2017 Resarch Forum

SG: M-5 Applicant: Sergey Kozyr MD Principal Investigator: Ruby Skinner MD FACS FCCP FCCM

High-risk injury patterns in Tier II Trauma activations: An analysis of under-triage at a Level II Trauma Center Sergey Kozyr MD, Santa Ponce MS RN, Hope Feramisco RN, Andrea Pakula MD MPH FACS, Ruby Skinner MD FACS FCCP FCCM

INTRODUCTION : Trauma under-triage is used as a surrogate for trauma quality and acceptable rates are less than 5% according to the American College of Surgeons Committee on Trauma. We sought to analyze factors that may impact our current under-triage rates of 10-13%, by a detailed analysis of pre- hospital mechanisms and patient factors that may be prominent in tier II trauma activations that meet criteria for under-triage. PURPOSE: To identify prominent mechanisms of injury, and patient factors associated with high injury acuity in tier II trauma activations. METHOD: Patients admitted to our trauma center from January 2015 to June 2016 who met criteria for under-triage using the Cribari method (Tier II Codes and ISS>15) were studied, n=160. Mechanisms included; motor vehicle collisions (MVC, n=100), bike/motor cycle collisions (n=24), falls (n=22), and other blunt injuries (n=14). Patient demographics, ED vital signs, operative intervention, and outcomes were included. Factors associated with critical care monitoring (ICU), operative intervention or mortality were deemed high-risk in the under-triaged group. RESULTS: Demographics - The mean age of the study group and ISS were 42 + 20, and 22 + 6, respectively. Alcohol or drug use at the time of injury occurred at 25%. Pre-morbid conditions (CAD, HTN, DM) were 26%. Mechanisms: MVC (Drivers 55%, Passengers 45%); Type of Impact- Frontal (29%), Lateral (18%), Rollover (10%), major vehicular intrusion (15%). Mean impact speeds were 50 + 16. Seatbelt use was 95%. Falls; Heights > 20 ft. were uncommon, n=2. Bikes/motor cycle collisions: the lack of helmet use was common (41%). ED characteristics and disposition: Hypotension (SBP<90) was uncommon (9%). A positive FAST was 15%. Overall 38% of patients required surgery; 5% were immediate. Orthopedic procedures were prominent (55%). Admission to ICU was common (60%). High-risk factors associated with ICU admits and mortality based on a logistic regression modes: Drug use at the time of injury predicted mortality, [OR=7.23, p=0.03, 95% CI (1.11, 47.26)]; MVC, speed of impact >40mph, predicted ICU admission, [OR=2.94, p=0.03 CI (1.06, 8.09)]. Patients requiring operative intervention had a high incidence of frontal collisions, 40%, which was statistically significant, p=0.01. Outcomes : Hospital LOS was 7 + 6 days, and ICU LOS was 4 + 5 days. Nosocomial infections were 14% and mortality was low at 3%. DISCUSSION/CONCLUSIONS: Motor vehicle collisions were predominant in tier II trauma activations meeting criteria for under-triage. Patterns of injury predicting invasive intervention, ICU monitoring, or death were based on frontal impacts, high speeds and patient drug use. Further study is warranted to assess the incorporation of high-risk injury patterns in field triage decisions and acute clinical algorithms aimed at enhancing trauma response quality.