Triage criteria for trauma centers and in-hospital mortality of victims of external causes: a Brazilian cohortAbstract
This study aimed to associate the triage criteria of the American College of Surgeons Committee on Trauma (ACS-COT) with hospital mortality among Brazilian trauma patients. A prospective cohort study was conducted in 2019 at 10 Brazilian institutions, involving trauma patients aged 18 or older who received prehospital care at the trauma scene. The 11 ACS-COT criteria were the independent variables, and the hospital clinical outcome (discharge or death) was the dependent variable. The Pearson’s Chi-Square and Fisher’s Exact tests and the Odds Ratio (OR) calculation were applied with a significance level of 5%. Of the 626 trauma patients, 54.95% were screened incorrectly. There were significant differences between the groups (hospital discharge or death) in 7 of the 11 ACS-COT criteria. The criteria with the highest odds for hospital death were systolic blood pressure less than 90 mmHg (OR 82.50), Glasgow Coma Scale equal to or less than 13 (OR 52.87), and respiratory rate less than 10 or greater than 29 breaths per minute (bpm) or the need for ventilatory support (OR 32.35). Altered vital signs at the trauma scene were conditions with the highest likelihood of hospital death, highlighting the importance of applying triage criteria for the correct referral of trauma patients to healthcare services.
Key words:
Triage; External causes; Emergencies; Injuries and wounds; Hospital mortality
Resumo
O objetivo foi associar os critérios de triagem do American College Surgeons Committee on Trauma (ACS-COT) com a mortalidade hospitalar de traumatizados no Brasil. Coorte prospectiva realizada no ano de 2019 em 10 instituições brasileiras, com traumatizados de 18 anos ou mais que receberam atendimento pré-hospitalar na cena do trauma. Os 11 critérios do ACS-COT foram as variáveis independentes e o desfecho clínico hospitalar (alta ou óbito) foi a variável dependente. Os testes Qui-Quadrado de Pearson e Exato de Fisher e o cálculo do Odds Ratio (OR) foram aplicados com nível de significância de 5%. Dos 626 traumatizados, 54,95% foram triados incorretamente. Houve diferenças significativas entre os grupos (alta ou óbito hospitalar) em 7 dos 11 critérios do ACS-COT. Os critérios com maiores chances para óbito hospitalar foram pressão arterial sistólica inferior a 90 mmHg (OR 82,50), Glasgow menor ou igual a 13 (OR 52,87) e frequência respiratória menor que 10 ou maior que 29 incursões por minuto ou necessidade de suporte ventilatório (OR 32,35). Sinais vitais alterados na cena do trauma foram condições com maior chance de óbito hospitalar, evidenciando a importância da aplicação dos critérios de triagem para o encaminhamento correto do traumatizado ao serviço de saúde.
Palavras-chave:
Triagem; Causas externas; Emergências; Ferimentos e lesões; Mortalidade hospitalar
Resumen
El objetivo fue asociar los criterios de triaje del American College Surgeons Committee on Trauma (ACS-COT) con la mortalidad hospitalaria de los traumatizados en Brasil. Se llevó a cabo un estudio de cohorte prospectivo en el año 2019 en 10 instituciones brasileñas, con pacientes traumatizados de 18 años o más que recibieron atención prehospitalaria en el escena del trauma. Los 11 criterios del ACS-COT fueron las variables independientes y el resultado clínico hospitalario (alta o fallecimiento) fue la variable dependiente. Se aplicaron las pruebas de Chi-cuadrado de Pearson y Exacta de Fisher y el cálculo de Odds Ratio (OR) con nivel de significancia del 5%. De los 626 traumatizados, 54,95% fue triado incorrectamente. Hubo diferencias significativas entre los grupos (alta hospitalaria o fallecimiento) en 7 de los 11 criterios del ACS-COT. Los criterios con mayores posibilidades de fallecimiento hospitalario fueron la presión arterial sistólica inferior a 90 mmHg (OR 82,50), ECG igual o menor a 13 (OR 52,87) y la frecuencia respiratoria menor de 10 o mayor de 29 respiraciones por minuto (rpm) o la necesidad de soporte ventilatorio (OR 32,35). Los signos vitales alterados en la escena del trauma fueron condiciones con mayor probabilidad de fallecimiento hospitalario, destacando la importancia de aplicar los criterios de triaje para la correcta derivación de los traumatizados a los servicios de salud.
