Efficacy of the protocol for trauma team activation in Taipei: A retrospective study

Efficacy of the protocol for trauma team activation in Taipei: A retrospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Efficacy of the protocol for trauma team activation in Taipei: A retrospective study Ju-Chi Ou, Wan-Lin Chen, Shih-Yu Ko, Wen-Ching Li, Hon-Ping Ma This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2862620/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Trauma triage is the use of trauma assessment for prioritizing patients for treatment or transport by injury severity. Accidents and their adverse events were the sixth leading cause of death and accounted for over 7,000 casualties in 2009. However, a lack of accuracy in identifying the severity of a patient’s injury and their prehospital information can result in inappropriate triage. This study evaluated the efficacy of field triage guidelines governing trauma team activation in Taipei and explored the characteristics of undertriaged and overtriaged patients. Methods ​This study retrospectively observed all patients with trauma transported to the emergency department by Taipei City public ambulance from 2016, to 2019. The Cribari matrix method was used to assess undertriage and overtriage. A logistic regression was employed to analyze the effect of risk factors in patients with major trauma. Results In this study, 320 and 1,895 patients with trauma had full and limited trauma team activation, respectively. Among them, 664 patients with trauma were older than 65 years, and most of them were injured in a traffic accident.The analysis revealed that patients with a Glasgow Coma Scale score of less than 13, with systolic blood pressure level of less than 90, and with respiratory rate over 30 breaths per minute were more likely to be appropriately triaged. Conclusion The Taipei prehospital field triage guidelines is acceptable but not an ideal tool for identifying patients with major trauma, with an overtriage rate of 48.12% and an undertriage rate of 12.03%. Health sciences/Diseases/Trauma Health sciences/Health care/Public health Trauma team activation undertriage Taipei prehospital field triage guidelines Injury Severity Score Figures Figure 1 Figure 2 Figure 3 Figure 4 Purpose Trauma triage is the use of trauma assessment for prioritizing patients for treatment or transport by injury severity. Trauma triage can be classified into field triage and hospital triage, and the lack of accuracy in identifying the severity of a patient’s injury and their prehospital information can result in inappropriate triage. The first edition of the criteria of field triage was developed according to the recommendations of the American College of Surgeons - Committee on Trauma (ACS-COT) in 1979( 1 ). The current Field Triage Decision Scheme was developed according to the evidence-based review of the ACS-COT and the National Highway Traffic Safety Administration and Center for Disease Control and Prevention( 2 ). Two-tier systems for trauma team activation have been used since the early stages of trauma system development. Early evaluations indicated their cost-effectiveness and efficient use of resources. Thus, the number of studies on two-tier trauma team activation systems have increased( 3 , 4 ) Undertriage and overtriage rates are key indicators of the quality of trauma systems. Specifically, undertriage and overtriage occur when too little and too much resources are allocated to caring for a patient, respectively. An undertriage rate of < 5% and an overtriage rate of < 35% are considered acceptable according to the ACS-COT. Injury triage systems were developed to ensure that resources are appropriately distributed to patients with trauma. According to Taiwan Public Health Report, accidents and their adverse events were the sixth leading cause of death and accounted for over 7,000 casualties in 2009( 5 ). Taipei City Government held seven field triage training sessions for paramedics from 2015 to 2016, and field trauma training was found to improve the accuracy of field triage scheme(6). In another study on Taipei City, no significant association was found between in-hospital mortality and trauma team activation (TTA). However, the group subject to TTA guidelines had a higher risk of intensive care unit (ICU) admission, prolonged length of hospital stay (LOS), and prolonged ICU LOS. In addition, a subgroup analysis revealed that in the TTA group, patients aged 60–80 years, with major injury (Injury Severity Score [ISS] ≥ 16), with clear consciousness, and with non-head injury had a higher risk of mortality. These findings indicate that patients selected using the TTA criteria had higher ISS and a higher risk of mortality( 7 ). According to our review of the literature, studies have yet to evaluate the effectiveness of the field triage system. Therefore, this study evaluated the effectiveness of Taipei field triage guidelines governing trauma team activation and explored the characteristics of undertriaged and overtriaged patients. Methods Data We explored the accuracy of Taipei prehospital field triage guidelines in identifying patients with major trauma (using Injury Severity Score (ISS) ≥ 16) and other factors that may affect accuracy. Taipei prehospital field triage guidelines comprise 4 major criteria with 11 items each. The four major criteria are vital signs, anatomic injuries, injury mechanism, and special considerations. If a patient with on-site trauma meets more than one criterion, the patient must be sent to a first-aid hospital, and the on-site team must notify the hospital to activate the trauma team. Patients with major trauma were classified as patients having an ISS of ≥ 16. We hypothesized that Taipei prehospital field triage guidelines could be used to accurately identify patients with major trauma (ISS ≥ 16). ​This study retrospectively observed all patients with trauma who were transported to the emergency department of a medical center by Taipei City public ambulance from January 1, 2016 to December 31, 2019. The following patients were excluded: patients who were transported by means other than a Taipei City public ambulance and patients with out-of-hospital cardiac arrest. A total of 1,322 people were included in the analysis. The flowchart of patient selection is shown in Fig. 1 . The Cribari matrix method (CMM) was used to assess undertriage and overtriage. We used a modified CMM for greater accuracy( 8 ). Ethical approval: This study was approved by the Institutional Review Board of Taipei Medical University (TMU-JIRB #N202107116). Taipei field triage system As shown in Figure 2, Taipei prehospital field triage guidelines cover five criteria: vital signs, anatomic injuries, injury mechanism, blast injury, and special considerations. The criterion of vital signs comprise the items of having a Glasgow Coma Scale (GSC) score of <13, systolic blood pressure (SBP) level of <90, respiratory rate of <30 or ≥30 breaths per minute, and a SpO 2 of <90%. The criterion of anatomic injuries comprise the items of having penetrating trauma; crushing injury in the head, neck, torso, or upper arms or thighs; fractures; amputation above the wrist or ankle; and limb paralysis. The criterion of injury mechanism comprise the items of having had a fall and having been involved in a traffic accident. The criterion of special considerations comprise the items of being a child or an infant, being pregnant, having bleeding disorders or anticoagulation, and having burn injury. Cribari matrix method The detail of Cribari Matrix method is shown in Table 1. The upper panel and lower panel are Standard version and Modified version, respectively. Table 1. Original and modified version of CMM for assessing triage tool Standard version ISS 0-9 ISS 10-14 ISS 15-24 ISS 25-75 Full trauma team activation OT OT AT AT partial trauma team activation AT AT AT UT trauma consultation AT AT UT UT Trauma service not notified AT UT UT UT Modified version ISS 0-15 ISS 16-75 trauma team activation OT AT no activation AT UT Statistical analysis Continuous and categorical variables are presented as mean ± standard deviation and frequency and percentage, respectively. A logistic regression was performed to analyze the impact of risk factors in patients with major trauma. All statistical analyses were conducted using R software. Significance was indicated by p < 0.05. Results The basic and clinical characteristics of the patients are shown in Table 2. The number of patients who met the Taipei TTA criteria is shown in Figure 3. Between 2016 and 2019, among patients with trauma, 195, 1,358, and 