Right patient to the right place: The impact of a 6-year regional trauma centre-led prehospital education program on EMS triage and patient outcomes

Right patient to the right place: The impact of a 6-year regional trauma centre-led prehospital education program on EMS triage and patient outcomes | 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 Research Article Right patient to the right place: The impact of a 6-year regional trauma centre-led prehospital education program on EMS triage and patient outcomes Donghwan Choi, Yo Huh, Byung Hee Kang, Sora Kim, Seoyoung Song, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4443129/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background In regional trauma systems, emergency medical service (EMS) providers play a crucial role by performing prehospital triage for severely injured patients and transporting them to regional trauma centres. Since 2016, a regional trauma centre has provided prehospital medical guidance to EMS providers through a trauma hotline, facilitated by trauma surgeon, to guide field triage, treatment, and transport. This study analysed the effects and clinical outcomes of a regional trauma centre-led performance improvement program that followed closed-loop principles for EMS providers. Methods Data from the regional trauma centre databases (2016–2021) were collected, and patients with trauma with Injury Severity Scores (ISSs) > 15 in the Gyeonggi Province who were injured, regardless of whether they visited the trauma centre directly or not, were included. After severity and baseline demographic adjustments through propensity score matching, clinical outcomes were analysed using the t-test and chi-squared test, and the results were expressed as medians with interquartile ranges (IQRs) or means with standard deviations (SDs). Results We included 3017 patients from the 6-year study period. Correct triage and undertriage were performed in 2528 and 489 patients, respectively. Prehospital medical guidance and feedback were provided 432 times (32.1%) in 2016 and increased to 1505 times (96.8%) in 2021 ( p < 0.001). The undertriage rate decreased from 32.7% (n = 55/168) to 6.3% (n = 52/820) ( p < 0.001), and the overall mortality decreased from 21.4–10% ( p < 0.001). After propensity score matching, 484 correctly triaged and 484 undertriaged patients were identified for subgroup analyses. The in-hospital mortality of undertriaged and correctly triaged patients was 20% (n = 99) and 13% (n = 61) (p = 0.001), respectively. The median (IQR) for undertriaged over correctly-triaged patients regarding hospital length of stay (LOS) and ICU day ratio was 17 (8–37) vs 19 (12–36) (p = 0.024) and 0.4 (0.2-1.0) vs 0.3 (0.2–0.6) (p = 0.059), respectively. Conclusion Undertriage was associated with increased in-hospital mortality and hospital LOS. There was a statistically significant difference between the increase in prehospital medical guidance and the decreased undertriage rate. Specifically, in the early stages of regional trauma-system development, the trauma center-led trauma hotline feedback and case-based education programs can be effective models to facilitate prehospital patient triage and patient centralisation. undertriage prehospital performance improvement regional trauma system EMS provider education Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Trauma is a leading cause of morbidity and mortality worldwide, underscoring the critical role of efficient emergency medical services (EMS) in prehospital triage and the swift management of severely injured patients [ 1 , 2 ]. A National Health Insurance Corporation Study in Korea showed that injuries, including trauma, incurred the greatest socioeconomic costs, primarily driven by future income losses due to premature deaths [ 3 ]. This is attributed to trauma-related mortality occurring within a relatively younger age demographic compared to other disease groups [ 4 ]. In the Republic of Korea, trauma is the third leading cause of death and the leading cause of death among individuals younger than 45 years [ 5 ]. The preventable trauma death rate (PTDR) in South Korea decreased from 50.4% in 1999 to 39.6% in 2006 [ 5 , 6 ], prompting the Korean government to promote a government-led trauma centre project since 2010 [ 6 , 7 ]. Correct prehospital triage and direct transportation of severely injured patients to regional trauma centres by EMS providers are pivotal components of a regional trauma system [ 7 – 9 ]. However, accurate triage of patients with severe trauma in the prehospital setting remains challenging [ 10 – 13 ]. Therefore, to improve trauma triage, a regional trauma centre-led training program for EMS providers, remote medical guidance by experienced trauma staff, and new triage criteria for patients with trauma have been proposed [ 14 – 20 ]. However, EMS providers insufficiently informed about the Korean trauma centre, established since 2014, and there has been no specialised training for paramedics regarding the triage of patients with severe trauma or the selection of transfer hospitals. Therefore, a program that provides education and appropriate onsite medical guidance to EMS providers regarding field triage, treatment, and transport is necessary to ensure prompt transportation of patients with severe trauma to trauma centres. As our regional trauma centre has been implementing trauma hotline feedback and case-based education programs for EMS providers since 2016, this study aimed to analyse the effects of these programs on clinical outcomes. Methods Current status of study population and trauma medical resources in the region The Gyeonggi Province has an area of 10,187 km 2 , which is slightly smaller than that of San Diego County, USA (11,720 km 2 ; Figure 1), with a population of 14 million as of 2023, of which 10.38 million (74%) and 3.62 million (26%) live in the southern and northern Gyeonggi Province (5,910 km 2 and 4,265 km 2 ), respectively. The Gyeonggi Province has 57 emergency medical facilities, including five regional emergency medical centres and one trauma centre each in the southern and northern Gyeonggi Provinces. This trauma centre in the southern Gyeonggi Province is in a catchment area, is the only Level I trauma centre in the province, and is the final referral institution for patients with severe trauma (Figure 1). In 2021, 3100 people visited the Trauma Center of Southern Gyeonggi Province, of which 39% (n = 1200) had an Injury Severity Score (ISS) >15. We retrospectively reviewed the case data of all adult patients with trauma (age ≥ 19 years) with an ISS > 15 who were registered in the Korean Trauma Data Bank (KTDB) between March 2016 and February 2021 at the Southern Gyeonggi Trauma Center. Definition and analysis of undertriage Undertriage can be defined in several ways. Despite several limitations, in general, an ISS > 15 defines severely injured and undertriaged patients if trauma team activation was not performed [13]. Therefore, in this study, an ISS > 15 in the Gyeonggi Province constituted a severe injury, and if the patient was not directly transported to the trauma centre, the case was defined as undertriaged and analysed accordingly in this study. EMS provider education and feedback programs Since 2016, our regional trauma centre has provided remote medical guidance for EMS providers. Trauma surgeons implemented a 24-hour trauma hotline and remotely evaluated the mechanisms of injuries, vital signs, and treatment (MIVT) provided by EMS providers at the scene of the accident. Upon reviewing the provided information, the on-duty trauma surgeon determined whether to deploy the doctor helicopter, taking into account the transfer time. The surgeon also guided the approach for airway management and decided on the application of a cervical collar, the establishment of IV lines with fluid administration, the employment of additional hemostasis techniques, and the administration of pain management strategies. Immediately after transporting the patient, EMS providers can report triage, treatment, and transport to the trauma surgeon and trauma team leader and receive real-time feedback simultaneously. Through feedback programs, field triage, first aid, airway management, haemostasis, splinting, and trauma severity assessment are briefly taught, and errors are corrected immediately (Figure 2). Hotline-based guidance is increasing annually. In addition, the trauma centre is implementing a training program for EMS providers. The primary courses were field triage, patient transport, initial field management, case-based feedback and discussion, and hands-on procedures (Table 1). Education was conducted online or offline, depending on the circumstances. In addition, there are regular and ad hoc training programs for EMS providers. Covariates and Outcomes Data from the trauma database of the Southern Gyeonggi Province Trauma Center from 2016 to 2021 were analysed. The extracted data included basic demographics, the abbreviated injury scale (AIS), ISS, vital signs prehospital and on arrival at the hospital, mechanism of injury, comorbidities, transfusions, transport, admission route, and prehospital medical guidance. Patients with trauma whose dead-on-arrival (DOA) and ISS classifications could not be calculated, or those who visited a hospital outside the Gyeonggi Province, were excluded. The primary outcome was the undertriage rate, and the secondary outcomes were in-hospital mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, and duration of mechanical ventilation. Statistical analyses After the normality test using the Kolmogorov–Smirnov test, continuous variables were compared between the two groups using the Mann–Whitney U or Student’s t -test, and the data were presented as medians and interquartile ranges (IQRs). Categorical variations were analysed using the chi-squared or Fisher’s exact test. Trauma patients with an ISS > 15 who were injured in the Gyeonggi Province and who did or did not visit the trauma centre directly were included in an analysis after adjustment for severity and baseline demographics through propensity score matching (PSM) using logistic regression. A 1:1 nearest neighbour matching was performed without replacement with a calliper of 0.2. Absolute standardised mean differences were calculated to evaluate balance, and variables were considered appropriately balanced if < 0.25. For all statistical analyses, SPSS version 23.0 (IBM Corp., Armonk, NY, USA) was used, and for PSM, the MatchIt