Eken, Torsten

Krüger, Andreas Jorstad

Lossius, Hans Morten

Rehn, Marius

Skaga, Nils Oddvar

Steen, Petter Andreas

English

PubMed

Krüger, Andreas J

Steen, Petter A

Skaga, Nils O

Lossius, Hans M

NORA - Norwegian Open Research Archives

BioMed CentralScandinavian Journal of Trauma, Resuscitation and Emergency MedicinessOpen AcceLetter to the EditorRE: Field triage in trauma – do the data really justify the conclusions?Marius Rehn*1,2, Torsten Eken3, Andreas Jorstad Krüger1,4, Petter Andreas Steen2,5, Nils Oddvar Skaga1,6 and Hans Morten Lossius1Address: 1Department of Research and Development, Norwegian Air Ambulance Foundation, Drobak, Norway, 2Faculty of Medicine, Faculty Division Ulleval University Hospital, University of Oslo, Norway, 3Department of Anaesthesiology, Aker University Hospital, Oslo, Norway, 4Department of Anaesthesiology and Emergency Medicine, St Olav University Hospital, Trondheim, Norway, 5Prehospital division, Ulleval University Hospital, Oslo, Norway and 6Department of Anaesthesiology, Division of Emergency Medicine, Ulleval University Hospital, Oslo, NorwayEmail: Marius Rehn* - marius.rehn@snla.no; Torsten Eken - torsten.eken@medisin.uio.no; Andreas Jorstad Krüger - andreas.kruger@snla.no; Petter Andreas Steen - p.a.steen@medisin.uio.no; Nils Oddvar Skaga - n.o.skaga@medisin.uio.no; Hans Morten Lossius - hans.morten.lossius@snla.no* Corresponding author    LetterDear Sir,Thank you for your interest in our article; "Precision offield triage in patients brought to a trauma centre afterintroducing trauma team activation guidelines" [1],which gives us the opportunity for expounding some con-clusions that could be open for misinterpretation.We agree with Dr. Sandberg that paramedics and anaes-thetists conduct missions with very skewed profiles. Wesuspect that this mission-selection bias applies to allanaesthetists-manned services, regardless of transportmethod. The differences in task profile may be beyond thescope of statistical adjustment contributing to a contra-comparison line of argumentation. This is a problem inmost epidemiologic studies. What is found is an associa-tion between factors; a good starting point for prospectiveintervention studies. In this case possibly testing changesin one or more of the links in the triage chain. Hopefully,readers agree with us in our statement "skewed missionprofiles make comparison of differences in triage preci-sion difficult".Dr. Sandberg correctly states that the formal decision toactivate the trauma team is not made in-field, but in-hos-pital by the ED nurse. We still used the term field triage, inan attempt to differentiate the study from those thatdescribe traditional ED triage algorithms. Regardless ofwhere the formal decision is made, triage decisions madebefore the patient arrives in the ED are based upon infor-mation gathered in-field and the triage decision have in-field consequences.We agree with Dr. Sandberg that it is difficult to isolate theaetiology of over- and undertriage. Over- and undertriagerates reflect a chain of events. We did not attempt to iden-tify the link in this chain with most potential for improve-ment. This is reflected in our recommended improvementinitiatives that address every major link in the traumatriage chain: improved on-scene patient evaluation, betterroutines in communicating patient data from EMS unitsto the nurse coordinator in the ED, additional training intriage decision-making for nurse coordinators, and devel-opment of a two-tiered trauma triage protocol.We acknowledge the complexity of describing undertriagein multi-centre trauma systems. Our analysis was limitedto patients primary admitted to Ulleval University Hospi-tal and did not include those admitted elsewhere in thetrauma system. Although not studying the entire traumasystem, the article's main findings support the general ten-dency of imprecise trauma triage in several Scandinavianstudies [2-5]. This trend deserves verification through aPublished: 29 May 2009Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17:25 doi:10.1186/1757-7241-17-25Received: 12 May 2009Accepted: 29 May 2009This article is available from: http://www.sjtrem.com/content/17/1/25© 2009 Rehn et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 2(page number not for citation purposes)Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17:25 http://www.sjtrem.com/content/17/1/25Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralNorwegian pan-trauma system analysis facilitated by thehopefully soon-to-be national trauma registry.A degree of both over- and undertriage is unavoidable,and trauma systems should prepare for handling under-triage most effectively. One possible contribution to effec-tively identify patients subject to undertriage would be tointroduce protocol-based ED triage algorithms as a safetynet. By introducing a minor trauma team that systemati-cally evaluates patients with uncertain injury panorama,the hospital acknowledges the difficulty of evaluatingpatients in-field by lowering the threshold for traumateam activation. This two-tiered system may contribute tolowering the undertriage rate while reducing the impact ofovertriage. In our opinion a constructive combination.References1. Rehn M, Eken T, Kruger AJ, Steen PA, Skaga NO, Lossius HM: Pre-cision of field triage in patients brought to a trauma centreafter introducing trauma team activation guidelines.  Scand JTrauma Resusc Emerg Med 2009, 17:1.2. Lossius HM, Langhelle A, Pillgram-Larsen J, Lossius TA, Soreide E,Laake P, Steen PA: Efficiency of activation of the trauma teamin a Norwegian trauma referral centre.  European Journal of Sur-gery 2000, 166:760-764.3. Kruger AJ, Hesselberg N, Abrahamsen GT, Bartnes K: [Whenshould the trauma team be activated?].  Tidsskrift for Den NorskeLaegeforening 2006, 126:1335-1337.4. Uleberg O, Vinjevoll OP, Eriksson U, Aadahl P, Skogvoll E: Over-triage in trauma – what are the causes?  Acta AnaesthesiologicaScandinavica 2007, 51:1178-1183.5. Kann SH, Hougaard K, Christensen EF: Evaluation of pre-hospitaltrauma triage criteria: a prospective study at a Danish levelI trauma centre.  Acta Anaesthesiologica Scandinavica 2007,51:1172-1177.Page 2 of 2(page number not for citation purposes)

