Clinical decision rules for secondary trauma triage: predictors of emergency operative management.
OBJECTIVE
Most injured patients taken by ambulance to hospital emergency departments do not require emergency surgery, yet most US trauma centers require a surgeon to be present on their arrival. If a clinical decision rule could be developed to accurately identify which injured patients require emergency operative intervention, then such "secondary triage" criteria could permit a trauma center to more efficiently use their surgeons' time.


METHODS
We analyzed 7.5 years of data (8,289 consecutive trauma activations) in our prospectively maintained Level I trauma center registry. We used classification and regression tree analyses to generate clinical decision rules using standard out-of-hospital variables to identify emergency operative intervention (within 1 hour) by a general surgeon (for adults) or a pediatric surgeon (if < or =14 years).


RESULTS
Emergency operative intervention occurred in 3.0% of adults and 0.35% of children. For adults, summoning a surgeon for any one of 3 criteria (penetrating mechanism, systolic blood pressure <96 mm Hg, pulse rate >104 beats/min) could reduce surgeon calls by 51.2% while failing to identify emergency operative intervention in only 0.08% (rule sensitivity 97.2% and specificity 48.6%). For children, no rule at all (ie, never automatically summoning a surgeon) would fail to identify emergency operative intervention in only 0.35% of patients, and use of a single criterion (penetrating mechanism) would reduce surgeon calls by 96.2% while failing to identify emergency operative intervention in only 0.09% (rule sensitivity 75.0% and specificity 96.5%).


CONCLUSIONS
We have derived simple decision rules for trauma centers that, if validated, could substantially reduce the need for routine surgeon presence on trauma patient arrival. These rules demonstrate low false-negative rates.
Steele
Robert
R
Department of Emergency Medicine, Loma Linda University Medical Center and Children's Hospital, Loma Linda, CA, USA. SteeleMD@sbcglobal.net
Green
Steve M
SM
Gill
Michelle
M
Coba
Victor
V
Oh
Bismark
B
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000556:Ambulatory Surgical Procedures / Q000145:classification* / Q000706:statistics & numerical data; D002140:California; D002648:Child; D002675:Child, Preschool; D003661:Decision Support Techniques; D004635:Emergency Medicine / Q000379:methods / Q000458:organization & administration*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008511:Medicine / Q000706:statistics & numerical data; D008875:Middle Aged; D010372:Pediatrics / Q000379:methods; D012042:Registries; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods; D013038:Specialization; D014218:Triage / Q000379:methods*; D014947:Wounds and Injuries / Q000145:classification* / Q000601:surgery*