664 patients were aged 65 (older adult group), respectively; these three age groups significantly differed with respect to patient characteristics (i.e., sex, age, and mechanism of injury). The young and adult groups had more women than men, and the older adult group had more men than women. The average ages of young, adult and older adult groups were 15.52 (±5.03), 40.51 (±14.66), and 78.26 (±8.28) years, respectively. Over 65% of the young and adult groups’ major traumas were caused by traffic accidents, whereas more than 58% of the older patients’ major traumas were caused by falls. Among the three age groups, TTA rate, average ISS, ISS higher than–16 rate, and undertriage rate significantly differed. The TTA rates of the young group and older adult group were the highest and lowest, respectively. The average ISSs of the older adult group and young group were the highest and lowest, respectively. The number of patients with an ISS of ≥16 in the older adult group was the highest (23.49%), and that in the young group was the lowest (12.31%). The undertriage rate of the older adult group was the highest (19%), and that of the young group was the lowest (4%). Table 2. Basic and clinical characteristics of patients from 2016 to 2020. Characteristic Age65 Older adult p value Sample size 195 1358 664 Gender# <0.01* Male 65(33.33%) 545(40.13%) 384(57.83%) Female 130(66.67%) 813(59.87%) 279(42.02%) Age, Mean(SD), years 15.52(5.03) 40.51(14.66) 78.26(8.28) <0.01* Mechanism of injury# <0.01* Fall 31(15.90%) 177(13.01%) 389(58.58%) Vehicle incident 134(68.72%) 1036(76.29%) 245(36.9%) Others 30(15.38%) 145(10.68%) 30(4.52%) Activation, n(%)# 36(18.46%) 218(16.05%) 66(9.94%) <0.01* ISS, mean (SD) 6.60(9.15) 7.64(8.91) 9.53(8.80) <0.01* ISS ≥16, n(%)# 24(12.31%) 214(15.76%) 156(23.49) <0.01* Overtriage rate 0.53 0.51 0.36 0.09 Undertriage rate 0.04 0.09 0.19 <0.01* #: Chi-square test; *: significant; ISS: injury severity Score; SD: standard deviation Undertriage A total of 7,107,114 patients with major trauma had limited TTA. The average age, SBP, and ISS were significantly different among the three age groups (Shown in Table 3). No significant differences were observed in sex, average GCS, SpO 2 , and respiratory rate among the three age groups. Most instances of major trauma in the young and adult groups were caused by traffic accidents, whereas most instances of major trauma in the older adult group were caused by falls. The average SBP level of the older adult group was the highest (153.45 ± 26.58) among the three groups. The average ISSs were 20.29 ± 4.46, 20.32 ± 5.13, and 18.68 ± 4.16 for the young, adult, and older adult groups, respectively. Table 3. Basic and clinical characteristics of patients with major trauma without TTA Characteristic Age65 p value Sample size 7 107 114 Gender# 0.07 Male 3(42.86%) 40(37.38%) 60(52.63%) Female 4(57.14%) 67(62.62%) 54(47.37%) Age, mean(SD), years 17.86(1.77) 44.99(14.6) 78.56(8.3) <0.01* Mechanism of injury# <0.01* Fall 1(14.29%) 12(11.21%) 65(57.02%) Vehicle incident 6(85.71%) 87(81.31%) 48(42.11%) Others 0(0%) 8(7.48%) 1(0.88%) GCS, mean(SD) 14.86(0.38) 14.97(0.22) 14.97(0.21) 0.39 SBP, mean(SD) 126(17.64) 133.03(18.93) 153.45(26.58) <0.01* SPO2, mean(SD) 97.29(0.95) 97.53(1.40) 97.40(1.50) 0.75 Breathe rate, 10-29/min 7(100%) 107(100%) 113(99.12%)+ 0.99 ISS, mean(SD) 20.29(4.46) 20.32(5.13) 18.68(4.16) 0.03* #: Chi-square test; *: significant; +: 1 missing value; ISS: injury severity Score; SD: standard deviation; GCS: Glasgow Coma Scale; SBP: systolic blood pressure; Overtriage The age groups did not significantly differ with respect to patient characteristics and overall overtriage rate (Table 4). The results of forest plot analysis for the 10 criteria among patients with full TTA are shown in Figure 4. Most patients with full TTA were women, aged 20–65 years, and their major trauma was caused by traffic accidents. However, no significant differences were observed in sex and injury mechanism among the three age groups. The average age and the average ISS significantly differed between the appropriate triage and overtriage groups. The average ISSs were 28.28 ± 13.88 and 5.32 ± 3.85 for the appropriate triage and overtriage groups, respectively. The significant risk factors for overtriage were a GCS score of 30 breaths per minute, and major trauma caused by a traffic accident. Table 4. Basic and clinical characteristics of patients with major traumas with full TTA Characteristic Appropriate triage n = 166 overtriage n = 154 p value Age, mean(SD),year 46.70(22.77) 41.64(20.85) 0.04 Age group 0.09 65 42(25.30%) 24(15.58%) Male, n (%) 57(34.34%) 46(29.87%) 0.46 Mechanism of injury 0.55 Falls 11(6.63%) 14(9.09%) Motor vehicle/collision 128(77.11%) 111(72.08%) Others 27(16.27%) 29(18.83%) ISS, mean (SD) 28.28(13.88) 5.32(3.85) <0.01 SD: standard deviation; ISS: injury severity score Four criteria were significantly associated with overtriage. Patients with a GCS score of less than 13, SBP level less than 90, and respiratory rate of over 30 breaths per minute were more likely to be appropriately triaged. By contrast, the patients with fractures were more likely to be overtriaged. Discussion In this study, 664 patients had trauma (30%) and were aged >65 years. Because Taiwan’s population is aging, older patients make up a large proportion of patients with trauma(10) Compared with those in young people, the injuries in older patients were more serious and even fatal; traffic accidents were the major cause of those injuries, followed by falls. We found that 320 patients notified the hospital to activate the trauma team of the fire department, and 394 patients had a diagnosis of major trauma after a physician’s evaluation, which indicates that most of the patients with major trauma were not rescued by the on-site emergency medical personnel. “Taipei City Prehospital On-site Triage Indicator“ can be used to send the right patient to the right hospital at the right time to improve the patient’s chance of survival and prevent permanent disability. The rapid determination of whether a patient has a major trauma is challenging and requires a detailed investigation and evaluation by the hospital. In addition, other challenges include assessment of the following: the mechanism of injury on-site, the patient’s vital signs and risk of their condition deteriorating, and the severity of injury and provision of immediate medical attention. Additional studies are required to investigate other factors that may be pertinent to the patient’s injury, such as their age or medical history. An accurate prehospital on-site triage indicator is crucial for trauma evaluation because inappropriate triage (undertriage or overtriage) may lead to detrimental outcomes. Undertriage is the most serious outcome in trauma care because it may result in delays of treatment or wrong diagnoses, leading to increased mortality.(11, 12) Conversely, overtriage may disrupt the overall management of critically ill patients and lead to increased health care costs and overcrowding of trauma centers.(13) Although the ACS-COT provides guidelines for on-site triage, several factors can influence undertriage rates (e.g., EMT judgment, family requests, and age-based differences in serious injury presentation)(14), none of the existing triage guidelines worldwide currently meet the criteria of the ACS-COT (e.g., over-diagnosis rate of 35%–50 %, the undertriage rate less than 5%)(15), and undertriage remains a challenge even for countries with advanced health care. In this study, the undertriage rate of older patients (aged >65 years) was 19%, which was 10% higher than that of young and adult patients (aged 20–64 years). These findings are consistent with those previous studies. Inappropriate triage of the older patients may be due to the following factors: having low impact injury mechanism (e.g., falls), receiving medication (e.g., anticoagulants), and differences in the pathophysiology of the older patients(16, 17), suggesting that older patients tend to have more cognitive and physical impairments with preexisting comorbidities. Therefore, the inappropriate triage of older patients will remain a major problem, and this warrants additional study. After all, Taiwan is less than 4 years from becoming a super-aged society. The “Taipei City Prehospital On-Site Triage Index” is acceptable but not an ideal tool for identifying major traumas in patients and thus requires improvement; it has an overtriage rate of 48.12% and an undertriage rate of 12.03%. Because this index has its limitations, a considerable number of patients with major trauma