[논문]Validation of guidelines for field triage of injured patients for major trauma in patients of brain and spinal injury

Lee, Sung Kgun; Kang, Jeong Ho; Song, Sung Wook

doi:10.22730/jmls.2020.17.1.7

Validation of guidelines for field triage of injured patients for major trauma in patients of brain and spinal injury 원문보기

The Journal of Medicine and Life Science = 의생명과학, v.17 no.1, 2020년, pp.7 - 15

Lee, Sung Kgun (Department of Emergency Medicine, Jeju National University School of Medicine) , Kang, Jeong Ho (Department of Emergency Medicine, Jeju National University School of Medicine) , Song, Sung Wook (Department of Emergency Medicine, Jeju National University School of Medicine)

Abstract ▼ AI-Helper

The field triage guidelines have been widely implemented in the Korean trauma system. This study aimed to evaluate and validate whether it is reliable to use the field triage guidelines for predicting severe traumatic brain injury (TBI) and traumatic spinal injury (TSI) patients. This study retrospectively analyzed in-hospital cohort registries of all TBI and TSI patients, who visited the emergency department (ED) of the Jeju National University Hospital from 1 January 2013 to 31 December 2015. The primary outcome was defined as TBI and TSI patients with an injury severity score (ISS)>15. Secondary outcomes were defined as cases in which one or more of the following conditions: in-hospital death, ISS>15, admission to the intensive care unit, emergency surgery. We enrolled 14,889 TBI and TSI patients who visited ED, of which 7,966 (53.5%) were triage positive. The overall sensitivity, specificity and area under the curve (AUC) of the full cumulative field triage guidelines step's model (Step 1+3+4 criteria) for primary outcome were 82.8%, 47.0%, and 0.646, respectively. In the results for secondary outcomes, the specificity did not show a significant difference, but the sensitivity decreased to 66.5% and AUC to 0.568. The results of this study suggest that further optimization of the field triage guidelines is needed to identify high-risk TBI and TSI patients.

주제어

표/그림 (7)

그림 Figure 1. Flowchart of study participants.
표 Table 1. Demographic characteristics of the "Triage positive" and "Triage negative" groups
표 Table 2. Injury characteristics of the "Triage positive" and "Triage negative" groups
표 Table 3. Validation of the each step of field triage guideline for primary outcome
그림 Figure 2. Comparison of receiver operating curves for primary outcome by cumulative steps.
그림 Figure 3. Comparison of receiver operating curves for secondary outcomes by cumulative steps.
표 Table 4. Validation of the each step of feld triage guideline for secondary outcome

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문제 정의

The authors are grateful to the Korea Center for Disease Control (KCDC) and Prevention for supporting data of Emergency Department-based Injury In-depth Surveillance (EDIIS).
^5,6)Until now, there have been few studies to validate the application of the field triage guidelines at the scene to identify the severe TBI and TSI in Korea. The purpose of this study is to evaluate and validate whether it is reliable to use the field triage guidelines for predicting severe TBI and TSI patients.

제안 방법

There are limitations to consider in this study. First,this study was a cross-sectional study in one nationaluniversity hospital in Jejudo and not a nationwide population based study. So, the results of this study did notreflect the difference in trauma system between domesticregions.
In addition, further optimization ofthe MOI criteria is needed to make EMS rescuers easierand more obvious to use. In the process of evaluating SCcriteria, EMS rescuers determine the level of destinationhospital based on the presence or absence of underlyingconditions or comorbidities to help identify patients withserious injuries among those who have not met the other three steps. In this study, the SC criteria showed aneffect of reducing the under-triage by 31.
The injury related characteristicsof the patients were activity at the time of injury, locationof injury, intentionality, and mechanism of injury. Thisstudy was designed to evaluate whether the applicationof the filed triage guidelines is effective for screening patients with severe TBI or TSI. Therefore, the primary outcome variable was defined as TBI and TSI patients withISS>15.