package for R software version 4.02 (R Foundation for Statistical Computing, Vienna, Austria, 2022) was used. Results were considered statistically significant at p < 0.05. Results From March 2016 to February 2022, 16,527 patients were registered with the KTDB in the southern Gyeonggi Province. A total of 7262 adult patients with trauma (age ≥ 19 years) visited the Southern Gyeonggi Trauma Center. After excluding those whose ISS could not be calculated and patients who were DOA, there were 6792 patients, of whom 3017 patients had an ISS > 15. The 2528 correctly triaged patients visited the trauma centre, whereas 489 undertriaged patients did not visit the centre (Figure 3). Prehospital medical guidance and feedback, which were conducted 432 times in 2016, increased to 1505 times in 2021. During the study period, 5500 prehospital medical guidance and feedback sessions were conducted (Figure 2) along with 43 education sessions, including regular and ad hoc programs and international trauma symposiums (Table 1). Undertriaged patients had a higher mean age (59.4 vs 50.6 years) and higher comorbidity rates (60.3% vs 42.7%, p < 0.001) (Table 2). In the undertriage group, the proportion of females was higher than that of males (31.5% vs 21.0%, p < 0.001), and the mean Glasgow Coma Scale (GCS) score was high (12.8 vs 11.9, p < 0.001). The mean ISS (24.8 vs 26.7, p < 0.001) of patients with undertriage was lower, and the blood product amount of all types of transfusions for 4 or 24 h after arrival at the hospital was lower than that of those with correct triage. There were no statistical differences between the two groups in terms of systolic blood pressure, pulse rate, or injury mechanisms. From 2016 to 2021, the undertriage rate decreased from 32.7% (n = 55/168) to 6.3% (n = 52/820) ( p < 0.001) (Figure 4). Primary and secondary outcomes To analyse the primary outcome (undertriage), PSM was performed to adjust for demographic variables and the trauma severity of the study population. Standardised mean differences were calculated to evaluate balance, and all variables were appropriately balanced (Figure 5). The in-hospital mortality in the adjusted cohort was 20% (n = 99) for undertriage vs 13% (n = 61) for correct triage (p = 0.001) (Table 3). The median (IQR) hospital LOS and ICU LOS ratio of undertriage compared to correct triage was 17 (8-37 days) vs 19 (12-36 days), p = 0.024 and 0.4 (0.2-1.0 days) vs 0.3 (0.2-0.6 days), p = 0.059. The duration of mechanical ventilation did not show a statistical difference (Table 3). Discussion This study showed that undertriage was associated with increased in-hospital mortality and hospital LOS. Moreover, there was a statistically significant difference between the increase in prehospital medical guidance and the decrease in the undertriage rate. Appropriate treatment at the right time and place is important to improve the survival rate of patients with severe trauma [ 21 ]. The American College of Surgeons Committee on Trauma (ACS-COT) recommends an undertriage rate target of 5% or less in regional trauma systems [ 21 , 22 ]. Although there may be differences by country or region, the subject of initial trauma triage is the EMS provider, which is the same in South Korea [ 4 , 23 ]. Therefore, undertriage is determined by hospital selection based on the initial triage by the EMS provider [ 23 ]. However, the triage of patients with trauma is difficult, and areas with well-developed trauma systems have high undertriage rates [ 11 , 13 ]. General physicians, including emergency physicians, report that triage accuracy is low if the experience with patients with severe trauma is insufficient [ 12 ]. Therefore, to reduce the undertriage of patients with severe trauma, various educational programs, medical guidance programs, mobile application developments, and revisions of the field triage scheme have been attempted for EMS providers, nurses, and physicians who perform field triage [ 14 – 20 , 24 – 26 ]. In this region, after the opening of a government-led designated trauma centre in 2016, a regional trauma centre-led program that educates and provides medical guidance to EMS providers was initiated. Trauma surgeons manned a 24-hour trauma hotline, remotely evaluated the MIVT provided by EMS providers at the scene of the accident, and provided medical advice on field triage, treatment, and transportation. Immediately after transporting the patient, EMS providers can report triage, treatment, and transport to the trauma surgeon and trauma team leader and receive feedback simultaneously. Prehospital medical guidance and feedback were conducted 432 times in 2016 and increased to 1505 times in 2021, and was conducted a total of 5541 times during the study period. The institutional undertriage rate decreased from 32.7% in 2016 to 6.3% in 2021. According to the ACS-COT, the criteria for distinguishing between level 1 and level 2 trauma centres are resources, trauma volume, and educational commitments [ 27 ]. Level I trauma centres maintain in-house availability of resuscitation, operative procedures, and critical care, in which attending trauma surgeons participate 24 hours a day, hospitalise more than 240 patients with trauma with ISSs ≥ 16 annually, and perform trauma education, training, and research. In implementing the regional trauma system, it is important to improve the ability of EMS providers to perform prehospital triage of patients with trauma [ 23 , 28 ]. The Korean Fire Agency partially supports the triage of patients with trauma and medical guidance by general or emergency physicians; however, the accuracy of triage by medical staff who do not have much experience with patients with severe trauma may not be high [ 12 ]. Chiu et al. reported that field triage training for EMS providers can improve triage accuracy; the authors have been operating a trauma education program for local EMS providers since 2017. We provided various educational programs based on cases of severe trauma triaged and treated by EMS providers. In all training sessions, the trauma hotline was introduced, and information was provided to communicate with the trauma surgeon 24 hours a day about field triage, medical guidance, and transport for patients suspected of severe trauma. Performance improvement programs based on the closed-loop principle have been widely adopted to improve trauma management quality [ 29 – 33 ]. Huh et al. reported improvements in in-hospital outcomes, such as the preventable trauma death rate after implementing the performance improvement and patient safety program based on the closed-loop principle at a new regional trauma centre [ 29 ]. Hietbrink et al. studied the Netherlands’ Trauma System and reported that the odds ratio for mortality in level I trauma centres decreased to 0.54 as the number of correct triage procedures increased [ 34 ]. To increase the correct triage rate, the EMS providers’ education and feedback program implemented by this regional trauma centre enables communication between regional trauma centres and EMS providers, according to the closed-loop principle. The undertriage rate decreased from 32.7% in 2016 to 6.3% in 2021, and the in-hospital mortality of the correct-triage group was 0.56 times that of the undertriage group. Our study had several limitations. First, because EMS providers move in and out of circulation frequently, it was not possible to identify the percentage of all EMS providers in the Gyeonggi Province who experienced training and feedback. Therefore, it was not possible to analyse the effects of education and feedback quantitatively. Second, in the southern Gyeonggi Province, the regional trauma system is still developing, and data sharing between the trauma centre and fire department is not being performed currently. Therefore, patients with severe trauma visiting our centre did not accurately represent the occurrence of severe trauma in the region, and those who did not visit our centre were not included in this study. Third, this study may have a selection bias owing to its nature of being a single-institution retrospective study. Therefore, a multicentre study is required to verify these results. However, since the establishment of the regional trauma centre, improvements in the PTDR and the development of the regional trauma system have been quantitatively confirmed [ 35 ]. Therefore, the authors believe that this study serves as evidence that the regional trauma centre-led performance improvement program contributed to the improvement of the undertriage rate and development of the regional trauma system. Lastly, the method of retrospectively evaluating triage accuracy based on the AIS and ISS at regional trauma centres may underestimate the actual severity because it does not reflect the physiological, anatomical, or mechanism of injury criteria of the field triage scheme proposed by the Center for Disease Control (CDC) and others [ 10 , 24 , 36 ]. However, for the convenience of trauma research and quality management of trauma treatment, the method of evaluating the accuracy of triage based on the ISS is widely adopted [ 10 , 26 , 37 ]. Conclusions In conclusion, we believe that the closed-loop communication program including prehospital hot-line medical guidance for EMS providers, which considers the maturity of the regional trauma system, contributed to an improvement in the undertriage rate. Specifically, trauma centre-led trauma hotline feedback and case-based education programs are suggested as models that can be helpful for pre-hospital patient triage and centralisation of patients with severe trauma to trauma centres in the early stages of the regional trauma system development. Abbreviations ACS-COT: The American College of Surgeons Committee on Trauma AIS: abbreviated injury scale CDC: Center for Disease Control DOA: dead-on arrival EMS: emergency medical service FFP: fresh frozen plasma GCS: Glasgow Coma Scale ICU: intensive care unit IQR: interquartile range ISS: Injury Severity Score KTDB: Korean Trauma Data Bank MIVT: mechanisms of injuries, vital signs, and treatment PR: pulse rate PRBC: packed red blood cells PSM: propensity score matching PTDR: preventable trauma death rate SBP: systolic blood pressure SD: standard deviation Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board (IRB) of Ajou University Hospital (IRB No. AJOUIRBDB-2023-322) and performed in accordance with the provisions of the Declaration of Helsinki. The need for obtaining informed consent was waived by IRB of Ajou University Hospital because of the observational nature of the study. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Not applicable Authors’ contributions DC and HJ conceived the study and designed the trial. DC, YH, BH, and KJ contributed to article search, data extraction, and quality assessment of studies. SK, SS supervised data collection and management. DC performed data analyses and manuscript writing. HJ reviewed the article independently and made minor revisions after consultation with DC. All the authors read and gave the final approval of the version to be submitted and contributed substantially to its revision. The manuscript, including related data, figures, and tables, has not been previously published. All authors read and approved the final manuscript. Acknowledgements We would like to thank Editage (www.editage.co.kr) for editing and reviewing this manuscript for English language. Autho r details 1 Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea, 2 Regional Trauma Center of Southern Gyeonggi Province, Ajou University School of Medicine, Suwon, Republic of Korea References Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. lancet. 2012;380(9859):2095–128. Lashoher A, Schneider EB, Juillard C, et al. Implementation of the World Health Organization Trauma Care Checklist Program in 11 centers across multiple economic strata: effect on care process measures. World J Surg. 2017;41:954–62. Hyun K, Lee S, Choi K, Lee S, Kim J. An analysis of socioeconomic costs of major diseases for prioritization on health security policy. 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Regional trauma center-led performance improvement programs for EMS providers Program types Year Number of sessions Number of participants Prehospital medical direction and feedback program 2016–2021 5541* 11082** Regular education program -Annual International Trauma Conference 2016–2021 5 -Regional EMS provider education program 2017–2021 25 786 Non regular education program -119 EMS provider education in the regional fire service academy (lecture) 2017 1 -Heli-EMS education course (lecture) 2018, 2019 2 -Conference for the establishment of a regional trauma system with the National Fire Agency (discussion, case review) 2021 1 -Fire Agency Cooperation Conference 2018 2 61 -EMS provider course for infants and toddler (lecture) 2019 1 -Field triage and treatment course of emergency patients (lecture, hands on practice) 2021 2 76 -Training course of standard field skill guideline for EMS provider (lecture, case discussion) 2021 1 -Trauma Saver Judge 2019-2021 3 *A total of 5541 direct admissions and feedback through the trauma bay were received after prehospital hotline calls. **EMS dispatch comprises a team of at least 2–3 EMS providers. Table 2. General characteristics of the study population and propensity score matched population Original population p Adjusted population p Correct_triage Undertriage Correct_triage Undertriage (n=2528) (n=489) (n=484) (n=484) Age, years 50.6 ± 17.0 59.4 ± 17.7 < 0.001 58.7 ± 17.9 59.2 ± 17.5 0.682 19–64 1993 (78.8 %) 297 (60.7 %) < 0.001 298 (61.6 %) 297 (61.4 %) 1.000 64 535 (21.2 %) 192 (39.3 %) < 0.001 186 (38.4 %) 187 (38.6 %) 1.000 Sex < 0.001 0.449 Male 1997 (79.0 %) 335 (68.5 %) 323 (66.7 %) 335 (69.2 %) Female 531 (21.0 %) 154 (31.5 %) 161 (33.3 %) 149 (30.8 %) Comorbidity 1079 (42.7 %) 295 (60.3 %) < 0.001 248 (51.2 %) 290 (59.9 %) 0.008 ISS 26.7 ± 10.0 24.8 ± 9.8 < 0.001 25.4 ± 9.3 24.9 ± 9.8 0.427 16–30 1860 (73.6 %) 412 (84.3 %) < 0.001 377 (77.9 %) 407 (84.1 %) 0.018 30 668 (26.4 %) 77 (15.7 %) < 0.001 107 (22.1 %) 77 (15.9 %) 0.018 Injury mechanism 0.209 1.000 Blunt 2434 (96.3 %) 477 (97.5 %) 473 (97.7 %) 472 (97.5 %) Penetrating 94 (3.7 %) 12 (2.5 %) 11 (2.3 %) 12 (2.5 %) Hospital value on arrival AVPU scale < 0.001 < 0.001 - Alert 1127 (44.6 %) 239 (48.9 %) 208 (43.0 %) 235 (48.6 %) - Verbal response 615 (24.3 %) 76 (15.5 %) 134 (27.7 %) 76 (15.7 %) - Painful response 507 (20.1 %) 99 (20.2 %) 102 (21.1 %) 99 (20.5 %) - Unresponsive 279 (11.0 %) 75 (15.3 %) 40 (8.3 %) 74 (15.3 %) SBP (mmHg) 134.7 ± 29.0 135.7 ± 33.4 0.6 136.4 ± 28.1 135.6 ± 33.3 0.722 PR (min -1 ) 90.8 ± 22.2 89.1 ± 21.0 0.15 88.3 ± 21.8 89.1 ± 21.0 0.587 GCS 11.9 ± 4.1 12.8 ± 3.4 < 0.001 12.1 ± 3.8 12.8 ± 3.4 0.006 Transfusion (unit) PRBC_4h 2.6 ± 5.6 1.7 ± 4.1 < 0.001 2.2 ± 4.7 1.7 ± 4.2 0.083 FFP_4h 1.8 ± 4.3 1.1 ± 3.1 < 0.001 1.4 ± 3.6 1.1 ± 3.1 0.159 Platlet_4h 0.2 ± 1.2 0.2 ± 1.2 0.361 0.2 ± 1.5 0.2 ± 1.1 0.885 PRBC_24h 4.0 ± 8.4 2.6 ± 5.7 < 0.001 3.7 ± 7.0 2.6 ± 5.7 0.013 FFP_24h 3.4 ± 7.7 2.5 ± 5.5 0.001 3.1 ± 6.8 2.5 ± 5.5 0.132 Platlet_24h 1.3 ± 3.9 1.2 ± 3.8 0.76 1.5 ± 3.9 1.2 ± 3.8 0.315 ISS, Injury Severity Score; SBP, systolic blood pressure; PR, pulse rate; GCS, Glasgow Coma Scale; PRBC, packed red blood cells; FFP, fresh frozen plasma Table 3. Inhospital outcomes of correct triage vs undertriage Original population Post PSM population Correct_triage Undertriage p Correct_triage Undertriage p (n=2528) (n=489) (n=484) (n=484) Hospital LOS, day 18 [11-35] 17 [8-36] 0.023 19 [12-36] 17 [8-37] 0.024 ICU_LOS, day 5 [3-12] 5 [2-15] 0.856 5 [3-11] 5 [2-16] 0.811 ICU_day ratio 0.3 [0.2-0.6] 0.4 [0.2-1.0] 0.030 0.3 [0.2-0.6] 0.4 [0.2-1.0] 0.059 MV_duration, day 1 [0-6] 1 [0-8] 0.459 1 [0-5] 1 [0-8] 0.190 Inhospital death (%) 329 (13%) 100 (20%) 0.000 61 (13%) 99 (20%) 0.001 PSM, propensity score matching; LOS, length of stay; MV, mechanical ventilator Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Reject, do not transfer 22 Sep, 2024 Reviewers agreed at journal 15 Aug, 2024 Reviewers invited by journal 07 Jun, 2024 Editor assigned by journal 23 May, 2024 First submitted to journal 21 May, 2024 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. 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Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yo","middleName":"","lastName":"Huh","suffix":""},{"id":311726464,"identity":"e9596a32-f53d-4323-b3ca-11863ac25c14","order_by":2,"name":"Byung Hee Kang","email":"","orcid":"","institution":"Ajou University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Byung","middleName":"Hee","lastName":"Kang","suffix":""},{"id":311726465,"identity":"37c08f24-3582-42e4-8cd9-c1dcc3d150c1","order_by":3,"name":"Sora Kim","email":"","orcid":"","institution":"Ajou University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sora","middleName":"","lastName":"Kim","suffix":""},{"id":311726466,"identity":"1bb269cd-0155-4736-89cd-e5c70b4eddf3","order_by":4,"name":"Seoyoung Song","email":"","orcid":"","institution":"Ajou University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Seoyoung","middleName":"","lastName":"Song","suffix":""},{"id":311726467,"identity":"580f6964-c719-460b-916c-a2ada3976f2d","order_by":5,"name":"Kyoungwon Jung","email":"","orcid":"","institution":"Ajou University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Kyoungwon","middleName":"","lastName":"Jung","suffix":""},{"id":311726468,"identity":"f1db083f-278b-4280-8a3d-db1a0ca52fe9","order_by":6,"name":"Hohyung Jung","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYBACxhk8jA8SKmzk+EG8hALitDAbPDiTZizZANJiQIw1Ejxskg/bDiduOADiEaOFeXbvAYkENmZj4/OrEz88MGCQ5xc7QMBhc84lGCTwsMmZ3Xi7WQLoMMOZsxMIaJmRY5CQIMFjbHbj7AaQlgSD20RoOZBgIJG4ecbZzT+I1WLYkJBgkLiBv3cb0bYYMyQcSDCWuMG7zQJoHWG/GM7IMf/5899/Of7+s5tv/qiwkeeXJqSlAcaSAKuUwK8cBOThLP4DhFWPglEwCkbByAQAWL9HvKwkO6sAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-5536-5483","institution":"Ajou University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Hohyung","middleName":"","lastName":"Jung","suffix":""}],"badges":[],"createdAt":"2024-05-19 06:06:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4443129/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4443129/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59138468,"identity":"e1216fda-2c00-4d56-89bf-56c47374fc0b","added_by":"auto","created_at":"2024-06-26 19:08:26","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":342316,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of the southern Gyeonggi province in the Republic of Korea\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4443129/v1/0e42671084944de1b66cea5a.jpeg"},{"id":59139346,"identity":"36f6321f-da98-49d1-8f13-c09137ab93a9","added_by":"auto","created_at":"2024-06-26 19:16:26","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":439462,"visible":true,"origin":"","legend":"\u003cp\u003eClosed loop model of the regional trauma centre-led performance improvement program for EMS providers\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4443129/v1/67f8a15f74b3530e42cc3e5a.jpeg"},{"id":59139347,"identity":"d94cccc6-7287-4dfc-ab9e-e404501fa71a","added_by":"auto","created_at":"2024-06-26 19:16:26","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":359729,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart depicting the study process\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4443129/v1/b69a031e09cd20f0100d3aca.jpeg"},{"id":59138470,"identity":"f849754e-2458-4710-93d4-874b47f06ac2","added_by":"auto","created_at":"2024-06-26 19:08:26","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":256025,"visible":true,"origin":"","legend":"\u003cp\u003eAnnual changes of triage and in-hospital mortality rates\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4443129/v1/037aa0cf10cbfe1ece7acf50.jpeg"},{"id":59138473,"identity":"9851a56c-32f3-447e-b647-9678cc2867d8","added_by":"auto","created_at":"2024-06-26 19:08:26","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":374544,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in the standardised mean differences from before and after the adjustment of covariates\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4443129/v1/34242188ee95fce9bf208266.jpeg"},{"id":59139631,"identity":"8682bdda-5f46-4d89-8c95-65f083da4120","added_by":"auto","created_at":"2024-06-26 19:24:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2516102,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4443129/v1/cfcd80fa-9350-457b-8773-f1f4706a35f3.pdf"}],"financialInterests":"","formattedTitle":"Right patient to the right place: The impact of a 6-year regional trauma centre-led prehospital education program on EMS triage and patient outcomes","fulltext":[{"header":"Background","content":"\u003cp\u003eTrauma is a leading cause of morbidity and mortality worldwide, underscoring the critical role of efficient emergency medical services (EMS) in prehospital triage and the swift management of severely injured patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A National Health Insurance Corporation Study in Korea showed that injuries, including trauma, incurred the greatest socioeconomic costs, primarily driven by future income losses due to premature deaths [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This is attributed to trauma-related mortality occurring within a relatively younger age demographic compared to other disease groups [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In the Republic of Korea, trauma is the third leading cause of death and the leading cause of death among individuals younger than 45 years [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The preventable trauma death rate (PTDR) in South Korea decreased from 50.4% in 1999 to 39.6% in 2006 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], prompting the Korean government to promote a government-led trauma centre project since 2010 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCorrect prehospital triage and direct transportation of severely injured patients to regional trauma centres by EMS providers are pivotal components of a regional trauma system [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, accurate triage of patients with severe trauma in the prehospital setting remains challenging [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Therefore, to improve trauma triage, a regional trauma centre-led training program for EMS providers, remote medical guidance by experienced trauma staff, and new triage criteria for patients with trauma have been proposed [\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, EMS providers insufficiently informed about the Korean trauma centre, established since 2014, and there has been no specialised training for paramedics regarding the triage of patients with severe trauma or the selection of transfer hospitals. Therefore, a program that provides education and appropriate onsite medical guidance to EMS providers regarding field triage, treatment, and transport is necessary to ensure prompt transportation of patients with severe trauma to trauma centres. As our regional trauma centre has been implementing trauma hotline feedback and case-based education programs for EMS providers since 2016, this study aimed to analyse the effects of these programs on clinical outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCurrent status of study population and trauma medical resources in the region\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Gyeonggi Province has an area of 10,187 km\u003csup\u003e2\u003c/sup\u003e, which is slightly smaller than that of San Diego County, USA (11,720 km\u003csup\u003e2\u003c/sup\u003e; Figure 1), with a population of 14 million as of 2023, of which 10.38 million (74%) and 3.62 million (26%) live in the southern and northern Gyeonggi Province (5,910 km\u003csup\u003e2\u003c/sup\u003e and 4,265 km\u003csup\u003e2\u003c/sup\u003e), respectively. The Gyeonggi Province has 57 emergency medical facilities, including five regional emergency medical centres and one trauma centre each in the southern and northern Gyeonggi Provinces. This trauma centre in the southern Gyeonggi Province is in a catchment area, is the only Level I trauma centre in the province, and is the final referral institution for patients with severe trauma (Figure 1). In 2021, 3100 people visited the Trauma Center of Southern Gyeonggi Province, of which 39% (n = 1200) had an Injury Severity Score (ISS) \u0026gt;15. We retrospectively reviewed the case data of all adult patients with trauma (age \u0026ge; 19 years) with an ISS \u0026gt; 15 who were registered in the Korean Trauma Data Bank (KTDB) between March 2016 and February 2021 at the Southern Gyeonggi Trauma Center.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;kindly insert Figure 1 here\u0026gt;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDefinition and analysis of undertriage\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUndertriage can be defined in several ways. Despite several limitations, in general, an ISS \u0026gt; 15 defines severely injured and undertriaged patients if trauma team activation was not performed [13]. Therefore, in this study, an ISS \u0026gt; 15 in the Gyeonggi Province constituted a severe injury, and if the patient was not directly transported to the trauma centre, the case was defined as undertriaged and analysed accordingly in this study.\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEMS provider education and feedback programs\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSince 2016, our regional trauma centre has provided remote medical guidance for EMS providers. Trauma surgeons implemented a 24-hour trauma hotline and remotely evaluated the mechanisms of injuries, vital signs, and treatment (MIVT) provided by EMS providers at the scene of the accident. Upon reviewing the provided information, the on-duty trauma surgeon determined whether to deploy the doctor helicopter, taking into account the transfer time. The surgeon also guided the approach for airway management and decided on the application of a cervical collar, the establishment of IV lines with fluid administration, the employment of additional hemostasis techniques, and the administration of pain management strategies. Immediately after transporting the patient, EMS providers can report triage, treatment, and transport to the trauma surgeon and trauma team leader and receive real-time feedback simultaneously. Through feedback programs, field triage, first aid, airway management, haemostasis, splinting, and trauma severity assessment are briefly taught, and errors are corrected immediately (Figure 2). Hotline-based guidance is increasing annually. In addition, the trauma centre is implementing a training program for EMS providers. The primary courses were field triage, patient transport, initial field management, case-based feedback and discussion, and hands-on procedures (Table 1). Education was conducted online or offline, depending on the circumstances. In addition, there are regular and ad hoc training programs for EMS providers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;kindly insert Table 1 here\u0026gt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;kindly insert Figure 1 here\u0026gt;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCovariates and Outcomes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from the trauma database of the Southern Gyeonggi Province Trauma Center from 2016 to 2021 were analysed. The extracted data included basic demographics, the abbreviated injury scale (AIS), ISS, vital signs prehospital and on arrival at the hospital, mechanism of injury, comorbidities, transfusions, transport, admission route, and prehospital medical guidance. Patients with trauma whose dead-on-arrival (DOA) and ISS classifications could not be calculated, or those who visited a hospital outside the Gyeonggi Province, were excluded. The primary outcome was the undertriage rate, and the secondary outcomes were in-hospital mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, and duration of mechanical ventilation.\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStatistical\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eanalyses\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter the normality test using the Kolmogorov\u0026ndash;Smirnov test, continuous variables were compared between the two groups using the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e or Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-test, and the data were presented as medians and interquartile ranges (IQRs). Categorical variations were analysed using the chi-squared or Fisher\u0026rsquo;s exact test. Trauma patients with an ISS \u0026gt; 15 who were injured in the Gyeonggi Province and who did or did not visit the trauma centre directly were included in an analysis after adjustment for severity and baseline demographics through propensity score matching (PSM) using logistic regression. A 1:1 nearest neighbour matching was performed without replacement with a calliper of 0.2. Absolute standardised mean differences were calculated to evaluate balance, and variables were considered appropriately balanced if \u0026lt; 0.25. For all statistical analyses, SPSS version 23.0 (IBM Corp., Armonk, NY, USA) was used, and for PSM, the MatchIt package for R software version 4.02 (R Foundation for Statistical Computing, Vienna, Austria, 2022) was used. Results were considered statistically significant at \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFrom March 2016 to February 2022, 16,527 patients were registered with the KTDB in the\u0026nbsp;southern\u0026nbsp;Gyeonggi Province. A total of 7262 adult patients with trauma (age \u0026ge; 19 years) visited the\u0026nbsp;Southern\u0026nbsp;Gyeonggi Trauma Center. After excluding those whose ISS could not be calculated and patients who\u0026nbsp;were DOA, there were 6792 patients, of whom 3017 patients had an ISS \u0026gt; 15. The 2528 correctly triaged patients visited the trauma centre, whereas 489 undertriaged patients did not visit the centre (Figure 3). Prehospital medical guidance and feedback, which were conducted 432 times in 2016, increased to 1505 times in 2021. During the study period, 5500 prehospital medical guidance and feedback sessions were conducted (Figure 2)\u0026nbsp;along with\u0026nbsp;43 education sessions, including regular and ad hoc programs and international trauma symposiums (Table 1).