Developing a national triage tool for use in NHS regional trauma networks: the MATTS mixed methods study.

内容摘要

There is currently wide variation in prehospital major trauma triage across the National Health Service, with regional ambulance services using different triage tools, varying in format, structure and variables. To develop a national triage tool that is acceptable, usable, accurate, and optimises under- and over-triage. A three-phase research programme, comprising Phase 1: development of a new triage tool by expert consensus informed by existing evidence, a systematic review of elderly triage, document analysis of current tools, decision-analytic modelling, expert consensus definition of a major trauma reference standard, and a qualitative examination of current triage; Phase 2: case-cohort study validating triage tools identified and developed in Phase 1, with identification of an optimally performing candidate triage tool; Phase 3: evaluation of the candidate triage tool following implementation, including cohort study investigating accuracy of triage decisions, cost-effectiveness analysis, and examination of user experiences. English regional trauma networks served by the South-Western, West Midlands, Yorkshire and London Ambulance Services. Phase 2 case-cohort study and Phase 3 cohort studies performed between 1 November 2019 and 28 February 2020, and 1 November 2021 and 15 May 2022, respectively. Injured patients presenting to ambulance services in participating regional trauma networks. In Phase 1, document analysis identified 19 United Kingdom triage tools and 34 published international tools. The systematic review demonstrated limited diagnostic accuracy of triage tools in the elderly, with divergent real-life triage decisions. The reference standard included the need for critical trauma-related interventions, significant individual anatomical injuries, burden of multiple minor injuries and specific patient attributes. Decision-analytic modelling indicated that high-specificity triage tools were favoured. Triage tool simplicity and the option for clinical judgement were valued by stakeholders, but real-world triage was a multifaceted, nonlinear, dynamic and multiagency process. Following review of Phase 1 evidence, a three-step Major Trauma Triage Study candidate triage tool targeting relatively higher specificity was developed through expert consensus. The Phase 2 case-cohort sample included 2757 patients, with a weighted prevalence of major trauma of 3.1% (95% confidence interval 2.3% to 4.0%). The Major Trauma Triage Study tool performed optimally compared to under- and over-triage targets (sensitivity 37.3%, specificity 95.1%). In Phase 3, the newly implemented Major Trauma Triage Study triage tool was received favourably by stakeholders. Prehospital triage decisions using the new tool demonstrated a sensitivity of 55.3% (95% confidence interval 51.8% to 58.7%) and specificity of 94.3% (95% confidence interval 94.1% to 94.6%, n = 38,010, 2.2% prevalence of major trauma). Minimal differences were apparent between the costs (£149) and benefits (0.006 quality-adjusted life-years) of triage decisions, regardless of the triage tool used, reflecting similar real-life triage accuracy. However, the new Major Trauma Triage Study tool appeared cost-effective when theoretical triage tool performance was examined, demonstrating an incremental cost effectiveness ratio of £21,163. The Major Trauma Triage Study triage tool performed optimally, targeted an appropriate under-/over-triage trade-off, and was perceived to perform well by stakeholders. National implementation could ensure evidence-based, standardised and cost-effective triage. Significant variation in National Health Service ambulance service and trauma network configurations could limit the generalisability of results. Paediatric triage, pre-alerting and the benefit of remote clinical support could benefit from future research. This trial is registered as Current Controlled Trials ISRCTN17968752. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/16/04) and is published in full in Health Technology Assessment; Vol. 30, No. 34. See the NIHR Funding and Awards website for further award information. Treatment in specialist hospitals, called major trauma centres, can improve survival after serious injury. Ambulance crews use a triage tool, a checklist of patient and injury features, to help them recognise whether a patient is seriously injured and indicate that early care in a major trauma centre care would be beneficial. The presence of serious injury is not always obvious. Taking patients with minor injuries to the major trauma centre (‘over-triage’) wastes time, money and resources. In contrast, failing to recognise serious injury (‘under-triage’) could result in less effective treatment and a worse outcome. Each NHS ambulance service currently uses a different triage tool, and this project aimed to develop a new national tool to get the right patient to the right place at the right time. The project had three phases. In Phase 1, background work was completed to help design the new triage tool. This work was carefully considered by a panel of experts who then designed a new triage tool (the ‘Major Trauma Triage Study tool’). In Phase 2, the accuracy of the Major Trauma Triage Study tool was compared with other current triage tools in 2607 patients from four ambulance services. The Major Trauma Triage Study tool was shown to perform best, achieving the best balance of under- and over-triage. In Phase 3, the Major Trauma Triage Study tool was introduced into practice in two ambulance services and information was collected on 38,010 patients. When ambulance crews using the tool thought early major trauma centre care was not needed, 99% of patients had injuries that could be safely managed initially in non-specialist hospitals. However, ambulance crews highlighted that they did not always use the tool, and often preferred using their own judgement. Wider implementation of the Major Trauma Triage Study tool might therefore have a limited impact on outcomes but could potentially improve the consistency of triage decisions.