Aspects of in-hospital triage in a Swedish trauma population : experiences and outcomes

Early and accurate prioritization of trauma patients, known as triage, is crucial to identify those in need of emergency life-saving interventions. Excellent trauma care relies strongly on correct triage, which impacts patients' experiences and outcomes. Undertriage has been shown to be associated with an elevated risk of undetected injuries and missed interventions. However, the definition of severe trauma is still debatable. This thesis aimed to study aspects and consequences of in-hospital triage, examine over-and undertriage, trauma care processes, experiences and outcomes, providing insights to improve care for this patient group. Qualitative and quantitative approaches were used. Paper I was a 'before and after' study where the effect of a criteria-directed protocol for in-hospital triage of trauma patients in a Swedish trauma center was evaluated. The results showed that by using the protocol, overtriage was reduced from 74% to 58% while undertriage increased from 7% to 10%. No preventable deaths were detected after peer-review of those undertriaged. In Paper II, trauma patients' experiences after initial trauma management were explored, using individual face-to-face semi-structured interviews. The interviews were recorded, transcribed and analyzed using qualitative content analysis. Patients reported emotional responses to the trauma, physical discomfort and feeling prioritized or being ignored by the trauma team. The main category that emerged was: "Feeling safe in a frightening situation". In Paper III, the two scoring systems, the anatomic New Injury Severity score (NISS) and the physiology-based GAP score, for prediction on ICU-admission and 30-day mortality after trauma, were evaluated: in the Swedish trauma population. The findings showed that the GAP- score was better at predicting 30-day mortality compared to NISS, with AUROC (95% CI) values of 0.92 (0.91-0.93) and 0.84 (0.83-0.85) respectively, while NISS performed better than GAP at predicting ICU-admission. Both scoring systems were less accurate in predicting mortality in the older patient group. In Paper IV, undertriaged trauma patients were characterized and compared to non- undertriaged trauma patients, in age groups, to investigate potential differences in trauma care processes and 30-day mortality. The study results showed that undertriaged patients had fewer intubations, longer time to CT-scan and fewer admissions to ICU, were less severely injured, and had lower mortality compared to non- undertriaged patients. This demonstrates that undertriage was not associated with poorer outcomes compared to non-undertriage, in the current study.

List of scientific papers

I. A criteria-directed protocol for in-hospital triage of trauma patients. Granström A, Strömmer L, Schandl A, Östlund A. European Journal of Emergency Medicine 2018;25(1):25-31 (Included in Licentiate thesis). https://doi.org/10.1097/mej.0000000000000397

II. Patient experiences of initial trauma care. Granström A, Strömmer L, Falk AC, Schandl A. International Emergency Nursing 2019;42:25-29 (Included in Licentiate thesis). https://doi.org/10.1016/j.ienj.2018.08.003

III. Using the GAP score as a compliment to the NISS score in identifying severely injured patients- A registry-based cohort study of adult trauma patients in Sweden. Granström A, Schandl A, Mårtensson J, Strömmer L. Injury 2024;55(9):111709. https://doi.org/10.1016/j.injury.2024.111709

IV. Impact of Undertriage on Trauma Care Processes and Mortality Across Age Groups. Granström A, Schandl A, Mårtensson J, Strömmer L. [Manuscript]