Palabras clave:
Triage; Causas externas; Emergencias; Heridas y lesiones; Mortalidad hospitalaria
Introduction
External causes, which include accidents and violence, represent a global Public Health problem. In Brazil, this situation is no different. Accidents and violence are the fourth leading cause of death, preceded only by circulatory system diseases, neoplasms, and respiratory diseases. Furthermore, the 154,197 deaths from external causes that occurred in 2023 were distributed across the following regions of the country: Southeast (36.3%), Northeast (31.4%), South (14.5%), North (9.3%), and Midwest (8.5%)1.
Faced with this problem, the trauma care line is one of the priorities of the Emergency Care Network (RAU) of the Unified Health System (“SUS”), which determines the following components: Health Promotion, Prevention, and Surveillance; Primary Health Care; Mobile Emergency Care Service (SAMU 192) and its Emergency Medical Regulation Centers; Stabilization Room; SUS National Health Force; Emergency Care Units (UPA 24h), and the set of 24-hour emergency services; Hospital; and Home Care2.
In this context, systematizing trauma patient care is a fundamental strategy for early identification of those requiring immediate treatment, aiming to reduce mortality and disabilities resulting from trauma injuries3. Trauma is a time-sensitive condition4, and therefore, adequate support provided during on-scene care, as well as correct triage (referring the patient to the most appropriate health service for definitive treatment), are essential for achieving favorable clinical outcomes5-7.
Therefore, the definition of the type of prehospital support to be activated (basic, intermediate, or advanced) to assist the trauma patient at the scene, as well as referral to the health service, must be carefully evaluated based on the structure required for treatment, the costs involved, the distance between the trauma scene and the reference unit, the availability of trained professionals, among other criteria and benefits3,4.
The Revised Trauma Score (RTS) is a physiological index, calculated at the trauma scene or upon hospital admission, which assesses the trauma patient’s respiratory rate (RR), systolic blood pressure (SBP), and Glasgow Coma Scale (GCS). Considering its simplicity and speed of application, it has been used in the prehospital context for triaging patients to Trauma Centers8.
In this regard, the American College of Surgeons Committee on Trauma (ACS-COT)9 has, since 1976, developed and implemented actions aimed at trauma prevention, promoting continuous improvement in the quality of care and applying best clinical practices. It also establishes criteria for defining the different Trauma Centers levels. The ACS-COT triage protocol (Admission Criteria for Trauma Centers) recommends that all trauma patients with severe and imminently life-threatening injuries be transported to Level I or II Trauma Centers. Those with less severe injuries should be referred to lower-level Trauma Centers (Levels III or IV) or referral hospitals for trauma patient care.5 In Brazil, the criteria for establishing the levels of Trauma Centers within the SUS are defined by the Ministry of Health through Ordinance N° 1.366 of 201310.
In 2014, the Optimal Resources Document determined that trauma systems should establish and monitor inadequate hospital triage rates (under- or overestimated triage rates). This monitoring is intended to contribute to the desired clinical outcome of trauma patients3. According to the ACS-COT, measuring physiological data such as RR, SBP, and GCS to calculate the RTS is only part of the essential criteria for assessing triage effectiveness3,11. In this setting, the application of different triage criteria, such as those of the ACS-COT, the joint action of pre- and in-hospital teams in trauma care, and a referenced regulatory system, is essential for achieving the correct patient care flow in the emergency department3,12.
Despite evidence regarding the benefits of using the ACS-COT admission criteria for Trauma Centers in improving trauma care, there are currently no studies in the literature analyzing the performance of these triage criteria in the Brazilian context. Thus, this study is justified by the need to improve Brazilian trauma care, given the high morbimortality burden associated with external causes and the relevance of efficient triage at different healthcare levels.