RE: Field triage in trauma – do the data really justify the conclusions?

Marius Rehn

Torsten Eken

Andreas Krüger

Petter Steen

Nils Skaga

Hans Lossius

Crossref

Springer - Publisher Connector

BioMed Central
Scandinavian Journal of Trauma, 
Resuscitation and Emergency Medicine
ssOpen AcceLetter to the Editor
RE: Field triage in trauma – do the data really justify the 
conclusions?
Marius Rehn*1,2, Torsten Eken3, Andreas Jorstad Krüger1,4, 
Petter Andreas Steen2,5, Nils Oddvar Skaga1,6 and Hans Morten Lossius1
Address: 1Department of Research and Development, Norwegian Air Ambulance Foundation, Drobak, Norway, 2Faculty of Medicine, Faculty 
Division Ulleval University Hospital, University of Oslo, Norway, 3Department of Anaesthesiology, Aker University Hospital, Oslo, Norway, 
4Department of Anaesthesiology and Emergency Medicine, St Olav University Hospital, Trondheim, Norway, 5Prehospital division, Ulleval 
University Hospital, Oslo, Norway and 6Department of Anaesthesiology, Division of Emergency Medicine, Ulleval University Hospital, Oslo, 
Norway
Email: Marius Rehn* - marius.rehn@snla.no; Torsten Eken - torsten.eken@medisin.uio.no; Andreas Jorstad Krüger - andreas.kruger@snla.no; 
Petter Andreas Steen - p.a.steen@medisin.uio.no; Nils Oddvar Skaga - n.o.skaga@medisin.uio.no; 
Hans Morten Lossius - hans.morten.lossius@snla.no
* Corresponding author    
Letter
Dear Sir,
Thank you for your interest in our article; "Precision of
field triage in patients brought to a trauma centre after
introducing trauma team activation guidelines" [1],
which gives us the opportunity for expounding some con-
clusions that could be open for misinterpretation.
We agree with Dr. Sandberg that paramedics and anaes-
thetists conduct missions with very skewed profiles. We
suspect that this mission-selection bias applies to all
anaesthetists-manned services, regardless of transport
method. The differences in task profile may be beyond the
scope of statistical adjustment contributing to a contra-
comparison line of argumentation. This is a problem in
most epidemiologic studies. What is found is an associa-
tion between factors; a good starting point for prospective
intervention studies. In this case possibly testing changes
in one or more of the links in the triage chain. Hopefully,
readers agree with us in our statement "skewed mission
profiles make comparison of differences in triage preci-
sion difficult".
Dr. Sandberg correctly states that the formal decision to
activate the trauma team is not made in-field, but in-hos-
pital by the ED nurse. We still used the term field triage, in
an attempt to differentiate the study from those that
describe traditional ED triage algorithms. Regardless of
where the formal decision is made, triage decisions made
before the patient arrives in the ED are based upon infor-
mation gathered in-field and the triage decision have in-
field consequences.
We agree with Dr. Sandberg that it is difficult to isolate the
aetiology of over- and undertriage. Over- and undertriage
rates reflect a chain of events. We did not attempt to iden-
tify the link in this chain with most potential for improve-
ment. This is reflected in our recommended improvement
initiatives that address every major link in the trauma
triage chain: improved on-scene patient evaluation, better
routines in communicating patient data from EMS units
to the nurse coordinator in the ED, additional training in
triage decision-making for nurse coordinators, and devel-
opment of a two-tiered trauma triage protocol.
We acknowledge the complexity of describing undertriage
in multi-centre trauma systems. Our analysis was limited
to patients primary admitted to Ulleval University Hospi-
tal and did not include those admitted elsewhere in the
trauma system. Although not studying the entire trauma
system, the article's main findings support the general ten-
