Abstract 2692: Predicting the Need for Emergent Surgery in Adult Trauma Patients: Comparison of a Validated Clinical Decision Rule to the American College of Surgeons’ Major Resuscitation Criteria
Trauma center emergency departments (ED) often use criteria-based secondary triage protocols to guide when surgeons are necessary in the care of severely injured patients. Recently, a decision rule was developed to predict which patients need emergent operative intervention (EOI), defined as general surgery within one hour of ED arrival. The rule includes penetrating mechanism, a systolic blood pressure (SBP) < 100 mmHg, and a pulse > 100 per minute. The American College of Surgeons (ACS) supports the following criteria for secondary triage: SBP < 90 mmHg; respiratory compromise; patients transferred requiring blood transfusion; gunshot wounds to the neck, chest or abdomen; Glasgow Coma Scale score < eight; or physician discretion. This study compares the decision rule to the ACSs’ criteria. This study used data from a prospectively-collected and maintained trauma registry from an urban Level 1 trauma center with an annual ED census of 55,000 patients. Patient demographics, injury severity scores (ISS), times of ED arrival and surgical intervention, and all variables of the decision rule and the ACSs’ criteria were obtained. EOI was confirmed by blinded physician abstractors using standardized abstraction methodology. Sensitivities and specificities and 95% confidence intervals (CIs) were calculated for both triage methods. Between 1993 and 2006, 17,080 consecutive adult trauma patients presented to our ED and represent our study sample. EOI occurred in 655 (4%) patients. The median age was 36 (IQR: 25 – 49) years, 72% were male, the median ISS was 9 (IQR: 4 – 16), and 15% had penetrating injuries. The sensitivity and specificity of the rule was 94% (95% CI: 91% – 95%) and 63% (95% CI: 62% – 64%), respectively; while the ACSs’ criteria were 82% (95% CI: 79% – 85%) and 80% (95% CI: 79% – 80%), respectively. The ACS suggests that a 10% false negative triage rate is “unavoidable” and a 50% false positive triage rate is “acceptable”. Their own proposed criteria, however, fail to meet this false negative rate. The decision rule exceeds the suggested thresholds, is more sensitive for predicting EOI than the ACSs’ criteria, and maintains a better than 50% false positive triage rate. This rule may improve the efficacy of trauma triage.