• Austin Yoder, Eric H Bradburn, Madison E Morgan, Tawnya M Vernon, Kellie E Bresz, Brian W Gross, Alan D Cook, and Frederick B Rogers.
• From the Trauma Services (A.Y., E.H.B., M.E.M., T.M.V., K.E.B., F.B.R.), Penn Medicine Lancaster General Health, Lancaster, Pennslyvania; Robert Larner, MD College of Medicine at the University of Vermont (B.W.G.), Burlington, Vermont; and University of Texas Health Science Center at Tyler (A.D.C.), UT Health East Texas, Tyler, Texas.
• J Trauma Acute Care Surg. 2020 May 1; 88 (5): 704-709.

BackgroundWhile issues regarding triage of severely injured trauma patients are well publicized, little information exists concerning the difference between triage rates for patients transported by advanced life support (ALS) and basic life support (BLS). We sought to analyze statewide trends in undertriage (UT) and overtriage (OT) to address this question, hypothesizing that there would be a difference between the UT and OT rates for ALS compared with BLS over a 13-year period.MethodsAll patients submitted to Pennsylvania Trauma Outcomes Study database from 2003 to 2015 were analyzed. Undertriage was defined as not calling a trauma alert for patients with an Injury Severity Score (ISS) of 16 or greater. Overtriage was defined as calling a trauma alert for patients with an ISS of 9 or less. A logistic regression was used to assess mortality between triage groups in ALS and BLS. A multinomial logistic regression assessed the adjusted impact of ALS versus BLS transport on UT and OT versus normal triage while controlling for age, sex, Glasgow Coma Scale, systolic blood pressure (SBP), pulse, Shock Index and injury year.ResultsA total of 462,830 patients met inclusion criteria, of which 115,825 had an ISS of 16 or greater and 257,855 had an ISS of 9 or less. Both ALS and BLS had significantly increased mortality when patients were undertriaged compared with the reference group. Multivariate analysis in the form of a multinomial logistic regression revealed that patients transported by ALS had a decreased adjusted rate of undertriage (relative risk ratio, 0.92; 95% confidence interval, 0.87-0.97; p = 0.003) and an increased adjusted rate of OT (relative risk ratio, 1.59; 95% confidence interval, 1.54-1.64; p < 0.001) compared with patients transported by BLS.ConclusionCompared with their BLS counterparts, while UT is significantly lower, OT is substantially higher in ALS-further increasing the high levels of resource (over)utilization in trauma patients. Undertriage in both ALS and BLS are associated with increased mortality rates. Additional education, especially in the BLS provider, on identifying the major trauma victim may be warranted based on the results of this study.Level Of EvidenceEpidemiological, Level III.

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