Elsevier

International Emergency Nursing

Volume 36, January 2018, Pages 27-33
International Emergency Nursing

The accuracy of acuity scoring tools to predict 24-h mortality in traumatic brain injury patients: A guide to triage criteria

https://doi.org/10.1016/j.ienj.2017.08.003Get rights and content

Highlights

  • RTS is valid to predict mortality among TBI patients in both prehospital and hospital settings.

  • RTS and NEWS are more valid than traditional vital signs in measuring the trauma severity.

  • Few studies have been focused on the role of acuity tools in terms of 24-h mortality.

  • In survival group, TBI patients experienced a significant loss of consciousness following the accident too.

  • The age is an independent factor for the mortality in TBI patients.

Abstract

Background and aim

Prompt identification of traumatic brain injury (TBI) is vital for patients in critical condition; however, it is not clear which acuity scoring tools are associated with short-term mortality. The aim of this study was to determine the accuracy of acuity scoring tools and 24-h mortality among TBI patients in both prehospital and hospital settings.

Methods

This study was an observational, prospective cohort, in which patients with TBI were followed from the accident scene to the hospital. Vital signs and acuity scoring tools, including the Revised Trauma Score (RTS), Injury Severity Score (ISS), National Early Warning Score (NEWS), Shock Index (SI), Modified Shock Index (MSI) and Trauma and Injury Severity Score (TRISS), were collected both on the scene as well as at the hospital. A logistic regression was performed to ascertain the effects of clinical parameters on the likelihood of survival of patients with TBI regarding 24-h mortality.

Results:

A total of 185 patients were included in this study. The mortality rate was 14% (25/185). The logistic regression model was statistically significant at χ2 = 60.8, p = 0.001. A hierarchical forward stepwise logistic regression analysis showed that age, hospital RTS and prehospital NEWS significantly improved mortality predictions. The model explained the 51.2% variance in survival of patients with TBI.

Conclusions

The NEWS and the RTS may be used to triage TBI patients for prehospital and hospital emergency care, respectively. Therefore, because traditional vital signs criteria may be of limited use for the triage of TBI patients, it is recommended that acuity scoring tools be used in such cases.

Introduction

Traumatic brain injury (TBI) is the main cause of disability as well as neurologic morbidity in young adults [1]. Severe trauma is considered a serious health problem, because disability affects victims’ roles in both family and society [2]. Notably, TBI is also associated with high socio-economic costs [3]. The first hour of trauma management is crucial for TBI patients due to the time-sensitive care required; therefore, mortality may be decreased if critically ill patients are recognized more readily and transferred promptly to trauma centres [4]. Paramedics are generally the first to assess and treat trauma patients in the prehospital environment, which makes them responsible for identifying life-threatening injuries and improving patients’ quality of care in stressful situations [5]. As such, it is essential to develop prehospital emergency criteria to promote prompt recognition of severe TBI patients [6].

In the prehospital phase, the initial steps are to assess the level of consciousness (LOC), maintain both the airway and oxygenation, initiate fluid replacement, immobilize the spine and promptly transfer the patient to a high-level trauma centre [7]. Trauma scoring systems are useful for the recognition of critically injured patients and are a prerequisite for establishing performance improvement among paramedics, which results from better outcome prediction and triage allocation as well as choosing the optimum hospital destination [8]. Trauma scoring systems are also useful for risk stratification. This is especially true for paramedics because they are usually working with little clinical information in the field. Paramedics must prioritise by transferring severe TBI patients for advanced care sooner than other TBI patients with lower priorities.

Most previous studies have focused on the accuracy of the trauma scoring system and long-term outcomes; therefore, the associations between clinical criteria and short-term outcomes remain unclear. Notably, only short-term outcomes are specific for the triage of TBI patients in both prehospital and emergency settings, while trauma-specific triage guidelines for TBI patients have rarely been developed [9]. Evidence that supports the trauma scoring system based on 24-h outcomes is thus required. To be more specific, the Glasgow Coma Scale (GCS) was found to be a good prognostic factor of long-term mortality among TBI patients in the emergency department (ED); conversely, its value in the prehospital setting remains unclear. Several studies have shown that the GCS improved the prediction of 48-h mortality, and motor scores were also significant predictors of long-term mortality (2 weeks to 6 months) [2], [7], [10], [11], [12], [13], [14]. However, the validity of these findings regarding 24-h outcomes are unclear.

Overall, an accurate tool is needed to identify the severity of TBI during early trauma, especially regarding 24-h outcomes, which could be employed for more accurate clinical decisions. In addition, because traumatic injuries are increasingly recognized as a leading source of morbidity and mortality in developing countries, context-specific research is necessary to identify opportunities for prevention and improved treatment. Therefore, the aim of this study was to determine the accuracy of acuity scoring tools and 24-h mortality among traumatic brain injury patients in both the prehospital and hospital settings.

Section snippets

Design

This study was an observational, prospective cohort that followed TBI patients from the accident scene to the hospital between February and September 2016.

Ethics

Data collection was carried out after receiving approval from the ethics committee at Mashhad University of Medical Sciences (No. 940948).

Setting

This study was conducted in the Hasheminezhad Hospital in Mashhad, Razavi Khorasan, Iran, which is the second largest Level 1 trauma centre (320 beds) in the city. The hospital provides several specialties,

Patient characteristics

Clinical characteristics of the 185 patients are demonstrated in Table 1. The median age of the patients was 33 (IQR: 24–50) years old, and 76% were men. Overall, 116 (71%) patients were pedestrians or motorcycle riders, and 170 (92%) had a blunt injury. The median transfer time was 32 (IQR: 24–43) minutes. The survival rate was 86% (160/185). Patients in the mortality group were not significantly older in either the prehospital or hospital setting (p > 0.05). The proportions of both groups also

Discussion

The current study shows that vital sign criteria alone may not predict short-term outcomes, while acuity scoring tools, including the RTS-hosp and NEWS-prehosp, predict 24-h mortality in hospital and prehospital settings among TBI patients respectively. It is vital for clinicians who work in the emergency field to identify critically ill patients based on valid criteria. The results show that clinicians should not rely on vital sign criteria alone in either the field or the triage room. Even

Conclusions

The RTS and the NEWS may be used to triage TBI patients in hospital and prehospital emergency care respectively because of their significant validity; therefore, traditional vital sign criteria may be of limited use for the triage of TBI patients especially in prehospital setting. Acuity scoring tools help clinicians stratify patients as well as allocate resources. Accurate triage is critical, especially for TBI patients, for finding the most relevant trauma centre. It is therefore recommended

Author contributions

A.M. and Z.N. designed the study. Z.N., H.Z. and A.M. collected data. A.M. analysed the data which Z.N., H.Z. and A.M. interpreted the result. Z.N., H.Z. and A.M. did perform the literature review and wrote the manuscript. All authors proofread the manuscript and revised it critically. All authors have read and approved the final manuscript.

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  • Cited by (0)

    1

    Department Medical-Surgical Nursing, Torbat Heydariyeh University of Medical Sciences, Razi Street, Torbat Heydariyeh, Razavi Khorasan 9516915169, Iran.

    2

    Department of Emergency Medicine, Hasheminejad Hospital, School of Medicine, Azadi square, Mashhad, Razavi Khorasan 9177948564, Iran.

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