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Implementation of trauma team activation criteria: a quality
improvement project to reduce overtriage at a level 1 trauma

SHSC-AV-Reducing Trauma Overtriage

Sunnybrook Health Sciences Centre (ED)

Background: Severely injured trauma patients have better outcomes when treated in trauma centres with a dedicated Trauma Team Activation (TTA). However, TTA is resource intensive, and must be used judiciously. Overtriage, defined as a TTA that does not meet criteria for severe injury after retrospective review, happens frequently at our centre. Historically, we used the Emergency Medical Services field triage criteria with or without input from Emergency Department (ED) physicians or nurses to activate the trauma team. On May 1, 2020, we implemented a formal process and evidence-based criteria to determine if TTA was warranted.We sought to reduce overtriage from 50 to 35% within 3 months of implementation of the new TTA process and criteria. 

Aim statement: ED triage nurses were provided with the new TTA criteria and algorithm, authorizing them to initiate the TTA when the criteria were met. If there was uncertainty, they were instructed to call an ED physician to assess using a checklist to help determine if TTA was warranted. The primary outcome measure was the proportion of overtriage out of all TTAs (excluding transfers). This was evaluated using a run chart, with overtriage rates calculated weekly for 3 months before and after implementation. A process measure was the number of patients assessed by ED physicians for possible TTA, and the proportion that led to TTA. A balancing measure was undertriage, defined as the proportion of patients assessed by ED physicians who did not have a TTA and did meet severe injury criteria. 

Measures and design: Fewer patients were overtriaged during the 3 months after implementation (144/316; 46%) than before implementation (153/287; 53%). There were 94 patients assessed by ED physicians for possible TTA, of which 27 (29%) proceeded to TTA. Out of all 94 patients, upon retrospective review 2 (2%) were undertriaged. We reviewed both cases and modified our criteria after one. The trauma team was activated later for one of the cases and no negative outcomes resulted from the undertriage in either case. 

Evaluation/results: The implementation of the process and criteria reduced overtriage but did not achieve our target. However, an absolute reduction in overtriage of 7% translated to 23 fewer TTA in 3 months, which is important. We are continuing PDSA cycles to further refine the criteria. We believe these criteria could be implemented at other trauma centres seeking to reduce their overtriage rate.

Authors: A. Verma, MD, MHSc, B. Tillmann, MD, K. Pardhan, MD, MMed, A. Nathens, MD, PhD, W. Thomas-Boaz, MN, BScN, C. Freedman, MHI, L. Notario, MSc, A. Phillips, BA, L. Da Luz, MD, MSc

Ongoing PDSA cycles

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