대상 데이터

The eligible participants were selected from all traumapatients who visited our ED from 1 January 2013 to 31 December 2015. Among the eligible participants, patients diagnosed with TBI or TSI in the ED were included inthis study.
There were 26,857 eligible participants during the study,of which 11,968 were excluded. A total of 14,889 participants was analyzed and divided into two groups, “Triagepositive” and “Triage negative”, based on their meetingthe field triage guidelines.
This study retrospectively analyzed in-hospital cohortregistries of all injured patients, who visited the emergency department (ED) of the Jeju National University Hospital over the period of three years(from 1 January 2013 to 31 December 2015). During the study period, our hospital served at the highest level of trauma center in there gional trauma system.
This study was presented as a poster at the 2017 autumn scientific meeting of the Korean Society of Emergency Medicines on October 19, 2017 in Incheon, Korea.

데이터처리

Categorical variables were presented as proportions and were compared using a Chi-square test or Fisher’s exact tests.
Continuous variables were presented as a mean±SD and were compared using t-tests for normal distribution.

이론/모형

Categorical variables were presented as proportions and were compared using a Chi-square test or Fisher’s exact tests.All statistical analyses were conducted using two-tailed tests. Significance levels of p<0.
This study used data from electronic medical records(EMRs) of the Jeju National University Hospital and theEmergency Department-based Injury In-depth Surveillance (EDIIS). Appropriate triage of trauma patients isone of the most important factors for prognosis of traumapatients not only in the field, but also in the initial processof ED.

성능/효과

8%. Considering that theproportions of children and the elderly in the triage-positive group were 57.5% and 37.4%, respectively, thesefindings suggest that the age criterion of the special consideration criteria have a significant impact on the triageresults of TBI and TSI patients. It also suggests the need to evaluate and improve the feasibility and effectivenessof each criterion of the SC criteria in order to reduce theproblem of over-triage.
In the diagnostic metrics for secondary outcomes, the overall sensitivity, specificity and AUC of thefull cumulative field triage guidelines step’s model (step1+3+4 criteria) were 66.5%, 47.1% and 0.568 respectively (Table 4).
In this study, the PHY criteria were highly specific, butinsensitive for identifying severe TBI and TSI patients.The PHY criteria are the most important indicators thatpredict severe TBI and TSI, and the strongest predictorsof trauma-related death.
In the process of evaluating SCcriteria, EMS rescuers determine the level of destinationhospital based on the presence or absence of underlyingconditions or comorbidities to help identify patients withserious injuries among those who have not met the other three steps. In this study, the SC criteria showed aneffect of reducing the under-triage by 31.6% in TBI andTSI patients, however, it was found that the over-triageincreased dramatically by 49.8%. Considering that theproportions of children and the elderly in the triage-positive group were 57.
In this study, the overall sensitivity, specificity of thefield triage guidelines for identifying TBI and TSI patients with ISS>15 were 82.8% and 47.0%.
The demographic characteristics of the patients included age, gender, Glasgow Coma Scale (GCS) score andvital sign on arrival at the ED, inter-hospital transfer,revised trauma score (RTS), ISS, EMS usage, operation,and disposition of ED. The injury related characteristicsof the patients were activity at the time of injury, locationof injury, intentionality, and mechanism of injury.
The overall sensitivity, specificity and AUC of the full cumulative field triageguidelines step’s model (step 1+3+4 criteria) for identifying TBI and TSI patients with ISS>15 were 82.8%and 47.0% and 0.646 respectively, and the overall rate of under-triage was 17.8% and the overall rate of over-triage was 53.0% (Table 3).
In actual field triageof TBI and TSI patients by EMS rescuers, the diagnosticmetrics of the field triage guidelines may differ from ourstudy results. Third, the impact of anatomical criteria wasnot reflected in this study, because it contained criteriafor injuries of other specific anatomical structures not associated with TBI and TSI.

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