Background
The creation of regionalized trauma centers has significantly decreased the morbidity and mortality of acutely injured patients by enabling a rapid resuscitation response.1–3 However, providing quality care while maintaining cost-effectiveness is labor intensive. It requires the continual development and assessment of various protocols and quality indicators to ensure the efficacy of care delivery.4 Effective triage protocols are the first part of an efficient trauma system. They must accurately reflect the needs of the injured patient to mobilize appropriate care resources. Overtriage results in unnecessary personnel and financial utilization whereas undertriage delays necessary care for the injured patient.5 6 To maximize field and in-hospital triage efficiency, physiological and anatomic criteria must be considered in conjunction with injury mechanisms, comorbidities, and age-related issues.7
Field triage guidelines were established in 1986 by the American College of Surgeons Committee on Trauma and most recently modified in 2011.8 Their purpose is to maintain the triage balance based on a 5% undertriage rate and 30% to 50% overtriage rate.9 However, such a high overtriage rate may not be sustainable nor desirable10 and decreasing overtriage will reduce cost.11 In the USA, treatment of traumatic injury is the second leading healthcare expenditure behind heart disease.12 Measures to reduce overtriage are complicated by the growing geriatric population with a higher prevalence of anticoagulant and antiplatelet usage. When combined with a reduced physiological reserve and increased comorbid conditions, these patients risk more adverse outcomes.13 14 While a full trauma team activation has been associated with shorter emergency department (ED) length of stay (LOS) and decreased in-hospital mortality in geriatric trauma patients, it is also cost intensive and places burdens on human and material resource utilization. It should only be used selectively and avoided altogether in less severely injured patients.10 15
Moreover, the San Diego County trauma system only designates level I and II trauma centers. There are no level III or lower centers with the resources committed to trauma care, and thus patients with significant injuries generally require secondary transfer to a trauma center. This creates a situation with potentially more overtriage than other inclusive trauma systems.
To decrease cost and resource utilization associated with overtriage, our trauma center previously devised a separate tier of triage designation named trauma resource (TR). Patients triaged to this tier were initially brought to an ED examination room rather than the trauma resuscitation bay. The full trauma team was not activated on arrival. Instead, the trauma nurse/ED nurse and ED physician performed the initial evaluation. Our initial study16 found that this designation decreased the utilization of resources without increasing LOS or in-hospital mortality. The TR patients also incurred an activation fee worth one-quarter of the trauma activation (TA) charge. Despite these benefits, we also observed increased duration from door to CT scans in this population. To further streamline the evaluation of these patients we modified our TR evaluation protocol by adding a rapid ‘Pit Stop’ (PS) evaluation. This rapid assessment would occur in the trauma resuscitation bay rather than go to an ED bed for their initial evaluation. This would allow for faster decision-making and transit to appropriate imaging studies. We hypothesized that we would further improve efficiency of care delivery without compromising safety.