By proposing a national, multicenter analysis of the association between ACS-COT triage criteria and in-hospital mortality from trauma, this research fills gaps in the literature. It offers relevant insights for organizing trauma care flows in both pre- and in-hospital contexts. The results of this study may improve strategies for regulating and referring trauma victims, strengthening public policies focused on RAU, with a direct impact on reducing adverse outcomes and improving the quality of care provided to SUS users.
Given the above, this research aimed to associate the ACS-COT triage criteria with hospital mortality of trauma patients in Brazil.
Methods
Study design
This prospective cohort study was conducted in ten Brazilian hospitals and guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) tool13.
Data were collected daily for 30 consecutive days from June to September 2019 in all ten institutions by study researchers and previously trained collection assistants, supervised by the local coordinator. A predetermined number of patients per institution was not established; however, in each participating institution, trauma patients who met the study eligibility criteria were monitored for 30 consecutive days on a shift basis performed by researchers and data collection assistants.
Patients were monitored from emergency room admission until hospital discharge, when the outcome (discharge or death) was identified.
Study location and case analysis
Public (n=8) and private (n=2) healthcare institutions from Brazilian metropolitan and rural regions participated in the study. Five were located in the state of São Paulo, two in the state of Paraná, and one in each of the following states: Pará, Sergipe, and Rio de Janeiro. All institutions provide urgent and emergency care in the specialties of general medical clinic, surgery, and orthopedics.
The convenience sample consisted of 626 trauma patients aged 18 years or older admitted to each of the ten institutions directly from the scene of the trauma event in 2019 (between June and September) and receiving prehospital care. Patients who did not provide sufficient information to meet the triage criteria, the clinical variables analyzed, or the in-hospital outcomes were excluded from the study.
Variables
The 11 ACS-COT triage criteria (admission criteria for Trauma Centers) were analyzed as independent variables. These criteria were classified as found or not at the time of hospital admission by the prehospital team that provided care at the trauma scene. The ACS-COT triage criteria are: GCS less than or equal to 13; SBP less than 90 mmHg; RR less than 10 breaths per minute (bpm) or greater than 29 bpm or need for ventilatory support; all penetrating injuries to head, neck, torso or extremities proximal to elbow or knee; chest wall instability or deformity (e.g., flail chest); two or more proximal long-bone fractures; crushed, degloved, mangled, or pulseless extremity; amputation proximal to the wrist or ankle; pelvic fracture; depressed or open skull fracture; and paralysis11.
The dependent variable was the patients’ in-hospital clinical outcome, categorized as discharge or death per the information in the physical or digital medical records. To characterize the sample, we analyzed medical record data on gender, age (in whole years), healthcare facility location, injury type and mechanism, type of prehospital support received, severity per the RTS8, Rapid Emergency Medicine Score (REMS)14, and modified Rapid Emergency Medicine Score (mREMS)15 indices, and hospital stay length (in days). Triage was categorized as correct, underestimated, or overestimated.
The RTS is a physiological index that identifies the severity of a patient’s condition through analysis of GCS, SBP, and RR. Each of these parameters, measured at hospital admission, is assigned a value from zero to four and then multiplied by its respective weight (0.9368 for GCS, 0.7326 for SBP, and 0.2908 for RR). The RTS can range from zero to 7.8408, with a lower value indicating a greater severity of the patient’s condition8.
The REMS estimates severity by analyzing GCS, RR, mean arterial pressure (MAP), heart rate (HR), and peripheral oxygen saturation (SpO2), as well as the patient’s age at emergency room admission. Each parameter is scored from zero to four, and age is scored from zero to six. The REMS is calculated by summing these scores, ranging from zero (no severity) to 26 points (maximum severity)14.
The mREMS estimates trauma severity based on RR, SBP, GCS, HR, and SpO2 values, as well as age, determined upon emergency room admission. These variables are scored from zero to four points, except for GCS (scored from zero to six). Like the REMS, the mREMS is calculated by summing the scores and ranges from zero to 26 points15.
