Under-Triage and Over-Triage Using the Field Triage Guidelines for Injured Patients: A Systematic Review

Abstract

Objectives

The Field Triage Guidelines (FTG) are used across North America to identify seriously injured patients for transport to appropriate level trauma centers, with a goal of under-triaging no more than 5% and over-triaging between 25% and 35%. Our objective was to systematically review the literature on under-triage and over-triage rates of the FTG.

Methods

We conducted a systematic review of the FTG performance. Ovid Medline, EMBASE, and the Cochrane databases were searched for studies published between January 2011 and February 2021. Two investigators dual-reviewed eligibility of abstracts and full-text. We included studies evaluating under- or over-triage of patients using the FTG in the prehospital setting. We excluded studies not reporting an outcome of under- or over-triage, studies evaluating other triage tools, or studies of triage not in the prehospital setting. Two investigators independently assessed the risk of bias for each included article. The primary accuracy measures to assess the FTG were under-triage, defined as seriously injured patients transported to non-trauma hospitals (1-sensitivity), and over-triage, defined as non-injured patients transported to trauma hospitals (1-specificity). Due to heterogeneity, results were synthesized qualitatively.

Results

We screened 2,418 abstracts, reviewed 315 full-text publications, and identified 17 studies that evaluated the accuracy of the FTG. Among eight studies evaluating the entire FTG (steps 1–4), under-triage rates ranged from 1.6% to 72.0% and were higher for older (≥55 or ≥65 years) adults (20.1–72.0%) and pediatric (<15 years) patients (15.9–34.8%) compared to all ages (1.6–33.8%). Over-triage rates ranged from 9.9% to 87.4% and were higher for all ages (12.2–87.4%) compared to older (≥55 or ≥65 years) adults (9.9–48.2%) and pediatric (<15 years) patients (28.0–33.6%). Under-triage was lower in studies strictly applying the FTG retrospectively (1.6–34.8%) compared to as-practiced (10.5–72.0%), while over-triage was higher retrospectively (64.2–87.4%) compared to as-practiced (9.9–48.2%).

Conclusions

Evidence suggests that under-triage, while improved if the FTG is strictly applied, remains above targets, with higher rates of under-triage in both children and older adults.

Acknowledgments

The authors gratefully acknowledge the following individuals for their contributions to this project Tracy Dana, Leah Williams, and Elaine Graham.

Disclosure statement

Authors report no conflict of interest.

Prior presentations

This work has not been publicly presented.

Additional information

Funding

Pacific Northwest Evidence-based Practice Center at Oregon Health & Science University (OHSU) was funded to perform a supplemental literature review by the American College of Surgeons (ACS) (Award # 693JJ91950007) as part of a Cooperative Agreement between ACS and the National Highway Traffic Safety Administration (NHTSA), Office of Emergency Medical Services (OEMS) funded in part by the Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB), Emergency Medical Services for Children Program (EMSC). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by the U.S. Government. For more information, please visit EMS.gov and HRSA.gov.