Substituting systolic blood pressure with shock index in the National Trauma Triage Protocol

Ansab A. Haider, Asad Azim, Peter Rhee, Narong Kulvatunyou, Kareem Ibraheem, Andrew Tang, Terence OKeeffe, Hajira Iftikhar, Gary Vercruysse, Bellal Joseph

Research output: Contribution to journalArticle

9 Citations (Scopus)

Abstract

INTRODUCTION The National Trauma Triage Protocol (NTTP) is an algorithm that guides emergency medical services providers through four decision steps to identify the patients that would benefit from trauma center care. The NTTP defines a systolic blood pressure (SBP) of less than 90 mm Hg as one of the criteria for trauma center need. The aim of our study was to determine the impact of substituting SBP of less than 90 mm Hg with shock index (SI) on triage performance. METHODS A 2-year (2011-2012) retrospective analysis of all trauma patients 18 years or older in the National Trauma Databank was performed. Transferred patients, patients dead on arrival, and those with missing data were excluded. Our outcome measure was trauma center need defined by Injury Severity Score greater than 15, need for emergent operation, death in the emergency department, and intensive care unit stay of more than 1 day. Area under the characteristic curve and triage characteristics were compared between SBP of less than 90 mm Hg and SI of more than 1.0. Logistic regression analysis was performed to compare the mortality between patients triaged under current protocol of SBP of less than 90 mm Hg and patients triaged using the new defined protocol (SI >1.0). RESULTS A total of 505,296 patients were included. Compared with SBP of less than 90 mm Hg, SI of more than 1.0 had a higher sensitivity (44.4% vs. 41.7%) but lower specificity (80.2% vs. 82.4%). The area under the curve was significantly higher for SI of more than 1.0 (0.623 [95% confidence interval, 0.622-.625] vs. 0.620 [95% confidence interval, 0.619-0.622]). Substituting SBP of less than 90 mm Hg with SI of more than 1.0 resulted in a decrease in undertriage rate of 30,233 patients (5.9%) but an increase in overtriage of only 6,386 patients (1.3%). CONCLUSION Substituting the current criterion of SBP of less than 90 mm Hg in the NTTP with an SI of more than 1.0 results in significant reduction in undertriage rate without causing large increase in overtriage. Because of simplicity of use, better discrimination power, and minimal effect on overtriage rates, future studies should consider exploring the possibility of replacing the current SBP of less than 90 mm Hg criterion with SI of more than 1.0 in the NTTP.

Original languageEnglish (US)
Pages (from-to)1136-1141
Number of pages6
JournalJournal of Trauma and Acute Care Surgery
Volume81
Issue number6
DOIs
StatePublished - Dec 1 2016
Externally publishedYes

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Triage
Shock
Blood Pressure
Wounds and Injuries
Trauma Centers
Emergency Medical Services
Area Under Curve
Confidence Intervals
Injury Severity Score
varespladib methyl

Keywords

  • Shock index
  • systolic blood pressure
  • trauma center need
  • trauma triage protocol

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Haider, A. A., Azim, A., Rhee, P., Kulvatunyou, N., Ibraheem, K., Tang, A., ... Joseph, B. (2016). Substituting systolic blood pressure with shock index in the National Trauma Triage Protocol. Journal of Trauma and Acute Care Surgery, 81(6), 1136-1141. https://doi.org/10.1097/TA.0000000000001205

Substituting systolic blood pressure with shock index in the National Trauma Triage Protocol. / Haider, Ansab A.; Azim, Asad; Rhee, Peter; Kulvatunyou, Narong; Ibraheem, Kareem; Tang, Andrew; OKeeffe, Terence; Iftikhar, Hajira; Vercruysse, Gary; Joseph, Bellal.

In: Journal of Trauma and Acute Care Surgery, Vol. 81, No. 6, 01.12.2016, p. 1136-1141.