Triage was considered correct when the patient met one or more ACS-COT11 criteria and was referred to a Trauma Center. Triage underestimation was considered when the trauma patient met one of the ACS-COT criteria and was referred to a less complex healthcare facility (not classified as a Trauma Center). Triage overestimation was considered when the trauma patient met none of the criteria and was referred to a Trauma Center by the prehospital team.
Considering that Brazil does not yet have Trauma Centers accredited by the American College of Surgeons, the health institutions included in this study were specified as Trauma Centers based on compliance with previously established minimum criteria: availability of X-ray, computed tomography, magnetic resonance imaging, ultrasound, surgical center, blood bank and laboratory analysis on a 24-hour basis, as well as the full-time (day and night) availability of the medical specialties of general surgery, orthopedics, neurosurgery, and vascular surgery, besides a trauma team in the emergency room. Seven of the ten institutions participating in the study met these criteria and were therefore considered Trauma Centers. Three were classified as lower complexity health institutions (they were not Trauma Centers) because they did not meet the minimum criteria previously mentioned.
Data collection operationalization
Previously trained researchers and collection assistants (nurses, doctors, and nursing students) collected data daily for 30 consecutive days, on a 24-hour basis (from 7:00 a.m. to 7:00 a.m. the following day), including daytime and nighttime shifts, as well as weekends and holidays. Data collection assistant training started after the selected hospitals and the National Research Ethics Committee approved the study. The study’s principal investigator provided this training. It lasted approximately one week and consisted of theoretical classes on initial trauma care, a presentation of the data collection instruments and their respective application guide, and detailed guidance on methodological procedures. At each institution, a lead researcher (local coordinator in charge) supervised data collection to clarify and address any questions during this stage.
The first phase of the research occurred during patient admission to the hospital emergency room. All patients admitted with trauma injuries were invited to participate in the study. At this point, information was collected from the prehospital team or hospital records to be entered into a data collection instrument created for this purpose. The second phase of data collection occurred during the hospital stay until discharge, where clinical information on patient outcomes was collected.
Statistical analyses
To ensure the security of the collected information, data were entered and managed using the Research Electronic Data Capture (RedCap) application, and R 4.1.1 was used for data analysis. Descriptive statistics were used to characterize the sample. Qualitative variables were described using absolute and relative frequencies, and continuous and discrete numerical variables were described using mean and standard deviation (SD).
Pearson’s chi-square and Fisher’s exact tests were used to identify the association between the ACS-COT triage criteria and in-hospital outcome (discharge or death). The odds ratio (OR) was calculated to identify the likelihood of in-hospital death considering each of the ACS-COT triage criteria significantly associated with the outcome in the previous analyses. A significance level of 5% was set for all analyses.
Ethical aspects
The study was reviewed and approved by the Research Ethics Committee of the study hospitals, by the proposing institution (University of São Paulo Nursing School), and, on April 17, 2019, by the National Research Ethics Commission (CAAE no. 02003218.60000.5392, Opinion N° 3.270.809). The informed consent form was obtained upon admission to the hospital emergency room from the patient or legal representative, in cases where the patient’s clinical condition does not allow for understanding the terms.
Results
Most of 626 study participants (64.85% men, mean age 44.49 years) were treated in institutions located in São Paulo (n=381; 60.86%), followed by Rio de Janeiro (n=127; 20.29%), Pará (n=46; 7.35%), Paraná (n=38; 6.07%), and Sergipe (n=34; 5.43%).
Table 1 shows a higher frequency of blunt trauma (94.89%) resulting from traffic accidents (56.55%), especially motorcyclists (n=223; 63.00%), and low physiological severity of the patients in the sample (mean RTS, REMS, and mREMS values close to normal). Most patients received prehospital care by a basic support team (76.36%), and overestimated triage prevailed (50.16%). The mean hospital stay length was approximately 4 days, and the mortality rate was 4.47% (Table 1).
