BACKGROUND: The American College of Surgeons Committee on Trauma (ACSCOT) advises trauma centers maintain <5% undertriage rate (UTR), but provides limited rationale for this figure. We sought to determine whether patients managed at Level I/II trauma centers with a UTR<5% had improved outcomes compared to centers with >5% UTR. We hypothesized that similar overall adjusted outcomes would be observed at trauma centers in Pennsylvania regardless of their compliance with ACSCOT undertriage recommendation.
METHODS: The Pennsylvania Trauma Outcome Study (PTOS) database was retrospectively queried for all trauma patients managed at accredited adult Level I/II trauma centers (n=27) from 2003-2015. Patients with missing data on Injury Severity Score (ISS) and/or Trauma Activation Status were excluded from the analysis. Institutional undertriage rates (UTR) were calculated for all trauma centers based on ACSCOT criteria (ISS >15; no Trauma Activation) and were categorized into <5% or >5% subgroups. A multilevel mixed-effects logistic regression model assessed the adjusted impact of management at centers with <5% undertriage. Statistical significance was set at p<0.05.
RESULTS: A total of 404,315 patients from 27 trauma centers met inclusion criteria. Institutional undertriage rates ranged from 0% to 20.5%, with 15 centers exhibiting UTR <5% and 12 centers with UTR >5%. No clinically meaningful difference in unadjusted mortality rate was observed between subgroups (<5% UTR: 5.19%; >5% UTR: 5.20%; p<0.001). In adjusted analysis, no difference in mortality was found for patients managed at centers with <5% UTR compared to those with >5% UTR (AOR: 1.06; 95% CI: 0.85-1.33; p = 0.608).
CONCLUSIONS: Achieving ACSCOT <5% undertriage standards appears to have limited impact on institutional mortality. Further research should seek to identify new triage criteria that can be uniformly applied to all trauma centers. LEVEL OF EVIDENCE: Level III epidemiological study.