\u003c/p\u003e\n\u003cp\u003eUndertriaged patients had a higher mean age (59.4 vs 50.6 years) and higher comorbidity rates (60.3% vs 42.7%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) (Table 2). In the undertriage group, the proportion of females was higher than that of males (31.5% vs 21.0%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), and the mean Glasgow Coma Scale (GCS) score was high (12.8 vs 11.9, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). The mean ISS (24.8 vs 26.7, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) of patients with undertriage was lower, and the blood product amount of all types of transfusions for 4 or 24 h after arrival at the hospital was lower than that of those with correct triage. There were no statistical differences between the two groups in terms of systolic blood pressure, pulse rate, or injury mechanisms. From 2016 to 2021, the undertriage rate decreased from 32.7% (n = 55/168) to 6.3% (n = 52/820) (\u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001) (Figure 4). \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;kindly insert Figure 3 here\u0026gt;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;kindly insert Table 2 here\u0026gt;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;kindly insert Figure 4 here\u0026gt;\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePrimary and secondary outcomes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo analyse the primary outcome (undertriage), PSM was performed to adjust for demographic variables and the trauma severity of the study population. Standardised mean differences were calculated to evaluate balance, and all variables were appropriately balanced (Figure 5). The in-hospital mortality in the adjusted cohort was 20% (n = 99) for undertriage vs 13% (n = 61) for correct triage (p = 0.001) (Table 3). The median (IQR) hospital LOS and ICU LOS ratio of undertriage compared to correct triage was 17 (8-37 days) vs 19 (12-36 days), p = 0.024 and 0.4 (0.2-1.0 days) vs 0.3 (0.2-0.6 days), p = 0.059. The duration of mechanical ventilation did not show a statistical difference (Table 3).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;kindly insert Figure 5 here\u0026gt;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study showed that undertriage was associated with increased in-hospital mortality and hospital LOS. Moreover, there was a statistically significant difference between the increase in prehospital medical guidance and the decrease in the undertriage rate.\u003c/p\u003e \u003cp\u003eAppropriate treatment at the right time and place is important to improve the survival rate of patients with severe trauma [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The American College of Surgeons Committee on Trauma (ACS-COT) recommends an undertriage rate target of 5% or less in regional trauma systems [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Although there may be differences by country or region, the subject of initial trauma triage is the EMS provider, which is the same in South Korea [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Therefore, undertriage is determined by hospital selection based on the initial triage by the EMS provider [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. However, the triage of patients with trauma is difficult, and areas with well-developed trauma systems have high undertriage rates [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. General physicians, including emergency physicians, report that triage accuracy is low if the experience with patients with severe trauma is insufficient [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Therefore, to reduce the undertriage of patients with severe trauma, various educational programs, medical guidance programs, mobile application developments, and revisions of the field triage scheme have been attempted for EMS providers, nurses, and physicians who perform field triage [\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In this region, after the opening of a government-led designated trauma centre in 2016, a regional trauma centre-led program that educates and provides medical guidance to EMS providers was initiated. Trauma surgeons manned a 24-hour trauma hotline, remotely evaluated the MIVT provided by EMS providers at the scene of the accident, and provided medical advice on field triage, treatment, and transportation. Immediately after transporting the patient, EMS providers can report triage, treatment, and transport to the trauma surgeon and trauma team leader and receive feedback simultaneously. Prehospital medical guidance and feedback were conducted 432 times in 2016 and increased to 1505 times in 2021, and was conducted a total of 5541 times during the study period. The institutional undertriage rate decreased from 32.7% in 2016 to 6.3% in 2021.\u003c/p\u003e \u003cp\u003eAccording to the ACS-COT, the criteria for distinguishing between level 1 and level 2 trauma centres are resources, trauma volume, and educational commitments [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Level I trauma centres maintain in-house availability of resuscitation, operative procedures, and critical care, in which attending trauma surgeons participate 24 hours a day, hospitalise more than 240 patients with trauma with ISSs\u0026thinsp;\u0026ge;\u0026thinsp;16 annually, and perform trauma education, training, and research. In implementing the regional trauma system, it is important to improve the ability of EMS providers to perform prehospital triage of patients with trauma [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The Korean Fire Agency partially supports the triage of patients with trauma and medical guidance by general or emergency physicians; however, the accuracy of triage by medical staff who do not have much experience with patients with severe trauma may not be high [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Chiu et al. reported that field triage training for EMS providers can improve triage accuracy; the authors have been operating a trauma education program for local EMS providers since 2017. We provided various educational programs based on cases of severe trauma triaged and treated by EMS providers. In all training sessions, the trauma hotline was introduced, and information was provided to communicate with the trauma surgeon 24 hours a day about field triage, medical guidance, and transport for patients suspected of severe trauma.\u003c/p\u003e \u003cp\u003ePerformance improvement programs based on the closed-loop principle have been widely adopted to improve trauma management quality [\u003cspan additionalcitationids=\"CR30 CR31 CR32\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Huh et al. reported improvements in in-hospital outcomes, such as the preventable trauma death rate after implementing the performance improvement and patient safety program based on the closed-loop principle at a new regional trauma centre [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Hietbrink et al. studied the Netherlands\u0026rsquo; Trauma System and reported that the odds ratio for mortality in level I trauma centres decreased to 0.54 as the number of correct triage procedures increased [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. To increase the correct triage rate, the EMS providers\u0026rsquo; education and feedback program implemented by this regional trauma centre enables communication between regional trauma centres and EMS providers, according to the closed-loop principle. The undertriage rate decreased from 32.7% in 2016 to 6.3% in 2021, and the in-hospital mortality of the correct-triage group was 0.56 times that of the undertriage group.\u003c/p\u003e \u003cp\u003eOur study had several limitations. First, because EMS providers move in and out of circulation frequently, it was not possible to identify the percentage of all EMS providers in the Gyeonggi Province who experienced training and feedback. Therefore, it was not possible to analyse the effects of education and feedback quantitatively. Second, in the southern Gyeonggi Province, the regional trauma system is still developing, and data sharing between the trauma centre and fire department is not being performed currently. Therefore, patients with severe trauma visiting our centre did not accurately represent the occurrence of severe trauma in the region, and those who did not visit our centre were not included in this study. Third, this study may have a selection bias owing to its nature of being a single-institution retrospective study. Therefore, a multicentre study is required to verify these results. However, since the establishment of the regional trauma centre, improvements in the PTDR and the development of the regional trauma system have been quantitatively confirmed [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Therefore, the authors believe that this study serves as evidence that the regional trauma centre-led performance improvement program contributed to the improvement of the undertriage rate and development of the regional trauma system. Lastly, the method of retrospectively evaluating triage accuracy based on the AIS and ISS at regional trauma centres may underestimate the actual severity because it does not reflect the physiological, anatomical, or mechanism of injury criteria of the field triage scheme proposed by the Center for Disease Control (CDC) and others [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. However, for the convenience of trauma research and quality management of trauma treatment, the method of evaluating the accuracy of triage based on the ISS is widely adopted [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, we believe that the closed-loop communication program including prehospital hot-line medical guidance for EMS providers, which considers the maturity of the regional trauma system, contributed to an improvement in the undertriage rate. Specifically, trauma centre-led trauma hotline feedback and case-based education programs are suggested as models that can be helpful for pre-hospital patient triage and centralisation of patients with severe trauma to trauma centres in the early stages of the regional trauma system development.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACS-COT: The American College of Surgeons Committee on Trauma\u003c/p\u003e\n\u003cp\u003eAIS: abbreviated injury scale\u003c/p\u003e\n\u003cp\u003eCDC: Center for Disease Control\u003c/p\u003e\n\u003cp\u003eDOA: dead-on arrival\u003c/p\u003e\n\u003cp\u003eEMS: emergency medical service\u003c/p\u003e\n\u003cp\u003eFFP: fresh frozen plasma\u003c/p\u003e\n\u003cp\u003eGCS: Glasgow Coma Scale\u003c/p\u003e\n\u003cp\u003eICU: intensive care unit\u003c/p\u003e\n\u003cp\u003eIQR: interquartile range\u003c/p\u003e\n\u003cp\u003eISS: Injury Severity Score\u003c/p\u003e\n\u003cp\u003eKTDB: Korean Trauma Data Bank\u003c/p\u003e\n\u003cp\u003eMIVT: mechanisms of injuries, vital signs, and treatment\u003c/p\u003e\n\u003cp\u003ePR: pulse rate\u003c/p\u003e\n\u003cp\u003ePRBC: packed red blood cells\u003c/p\u003e\n\u003cp\u003ePSM: propensity score matching\u003c/p\u003e\n\u003cp\u003ePTDR: preventable trauma death rate\u003c/p\u003e\n\u003cp\u003eSBP: systolic blood pressure\u003c/p\u003e\n\u003cp\u003eSD: standard deviation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board (IRB) of Ajou University Hospital (IRB No. AJOUIRBDB-2023-322) and performed in accordance with the provisions of the Declaration of Helsinki. The need for obtaining informed consent was waived by IRB of Ajou University Hospital because of the observational nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDC and HJ conceived the study and designed the trial. DC, YH, BH, and KJ contributed to article search, data extraction, and quality assessment of studies. SK, SS supervised data collection and management. DC performed data analyses and manuscript writing. HJ reviewed the article independently and made minor revisions after consultation with DC. All the authors read and gave the final approval of the version to be submitted and contributed substantially to its revision. The manuscript, including related data, figures, and tables, has not been previously published. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Editage (www.editage.co.kr)\u0026nbsp;for editing and reviewing this manuscript for English language.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAutho\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003er\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003edetails\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDivision\u0026nbsp;of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Republic of Korea,\u0026nbsp;\u003csup\u003e2\u003c/sup\u003eRegional Trauma Center of Southern Gyeonggi Province, Ajou University School of Medicine, Suwon, Republic of Korea\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLozano R, Naghavi M, Foreman K, et al. 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J Surg Res. 2022;279:474\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHietbrink F, Houwert RM, van Wessem KJP, et al. The evolution of trauma care in the Netherlands over 20 years. Eur J Trauma Emerg Surg. 2020;46(2):329\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwon J, Lee J-H, Hwang K et al. Systematic preventable trauma death rate survey to establish the region-based inclusive trauma system in a representative province of Korea. J Korean Med Sci 2020; 35(50).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGage AM, Traven N, Rivara FP, Jurkovich GJ, Arbabi S. Compliance with Centers for Disease Control and Prevention field triage guidelines in an established trauma system. J Am Coll Surg. 2012;215(1):148\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaalwijk JF, Lokerman RD, Van Der Sluijs R et al. The influence of inter-hospital transfers on mortality in severely injured patients. Eur J Trauma Emerg Surg 2022.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eRegional trauma center-led performance improvement programs for EMS providers\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"699\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.36480686695279%\"\u003e\n \u003cp\u003e\u003cstrong\u003eProgram types\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.447782546494993%\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.590844062947067%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of sessions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.59656652360515%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.36480686695279%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrehospital medical direction and feedback program\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.447782546494993%\"\u003e\n \u003cp\u003e2016\u0026ndash;2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.590844062947067%\"\u003e\n \u003cp\u003e5541*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.59656652360515%\"\u003e\n \u003cp\u003e11082**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.36480686695279%\"\u003e\n \u003cp\u003e\u003cstrong\u003eRegular education program\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.447782546494993%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.590844062947067%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.59656652360515%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.36480686695279%\"\u003e\n \u003cp\u003e-Annual International Trauma Conference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.447782546494993%\"\u003e\n \u003cp\u003e2016\u0026ndash;2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.590844062947067%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.59656652360515%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.36480686695279%\"\u003e\n \u003cp\u003e-Regional EMS provider education program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.447782546494993%\"\u003e\n \u003cp\u003e2017\u0026ndash;2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.590844062947067%\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.59656652360515%\"\u003e\n \u003cp\u003e786\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.36480686695279%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon regular education program\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.447782546494993%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.590844062947067%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.59656652360515%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.36480686695279%\"\u003e\n \u003cp\u003e-119 EMS provider education in the regional fire service academy (lecture)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.447782546494993%\"\u003e\n \u003cp\u003e2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.590844062947067%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.59656652360515%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.36480686695279%\"\u003e\n \u003cp\u003e-Heli-EMS education course (lecture)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.447782546494993%\"\u003e\n \u003cp\u003e2018, 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.590844062947067%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.59656652360515%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.36480686695279%\"\u003e\n \u003cp\u003e-Conference for the establishment of a regional trauma system with the National Fire Agency (discussion, case review)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.447782546494993%\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.590844062947067%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.59656652360515%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.36480686695279%\"\u003e\n \u003cp\u003e-Fire Agency Cooperation Conference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.447782546494993%\"\u003e\n \u003cp\u003e2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.590844062947067%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.59656652360515%\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.36480686695279%\"\u003e\n \u003cp\u003e-EMS provider course for infants and toddler (lecture)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.447782546494993%\"\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.590844062947067%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.59656652360515%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.36480686695279%\"\u003e\n \u003cp\u003e-Field triage and treatment course of emergency patients (lecture, hands on practice)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.447782546494993%\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.590844062947067%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.59656652360515%\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.36480686695279%\"\u003e\n \u003cp\u003e-Training course of standard field skill guideline for EMS provider (lecture, case discussion)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.447782546494993%\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.590844062947067%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.59656652360515%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.36480686695279%\"\u003e\n \u003cp\u003e-Trauma Saver Judge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.447782546494993%\"\u003e\n \u003cp\u003e2019-2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.590844062947067%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.59656652360515%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*A total of 5541 direct admissions and feedback through\u0026nbsp;the trauma bay were received after prehospital hotline calls.\u003c/p\u003e\n\u003cp\u003e**EMS dispatch comprises a team of at least 2\u0026ndash;3 EMS providers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e General characteristics of the study population and propensity score matched population\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"709\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.005657708628007%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eOriginal population\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.005657708628007%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted population\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.60511882998172%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.012797074954296%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCorrect_triage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.184643510054844%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUndertriage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.012797074954296%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCorrect_triage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.184643510054844%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUndertriage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.60511882998172%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.012797074954296%\"\u003e\n \u003cp\u003e\u003cstrong\u003e(n=2528)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.184643510054844%\"\u003e\n \u003cp\u003e\u003cstrong\u003e(n=489)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.012797074954296%\"\u003e\n \u003cp\u003e\u003cstrong\u003e(n=484)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.184643510054844%\"\u003e\n \u003cp\u003e\u003cstrong\u003e(n=484)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e50.6 \u0026plusmn; 17.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e59.4 \u0026plusmn; 17.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e58.7 \u0026plusmn; 17.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e59.2 \u0026plusmn; 17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.682\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003e19\u0026ndash;64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e1993 (78.8 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e297 (60.