title: Evidence-based improvement of the National Trauma Triage Protocol: The Glasgow Coma Scale versus Glasgow Coma Scale motor subscale.
abstract: BACKGROUND
  Ideal triage uses simple criteria to identify severely injured patients. Glasgow Coma Scale motor (GCSm) may be easier for field use and was considered for the National Trauma Triage Protocol (NTTP). This study evaluated performance of the NTTP if GCSm is substituted for the current GCS score ≤ 13 criterion.
  
  
  METHODS
  Subjects in the National Trauma Data Bank undergoing scene transport were included. Presence of NTTP physiologic (Step 1) and anatomic (Step 2) criteria was determined. GCSm score ≤ 5 was defined as a positive criterion. Trauma center need (TCN) was defined as Injury Severity Score (ISS) > 15, intensive care unit admission, urgent operation, or emergency department death. Test characteristics were calculated to predict TCN. Area under the curve was compared between GCSm and GCS scores, individually and within the NTTP. Logistic regression was used to determine the association of GCSm score ≤ 5 and GCS score ≤ 13 with TCN after adjusting for other triage criteria. Predicted versus actual TCN was compared.
  
  
  RESULTS
  There were 811,143 subjects. Sensitivity was lower (26.7% vs. 30.3%), specificity was higher (95.1% vs. 93.1%), and accuracy was similar (66.1% vs. 66.3%) for GCSm score ≤ 5 compared with GCS score ≤ 13. Incorporated into the NTTP Steps 1 + 2, GCSm score ≤ 5 traded sensitivity (60.4% vs. 62.1%) for specificity (67.1% vs. 65.7%) with similar accuracy (64.2% vs. 64.2%) to GCS score ≤ 13. There was no difference in the area under the curve between GCSm score ≤ 5 and GCS score ≤ 13 when incorporated into the NTTP Steps 1 + 2 (p = 0.10). GCSm score ≤ 5 had a stronger association with TCN (odds ratio, 3.37; 95% confidence interval, 3.27-3.48; p < 0.01) than GCS score ≤ 13 (odds ratio, 3.03; 95% confidence interval, 2.94-3.13; p < 0.01). GCSm had a better fit of predicted versus actual TCN than GCS at the lower end of the scales.
  
  
  CONCLUSIONS
  GCSm score ≤ 5 increases specificity at the expense of sensitivity compared with GCS score ≤ 13. When applied within the NTTP, there is no difference in discrimination between GCSm and GCS. GCSm score ≤ 5 is more strongly associated with TCN and better calibrated to predict TCN. Further study is warranted to explore replacing GCS score ≤ 13 with GCSm score ≤ 5 in the NTTP.
  
  
  METHODS
  Prognostic study, level III.
authors: From the Division of General Surgery and Trauma (J.B.B., R.M.F., A.B.P., T.R.B., J.L.S.), Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and Division of Acute Care Surgery (N.A.S., M.L.G.), Department of Surgery, University of Rochester Medical Center, Rochester, New York.
authors: Joshua B
authors: JB
authors: Brown
authors: Raquel M
authors: RM
authors: Forsythe
authors: Nicole A
authors: NA
authors: Stassen
authors: Andrew B
authors: AB
authors: Peitzman
authors: Timothy R
authors: TR
authors: Billiar
authors: Jason L
authors: JL
authors: Sperry
authors: Mark L
authors: ML
authors: Gestring
mesh_terms: D000328:Adult; D005260:Female; D015600:Glasgow Coma Scale / Q000592:standards; D006801:Humans; D015601:Injury Severity Score; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D014218:Triage / Q000592:standards*