Criteria for Retriage to Improve Trauma Induced Coagulopathy and hemorrhage Associated Lethality

About This Grant

Project Summary/Abstract Injury is the most common cause of death in people 46 years of age and younger. Bleeding from injury (trauma-induced hemorrhage) is the second leading cause of injury-associated death and the most common cause of preventable death. Annually, 70-100,000 Americans suffer a preventable death from trauma-induced hemorrhage. These deaths could be prevented were patients to receive timely care (e.g., hemostatic resuscitation and hemorrhage control procedures within two hours of injury) in hospitals that specialize in injury care (e.g., high level trauma centers). These high-level trauma centers have the equipment, blood products, medications, massive transfusion protocols and staff 24 hours a day, 7 days a week to provide hemostatic resuscitation and hemorrhage control procedures. These resources and services are not available at non- specialized hospitals. Management of bleeding requires timely procedures to stop the bleeding as well as medications and blood transfusions to prevent blood from thinning (trauma-induced coagulopathy). Our previous work demonstrated that the most common reason patients were not quickly transferred (retriaged) from non-specialized hospitals to another specialized high-level trauma center was because clinicians did not know who should be retriaged. There are no national retriage guidelines. Our literature review demonstrated only 22 out of 50 states in the United States have any retriage guidelines. Even among states that have retriage guidelines, most guidelines are very vague (e.g., hypotension requiring blood transfusions). This application’s broad, long-term objective is to improve the timeliness of care of trauma-induced hemorrhage. We propose to comperehensively determine who should be quickly retriaged to specialized high-level trauma centers, and determine if state-of-the-art approaches to informing retriage decisions could improve timliness of treatment and reduce death rates. This study’s first specific aim will identify which patients and injuries have the greatest reduction in death rates upon retriage from non-specialized to specialized high-level trauma centers using Causal Graphical Models. The second aim will understand which patient injury and context attributes multi-speciality injury experts prioritize when making retriage choices using Discrete Choice Experiments. The third aim will determine if a protocol providing retriage decision support [PRotocol for OpMTimal reTRiage [PROMTR)] could improve time to treatment and death rates compared to usual care using Discrete Event Simulation. Upon demonstrating efficacy in improved timeliness of treatment and death rates in this simulation study, our future direction will be implementing and evaluating effectiveness of PROMTR in a Hybrid Type II Cluster Randomized Controlled Trial. This line of research has high potential to improve and standardize existing retriage practices, resulting in the reduction of preventable injury-associated death from bleeding.