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

Figures & data

Figure 1. Literature flow diagram of the systematic review.

Table 1. Characteristics of included studies.

Category	Characteristics	Number of studies
Year of Publication	2011–2015	7
	2016–2021	10
Field Triage Guidelines	2011	7
	Earlier Field Triage Guidelines (1999–2006)	10
Study Design	Prospective cohort	4
	Retrospective cohort	12
	Before/after	1
Data Source	US National Trauma Data Bank	1
	National Automotive Sampling System Crashworthiness Data System	2
	State or regional data	9
	Other	4
	Other national data base	1
Type of Receiving Hospitals	Trauma centers only (Level 1 or 2)	2
	Mixed	15
	Not reported	0
Number of Agencies/ Institutions	Single	0
	Multiple	17
	Not reported	0
Separately Reported Patient Age Group	Pediatric	4
	Geriatric	13
Risk of Bias Rating	High	0
	Moderate	4
	Low	13

Table 2. Under- and over-triage with strict application of the 2011 field triage guidelines.

Article	FTG Steps	Outcome	Under-triage % (95% CI)	Over-triage % (95% CI)	n	Age Range
Newgard, 2017[11]	All**	ISS ≥ 16	8.9 (7.6–10.4)	64.2 (63.8–64.6)	17,633	All
	All**	Composite^a	4.2 (3.0–5.8)	64.6 (64.1–65.0)	17,633	All
	All**	In-hospital mortality	1.6 (0.7–3.4)	64.8 (64.4–65.2)	17,633	All
Parikh, 2017[21]	All**	ISS ≥ 16	9.1 (NR)	87.4 (NR)	4,757	All
Lerner, 2017[20]	All**	Composite^b	34.8 (29.2–40.7)	28.0 (26.8–29.3)	5,594	<15
Hon, 2020[19]	1-3**	Intracranial hemorrhage	73.7 (62.8–82.3)	11.7 (9.4-14.6)	673	≥55
Nishijima, 2017[18]	1-3**	Intracranial hemorrhage	80.2 (48.8–94.5)	6.9 (5.3–8.8)	2,110	≥55
	1-3**	Composite^c	65.8 (49.4–79.9)	7.7 (6.1–8.3)	2,110	≥55
Nishijima, 2018[17]	1-3**	Intracranial hemorrhage	73.2 (64.0–81.1)	9.1 (8.0–11.6)	1,304	≥55
	1-3**	Composite^c	40.9 (NR)	NR	1,304	≥55

** Applying strict FTG retrospectively. Abbreviations: NR = Not Reported, ISS = Injury Severity Score; FTG = Field Triage Guidelines. Composite definitions included: ^aEarly critical resource use defined as emergent intubation in the emergency department, major non-orthopedic surgery, interventional radiology procedures, at least six units of red blood cells transfused, or death within 24 hours. ^bComposite defined as non-orthopedic surgery within 24 hours, intensive care unit admission, or death. ^cComposite defined as death or neurosurgical intervention during hospitalization.

Figure 2. The relationship between under- and over-triage in studies evaluated all steps in the field triage guidelines. Numbers above the data points (circles) correspond to the manuscript citations also present in Tables 2 and 3 for the nine studies evaluating all steps of the 2011 or 2006 FTG. The sizes of the corresponding data points (circles) are proportional to the study sample size (Tables 2 and 3). Values used from under- and over-triage are reported for each study in Tables 2 and 3. A color version of this figure is available online.

Table 3. Under- and over-triage of the 2006 field triage guidelines, as-practiced.

Article	FTG Steps	Outcome	Under-triage % (95% CI)	Over-triage % (95% CI)	n	Age Range
Newgard, 2011[13]	All*	ISS ≥ 16	14.2 (13.4–15.0)	31.3 (31.1–31.6)	122,345	All
	All*	ISS ≥ 16	15.9 (13.2–18.7)	33.6 (32.9–34.4)	14,874	0-17
	All*	ISS ≥ 16	10.5 (9.6–11.4)	35.7 (35.3–36.1)	62,442	18-54
	All*	ISS ≥ 16	20.1 (18.5–21.7)	24.6 (24.2–25.0)	12,372	≥55
Newgard, 2016 & 2017[11,24]	All*	ISS ≥ 16	33.8 (28.3–39.2)	12.2 (12.0–12.3)	17,633	All
	All*	Composite^a	19.9 (10.6–34.2)	12.7 (12.6–12.9)	17,633	All
Newgard, 2016[12]	All*	ISS ≥ 16	24.1 (20.7–27.5)	22.2 (21.5–22.9)	33,298	≥65
	All*	Serious TBI^b	35.5 (31.8–39.2)	22.6 (21.9–23.4	33,298	≥65
	All*	Serious Chest Injury^c	42.8 (38.3–47.4)	23.5 (22.7–24.2)	33,298	≥65
	All*	Serious abdominal injury^d	61.4 (55.1–67.6)	24.4 (23.6–25.1)	33,298	≥65
Newgard, 2019[22]	All*	ISS ≥ 16	60.1 (54.0–66.3)	10.1 (9.3–11.0)	5,021	≥65
	All*	Composite^e	63.4 (58.0–68.8)	9.9 (9.0–10.8)	5,021	≥65
	All*	Head, chest, or abdominal-pelvic AIS ≥3	72.0 (65.9–78.1)	10.1 (9.3–11.0)	5,021	≥65
	All*	Head AIS ≥3	66.1 (57.0–75.2)	10.5 (9.6–11.4)	5,021	≥65
	All*	30-day mortality	84.3 (79.6–89.0)	11.4 (10.5–12.2)	5,021	≥65
Scheetz, 2011 [14]	All*	mAIS3-5	21.7 (21.2–22.3)	48.2 (48.0–48.5)	154,608	≥55
Brown, 2011[8]	1-2**	Composite	68.0 (NR)	9.0 (NR)	1,086,764	≥18

* As-practiced FTG performance. **Applying strict FTG retrospectively. ^aComposite defined as emergency airway intervention in the emergency department, major non-orthopedic surgical intervention, interventional radiology procedure, six or more units of blood transfused, or death within 24 hours. ^bSerious TBI defined as maximum head AIS ≥ 3 or intracranial procedure. ^cSerious chest injury defined as maximum thoracic AIS ≥ 3 or thoracic surgery. ^dSerious abdominal injury defined as maximum abdominal-pelvic AIS ≥ 3 or therapeutic laparotomy or pelvic surgery. ^eComposite defined as ISS ≥ 16, non-orthopedic surgery, or early mortality. Abbreviations: mAIS = maximum abbreviated injury scale; NR = Not Reported; ISS = Injury Severity Score; FTG = Field Triage Guidelines; TBI = traumatic brain injury.