trauma center designation. The American College of Surgeons has a goal for trauma systems to achieve less than 5% undertriage. However, studies frequently estimate a much higher rate. Like the study published in this journal, undertriage rates are higher with elderly patients.2 Centers for Medicare/Medicaid Services claims also identify a high rate of undertriage, and these non-trauma center visits are associated with worse outcomes. Staudenmayer, et al3 found that in California undertriage varied substantially by region. Patient factors such as age greater than 55 years, female sex, University Hospital, SUNY Upstate Medical University, Department of Emergency Medicine, Syracuse, New York