Research output: Contribution to journalArticle

Haider, AA, Azim, A, Rhee, P, Kulvatunyou, N, Ibraheem, K, Tang, A, OKeeffe, T, Iftikhar, H, Vercruysse, G & Joseph, B 2016, 'Substituting systolic blood pressure with shock index in the National Trauma Triage Protocol', Journal of Trauma and Acute Care Surgery, vol. 81, no. 6, pp. 1136-1141. https://doi.org/10.1097/TA.0000000000001205
Haider, Ansab A. ; Azim, Asad ; Rhee, Peter ; Kulvatunyou, Narong ; Ibraheem, Kareem ; Tang, Andrew ; OKeeffe, Terence ; Iftikhar, Hajira ; Vercruysse, Gary ; Joseph, Bellal. / Substituting systolic blood pressure with shock index in the National Trauma Triage Protocol. In: Journal of Trauma and Acute Care Surgery. 2016 ; Vol. 81, No. 6. pp. 1136-1141.
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abstract = "INTRODUCTION The National Trauma Triage Protocol (NTTP) is an algorithm that guides emergency medical services providers through four decision steps to identify the patients that would benefit from trauma center care. The NTTP defines a systolic blood pressure (SBP) of less than 90 mm Hg as one of the criteria for trauma center need. The aim of our study was to determine the impact of substituting SBP of less than 90 mm Hg with shock index (SI) on triage performance. METHODS A 2-year (2011-2012) retrospective analysis of all trauma patients 18 years or older in the National Trauma Databank was performed. Transferred patients, patients dead on arrival, and those with missing data were excluded. Our outcome measure was trauma center need defined by Injury Severity Score greater than 15, need for emergent operation, death in the emergency department, and intensive care unit stay of more than 1 day. Area under the characteristic curve and triage characteristics were compared between SBP of less than 90 mm Hg and SI of more than 1.0. Logistic regression analysis was performed to compare the mortality between patients triaged under current protocol of SBP of less than 90 mm Hg and patients triaged using the new defined protocol (SI >1.0). RESULTS A total of 505,296 patients were included. Compared with SBP of less than 90 mm Hg, SI of more than 1.0 had a higher sensitivity (44.4{\%} vs. 41.7{\%}) but lower specificity (80.2{\%} vs. 82.4{\%}). The area under the curve was significantly higher for SI of more than 1.0 (0.623 [95{\%} confidence interval, 0.622-.625] vs. 0.620 [95{\%} confidence interval, 0.619-0.622]). Substituting SBP of less than 90 mm Hg with SI of more than 1.0 resulted in a decrease in undertriage rate of 30,233 patients (5.9{\%}) but an increase in overtriage of only 6,386 patients (1.3{\%}). CONCLUSION Substituting the current criterion of SBP of less than 90 mm Hg in the NTTP with an SI of more than 1.0 results in significant reduction in undertriage rate without causing large increase in overtriage. Because of simplicity of use, better discrimination power, and minimal effect on overtriage rates, future studies should consider exploring the possibility of replacing the current SBP of less than 90 mm Hg criterion with SI of more than 1.0 in the NTTP.",
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T1 - Substituting systolic blood pressure with shock index in the National Trauma Triage Protocol

AU - Haider, Ansab A.

AU - Azim, Asad

AU - Rhee, Peter

AU - Kulvatunyou, Narong

AU - Ibraheem, Kareem

AU - Tang, Andrew

AU - OKeeffe, Terence

AU - Iftikhar, Hajira

AU - Vercruysse, Gary

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N2 - INTRODUCTION The National Trauma Triage Protocol (NTTP) is an algorithm that guides emergency medical services providers through four decision steps to identify the patients that would benefit from trauma center care. The NTTP defines a systolic blood pressure (SBP) of less than 90 mm Hg as one of the criteria for trauma center need. The aim of our study was to determine the impact of substituting SBP of less than 90 mm Hg with shock index (SI) on triage performance. METHODS A 2-year (2011-2012) retrospective analysis of all trauma patients 18 years or older in the National Trauma Databank was performed. Transferred patients, patients dead on arrival, and those with missing data were excluded. Our outcome measure was trauma center need defined by Injury Severity Score greater than 15, need for emergent operation, death in the emergency department, and intensive care unit stay of more than 1 day. Area under the characteristic curve and triage characteristics were compared between SBP of less than 90 mm Hg and SI of more than 1.0. Logistic regression analysis was performed to compare the mortality between patients triaged under current protocol of SBP of less than 90 mm Hg and patients triaged using the new defined protocol (SI >1.0). RESULTS A total of 505,296 patients were included. Compared with SBP of less than 90 mm Hg, SI of more than 1.0 had a higher sensitivity (44.4% vs. 41.7%) but lower specificity (80.2% vs. 82.4%). The area under the curve was significantly higher for SI of more than 1.0 (0.623 [95% confidence interval, 0.622-.625] vs. 0.620 [95% confidence interval, 0.619-0.622]). Substituting SBP of less than 90 mm Hg with SI of more than 1.0 resulted in a decrease in undertriage rate of 30,233 patients (5.9%) but an increase in overtriage of only 6,386 patients (1.3%). CONCLUSION Substituting the current criterion of SBP of less than 90 mm Hg in the NTTP with an SI of more than 1.0 results in significant reduction in undertriage rate without causing large increase in overtriage. Because of simplicity of use, better discrimination power, and minimal effect on overtriage rates, future studies should consider exploring the possibility of replacing the current SBP of less than 90 mm Hg criterion with SI of more than 1.0 in the NTTP.

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