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e298 (61.6 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e297 (61.4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cul\u003e\n \u003cli\u003e64\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e535 (21.2 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e192 (39.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e186 (38.4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e187 (38.6 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.449\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e1997 (79.0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e335 (68.5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e323 (66.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e335 (69.2 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e531 (21.0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e154 (31.5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e161 (33.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e149 (30.8 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidity \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e1079 (42.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e295 (60.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e248 (51.2 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e290 (59.9 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003e\u003cstrong\u003eISS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e26.7 \u0026plusmn; 10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e24.8 \u0026plusmn; 9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e25.4 \u0026plusmn; 9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e24.9 \u0026plusmn; 9.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.427\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003e16\u0026ndash;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e1860 (73.6 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e412 (84.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e377 (77.9 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e407 (84.1 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cul\u003e\n \u003cli\u003e30\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e668 (26.4 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e77 (15.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e107 (22.1 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e77 (15.9 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003e\u003cstrong\u003eInjury mechanism\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e0.209\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003eBlunt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e2434 (96.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e477 (97.5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e473 (97.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e472 (97.5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003ePenetrating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e94 (3.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e12 (2.5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e11 (2.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e12 (2.5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital value on arrival\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003eAVPU scale \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;- Alert \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e1127 (44.6 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e239 (48.9 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e208 (43.0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e235 (48.6 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;- Verbal response \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e615 (24.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e76 (15.5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e134 (27.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e76 (15.7 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;- Painful response\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e507 (20.1 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e99 (20.2 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e102 (21.1 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e99 (20.5 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;- Unresponsive \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e279 (11.0 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e75 (15.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e40 (8.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e74 (15.3 %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003eSBP (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e134.7 \u0026plusmn; 29.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e135.7 \u0026plusmn; 33.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e136.4 \u0026plusmn; 28.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e135.6 \u0026plusmn; 33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.722\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003ePR (min\u003csup\u003e-1\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e90.8 \u0026plusmn; 22.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e89.1 \u0026plusmn; 21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e88.3 \u0026plusmn; 21.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e89.1 \u0026plusmn; 21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.587\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003eGCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e11.9 \u0026plusmn; 4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e12.8 \u0026plusmn; 3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e12.1 \u0026plusmn; 3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e12.8 \u0026plusmn; 3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTransfusion (unit)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003ePRBC_4h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e\u0026nbsp;2.6 \u0026plusmn; 5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e\u0026nbsp;1.7 \u0026plusmn; 4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e\u0026nbsp;2.2 \u0026plusmn; 4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e\u0026nbsp;1.7 \u0026plusmn; 4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003eFFP_4h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e\u0026nbsp;1.8 \u0026plusmn; 4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e\u0026nbsp;1.1 \u0026plusmn; 3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e\u0026nbsp;1.4 \u0026plusmn; 3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e\u0026nbsp;1.1 \u0026plusmn; 3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.159\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003ePlatlet_4h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e\u0026nbsp;0.2 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e\u0026nbsp;0.2 \u0026plusmn; 1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e0.361\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e\u0026nbsp;0.2 \u0026plusmn; 1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e\u0026nbsp;0.2 \u0026plusmn; 1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.885\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003ePRBC_24h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e\u0026nbsp;4.0 \u0026plusmn; 8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e\u0026nbsp;2.6 \u0026plusmn; 5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e\u0026nbsp;3.7 \u0026plusmn; 7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e\u0026nbsp;2.6 \u0026plusmn; 5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003eFFP_24h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e\u0026nbsp;3.4 \u0026plusmn; 7.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e\u0026nbsp;2.5 \u0026plusmn; 5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e\u0026nbsp;3.1 \u0026plusmn; 6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e\u0026nbsp;2.5 \u0026plusmn; 5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.132\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.35785007072136%\"\u003e\n \u003cp\u003ePlatlet_24h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e\u0026nbsp;1.3 \u0026plusmn; 3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e\u0026nbsp;1.2 \u0026plusmn; 3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.335219236209335%\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.71004243281471%\"\u003e\n \u003cp\u003e\u0026nbsp;1.5 \u0026plusmn; 3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e\u0026nbsp;1.2 \u0026plusmn; 3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.295615275813295%\"\u003e\n \u003cp\u003e0.315\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eISS, Injury Severity Score; SBP, systolic blood pressure; PR, pulse rate; GCS, Glasgow Coma Scale; PRBC, packed red blood cells; FFP, fresh frozen plasma\u003c/p\u003e\n\u003cp\u003eTable 3. Inhospital outcomes of correct triage vs undertriage\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.51260504201681%\" style=\"width: 19.0068%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"37.3109243697479%\" colspan=\"3\" style=\"width: 34.0121%;\"\u003e\n \u003cp\u003eOriginal population\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.65546218487395%\" colspan=\"3\" style=\"width: 30.5824%;\"\u003e\n \u003cp\u003ePost PSM population\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.51260504201681%\" style=\"width: 19.0068%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"15.294117647058824%\" style=\"width: 14.8625%;\"\u003e\n \u003cp\u003eCorrect_triage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.621848739495798%\" style=\"width: 13.5763%;\"\u003e\n \u003cp\u003eUndertriage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.394957983193278%\" rowspan=\"2\" style=\"width: 5.7163%;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.46218487394958%\" style=\"width: 14.2908%;\"\u003e\n \u003cp\u003eCorrect_triage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" style=\"width: 11.1468%;\"\u003e\n \u003cp\u003eUndertriage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.907563025210084%\" rowspan=\"2\" style=\"width: 5.2876%;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.70281124497992%\" style=\"width: 19.0068%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.27309236947791%\" style=\"width: 