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July 2018

Accuracy of Pediatric Trauma Field Triage: A Systematic Review

Author Affiliations
  • 1Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
  • 2Department of Surgery, Diakonessenhuis Utrecht-Zeist-Doorn, Utrecht, the Netherlands
JAMA Surg. 2018;153(7):671-676. doi:10.1001/jamasurg.2018.1050
Key Points

Question  What is the accuracy of prehospital trauma triage and diagnostic tests for identifying children in need of specialized trauma care?

Findings  In this systematic review, no field triage protocol was both highly sensitive and specific for classifying the need of specialized pediatric trauma care; no protocol alone complied with the international standard of at least 95% sensitivity. Regional triage quality regarding initial transportation destination was unknown.

Meaning  Inability of field triage protocols to identify children in need of specialized trauma care can lead to an incorrect choice of initial destination hospital, and this incorrect choice has been associated with higher mortality rates and increased costs.


Importance  Field triage of pediatric patients with trauma is critical for transporting the right patient to the right hospital. Mortality and lifelong disabilities are potentially attributable to erroneously transporting a patient in need of specialized care to a lower-level trauma center.

Objective  To quantify the accuracy of field triage and associated diagnostic protocols used to identify children in need of specialized trauma care.

Evidence Review  MEDLINE, Embase, PsycINFO, and Cochrane Register of Controlled Trials were searched from database inception to November 6, 2017, for studies describing the accuracy of diagnostic tests to identify children in need of specialized trauma care in a prehospital setting. Identified articles with a study population including patients not transported by emergency medical services were excluded. Quality assessment was performed using a modified version of the Quality Assessment of Diagnostic Accuracy Studies–2.

Findings  After deduplication, 1430 relevant articles were assessed, a full-text review of 38 articles was conducted, and 5 of those articles were included. All studies were observational, published between 1996 and 2017, and conducted in the United States, and data collection was prospective in 1 study. Three different protocols were studied that analyzed a combined total of 1222 children in need of specialized trauma care. One protocol was specifically developed for a pediatric out-of-hospital cohort. The percentage of pediatric patients requiring specialized trauma care in each study varied between 2.6% (110 of 4197) and 54.7% (58 of 106). The sensitivity of the prehospital triage tools ranged from 49.1% to 87.3%, and the specificity ranged from 41.7% to 84.8%. No prehospital triage protocol alone complied with the international standard of 95% or greater sensitivity. Undertriage and overtriage rates, representative of the quality of the full diagnostic strategy to transport a patient to the right hospital, were not reported for inclusive trauma systems or emergency medical services regions.

Conclusions and Relevance  It is crucial to transport the right patient to the right hospital. Yet the quality of the full diagnostic strategy to determine the optimal receiving hospital is unknown. None of the investigated field triage protocols complied with current sensitivity targets. Improved efforts are needed to develop accurate child-specific tools to prevent undertriage and its potential life-threatening consequences.

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