do not receive proper care. Older patients (≥65 years old) with trauma should receive special attention from emergency medical personnel. When the on-site patient meets one of the following criteria: having a GCS score of <13, respiratory rate of <10 or ≥30 breaths per minute (or oxygen saturation of <90% in room air), or a fall height equivalent to the height of a 2-story building, the on-site emergency medical personnel should provide quality care for patient and notify the hospital to activate the trauma team. If the hospital receives this notification, it should activate the trauma team. The overall rescue time of patients can be reduced, because the activation of the hospital trauma team can reduce the time taken to transport the patient with major trauma from an emergency room to an operating room(18), and can reduce the mortality rate (19) , resulting in more efficient treatment and better outcomes for patients with major trauma. This study has several limitations. This research is a retrospective study, and some data were thus unavailable. Furthermore, the study setting was a single medical center (a first-aid-responsibility hospital with a heavy patient load), and the findings may not be generalizable to moderate sized and general emergency hospitals. However, because the data collected by this medical center are currently the most complete among hospitals in Taipei, we used the data of that hospital. In addition, the on-site ambulance personnel may be using different standards, however, they are subject to continual training (6) . Finally, because the ambulance personnel before arriving at the hospital were unable to identify the potential head trauma of patients, the injury mechanism could not be accurately presented. This warrants further investigation with regard to the provision of treatment for the injury site after arriving at the hospital and before arriving at the hospital. Conclusion Future research should include the emergency responsibility hospitals in the entire Taipei City to ensure that more samples are obtained to explore its related indicators and continue improving the accuracy and completeness of the registration data of the Taipei City Government Trauma System. More reliable data nay be provided in the future. To improve the overall quality of the treatment of trauma, the emergency medical personnel should continuously receive training to improve the overall quality of care. Every minute in the hospital counts, and the horizontal communication and contact before and after hospital should thus be strengthened to reduce the treatment time of patients with major trauma. Declarations A cknowledgement This study was founded by Sunny Brain Tumor and Brain Disease Research and Development Fund. All procedures were performed in accordance with relevant guidelines. Funding This work was supported by Sunny Brain Tumor and Brain Disease Research and Development Fund. Competing Interests None Author Contributions Wan-Lin Chen: Conceptualization, Methodology, Writing- Original draft preparation, Writing- Reviewing and Editing Ju-Chi Ou: Data curation, formal analysis, Writing- software, Visualization, Original draft preparation, Writing- Reviewing and Editing Shih Yu Ko: Investigation. Writing- Original draft Wen-Ching Li: Conceptualization Hon-Ping Ma: Supervision, Writing- Reviewing and Editin Ethics approval This study was approved by the Institutional Review Board of Taipei Medical University (TMU-JIRB #N202107116). Consent to participate Informed consent waiver with the Institutional Review Board of Taipei Medical University that waived the need for informed consent. Availability of Data and Materials The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. References Trauma ACoSCo. Resources for optimal care of the injured patient: Amer College of Surgeons; 1990. Sasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T, et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recomm Rep. 2012;61(Rr-1):1-20. Jenkins P, Kehoe A, Smith J. Is a two-tier trauma team activation system the most effective way to manage trauma in the UK? Trauma. 2013;15(4):322-30. Kouzminova N, Shatney C, Palm E, McCullough M, Sherck J. The efficacy of a two-tiered trauma activation system at a level I trauma center. Journal of Trauma and Acute Care Surgery. 2009;67(4):829-33. Taiwan Public Health Report 2009. 2010. Chiu Y-C, Wang L-H, Hsieh M-J, Chien Y-C, Wang Y-C, Ma MH-M, et al. Effect of Field Triage Training on Emergency Medical Technicians in Taipei City. Journal of acute medicine. 2021;11(1):22. Chien D-S, Yiang G-T, Liu C-Y, Tzeng I-S, Chang C-Y, Hou Y-T, et al. Association of in-hospital mortality and trauma team activation: a 10-year study. Diagnostics. 2022;12(10):2334. Beam G, Gorman K, Nannapaneni S, Zipf J, Simunich T. Need for Trauma Intervention and Improving Under-Triaging in Geriatric Trauma Patients: Under-Triaged or Misclassified. Int J Crit Care Emerg Med. 2022;8:136. Sasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T, et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. Morbidity and Mortality Weekly Report: Recommendations and Reports. 2012;61(1):1-20. Share of population aged 65 and older in Taiwan from 1960 to 2021 with forecasts until 2060. 2022. Haas B, Gomez D, Zagorski B, Stukel TA, Rubenfeld GD, Nathens AB. Survival of the fittest: the hidden cost of undertriage of major trauma. Journal of the American College of Surgeons. 2010;211(6):804-11. Staudenmayer KL, Hsia RY, Mann NC, Spain DA, Newgard CD. Triage of elderly trauma patients: a population-based perspective. Journal of the American College of Surgeons. 2013;217(4):569-76. Newgard CD, Staudenmayer K, Hsia RY, Mann NC, Bulger EM, Holmes JF, et al. The cost of overtriage: more than one-third of low-risk injured patients were taken to major trauma centers. Health affairs. 2013;32(9):1591-9. Newgard CD, Uribe-Leitz T, Haider AH. Undertriage remains a vexing problem for even the Most highly developed trauma systems: the need for innovations in field triage. JAMA surgery. 2018;153(4):328-. Resources for Optimal Care of the Injured Patient (2014 Standards). 2014. Chisholm KM, Harruff RC. Elderly deaths due to ground-level falls. The American Journal of Forensic Medicine and Pathology. 2010;31(4):350-4. Spaniolas K, Cheng JD, Gestring ML, Sangosanya A, Stassen NA, Bankey PE. Ground level falls are associated with significant mortality in elderly patients. Journal of Trauma and Acute Care Surgery. 2010;69(4):821-5. Wang C-H, Hsiao K-Y, Shih H-M, Tsai Y-H, Chen I-C. The role of trauma team activation by emergency physicians on outcomes in severe trauma patients. Journal of Acute Medicine. 2014;4(1):1-5. Petrie D, Lane P, Stewart TC. An evaluation of patient outcomes comparing trauma team activated versus trauma team not activated using TRISS analysis. Journal of Trauma and Acute Care Surgery. 1996;41(5):870-5. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2862620","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":205443345,"identity":"d3453e04-d5f9-466d-8820-4367e780a09f","order_by":0,"name":"Ju-Chi Ou","email":"","orcid":"","institution":"Taipei Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ju-Chi","middleName":"","lastName":"Ou","suffix":""},{"id":205443348,"identity":"72fb3b00-c1dd-485f-9b57-330939939b80","order_by":1,"name":"Wan-Lin Chen","email":"","orcid":"","institution":"Taipei Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wan-Lin","middleName":"","lastName":"Chen","suffix":""},{"id":205443349,"identity":"700a8165-801e-4a00-97a8-c269eff7bb48","order_by":2,"name":"Shih-Yu Ko","email":"","orcid":"","institution":"Taipei Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shih-Yu","middleName":"","lastName":"Ko","suffix":""},{"id":205443350,"identity":"a187f33f-a604-45b2-bffe-49bb6a99274b","order_by":3,"name":"Wen-Ching Li","email":"","orcid":"","institution":"Taipei Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wen-Ching","middleName":"","lastName":"Li","suffix":""},{"id":205443351,"identity":"a22b1816-99f9-46f1-adb1-d2563ccb9d32","order_by":4,"name":"Hon-Ping Ma","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYFAC5gaGDwYSPPxQHjFaGBsYZ1TYyEm2wbSwEaGFmedMmrHBMWK18LcfbP7A23Y4cfP97jQJhgrrxAb5HgO8WiTOJLZJSAK1bDvGu02C4Ux6YgMbD34tDDcY2xgMYVoYgYwGNt4NeHXI32Bs/pAIclgbSMs/IrQY3GBskDgA8j4bSEsDEVoMgX6RbAAGssSx3M0WCcfSjdvY8j/g1SJ3/PDhz39AUdl8duONDzXWsv3MxxLwakEFILWEY3IUjIJRMApGAUEAALYhSBaedYvCAAAAAElFTkSuQmCC","orcid":"","institution":"Taipei Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Hon-Ping","middleName":"","lastName":"Ma","suffix":""}],"badges":[],"createdAt":"2023-04-26 07:29:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2862620/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2862620/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":37855508,"identity":"0a34379e-3ad3-4861-846a-59650d7cdf17","added_by":"auto","created_at":"2023-06-01 15:26:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":155739,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flow chart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-2862620/v1/15556726b65f9391b2e080e6.png"},{"id":37855079,"identity":"54ce0ff2-6f5d-46c2-97a4-2732d205e65f","added_by":"auto","created_at":"2023-06-01 15:18:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":25657,"visible":true,"origin":"","legend":"\u003cp\u003eDecision scheme of Taipei TTA criteria(9)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-2862620/v1/78d84aadf8071a359755c43b.png"},{"id":37855507,"identity":"6581b7fd-c2da-45a8-bc92-5ae08bee0705","added_by":"auto","created_at":"2023-06-01 15:26:17","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":21217,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of patients who met TTA criteria.