Help with improving our trauma criteria

[Hardcastle, Tim, Dr <tch at sun.ac.za>]

Johan
 
It seems to me all you need to do is change the "team" that responds to the "orange" alert. You would rather overtriage and stand-down unneeded staff than run short, particularly in the context of your personnel-rich environment. Also there should always be access to at least one senior person to act as team leader, even for your orange alerts.
 
Alternately you should use one alert for all cases and stand-down team members not required as soon as practically possible. We know that mechanism alone is not a good predictor of individual patient outcome, but it does identify groups with more severe injury patterns: exclude severity and stand people down!
 
Having worked here with us, you know much can be achieved with smaller numbers and that it doesn't imply higher mortality.
 
Tim
Dr T C Hardcastle 
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA) 
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU) 
ATLS  instructor and DSTC Cape Town Course Director 
Intern program Coordinator: Surgery 
M.Med (Emergency Medicine) Executive Committee member 
Clinical Head (Director): Diana Princess of Wales Trauma Unit 
Division of Surgery (General) Room 4064 
Department of Surgical Sciences 
Tygerberg Hospital / University of Stellenbosch 
PO Box 19063 
Tygerberg 7505 
Western Cape 
South Africa 
e-mail: tch at sun.ac.za 
Cell: +27824681615 
Office: +27219389281 or 4911 pager 0302 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]On Behalf Of johan.malmgren at vgregion.se
Sent: Thursday, April 05, 2007 9:34 AM
To: trauma-list at trauma.org
Subject: Help with improving our trauma criteria



Hi, I know these issues are discussed from time to time here.
We're one of the two major trauma-centres in Sweden, meaning about 1000 annual alerts, of which some 80% blunt. 
The problem is with undertriage, and we're remaking the algorithm, and I would appreciate some advice and inputs from the list! 
  
As of now, we have two levels, red and orange. The red ones basiclly includes all possible staffmembers (2 surgeons, 2 anesthesiologists + 1 anesth nurse (compared to a RN), 1 orthopedic, radiology and a lot of ER nurses.), so we're almost too crowded here. 
 
The orange is the interesting one. It includes a junior to senior surgeon depending on time of day and pure luck, and a couple of ER-nurses. No anesthesia, no traumasurgeon, no ortho, no radiology. The traumasurgeon and Critical Care/Anesth guy on call are notified by phone but doesn't have to attend the alert.
  
Our criterias for red alert are 
Vitals: 
SpO2 < 90% on room air 
Compromised airway 
Resp freq > 25 
Pulse > 120 
BP < 90 
RLS > 3 (would be comparable to GCS under about 10-11) 
Neurology 
  
and/or 
Injuries: 
Penetrating injury head/neck/torso
Fractures in at least 2 long bones
Unstable pelvis
Amputation above hand/foot
Burn > 18% or inhalation
Drowning/hypothermia
Flail chest
Spinal Cord Injury with neurology.
 
Now, what happens is that a considerable proportion of the orange alerts ends up in ICU or even in acute surgery, which I would consider an indicator of a undertriage-system. The criterias for orange alerts are, and remember that these alerts basically brings no senior competence at all to the ER:
 
"If red alerts criteria are not by any mean fulfilled, but the MoI was either of the following:
MVA with either >50km/h without seatbelt/airbag, or >70km/h with bealt or airbag.
Pt had to be extricated or vehicle has been tumbling
Moped/motorcycle accident >30km/h
Thrown out of vehicle
Other person dead in same vehicle
Pedestrian or bicyclist hit by motor vehicle
Fall from above 3meters"
 
I'm thinking that the problem might be with not having any mechanism per se as a criteria for red alerts. Any input at all would be much appreciated! Also, if anyone of You have their criteria easy at hand, I'd appreciate an off-list email with them attached!
 
/Johan Malmgren
MD, Dep of Traumatology, Critical Care & Anesthesiology
Sahlgrenska University Hospital, Sweden