Paper of the Month: Trauma, triage and the role of patient choice

October 29, 2013

This month's featured paper was written by Dr. Craig Newgard, and is titled, "Patient choice in the selection of hospitals by 9-1-1 emergency medical services providers in trauma systems." It was published in the journal Academic Emergency Medicine. Dr. Newgard led a team of researchers from across the Pacific Northwest, including Dr. O. John Ma and Dr. Ritu Sahni from OHSU. Drs. Newgard, Ma and Sahni are appointed to the Center for Policy and Research in Emergency Medicine within the Department of Emergency Medicine.

newgard-102913Severe injury is a complex health care issue, requiring immediate decisions in the field regarding triage. Since 1987, the process of field triage has been set by a national guideline for identification and transport of seriously injured patients to designated major trauma centers, with patients not meeting the triage guidelines being transported to non-trauma hospitals. In older adults, two related and perplexing system-level issues disrupt the field triage model: First, seriously injured older adults are less likely to go to major trauma centers (a process known as under-triage). Secondly, their outcomes appear to be the same in non-trauma hospitals, in contradiction to the major trauma center model which would predict better outcomes when treated at a major trauma center. Understanding these issues is an important step in optimizing geriatric trauma care and improving functional outcomes after injury.

To better address these and other questions, Craig Newgard, M.D., MPH, an associate professor of emergency medicine, created the Western Emergency Services Translational Research Network (WESTRN), a consortium of geographic regions, EMS agencies and hospitals linked through Clinical and Translational Science Awards. WESTRN previously demonstrated that under-triage, which has a national target of less than or equal to 5 percent, remains fairly constant in younger patients (about 20 percent), and only begins to rise after age 60 years. Under-triage peaks at 62 percent for patients over 90 years. Dr. Newgard hypothesized that reasons for selecting specific hospitals by EMS providers may partially explain the high rate of under-triage and apparent lack of trauma center benefit among older patients.

WESTRN collected 911-dispatch, EMS and hospital data for over 175,000 injured patients transported by 61 EMS agencies to 93 hospitals (trauma and non-trauma centers) in 5 regions to evaluate reasons by EMS providers for selecting specific hospitals. The results were presented in the October 2013 Paper of the Month: Patient choice in the selection of hospitals by 9-1-1 emergency medical services providers in trauma systems.

"We found that the three most common reasons were patient choice, closest facility and specialty center," said Dr. Newgard. "Patient choice in selecting a hospital steadily increased with increasing patient age and closely paralleled under-triage rates. Even when restricted to patients with the most serious injuries, these trends persisted. We also found that patients with the worst prognosis tended to be transported to major trauma centers, while patients with better prognosis were more likely to choose specific generally non-trauma hospitals. These findings were most evident among older patients and were not explained by the triage guidelines."

These results suggest that hospital selection is a shared decision-making process between the patient and emergency services personnel. This contributes to under-triage and distortion when evaluating the benefit of trauma centers, particularly among older adults. "This paper shows that particularly as patients get older, they take a more active role in directing their care - even in emergency settings - and that this factor must be considered when comparing hospital performance and the effectiveness of care in observational settings," said Dr. Newgard.

The concept of shared decision-making and patient-centered outcomes in medicine is gaining momentum, catalyzed by creation of the Patient Centered Outcomes Research Institute (PCORI). While this study demonstrates the influence of shared decision-making among injured patients accessing 911 emergency services, the influence likely exists in all aspects of medicine. "We have generally failed to account for such factors in observational research comparing hospitals, variability in care, and the effectiveness of certain clinical interventions," said Dr. Newgard. WESTRN hopes to address these issues in future studies. "We plan to further explore shared decision-making in emergency services, including hospital-level outcomes after accounting for patient choice, outcomes that are most meaningful to patients, balancing patient choice with costs of care, and better delineating the role of major trauma centers among older adults."

While selecting this study, Associate Dean for Clinical Science Eric Orwoll, M.D., professor of medicine, noted that Dr. Newgard and WESTRNs insights should lead to not only improved systems for triage and transport, but to a better of understanding of the reasons for specific patient outcomes. "This is but one project the WESTRN Consortium has made possible, illustrating the power of inter-institutional collaboration," said Dr. Orwoll.

Additional Reading

Dr. Newgard:



Paper citation:


About the Paper of the Month

The School of Medicine newsletter spotlights a recently published faculty research paper in each issue. The goals are to highlight the great research happening at OHSU and to share this information across departments, institutes and disciplines. The monthly paper summary is selected by Associate Dean for Basic Science Mary Stenzel-Poore, Ph.D., and Associate Dean for Clinical Science Eric Orwoll, M.D.

More Published Papers

The entire list of OHSU papers published this month is here.

The Paper of the Month article is written by Jackie Wirz, Ph.D.