title: Increased mortality with undertriaged patients in a mature trauma center with an aggressive trauma team activation system.
abstract: OBJECTIVE
  The American College of Surgeons Committee on Trauma (ACS-COT) has determined that a 5 % pre-hospital undertriage [UT; defined as Injury Severity Score (ISS) > 15 and not sent to a trauma center] is an acceptable rate for pre-hospital transfer to a non-trauma center. We sought to determine if this level of undertriage is acceptable within a mature Level II trauma center as a measure of the adequacy of its trauma activation system.
  
  
  METHODS
  Our trauma activation system encompasses anatomic, physiologic, and mechanism of injury criteria. We defined UT as ISS > 15 and no trauma activation. All UT patients during the period 2000-2010 were compared to properly triaged patients (CT). The variables examined were mortality, emergency department (ED) length of stay (LOS), hospital LOS, complications, Coumadin use, and age >64 years.
  
  
  RESULTS
  There were 18,324 patients admitted, with 1,156 (6.3 %) UT. UT is associated with an increase in mortality [odds ratio (OR) 3.0; 95 % confidence interval (CI) 2.4-3.8; p < 0.001), longer ED LOS (OR 54.5; 95 % CI 45.5-63.5; p < 0.001), and longer hospital LOS (OR 1.7; 95 % CI 1.4-2.1; p < 0.001). In addition, UT patients had a two-fold increase in complications (OR 2.0; 95 % CI 1.6-2.5; p < 0.001). When controlling for age ≥65 years, Revised Trauma Score (RTS) > 7.0, and one or more co-morbidities, UT patients had 2.18 times higher odds of mortality than their CT counterparts (OR 2.18; 95 % CI 1.57-3.01; p < 0.001). Patients on pre-hospital Coumadin (OR 3.61; 95 % CI 3.04-4.30; p < 0.001) and age >64 years (OR 4.93; 95 % CI 4.36-5.58; p < 0.001) were significant predictors of being undertriaged. A p-value ≤ 0.05 was considered to be significant.
  
  
  CONCLUSIONS
  Standard trauma activation criteria may not be adequate to identify the at-risk severely injured trauma patient. Further refinement of in-house trauma triage protocols is necessary if trauma centers are to improve outcomes following trauma.
authors.affiliation: Lancaster General Health, 555 N. Duke St., Lancaster, PA, 17602, USA. arogers2@lghealth.org.
authors.forename: A
authors.initials: A
authors.lastname: Rogers
authors.affiliation: Lancaster General Health, 555 N. Duke St., Lancaster, PA, 17602, USA. frogers2@lghealth.org.
authors.forename: F B
authors.initials: FB
authors.lastname: Rogers
authors.affiliation: The Trauma Center at Penn, University of Pennsylvania, Philadelphia, PA, USA. Charles.schwab@uphs.upenn.edu.
authors.forename: C W
authors.initials: CW
authors.lastname: Schwab
authors.affiliation: Lancaster General Health, 555 N. Duke St., Lancaster, PA, 17602, USA. ehbradburn@carilionclinic.org.
authors.forename: E
authors.initials: E
authors.lastname: Bradburn
authors.affiliation: Lancaster General Health, 555 N. Duke St., Lancaster, PA, 17602, USA. jclee@lghealth.org.
authors.forename: J
authors.initials: J
authors.lastname: Lee
authors.affiliation: Lancaster General Health, 555 N. Duke St., Lancaster, PA, 17602, USA. dwu2@lghealth.org.
authors.forename: D
authors.initials: D
authors.lastname: Wu
authors.affiliation: Lancaster General Health, 555 N. Duke St., Lancaster, PA, 17602, USA. jvmiller@lghealth.org.
authors.forename: J A
authors.initials: JA
authors.lastname: Miller
keywords: Increased mortality; Undertriage
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