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-2862620/v1/fa249c812177fb449f0ea1a0.png"},{"id":37855081,"identity":"5a732e3f-3f9d-4085-b63b-5d3db555cf03","added_by":"auto","created_at":"2023-06-01 15:18:17","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":37658,"visible":true,"origin":"","legend":"\u003cp\u003eResults of forest plot analysis for the 10 criteria among patients with full TTA.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-2862620/v1/64d508ba4eb01489f26a9731.png"},{"id":41928236,"identity":"f5ac5f72-22fc-452d-a2e4-b2ee9ededdf9","added_by":"auto","created_at":"2023-08-22 10:37:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":451336,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2862620/v1/ee8b2ac2-aa15-43a0-8c1f-d5597bcf01ed.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy of the protocol for trauma team activation in Taipei: A retrospective study","fulltext":[{"header":"Purpose","content":"\u003cp\u003eTrauma triage is the use of trauma assessment for prioritizing patients for treatment or transport by injury severity. Trauma triage can be classified into field triage and hospital triage, and the lack of accuracy in identifying the severity of a patient\u0026rsquo;s injury and their prehospital information can result in inappropriate triage.\u003c/p\u003e \u003cp\u003eThe first edition of the criteria of field triage was developed according to the recommendations of the American College of Surgeons - Committee on Trauma (ACS-COT) in 1979(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The current Field Triage Decision Scheme was developed according to the evidence-based review of the ACS-COT and the National Highway Traffic Safety Administration and Center for Disease Control and Prevention(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTwo-tier systems for trauma team activation have been used since the early stages of trauma system development. Early evaluations indicated their cost-effectiveness and efficient use of resources. Thus, the number of studies on two-tier trauma team activation systems have increased(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Undertriage and overtriage rates are key indicators of the quality of trauma systems. Specifically, undertriage and overtriage occur when too little and too much resources are allocated to caring for a patient, respectively. An undertriage rate of \u0026lt;\u0026thinsp;5% and an overtriage rate of \u0026lt;\u0026thinsp;35% are considered acceptable according to the ACS-COT. Injury triage systems were developed to ensure that resources are appropriately distributed to patients with trauma.\u003c/p\u003e \u003cp\u003eAccording to Taiwan Public Health Report, accidents and their adverse events were the sixth leading cause of death and accounted for over 7,000 casualties in 2009(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Taipei City Government held seven field triage training sessions for paramedics from 2015 to 2016, and field trauma training was found to improve the accuracy of field triage scheme(6). In another study on Taipei City, no significant association was found between in-hospital mortality and trauma team activation (TTA). However, the group subject to TTA guidelines had a higher risk of intensive care unit (ICU) admission, prolonged length of hospital stay (LOS), and prolonged ICU LOS. In addition, a subgroup analysis revealed that in the TTA group, patients aged 60\u0026ndash;80 years, with major injury (Injury Severity Score [ISS]\u0026thinsp;\u0026ge;\u0026thinsp;16), with clear consciousness, and with non-head injury had a higher risk of mortality. These findings indicate that patients selected using the TTA criteria had higher ISS and a higher risk of mortality(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). According to our review of the literature, studies have yet to evaluate the effectiveness of the field triage system. Therefore, this study evaluated the effectiveness of Taipei field triage guidelines governing trauma team activation and explored the characteristics of undertriaged and overtriaged patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData\u003c/h2\u003e \u003cp\u003e We explored the accuracy of Taipei prehospital field triage guidelines in identifying patients with major trauma (using Injury Severity Score (ISS)\u0026thinsp;\u0026ge;\u0026thinsp;16) and other factors that may affect accuracy.\u003c/p\u003e \u003cp\u003e Taipei prehospital field triage guidelines comprise 4 major criteria with 11 items each. The four major criteria are vital signs, anatomic injuries, injury mechanism, and special considerations. If a patient with on-site trauma meets more than one criterion, the patient must be sent to a first-aid hospital, and the on-site team must notify the hospital to activate the trauma team. Patients with major trauma were classified as patients having an ISS of \u0026ge;\u0026thinsp;16. We hypothesized that Taipei prehospital field triage guidelines could be used to accurately identify patients with major trauma (ISS\u0026thinsp;\u0026ge;\u0026thinsp;16).\u003c/p\u003e \u003cp\u003e​This study retrospectively observed all patients with trauma who were transported to the emergency department of a medical center by Taipei City public ambulance from January 1, 2016 to December 31, 2019. The following patients were excluded: patients who were transported by means other than a Taipei City public ambulance and patients with out-of-hospital cardiac arrest. A total of 1,322 people were included in the analysis. The flowchart of patient selection is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe Cribari matrix method (CMM) was used to assess undertriage and overtriage. We used a modified CMM for greater accuracy(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003cp\u003eEthical approval: This study was approved by the Institutional Review Board of Taipei Medical University (TMU-JIRB #N202107116).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eTaipei field triage system\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Figure 2, Taipei prehospital field triage guidelines cover five criteria: vital signs, anatomic injuries, injury mechanism, blast injury, and special considerations. The criterion of vital signs comprise the items of having a Glasgow Coma Scale (GSC) score of \u0026lt;13, systolic blood pressure (SBP) level of \u0026lt;90, respiratory rate of \u0026lt;30 or \u0026ge;30 breaths per minute, and a SpO\u003csub\u003e2\u003c/sub\u003e of \u0026lt;90%. The criterion of anatomic injuries comprise the items of having penetrating trauma; crushing injury in the head, neck, torso, or upper arms or thighs; fractures; amputation above the wrist or ankle; and limb paralysis. The criterion of injury mechanism comprise the items of having had a fall and having been involved in a traffic accident. The criterion of special considerations comprise the items of being a child or an infant, being pregnant, having bleeding disorders or anticoagulation, and having burn injury.