M. Soult1, J. N. Collins1, T. J. Novosel1, L. D. Britt1, L. J. Weireter1 1Eastern Virginia Medical School,Norfolk, VA, USA
Introduction: As the number of emergency department (ED) visits continues to increase, trauma systems can become a resource for busy EDs to allow for the rapid evaluation of patients. Over time at a mature trauma center, the rate of trauma alerts being discharged home from the trauma bay continued to rise. The objective of this study was to investigate the cause of the increased over triage rate and determine if the over triage rate could be reduced by adherence to activation protocols.
Methods: A retrospective chart review was performed all patients who presented as a trauma alert to a single level I trauma center from January 2000 to February 2014. Full activation was designated as an alpha alert, while partial activation was a bravo alert. Using the Cribari method for over and under triage, yearly rates were calculated. Additionally, discharge rates as a function of activation level were calculated.
Results: During the study period trauma activation was required for 25,348 patients. From 2000-2006 there was an average of 1710 activations and the over triage rate was 63%. The emergency department (ED) underwent expansion that was completed near the end of 2006. From 2007-2012 there was an average of 1804 activations and the over triage rate of 74% (p<0.05). Discharge rates mirrored the over triage rate with 14% of alpha and 41% of bravo alerts were discharged from the trauma bay from 2000-2006 and 22% of alpha and 50% of bravo alerts were discharged from the trauma bay from 2007-2012 (p<0.05). In order to assess if adherence to defined activation criteria was being adhered to, activations were audited from May 2013-February 2014. There were 2005 activations and the over triage rate underwent a significant decrease to 69%. However, 24% of alphas and 52% of bravo alerts were discharged from the trauma bay. The audit revealed that when criteria from the protocol were met and documented, the over triage rate further declined to 65%. However, even with activation criteria being complied with, discharge rates remained unchanged with 22% of alphas and 56% of bravos being discharged.
Conclusion: Over utilization of resources remains an issue in this trauma system. Through the maturation of a level I trauma center, comfort with trauma activations increased and there was a departure from identifying alert activation criteria and documenting reason for activation. However, after identification of this departure, increased adherence to defined protocols caused a decrease in over triage rates. While current criteria do not cause triage rates to meet national benchmarks, they provide significant improvement and further modification of activation criteria is being evaluated.