P2B031: A Failure to Activate: Factors Associated with Under-triage of Pediatric Major Trauma Victims

Background: Traumatic injuries are the leading cause of death for children in the United States. In hospital-based settings, trauma team activations ensure prompt, comprehensive bedside resources at the time of patient arrival. Measures of hospital-based under-triage include the failure to trigger “highest-level” activations for both patients meeting prehospital criteria as well as those with “major trauma”, who ultimately require substantial resources for stabilization. The objective of this study was to identify factors associated with under-triage of pediatric victims of major trauma.

Methods: We performed a retrospective cross-sectional study of children < 16 years using the 2021 American College of Surgeons (ACS) National Trauma Data Bank, excluding children with primary injury mechanisms of burns or drownings and those missing activation level or emergency department (ED) disposition. We considered differing criteria for critical trauma, including pre-hospital criteria developed by the ACS (hypotension, intubation, Glasgow coma score [GCS] < 9, and proximal penetrating injury) and three sets of major trauma criteria: the Cribari Matrix (CM; injury severity score >15), Need for Trauma Intervention (NFTI; procedural interventions, transfusion needs, intensive care, and/or early mortality), and Standard Triage Assessment Tool (STAT; combination of CM and NFTI). We defined children who were under-triaged as those meeting each set of criteria who did not receive a highest-level activation. We evaluated the proportion of children under-triaged for each set of criteria and described their demographic, trauma, and transport/hospital characteristics. We performed univariable and multivariable logistic regression to determine factors associated with STAT under-triage, excluding out-of-ED transfers.

Results: We included 109,920 children. Of these, 6.0% met criteria for highest-level activation per the ACS, while 9.1%, 13.0%, and 4.9% met criteria for major trauma per the CM, NFTI, and STAT, respectively. Of those meeting criteria, 29%, 56%, 58%, and 33% were under-triaged, respectively (Table 1). In multivariable analysis of 5,129 children with major trauma (Table 2), factors associated with higher odds of under-triage included falls and striking mechanisms, arrival by private vehicle, and transfers from outside hospitals. Factors associated with lower odds of under-triage included objective measures of clinical instability (hypotension, low GCS, intubation, tachycardia, hypothermia), penetrating mechanisms (firearms, cut/pierce), arrival by flight, and evaluation at adult level 1 or pediatric level 2 trauma centers.

Conclusion: Regardless of criteria, many children with major trauma were under-triaged, exposing them to potentially higher mortality and morbidity. While most children with major trauma with vital sign instability or high-risk penetrating mechanisms were triaged appropriately, those with lower-risk histories, such as private vehicle arrivals or fall mechanisms, were frequently under-triaged. Future work should seek to develop risk-stratification systems that are both sensitive and specific at identifying children with major trauma, particularly those with blunt traumatic mechanisms.