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCribari matrix method\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe detail of Cribari Matrix method is shown in Table 1. The upper panel and lower panel are Standard version and Modified version, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1. Original and modified version of CMM for assessing triage tool\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.38255033557047%\"\u003e\n \u003cp\u003e Standard version\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.288590604026847%\"\u003e\n \u003cp\u003eISS 0-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.953020134228186%\"\u003e\n \u003cp\u003eISS 10-14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.436241610738255%\"\u003e\n \u003cp\u003eISS 15-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.939597315436242%\"\u003e\n \u003cp\u003eISS 25-75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.38255033557047%\"\u003e\n \u003cp\u003eFull trauma team activation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.288590604026847%\"\u003e\n \u003cp\u003eOT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.953020134228186%\"\u003e\n \u003cp\u003eOT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.436241610738255%\"\u003e\n \u003cp\u003eAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.939597315436242%\"\u003e\n \u003cp\u003eAT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.38255033557047%\"\u003e\n \u003cp\u003epartial trauma team activation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.288590604026847%\"\u003e\n \u003cp\u003eAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.953020134228186%\"\u003e\n \u003cp\u003eAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.436241610738255%\"\u003e\n \u003cp\u003eAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.939597315436242%\"\u003e\n \u003cp\u003eUT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.38255033557047%\"\u003e\n \u003cp\u003etrauma consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.288590604026847%\"\u003e\n \u003cp\u003eAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.953020134228186%\"\u003e\n \u003cp\u003eAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.436241610738255%\"\u003e\n \u003cp\u003eUT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.939597315436242%\"\u003e\n \u003cp\u003eUT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.38255033557047%\"\u003e\n \u003cp\u003eTrauma service not notified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.288590604026847%\"\u003e\n \u003cp\u003eAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.953020134228186%\"\u003e\n \u003cp\u003eUT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.436241610738255%\"\u003e\n \u003cp\u003eUT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.939597315436242%\"\u003e\n \u003cp\u003eUT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.436974789915965%\"\u003e\n \u003cp\u003e Modified version\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.30252100840336%\" colspan=\"2\"\u003e\n \u003cp\u003eISS 0-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.26050420168067%\" colspan=\"2\"\u003e\n \u003cp\u003eISS 16-75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.436974789915965%\"\u003e\n \u003cp\u003etrauma team activation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.30252100840336%\" colspan=\"2\"\u003e\n \u003cp\u003eOT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.26050420168067%\" colspan=\"2\"\u003e\n \u003cp\u003eAT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.436974789915965%\"\u003e\n \u003cp\u003eno activation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.30252100840336%\" colspan=\"2\"\u003e\n \u003cp\u003eAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.26050420168067%\" colspan=\"2\"\u003e\n \u003cp\u003eUT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cu\u003eStatistical analysis\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eContinuous and categorical variables are presented as mean \u0026plusmn; standard deviation and frequency and percentage, respectively. A logistic regression was performed to analyze the impact of risk factors in patients with major trauma. All statistical analyses were conducted using R software. Significance was indicated by \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe basic and clinical characteristics of the patients are shown in Table 2. The number of patients who met the Taipei TTA criteria is shown in Figure 3. Between 2016 and 2019, among patients with trauma, 195, 1,358, and 664 patients were aged \u0026lt;20 years (young group), aged 20\u0026ndash;65 years (adult group), and aged \u0026gt;65 (older adult group), respectively; these three age groups significantly differed with respect to patient characteristics (i.e., sex, age, and mechanism of injury). The young and adult groups had more women than men, and the older adult group had more men than women. The average ages\u0026nbsp;of young, adult and older adult groups were 15.52 (\u0026plusmn;5.03), 40.51 (\u0026plusmn;14.66), and 78.26 (\u0026plusmn;8.28) years, respectively. Over 65% of the young and adult groups\u0026rsquo; major traumas were caused by traffic accidents, whereas more than 58% of the older patients\u0026rsquo; major traumas were caused by falls.\u003c/p\u003e\n\u003cp\u003eAmong the three age groups, TTA rate, average ISS, ISS higher than\u0026ndash;16 rate, and undertriage rate significantly differed. The TTA rates of the young group and older adult group were the highest and lowest, respectively. The average ISSs of the older adult group and young group were the highest and lowest, respectively. The number of patients with an ISS of \u0026ge;16 in the older adult group was the highest (23.49%), and that in the young group was the lowest (12.31%). The undertriage rate of the older adult group was the highest (19%), and that of the young group was the lowest (4%).\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eTable 2. Basic and clinical characteristics of patients from 2016 to 2020.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u0026lt;20\u003c/p\u003e\n \u003cp\u003eYoung\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003eAge 20\u0026ndash;65\u003c/p\u003e\n \u003cp\u003eAdult\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003eAge \u0026gt;65\u003c/p\u003e\n \u003cp\u003eOlder adult\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eSample size\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e1358\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e664\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eGender#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e65(33.33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e545(40.13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e384(57.83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e130(66.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e813(59.87%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e279(42.02%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eAge, Mean(SD), years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e15.52(5.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e40.51(14.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e78.26(8.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eMechanism of injury#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eFall\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e31(15.90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e177(13.01%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e389(58.58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eVehicle incident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e134(68.72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e1036(76.29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e245(36.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e30(15.38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e145(10.68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e30(4.52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eActivation, n(%)#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e36(18.46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e218(16.05%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e66(9.94%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eISS, mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e6.60(9.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e7.64(8.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e9.53(8.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eISS \u0026ge;16, n(%)#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e24(12.31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e214(15.76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e156(23.