The data in Table 2 show that, under the ACS-COT triage criteria, there was a higher frequency of patients with a GCS less than or equal to 13 (7.51%), a penetrating injury to the head, neck, torso, or extremities proximal to the elbow or knee (3.51%), SBP less than 90 mmHg (2.24%), two or more proximal long-bone fractures (2.24%), or pelvic fracture (2.24%) identified at the trauma scene by the prehospital team. There were no cases of amputation proximal to the wrist or ankle in the sample.
A significant association (p≤0.050) was observed between seven ACS-COT triage criteria (GCS less than or equal to 13; SBP less than 90 mmHg; RR less than 10 bpm or greater than 29 bpm or need for ventilatory support; penetrating injury to the head, neck, torso and/or extremities proximal to the knees or elbows; chest wall instability or deformity; crushed, degloved, mangled, or pulseless extremity; and depressed or open skull fracture) and the in-hospital clinical outcome, with a higher frequency of cases among non-survivors (Table 2).
Table 3 shows that, among the seven triage criteria that differed between the groups, those related to hemodynamic and neurological changes identified at the trauma scene stood out as having the highest risk of hospital death: SBP less than 90 mmHg (OR 82.50), GCS score less than or equal to 13 (OR 52.87) and RR less than 10 bpm or greater than 29 bpm or need for ventilatory support (OR 32.35).
Discussion
Trauma mechanisms, within the context of external causes, strongly correlate with injury severity and clinical outcomes. In our study, we observed that most patients suffered traffic accidents, with a predominance of motorcycle accidents, especially among young individuals. This finding reflects a widely recognized epidemiological pattern in which motorcycle accidents are one of the main mechanisms of high-energy trauma in the economically active population, resulting in severe injuries, high demand for hospital resources, irreversible sequelae, and significant socioeconomic impact16.
Supporting this perspective, researchers have shown that triage failures are associated not only with patients’ clinical conditions but also with the trauma mechanism and care dynamics17. While traffic accidents, especially high-energy ones, require rapid response and efficient resource allocation, falls among older adults, often underestimated, result in high mortality and extended hospital stays. This risk is compounded by the silent physiological deterioration of older adults, which compromises their response to trauma, even in seemingly minor injuries17.
The results of this study show that seven of the 11 triage criteria proposed by the ACS-COT were significantly associated with in-hospital mortality in the sample analyzed. Among these, three criteria with a higher probability of death stand out: SBP less than 90 mmHg, GCS score less than or equal to 13, and RR less than 10 bpm or greater than 29 bpm, or the need for ventilatory support identified at the trauma scene.
The scientific literature highlights that arterial hypotension, reduced level of consciousness, and changes in respiratory pattern are clinically significant variables and highly predictive of mortality in trauma patients. These parameters constitute three of the four fundamental criteria used in a study aimed at improving triage accuracy, particularly in reducing overtriage rates in prehospital care settings18.
Evidence also indicates that hypotension at the scene of a trauma event is directly associated with a significant increase in mortality rates and functional disability. This outcome is significantly deteriorated when concomitant with hypoxia, increasing the risk of adverse outcomes19.
Corroborating these findings, a study conducted in the United States analyzed a cohort of approximately 51,000 patients and applied six minimum ACS/COT criteria for activating the trauma team (SBP less than 90 mmHg; GCS less than 9; gunshot wound to the head, neck, abdomen, or proximal extremities - above the knee or elbow; respiratory impairment or need for intubation; inter-hospital transfer for blood transfusion; and emergency doctor’s discretion) identified that the presence of any of these criteria was strongly associated with an increased risk of death (OR 16.7; 95% confidence interval: 15.2-18.3; p<0.001)5.
The triage criteria recommended by the ACS-COT guide risk stratification in the prehospital setting and have proven to be robust tools for improving hospital care for trauma patients3. The systematic application of these criteria streamlines the allocation of care resources, directing patients to the most appropriate health service for their needs and directly reducing mortality and disability rates associated with trauma3.
