Consequences of pediatric undertriage and overtriage in a statewide trauma system.

BACKGROUND: With increasing attention to the quality of health care delivery, evaluating trauma triage decisions in a large system of emergency care can help decision makers reduce mortality, morbidity, unnecessary transfers, and health care costs. OBJECTIVES: To quantify the magnitude of pediatric traumatic injury undertriage (hospital mortality risk) and overtriage (early trauma center discharge after transfer) in a statewide trauma system. METHODS: A statewide population-based evaluation of pediatric trauma outcomes and secondary triage (interfacility transfers) patterns from 2001 to 2013 among 45 hospitals in Utah's statewide trauma system. RESULTS: The odds of pediatric transfer were 13 times lower (odds ratio, 13.15; p < 0.0001; 95% confidence interval, 11.0-15.7) in acute care hospitals meeting undertriage criteria than hospitals meeting overtriage criteria. Hospital triage practice was a stronger predictor of pediatric transfer than injury severity, injury diagnoses, age, and geographic distance. The likelihood of pediatric trauma mortality was more than twice higher in undertriage hospitals than overtriage hospitals (OR, 2.44; p < 0.0001; 95% confidence interval, 1.5-3.8). Among pediatric patients that survived the injury to transfer, 61% were discharged from the pediatric center in < 24 hours. CONCLUSION: Substantial opportunity exists in the state trauma system to improve pediatric trauma patient transfer practices to reduce pediatric trauma mortality, morbidity, and health care costs associated with unnecessary transfers. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Analysis of preventable trauma deaths and opportunities for trauma care improvement in utah.

BACKGROUND: The objective is to determine the rate of preventable mortality and the volume and nature of opportunities for improvement (OFI) in care for cases of traumatic death occurring in the state of Utah. METHODS: A retrospective case review of deaths attributed to mechanical trauma throughout the state occurring between January 1, 2005, and December 31, 2005, was conducted. Cases were reviewed by a multidisciplinary panel of physicians and nonphysicians representing the prehospital and hospital phases of care. Deaths were judged frankly preventable, possibly preventable, or nonpreventable. The care rendered in both preventable and nonpreventable cases was evaluated for OFI according to nationally accepted guidelines. RESULTS: The overall preventable death rate (frankly and possibly preventable) was 7%. Among those patients surviving to be treated at a hospital, the preventable death rate was 11%. OFIs in care were identified in 76% of all cases; this cumulative proportion includes 51% of prehospital contacts, 67% of those treated in the emergency department (ED), and 40% of those treated post-ED (operating room, intensive care unit, and floor). Issues with care were predominantly related to management of the airway, fluid resuscitation, and chest injury diagnosis and management. CONCLUSIONS: The preventable death rate from trauma demonstrated in Utah is similar to that found in other settings where the trauma system is under development but has not reached full maturity. OFIs predominantly exist in the ED and relate to airway management, fluid resuscitation, and chest injury management. Resource organization and education of ED primary care providers in basic principles of stabilization and initial treatment may be the most cost-effective method of reducing preventable deaths in this mixed urban and rural setting. Similar opportunities exist in the prehospital and post-ED phases of care.

Tourniquets: a review of current use with proposals for expanded prehospital use.

The use of arterial tourniquets in prehospital emergency care has been fraught with controversy and superstition for many years despite the potential utility of these tools. This review examines this controversy in the context of the history of the tourniquet as well as its recent use in surgery and modern battlefield casualty care. Safe prehospital tourniquet use is widespread in the military and is based on sound physiologic data and clinical experience from the surgical use of tourniquets. The physiologic, pathophysiologic, and clinical underpinnings of safe tourniquet use are reviewed here, along with a discussion of alternatives to tourniquets. Prehospital settings in which tourniquets are useful include tactical emergency medical services (EMS) and other law enforcement environments as well as disaster and mass casualty incidents. Beyond this, we present arguments for tourniquet use in more routine EMS settings, in which it may be beneficial but has heretofore been considered inappropriate. Protocols that foster safe, effective prehospital tourniquet use in these settings are then presented. Finally, we discuss future directions in which tourniquet research and other initiatives will further enhance the safe, rational use of this potentially life-saving tool.