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eOvertriage rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.72093023255814%\" valign=\"top\"\u003e\n \u003cp\u003eUndertriage rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.777408637873755%\" valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.272425249169434%\" valign=\"top\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.953488372093023%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003csup\u003e#: Chi-square test; *: significant; ISS: injury severity Score; SD: standard deviation\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cu\u003eUndertriage\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eA total of 7,107,114 patients with major trauma had limited TTA. The average age, SBP, and ISS were significantly different among the three age groups (Shown in Table 3). No significant differences were observed in sex, average GCS, SpO\u003csub\u003e2\u003c/sub\u003e, and respiratory rate among the three age groups. Most instances of major trauma in the young and adult groups were caused by traffic accidents, whereas most instances of major trauma in the older adult group were caused by falls. The average SBP level of the older adult group was the highest (153.45 \u0026plusmn; 26.58) among the three groups. The average ISSs were 20.29 \u0026plusmn; 4.46, 20.32 \u0026plusmn; 5.13, and 18.68 \u0026plusmn; 4.16 for the young, adult, and older adult groups, respectively.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"604\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eTable 3. Basic and clinical characteristics of patients with major trauma without TTA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u0026lt;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003eage 20- 65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003eage \u0026gt;65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eSample size\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eGender#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003e3(42.86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e40(37.38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e60(52.63%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003e4(57.14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e67(62.62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e54(47.37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eAge, mean(SD), years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003e17.86(1.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e44.99(14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e78.56(8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eMechanism of injury#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eFall\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003e1(14.29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e12(11.21%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e65(57.02%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eVehicle incident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003e6(85.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e87(81.31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e48(42.11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003e0(0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e8(7.48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e1(0.88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eGCS, mean(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003e14.86(0.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e14.97(0.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e14.97(0.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eSBP, mean(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003e126(17.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e133.03(18.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e153.45(26.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eSPO2, mean(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003e97.29(0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e97.53(1.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e97.40(1.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eBreathe rate, 10-29/min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003e7(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e107(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e113(99.12%)+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.28476821192053%\" valign=\"top\"\u003e\n \u003cp\u003eISS, mean(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.37748344370861%\" valign=\"top\"\u003e\n \u003cp\u003e20.29(4.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e20.32(5.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.211920529801326%\" valign=\"top\"\u003e\n \u003cp\u003e18.68(4.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.913907284768213%\" valign=\"top\"\u003e\n \u003cp\u003e0.03*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003csup\u003e#: Chi-square test; *: significant; +: 1 missing value; ISS: injury severity Score; SD: standard deviation; GCS: Glasgow Coma Scale; SBP: systolic blood pressure;\u0026nbsp;\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cu\u003eOvertriage\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe age groups did not significantly differ with respect to patient characteristics and overall overtriage rate (Table 4). The results of forest plot analysis for the 10 criteria among patients with full TTA are shown in Figure 4. Most patients with full TTA were women, aged 20\u0026ndash;65 years, and their major trauma was caused by traffic accidents. However, no significant differences were observed in sex and injury mechanism among the three age groups. The average age and the average ISS significantly differed between the appropriate triage and overtriage groups. The average ISSs were 28.28 \u0026plusmn; 13.88 and 5.32 \u0026plusmn; 3.85 for the appropriate triage and overtriage groups, respectively. The significant risk factors for overtriage were a GCS score of \u0026lt;13, respiratory rate of \u0026gt;30 breaths per minute, and major trauma caused by a traffic accident.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4. Basic and clinical characteristics of patients with major traumas with full TTA\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"630\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.657686212361334%\" valign=\"top\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.356576862123614%\" valign=\"top\"\u003e\n \u003cp\u003eAppropriate triage\u003c/p\u003e\n \u003cp\u003en = 166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.771790808240887%\" valign=\"top\"\u003e\n \u003cp\u003eovertriage\u003c/p\u003e\n \u003cp\u003en = 154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.213946117274167%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.657686212361334%\" valign=\"top\"\u003e\n \u003cp\u003eAge, mean(SD),year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.356576862123614%\" valign=\"top\"\u003e\n \u003cp\u003e46.70(22.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.771790808240887%\" valign=\"top\"\u003e\n \u003cp\u003e41.64(20.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.213946117274167%\" valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.657686212361334%\" valign=\"top\"\u003e\n \u003cp\u003eAge group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.356576862123614%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.771790808240887%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.213946117274167%\" valign=\"top\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.657686212361334%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.356576862123614%\" valign=\"top\"\u003e\n \u003cp\u003e17(10.24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.771790808240887%\" valign=\"top\"\u003e\n \u003cp\u003e19(12.34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.213946117274167%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.657686212361334%\" valign=\"top\"\u003e\n \u003cp\u003e20\u0026ndash;65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.356576862123614%\" valign=\"top\"\u003e\n \u003cp\u003e107(64.46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.771790808240887%\" valign=\"top\"\u003e\n \u003cp\u003e111(72.08%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.213946117274167%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.657686212361334%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.356576862123614%\" valign=\"top\"\u003e\n \u003cp\u003e42(25.30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.771790808240887%\" valign=\"top\"\u003e\n \u003cp\u003e24(15.58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.213946117274167%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.657686212361334%\" valign=\"top\"\u003e\n \u003cp\u003eMale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.356576862123614%\" valign=\"top\"\u003e\n \u003cp\u003e57(34.34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.771790808240887%\" valign=\"top\"\u003e\n \u003cp\u003e46(29.87%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.213946117274167%\" valign=\"top\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.657686212361334%\" valign=\"top\"\u003e\n \u003cp\u003eMechanism of injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.356576862123614%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.771790808240887%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.213946117274167%\" valign=\"top\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.657686212361334%\" valign=\"top\"\u003e\n \u003cp\u003eFalls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.356576862123614%\" valign=\"top\"\u003e\n \u003cp\u003e11(6.63%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.771790808240887%\" valign=\"top\"\u003e\n \u003cp\u003e14(9.09%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.213946117274167%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.657686212361334%\" valign=\"top\"\u003e\n \u003cp\u003eMotor vehicle/collision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.356576862123614%\" valign=\"top\"\u003e\n \u003cp\u003e128(77.11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.771790808240887%\" valign=\"top\"\u003e\n \u003cp\u003e111(72.08%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.213946117274167%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.657686212361334%\" valign=\"top\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.356576862123614%\" valign=\"top\"\u003e\n \u003cp\u003e27(16.27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.771790808240887%\" valign=\"top\"\u003e\n \u003cp\u003e29(18.83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.213946117274167%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.657686212361334%\" valign=\"top\"\u003e\n \u003cp\u003eISS, mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.356576862123614%\" valign=\"top\"\u003e\n \u003cp\u003e28.28(13.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.771790808240887%\" valign=\"top\"\u003e\n \u003cp\u003e5.32(3.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.213946117274167%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eSD: standard deviation; ISS: injury severity score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFour criteria were significantly associated with overtriage. Patients with a GCS score of less than 13, SBP level less than 90, and respiratory rate of over 30 breaths per minute were more likely to be appropriately triaged. By contrast, the patients with fractures were more likely to be overtriaged.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, 664 patients had trauma (30%) and were aged \u0026gt;65 years. Because Taiwan\u0026rsquo;s population is aging, older patients make up a large proportion of patients with trauma(10)\u0026nbsp;Compared with those in young people, the injuries in older patients were more serious and even fatal; traffic accidents were the major cause of those injuries, followed by falls. We found that 320 patients notified the hospital to activate the trauma team of the fire department, and 394 patients had a diagnosis of major trauma after a physician\u0026rsquo;s evaluation, which indicates that most of the patients with major trauma were not rescued by the on-site emergency medical personnel.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Taipei City Prehospital On-site Triage Indicator\u0026ldquo; can be used to send the right patient to the right hospital at the right time to improve the patient\u0026rsquo;s chance of survival and prevent permanent disability. The rapid determination of whether a patient has a major trauma is challenging and requires a detailed investigation and evaluation by the hospital. In addition, other challenges include assessment of the following: the mechanism of injury on-site, the patient\u0026rsquo;s vital signs and risk of their condition deteriorating, and the severity of injury and provision of immediate medical attention. Additional studies are required to investigate other factors that may be pertinent to the patient\u0026rsquo;s injury, such as their age or medical history.\u003c/p\u003e\n\u003cp\u003eAn accurate prehospital on-site triage indicator is crucial for trauma evaluation because inappropriate triage (undertriage or overtriage) may lead to detrimental outcomes. Undertriage is the most serious outcome in trauma care because it may result in delays of treatment or wrong diagnoses, leading to increased mortality.(11, 12)\u0026nbsp;Conversely, overtriage may disrupt the overall management of critically ill patients and lead to increased health care costs and overcrowding of trauma centers.(13)\u003c/p\u003e\n\u003cp\u003eAlthough the ACS-COT provides guidelines for on-site triage, several factors can influence undertriage rates (e.g., EMT judgment, family requests, and age-based differences in serious injury presentation)(14), none of the existing triage guidelines worldwide currently meet the criteria of the ACS-COT (e.g., over-diagnosis rate of 35%\u0026ndash;50 %, the undertriage rate less than 5%)(15), and undertriage remains a challenge even for countries with advanced health care.\u003c/p\u003e\n\u003cp\u003eIn this study, the undertriage rate of older patients (aged \u0026gt;65 years) was 19%, which was 10% higher than that of young and adult patients (aged 20\u0026ndash;64 years). These findings are consistent with those previous studies. Inappropriate triage of the older patients may be due to the following factors: having low impact injury mechanism (e.g., falls), receiving medication (e.g., anticoagulants), and differences in the pathophysiology of the older patients(16, 17), suggesting that older patients tend to have more cognitive and physical impairments with preexisting comorbidities. Therefore, the inappropriate triage of older patients will remain a major problem, and this warrants additional study. After all, Taiwan is less than 4 years from becoming a super-aged society.\u003c/p\u003e\n\u003cp\u003eThe \u0026ldquo;Taipei City Prehospital On-Site Triage Index\u0026rdquo; is acceptable but not an ideal tool for identifying major traumas in patients and thus requires improvement; it has an overtriage rate of 48.12% and an undertriage rate of 12.03%. Because this index has its limitations, a considerable number of patients with major trauma do not receive proper care. Older patients\u0026nbsp;(\u0026ge;65 years old)\u0026nbsp;with trauma should receive special attention from emergency medical personnel. When the on-site patient meets one of the following criteria: having a GCS score of \u0026lt;13, respiratory rate of \u0026lt;10 or \u0026ge;30 breaths per minute (or oxygen saturation of \u0026lt;90% in room air), or a fall height equivalent to the height of a 2-story building, the on-site emergency medical personnel should provide quality care for patient and notify the hospital to activate the trauma team. If the hospital receives this notification, it should activate the trauma team. The overall rescue time of patients can be reduced, because the activation of the hospital trauma team can reduce the time taken to transport the patient with major trauma from an emergency room to an operating room(18), and can reduce the mortality rate\u003csup\u003e(19)\u003c/sup\u003e, resulting in more efficient treatment and better outcomes for patients with major trauma.\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. This research is a retrospective study, and some data were thus unavailable. Furthermore, the study setting was a single medical center (a first-aid-responsibility hospital with a heavy patient load), and the findings may not be generalizable to moderate sized and general emergency hospitals. However, because the data collected by this medical center are currently the most complete among hospitals in Taipei, we used the data of that hospital. In addition, the on-site ambulance personnel may be using different standards, however, they are subject to continual training\u003csup\u003e(6)\u003c/sup\u003e. Finally, because the ambulance personnel before arriving at the hospital were unable to identify the potential head trauma of patients, the injury mechanism could not be accurately presented. This warrants further investigation with regard to the provision of treatment for the injury site after arriving at the hospital and before arriving at the hospital.