In healthcare practice, there is a significant gap in the thorough adoption of protocols during initial trauma care, which compromises care effectiveness and clinical outcomes. In the present study, 344 patients were inadequately triaged by the prehospital team. Three hundred fourteen of these were overclassified, meaning they had less severe injuries but were still referred to Trauma Centers.
The literature establishes that acceptable overestimated screening rates are between 25% and 35%, while the underestimation rate should be less than 5%3. Thus, the results of this research showed that the underestimated screening rate (4.79%) remained within acceptable parameters; however, the overestimation rate was considerably higher (50.16%) than the recommended limit.
A systematic review found that overestimated triage rates ranged from 9.9% to 87.4%. When analyzing the subgroup of elderly trauma patients, the authors observed a distinct pattern, with a predominance of underestimated triage (20.1% to 72.0%) compared to overestimated triage (9.9% to 48.2%). These findings highlight a significant failure in the triage of severely traumatized older adults, who are often not referred to specialized and highly complex services20.
In developing countries, such as Brazil, which has one of the highest global trauma burdens, the financial impact of resource overuse coupled with overestimated triage is significant, especially in already overburdened healthcare systems. Well-defined protocols, effective communication between pre- and in-hospital teams, properly trained professionals, adequate physical infrastructure, and the availability of material and technological resources are essential for an appropriate triage process3.
As mentioned above, Brazil currently lacks Trauma Centers accredited by the American College of Surgeons, which is why the ACS/COT criteria are not applied in a standardized manner nationwide. In clinical practice, most patients treated by prehospital care teams are triaged based on the RTS or the clinical experience of the professionals. The non-uniform triage criteria, coupled with limited hospital beds, significantly contribute to inadequate triage, increasing the risk of adverse outcomes.
The criteria established by the ACS/COT are considered the gold standard for triage protocols. However, a study suggests that these criteria should be adapted to the specificities of each trauma system to safely reduce overtriage rates, since patient demographics and trauma mechanisms vary significantly across regions21. Inadequate triage of trauma patients can result in increased mortality, adverse clinical outcomes, hospital costs, and overloaded trauma centers22.
Performing accurate triage in trauma care is a significant challenge for prehospital care teams, primarily due to the diagnostic limitations inherent to the trauma scene. In the present study, we observed that patients with a GCS score of 13 or less at the scene were more likely to die than those with the other triage criteria evaluated.
Although the GCS is an easy-to-apply tool, used for more than four decades in clinical practice, its accuracy can be compromised by several factors, such as the use of alcohol and drugs, hearing impairment, ocular trauma, the type of therapeutic intervention performed (such as sedation), and the level of experience of the professional responsible for the assessment23. Despite these limitations, GCS has performed well in identifying patients with severe trauma. A study showed that, among 233 patients who were under-tried according to trauma team activation criteria, 14 died from traumatic brain injury. Of these, 10 had GCS scores below 11 upon admission, but did not meet any of the formal criteria for specialized team activation24.
Finally, the findings of this study reinforce that the ACS-COT triage criteria are effective in the early identification of patients with severe injuries and a high risk of death. However, some methodological limitations should be considered. The study sample size was limited to the one-month data collection period, and the participating institutions varied in size, nature (public or private), and hospital profile. Furthermore, institutions from all Brazilian regions and states were not represented. These limitations should be carefully considered when interpreting and generalizing the results.
In conclusion, this study revealed a high frequency of overestimated triage in the analyzed sample. It was evident that seven of the 11 ACS-COT triage criteria were significantly associated with in-hospital mortality. The reduced level of consciousness, respiratory rate changes, and hypotension identified at the trauma scene stood out as higher risk predictors, conditions strongly associated with a higher likelihood of death during hospitalization.
This study’s findings strengthen the body of evidence on the association of triage criteria with in-hospital mortality among trauma patients. They support the formulation of public policies to improve Brazilian prehospital and hospital care systems. These results reinforce the need for investment in standardized protocols, professional training, and the organization of trauma systems to improve clinical outcomes for trauma victims in the country.
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The data sources used in the research are indicated in the body of the article.
