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Risk factors and mortality associated with undertriage after major trauma in a physician-led prehospital system: a retrospective multicentre cohort study

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European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Purpose

To assess the incidence of undertriage in major trauma, its determinant, and association with mortality.

Methods

A multicentre retrospective cohort study was conducted using data from a French regional trauma registry (2011–2017). All major trauma (Injury Severity Score ≥ 16) cases aged ≥ 18 years and managed by a physician-led mobile medical team were included. Those transported to a level-II/III trauma centre were considered as undertriaged. Multivariable logistic regression was used to identify factors associated with undertriage.

Results

A total of 7110 trauma patients were screened; 2591 had an ISS ≥ 16 and 320 (12.4%) of these were undertriaged. Older patients had higher risk for undertriage (51–65 years: OR = 1.60, 95% CI [1.11; 2.26], p = 0.01). Conversely, injury mechanism (fall from height: 0.62 [0.45; 0.86], p = 0.01; gunshot/stab injuries: 0.45 [0.22; 0.90], p = 0.02), on-scene time (> 60 min: 0.62 [0.40; 0.95], p = 0.03), prehospital endotracheal intubation (0.53 [0.39; 0.71], p < 0.001), and prehospital focussed assessment with sonography [FAST] (0.15 [0.08; 0.29], p < 0.001) were associated with a lower risk for undertriage. After adjusting for severity, undertriage was not associated with a higher risk of mortality (1.22 [0.80; 1.89], p = 0.36).

Conclusions

In our physician-led prehospital EMS system, undertriage was higher than recommended. Advanced aged was identified as a risk factor highlighting the urgent need for tailored triage protocol in this population. Conversely, the potential benefit of prehospital FAST on triage performance should be furthered explored as it may reduce undertriage. Fall from height and penetrating trauma were associated with a lower risk for undertriage suggesting that healthcare providers should remain vigilant of the potential seriousness of trauma associated with low-energy mechanisms.

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Availability of data and materials

The datasets generated and analysed in the current study are not publicly available due to ethical restrictions on sharing a dataset because the data contain potentially identifying information. Further description or data analysis are available from the authors upon reasonable request at c.claustre@resuval.fr.

Abbreviations

AIS:

Abbreviated injury scale

EMS:

Emergency medical services

FAST:

Focussed assessment with sonography for trauma

GCS:

Glasgow coma scale

ICU:

Intensive Care Unit

ISS:

Injury severity score

MMT:

Mobile medical team

SAMU:

Service d’aide médicale d’urgence

SMUR:

Service mobile d’urgence et de réanimation

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Acknowledgements

We thank Philip Robinson (DRS, Hospices Civils de Lyon) for help in the manuscript preparation as well as the local investigators of the trauma registry: Antoine Blum (Saint Vallier), Djamel Bekka (Privas), Eric Cesareo (Lyon), Patricia Trinquet (Vienne), Stéphane Blain (Ambérieu), Thomas Paita (Bourgoin-Jallieu), Johan Restier (Valence), Olivier Debas (Belley), Raphael Brilland (Tarare), Nicolas Roumestand (Montélimar), Xavier-Jean Taverna (HEH), Jean-Stéphane David (CHLS), Etienne Javouhey (HFME), Loïs Grattier (Valence), Frédéric Verbois (Villefranche-sur-Saone), Patrice Serre (Bourg-en-Bresse).

Funding

The authors did not receive any funding for this work. The trauma registry is funded by the Regional Agency for Health (ARS, Agence Régionale de Santé Auvergne Rhône-Alpes) and coordinated by the RESCUe-RESUVal. This research did not receive any specific grant.

Author information

Authors and Affiliations

  1. Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 5 Place d’Arsonval, 69437, Lyon, France

    Axel Benhamed, Amaury Gossiome, Eric Cesareo & Karim Tazarourte

  2. EA4129, Systemic Health Pathway Laboratory, Lyon, France

    Laurie Fraticelli

  3. RESUVal and RESCUe Network, Lucien Hussel Hospital, Vienne, France

    Clément Claustre & Carlos El Khoury

  4. SAMU 94 and Emergency Department, Assistance Publique-Hôpitaux de Paris (AP-HP) University Hospital Henri Mondor, Créteil, France

    Matthieu Heidet

  5. Université Paris-Est Créteil (UPEC), EA-3956 (CIR), Créteil, France

    Matthieu Heidet

  6. Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada

    Marcel Emond, Eric Mercier & Valérie Boucher

  7. Trauma Centre and Critical Care, Centre Hospitalier Universitaire Lyon Sud, Pierre-Bénite, France

    Jean-Stéphane David

  8. Emergency Department, Médipôle Hôpital Mutualiste, Villeurbanne, France

    Carlos El Khoury

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  1. Axel Benhamed
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Contributions

AB: literature search, study design, data collection, data interpretation, writing. LF, CC: study design, data analysis, critical revision. MH, ME, EM, VB: critical revision. EC, AG, JSD, CEK: data collection, critical revision. KT: Literature search, study design, data collection, data interpretation, writing.

Corresponding author

Correspondence to Axel Benhamed.

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Benhamed, A., Fraticelli, L., Claustre, C. et al. Risk factors and mortality associated with undertriage after major trauma in a physician-led prehospital system: a retrospective multicentre cohort study. Eur J Trauma Emerg Surg 49, 1707–1715 (2023). https://doi.org/10.1007/s00068-022-02186-5

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