A prospective stepped wedge cohort evaluation of the new national trauma team activation criteria in Sweden - the TRAUMALERT study

Background: Trauma triage based on prehospital information facilitates correct allocation of in-hospital resources. The Swedish national two-tier trauma team activation (TTA) criteria were revised in 2016. The current study aimed to evaluate the safety and efficacy of the new criteria. Methods: Five centres covering trauma care for 1.2 million inhabitants registered all trauma patients prospectively in the Swedish trauma registry (SweTrau) prior to and after stepwise introduction of new TTA criteria within the cohort (a prospective stepped-wedge cohort study design; period August 2016-November 2017). Evaluation of full- and limited-TTA frequency, under- and overtriage were performed at equal duration before and after this change. Results: The centres registered 1948 patients, 1882 (96.6%) of which were included in the study. With new criteria, frequency of full-TTA was unchanged, while limited-TTA decreased with 46.3% (from 988 to 531). 30-day trauma mortality was unchanged. The overtriage was 107/150 (71.3%) with former criteria, and 104/144 (72.2%) with new criteria, p=0.866. Undertriage was 50/1037 (4.8%) versus 39/551 (7.1%), p=0.063. Undertriage was consistently >20% in patients with fall injury. Among patients with Injury Severity Score (ISS) >15, 50/93 (53.8%) did not initiate full-TTA with former, vs 39/79 (49.4%) with new criteria, p=0.565. Age>60-years was a risk factor for undertriage (OR 2.89, p<0.001), while low fall injuries indicated a trend (OR 2.70, p=0.051). Conclusions: The newly implemented Swedish TTA criteria result in a reduction in limited TTA frequency, indicating an increased efficiency in use of resources. The over- and undertriage is unchanged compared to former criteria, thus upholding patient safety.