14.8625%;\"\u003e\n \u003cp\u003e(n=2528)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46987951807229%\" style=\"width: 13.5763%;\"\u003e\n \u003cp\u003e(n=489)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.473895582329316%\" style=\"width: 14.2908%;\"\u003e\n \u003cp\u003e(n=484)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.068273092369477%\" style=\"width: 11.1468%;\"\u003e\n \u003cp\u003e(n=484)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.51260504201681%\" style=\"width: 19.0068%;\"\u003e\n \u003cp\u003eHospital LOS, day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.294117647058824%\" style=\"width: 14.8625%;\"\u003e\n \u003cp\u003e18 [11-35]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.621848739495798%\" style=\"width: 13.5763%;\"\u003e\n \u003cp\u003e17 [8-36]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.394957983193278%\" style=\"width: 5.7163%;\"\u003e\n \u003cp\u003e\u003cem\u003e0.023\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.46218487394958%\" style=\"width: 14.2908%;\"\u003e\n \u003cp\u003e19 [12-36]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" style=\"width: 11.1468%;\"\u003e\n \u003cp\u003e17 [8-37]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.907563025210084%\" style=\"width: 5.2876%;\"\u003e\n \u003cp\u003e\u003cem\u003e0.024\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.51260504201681%\" style=\"width: 19.0068%;\"\u003e\n \u003cp\u003eICU_LOS, day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.294117647058824%\" style=\"width: 14.8625%;\"\u003e\n \u003cp\u003e5 [3-12]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.621848739495798%\" style=\"width: 13.5763%;\"\u003e\n \u003cp\u003e5 [2-15]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.394957983193278%\" style=\"width: 5.7163%;\"\u003e\n \u003cp\u003e\u003cem\u003e0.856\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.46218487394958%\" style=\"width: 14.2908%;\"\u003e\n \u003cp\u003e5 [3-11]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" style=\"width: 11.1468%;\"\u003e\n \u003cp\u003e5 [2-16]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.907563025210084%\" style=\"width: 5.2876%;\"\u003e\n \u003cp\u003e\u003cem\u003e0.811\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.51260504201681%\" style=\"width: 19.0068%;\"\u003e\n \u003cp\u003eICU_day ratio \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.294117647058824%\" style=\"width: 14.8625%;\"\u003e\n \u003cp\u003e0.3 [0.2-0.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.621848739495798%\" style=\"width: 13.5763%;\"\u003e\n \u003cp\u003e0.4 [0.2-1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.394957983193278%\" style=\"width: 5.7163%;\"\u003e\n \u003cp\u003e\u003cem\u003e0.030\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.46218487394958%\" style=\"width: 14.2908%;\"\u003e\n \u003cp\u003e0.3 [0.2-0.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" style=\"width: 11.1468%;\"\u003e\n \u003cp\u003e0.4 [0.2-1.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.907563025210084%\" style=\"width: 5.2876%;\"\u003e\n \u003cp\u003e\u003cem\u003e0.059\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.51260504201681%\" style=\"width: 19.0068%;\"\u003e\n \u003cp\u003eMV_duration, day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.294117647058824%\" style=\"width: 14.8625%;\"\u003e\n \u003cp\u003e1 [0-6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.621848739495798%\" style=\"width: 13.5763%;\"\u003e\n \u003cp\u003e1 [0-8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.394957983193278%\" style=\"width: 5.7163%;\"\u003e\n \u003cp\u003e\u003cem\u003e0.459\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.46218487394958%\" style=\"width: 14.2908%;\"\u003e\n \u003cp\u003e1 [0-5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" style=\"width: 11.1468%;\"\u003e\n \u003cp\u003e1 [0-8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.907563025210084%\" style=\"width: 5.2876%;\"\u003e\n \u003cp\u003e\u003cem\u003e0.190\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.51260504201681%\" style=\"width: 19.0068%;\"\u003e\n \u003cp\u003eInhospital death (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.294117647058824%\" style=\"width: 14.8625%;\"\u003e\n \u003cp\u003e329 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.621848739495798%\" style=\"width: 13.5763%;\"\u003e\n \u003cp\u003e100 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.394957983193278%\" style=\"width: 5.7163%;\"\u003e\n \u003cp\u003e\u003cem\u003e0.000\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.46218487394958%\" style=\"width: 14.2908%;\"\u003e\n \u003cp\u003e61 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" style=\"width: 11.1468%;\"\u003e\n \u003cp\u003e99 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.907563025210084%\" style=\"width: 5.2876%;\"\u003e\n \u003cp\u003e\u003cem\u003e0.001\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003ePSM,\u003c/em\u003e propensity score matching; \u003cem\u003eLOS,\u003c/em\u003e length of stay; \u003cem\u003eMV,\u003c/em\u003e mechanical ventilator\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"scandinavian-journal-of-trauma-resuscitation-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"stre","sideBox":"Learn more about [Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine](http://sjtrem.biomedcentral.com)","snPcode":"13049","submissionUrl":"https://submission.nature.com/new-submission/13049/3","title":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine","twitterHandle":"@SJTREM","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"undertriage, prehospital, performance improvement, regional trauma system, EMS provider education","lastPublishedDoi":"10.21203/rs.3.rs-4443129/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4443129/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn regional trauma systems, emergency medical service (EMS) providers play a crucial role by performing prehospital triage for severely injured patients and transporting them to regional trauma centres. Since 2016, a regional trauma centre has provided prehospital medical guidance to EMS providers through a trauma hotline, facilitated by trauma surgeon, to guide field triage, treatment, and transport. This study analysed the effects and clinical outcomes of a regional trauma centre-led performance improvement program that followed closed-loop principles for EMS providers.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData from the regional trauma centre databases (2016\u0026ndash;2021) were collected, and patients with trauma with Injury Severity Scores (ISSs)\u0026thinsp;\u0026gt;\u0026thinsp;15 in the Gyeonggi Province who were injured, regardless of whether they visited the trauma centre directly or not, were included. After severity and baseline demographic adjustments through propensity score matching, clinical outcomes were analysed using the t-test and chi-squared test, and the results were expressed as medians with interquartile ranges (IQRs) or means with standard deviations (SDs).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe included 3017 patients from the 6-year study period. Correct triage and undertriage were performed in 2528 and 489 patients, respectively. Prehospital medical guidance and feedback were provided 432 times (32.1%) in 2016 and increased to 1505 times (96.8%) in 2021 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The undertriage rate decreased from 32.7% (n\u0026thinsp;=\u0026thinsp;55/168) to 6.3% (n\u0026thinsp;=\u0026thinsp;52/820) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the overall mortality decreased from 21.4\u0026ndash;10% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). After propensity score matching, 484 correctly triaged and 484 undertriaged patients were identified for subgroup analyses. The in-hospital mortality of undertriaged and correctly triaged patients was 20% (n\u0026thinsp;=\u0026thinsp;99) and 13% (n\u0026thinsp;=\u0026thinsp;61) (p\u0026thinsp;=\u0026thinsp;0.001), respectively. The median (IQR) for undertriaged over correctly-triaged patients regarding hospital length of stay (LOS) and ICU day ratio was 17 (8\u0026ndash;37) vs 19 (12\u0026ndash;36) (p\u0026thinsp;=\u0026thinsp;0.024) and 0.4 (0.2-1.0) vs 0.3 (0.2\u0026ndash;0.6) (p\u0026thinsp;=\u0026thinsp;0.059), respectively.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eUndertriage was associated with increased in-hospital mortality and hospital LOS. There was a statistically significant difference between the increase in prehospital medical guidance and the decreased undertriage rate. Specifically, in the early stages of regional trauma-system development, the trauma center-led trauma hotline feedback and case-based education programs can be effective models to facilitate prehospital patient triage and patient centralisation.\u003c/p\u003e","manuscriptTitle":"Right patient to the right place: The impact of a 6-year regional trauma centre-led prehospital education program on EMS triage and patient outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-26 19:08:21","doi":"10.21203/rs.3.rs-4443129/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Reject, do not transfer","date":"2024-09-22T04:55:50+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-08-15T11:22:10+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-07T10:11:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-23T05:09:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine","date":"2024-05-21T04:09:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scandinavian-journal-of-trauma-resuscitation-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"stre","sideBox":"Learn more about [Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine](http://sjtrem.biomedcentral.com)","snPcode":"13049","submissionUrl":"https://submission.nature.com/new-submission/13049/3","title":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine","twitterHandle":"@SJTREM","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9113fce1-76d6-432f-b190-c73051c2429d","owner":[],"postedDate":"June 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-06-26T19:08:21+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-26 19:08:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4443129","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4443129","identity":"rs-4443129","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}