dency of imprecise trauma triage in several Scandinavian
studies [2-5]. This trend deserves verification through a
Published: 29 May 2009
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17:25 doi:10.1186/1757-7241-17-25
Received: 12 May 2009
Accepted: 29 May 2009
This article is available from: http://www.sjtrem.com/content/17/1/25
© 2009 Rehn et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 2
(page number not for citation purposes)
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17:25 http://www.sjtrem.com/content/17/1/25Publish with BioMed Central   and  every 
scientist can read your work free of charge
"BioMed Central will be the most significant development for 
disseminating the results of biomedical research in our lifetime."
Sir Paul Nurse, Cancer Research UK
Your research papers will be:
available free of charge to the entire biomedical community
peer reviewed and published immediately upon acceptance
cited in PubMed and archived on PubMed Central 
yours — you keep the copyright
Submit your manuscript here:
http://www.biomedcentral.com/info/publishing_adv.asp
BioMedcentral
Norwegian pan-trauma system analysis facilitated by the
hopefully soon-to-be national trauma registry.
A degree of both over- and undertriage is unavoidable,
and trauma systems should prepare for handling under-
triage most effectively. One possible contribution to effec-
tively identify patients subject to undertriage would be to
introduce protocol-based ED triage algorithms as a safety
net. By introducing a minor trauma team that systemati-
cally evaluates patients with uncertain injury panorama,
the hospital acknowledges the difficulty of evaluating
patients in-field by lowering the threshold for trauma
team activation. This two-tiered system may contribute to
lowering the undertriage rate while reducing the impact of
overtriage. In our opinion a constructive combination.
References
1. Rehn M, Eken T, Kruger AJ, Steen PA, Skaga NO, Lossius HM: Pre-
cision of field triage in patients brought to a trauma centre
after introducing trauma team activation guidelines.  Scand J
Trauma Resusc Emerg Med 2009, 17:1.
2. Lossius HM, Langhelle A, Pillgram-Larsen J, Lossius TA, Soreide E,
Laake P, Steen PA: Efficiency of activation of the trauma team
in a Norwegian trauma referral centre.  European Journal of Sur-
gery 2000, 166:760-764.
3. Kruger AJ, Hesselberg N, Abrahamsen GT, Bartnes K: [When
should the trauma team be activated?].  Tidsskrift for Den Norske
Laegeforening 2006, 126:1335-1337.
4. Uleberg O, Vinjevoll OP, Eriksson U, Aadahl P, Skogvoll E: Over-
triage in trauma – what are the causes?  Acta Anaesthesiologica
Scandinavica 2007, 51:1178-1183.
5. Kann SH, Hougaard K, Christensen EF: Evaluation of pre-hospital
trauma triage criteria: a prospective study at a Danish level
I trauma centre.  Acta Anaesthesiologica Scandinavica 2007,
51:1172-1177.Page 2 of 2
(page number not for citation purposes)


Krüger Andreas

Eken Torsten

Rehn Marius

Steen Petter

Skaga Nils

Lossius Hans

Directory of Open Access Journals

Scandinavian Journal of Trauma Resuscitation and Emergency Medicine

[When should the trauma team be activated?]. Tidsskrift for Den Norske Laegeforening

EF: Evaluation of pre-hospital trauma triage criteria: a prospective study at a Danish level I trauma centre. Acta Anaesthesiologica Scandinavica

Lossius HM: Precision of field triage in patients brought to a trauma centre after introducing trauma team activation guidelines. Scand J Trauma Resusc Emerg Med

PA: Efficiency of activation of the trauma team in a Norwegian trauma referral centre.

Skogvoll E: Overtriage in trauma – what are the causes? Acta Anaesthesiologica Scandinavica

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RE: Field triage in trauma – do the data really justify the conclusions?

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