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFuture research should include the emergency responsibility hospitals in the entire Taipei City to ensure that more samples are obtained to explore its related indicators and continue improving the accuracy and completeness of the registration data of the Taipei City Government Trauma System. More reliable data nay be provided in the future. To improve the overall quality of the treatment of trauma, the emergency medical personnel should continuously receive training to improve the overall quality of care. Every minute in the hospital counts, and the horizontal communication and contact before and after hospital should thus be strengthened to reduce the treatment time of patients with major trauma.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003cstrong\u003ecknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was founded by\u0026nbsp;Sunny Brain Tumor and Brain Disease Research and Development Fund.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAll procedures were performed in accordance with relevant guidelines.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Sunny Brain Tumor and Brain Disease Research and Development Fund.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWan-Lin Chen: Conceptualization, Methodology, Writing- Original draft preparation, Writing- Reviewing and Editing\u003c/p\u003e\n\u003cp\u003eJu-Chi Ou: Data curation, formal analysis, Writing- software, Visualization, Original draft preparation, Writing- Reviewing and Editing\u003c/p\u003e\n\u003cp\u003eShih Yu Ko: Investigation. Writing- Original draft\u003c/p\u003e\n\u003cp\u003eWen-Ching Li: Conceptualization\u003c/p\u003e\n\u003cp\u003eHon-Ping Ma: Supervision, Writing- Reviewing and Editin\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of Taipei Medical University (TMU-JIRB #N202107116).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent waiver with\u0026nbsp;\u003c/strong\u003ethe Institutional Review Board of Taipei Medical University \u003cstrong\u003ethat waived the need for informed consent.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTrauma ACoSCo. Resources for optimal care of the injured patient: Amer College of Surgeons; 1990.\u003c/li\u003e\n\u003cli\u003eSasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T, et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recomm Rep. 2012;61(Rr-1):1-20.\u003c/li\u003e\n\u003cli\u003eJenkins P, Kehoe A, Smith J. Is a two-tier trauma team activation system the most effective way to manage trauma in the UK? Trauma. 2013;15(4):322-30.\u003c/li\u003e\n\u003cli\u003eKouzminova N, Shatney C, Palm E, McCullough M, Sherck J. The efficacy of a two-tiered trauma activation system at a level I trauma center. Journal of Trauma and Acute Care Surgery. 2009;67(4):829-33.\u003c/li\u003e\n\u003cli\u003eTaiwan Public Health Report 2009. 2010.\u003c/li\u003e\n\u003cli\u003eChiu Y-C, Wang L-H, Hsieh M-J, Chien Y-C, Wang Y-C, Ma MH-M, et al. Effect of Field Triage Training on Emergency Medical Technicians in Taipei City. Journal of acute medicine. 2021;11(1):22.\u003c/li\u003e\n\u003cli\u003eChien D-S, Yiang G-T, Liu C-Y, Tzeng I-S, Chang C-Y, Hou Y-T, et al. Association of in-hospital mortality and trauma team activation: a 10-year study. Diagnostics. 2022;12(10):2334.\u003c/li\u003e\n\u003cli\u003eBeam G, Gorman K, Nannapaneni S, Zipf J, Simunich T. Need for Trauma Intervention and Improving Under-Triaging in Geriatric Trauma Patients: Under-Triaged or Misclassified. Int J Crit Care Emerg Med. 2022;8:136.\u003c/li\u003e\n\u003cli\u003eSasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T, et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. Morbidity and Mortality Weekly Report: Recommendations and Reports. 2012;61(1):1-20.\u003c/li\u003e\n\u003cli\u003eShare of population aged 65 and older in Taiwan from 1960 to 2021 with forecasts until 2060. 2022.\u003c/li\u003e\n\u003cli\u003eHaas B, Gomez D, Zagorski B, Stukel TA, Rubenfeld GD, Nathens AB. Survival of the fittest: the hidden cost of undertriage of major trauma. Journal of the American College of Surgeons. 2010;211(6):804-11.\u003c/li\u003e\n\u003cli\u003eStaudenmayer KL, Hsia RY, Mann NC, Spain DA, Newgard CD. Triage of elderly trauma patients: a population-based perspective. Journal of the American College of Surgeons. 2013;217(4):569-76.\u003c/li\u003e\n\u003cli\u003eNewgard CD, Staudenmayer K, Hsia RY, Mann NC, Bulger EM, Holmes JF, et al. The cost of overtriage: more than one-third of low-risk injured patients were taken to major trauma centers. Health affairs. 2013;32(9):1591-9.\u003c/li\u003e\n\u003cli\u003eNewgard CD, Uribe-Leitz T, Haider AH. Undertriage remains a vexing problem for even the Most highly developed trauma systems: the need for innovations in field triage. JAMA surgery. 2018;153(4):328-.\u003c/li\u003e\n\u003cli\u003eResources for Optimal Care of the Injured Patient (2014 Standards). 2014.\u003c/li\u003e\n\u003cli\u003eChisholm KM, Harruff RC. Elderly deaths due to ground-level falls. The American Journal of Forensic Medicine and Pathology. 2010;31(4):350-4.\u003c/li\u003e\n\u003cli\u003eSpaniolas K, Cheng JD, Gestring ML, Sangosanya A, Stassen NA, Bankey PE. Ground level falls are associated with significant mortality in elderly patients. Journal of Trauma and Acute Care Surgery. 2010;69(4):821-5.\u003c/li\u003e\n\u003cli\u003eWang C-H, Hsiao K-Y, Shih H-M, Tsai Y-H, Chen I-C. The role of trauma team activation by emergency physicians on outcomes in severe trauma patients. Journal of Acute Medicine. 2014;4(1):1-5.\u003c/li\u003e\n\u003cli\u003ePetrie D, Lane P, Stewart TC. An evaluation of patient outcomes comparing trauma team activated versus trauma team not activated using TRISS analysis. Journal of Trauma and Acute Care Surgery. 1996;41(5):870-5.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Trauma team activation, undertriage, Taipei prehospital field triage guidelines, Injury Severity Score","lastPublishedDoi":"10.21203/rs.3.rs-2862620/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2862620/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTrauma triage is the use of trauma assessment for prioritizing patients for treatment or transport by injury severity. Accidents and their adverse events were the sixth leading cause of death and accounted for over 7,000 casualties in 2009. However, a lack of accuracy in identifying the severity of a patient\u0026rsquo;s injury and their prehospital information can result in inappropriate triage. This study evaluated the efficacy of field triage guidelines governing trauma team activation in Taipei and explored the characteristics of undertriaged and overtriaged patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e​This study retrospectively observed all patients with trauma transported to the emergency department by Taipei City public ambulance from 2016, to 2019. The Cribari matrix method was used to assess undertriage and overtriage. A logistic regression was employed to analyze the effect of risk factors in patients with major trauma.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn this study, 320 and 1,895 patients with trauma had full and limited trauma team activation, respectively. Among them, 664 patients with trauma were older than 65 years, and most of them were injured in a traffic accident.The analysis revealed that patients with a Glasgow Coma Scale score of less than 13, with systolic blood pressure level of less than 90, and with respiratory rate over 30 breaths per minute were more likely to be appropriately triaged.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e The Taipei prehospital field triage guidelines is acceptable but not an ideal tool for identifying patients with major trauma, with an overtriage rate of 48.12% and an undertriage rate of 12.03%.\u003c/p\u003e","manuscriptTitle":"Efficacy of the protocol for trauma team activation in Taipei: A retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-06-01 15:18:13","doi":"10.21203/rs.3.rs-2862620/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95987ddd-3cc2-4638-aeb9-638adbb5be13","owner":[],"postedDate":"June 1st, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":21969509,"name":"Health sciences/Diseases/Trauma"},{"id":21969510,"name":"Health sciences/Health care/Public health"}],"tags":[],"updatedAt":"2023-08-22T10:29:16+00:00","versionOfRecord":[],"versionCreatedAt":"2023-06-01 15:18:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2862620","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2862620","identity":"rs-2862620","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}