Article Text

An evaluation of the use of a two-tiered trauma team activation system in a UK major trauma centre
  1. P Jenkins1,
  2. J Rogers2,
  3. A Kehoe2,
  4. J E Smith2,3,4
  1. 1University of Plymouth, Plymouth, UK
  2. 2Emergency Department, Derriford Hospital, Plymouth, UK
  3. 3Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK
  4. 4College of Emergency Medicine, UK
  1. Correspondence to Dr Jason E Smith, Emergency Department, Derriford Hospital, Plymouth PL6 8DH, UK; jasonesmith{at}


Objectives and background Appropriate activation of multidisciplinary trauma teams improves outcome for severely injured patients but can disrupt normal service in the rest of the hospital. Derriford Hospital uses a two-tiered trauma team activation system. The emergency department trauma team (EDTT) is activated in response to a significant traumatic mechanism; the hospital trauma team (HTT) is activated when this mechanism coexists with physiological abnormality or specific anatomical injury. The aim of this study was to compare characteristics, process measures and outcomes between patients treated by EDTTs or HTTs to evaluate the approach in a UK setting.

Methods A retrospective database review was performed using Trauma Audit Research Network (TARN) and the local source trauma database. Patients who activated a trauma team between 1 April and 30 September 2012 were included. Patients were categorised according to the type of trauma team activated. Data included time to X-rays, time to CT, time to intubation, numbers discharged from ED, intensive care unit admission, injury severity score and mortality.

Results During the study period, 456 patients activated a trauma team with 358 EDTT and 98 HTT activations. Patients seen by the ED team were significantly less likely to have severe injury or require hospital admission, intubation, emergency operation or blood transfusion. Differences in time taken to key investigations were statistically but not clinically significant.

Conclusions A two-tiered trauma team activation system is an efficient and cost-effective way of dealing with trauma patients presenting to a major trauma centre in the UK.

  • major trauma
  • trauma team activation
  • two-tier trauma team

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Traumatic injury is the commonest cause of death and disability in patients under 40 years old in Western countries.1 Outcome from traumatic injury can be optimised by the appropriate activation of a multidisciplinary trauma team to receive the patient on arrival at hospital, reducing time to effective diagnosis and intervention, influencing both morbidity and mortality.2 In a major trauma centre (MTC), in addition to seriously injured patients, a large number of less severely injured patients may also need to be treated.3 As activation of trauma teams is time and labour intensive, it is essential that resources are appropriately used. However, underactivation of a trauma team may lead to poorer outcomes.1 ,4

A two-tier activation system may be an appropriate system to manage trauma in a UK MTC. This approach consists of a smaller emergency department trauma team (EDTT) being activated in response to certain mechanistic triggers and a larger hospital trauma team (HTT) being activated according to additional specific physiological and anatomical criteria. If it becomes apparent that a patient who is the subject of an EDTT activation would benefit from the larger multidisciplinary team, then the trauma call can be escalated to a HTT response at any stage. Although this approach has been previously described in other countries, there have been no UK studies demonstrating the effectiveness and safety of such a system.5 Our hospital has used a two-tier system since 2005 and was designated as a MTC in April 2012. We suggest that a two-tier system distinguishes between patients with serious injuries requiring intervention and those less seriously injured, requiring less intensive treatment. In an age when healthcare is dominated by efficiency savings and lean methodology, a two-tier system may be the most appropriate way to manage trauma within the UK.6 ,7

Prealerts are received from the prehospital environment using the ATMIST structure (Age of the patient; Time of injury; Mechanism of injury; Injuries apparent; vital Signs; Treatment administered).8 Activation of trauma teams is then performed via switchboard and the ED intercom system using a predefined triage strategy (available as a web resource).5 These criteria are based on recommendations made by the American College of Surgeons (ACS) Committee on Trauma and Royal College of Surgeons modified according to local experience and clinical policy.4 ,9 Trauma teams are assembled prior to patient arrival and are briefed by the team leader with roles allocated and the expected resuscitation trajectory outlined. Data are transcribed in real time in trauma booklets by the scribe, and subsequently analysed by trauma nurse coordinators, who populate a local trauma database prior to data submission to the Trauma Audit Research Network (TARN).

The aim of this study was to compare characteristics, process measures, resource use and outcomes between patients treated by EDTT or HTT in our hospital to evaluate the approach in a UK setting.


Derriford Hospital ED receives approximately 90 000 patients per year and is the MTC within the Peninsula Trauma Network, where there are four other designated trauma units.

We conducted a retrospective analysis of all adult and paediatric trauma calls attending the ED during the period 1 April to 30 September 2012 using the local source trauma database and the national TARN database. TARN eligibility includes trauma patients of any age who are admitted to hospital for 72 h or more, are admitted to a critical care unit, die in hospital or are transferred to another hospital for specialist care. Specific patient groups, such as those aged over 65 years, who are admitted due to a fracture of the neck of femur, are excluded.10 ,11

Patients were categorised according to the type of trauma team activated to receive them (EDTT or HTT). Data collected included mechanism of injury, grade of trauma team leader, time to primary survey radiographs, time and nature of advanced imaging, interventions required in the resuscitation room, blood products used, prehospital vital signs, injury severity score (ISS), disposal and outcome. Patients transferred in from other centres were not included in this study as the two-tier activation system is not used for these patients in our trust (all are routinely met by a HTT, and time-critical investigations and interventions will usually already have been performed at the referring hospital). There were no other exclusion criteria. Patients in whom an EDTT was initially called, and then escalated to a HTT on arrival, were classified as HTT for the purposes of the analysis.

Although prehospital systems alert the department to the majority of trauma patients, occasionally cases are not appropriately alerted, or patients self-present following significant trauma. These patients were also taken into account, consulting the TARN database for those patients that did not receive a trauma team response. These were then cross-referenced with the ED electronic system to determine the appropriateness of care. Data analysis was performed using SPSS software (IBM Armonk, New York, USA). The study was registered with the Plymouth Hospitals NHS Trust Clinical Audit Department.


During the 6-month period, there were 456 primary trauma team activations. Of these, 358 patients (78.7%) prompted EDTT activation and 98 (21.3%) provoked a HTT response. A further 101 patients were transferred urgently from referring trauma units and either received a HTT response or bypassed the ED and were admitted directly to theatre, the intensive care unit (ICU) or specialist wards. This group was not included in our analysis.

Mechanism of injury differed somewhat between the two remaining groups (see table 1). Motor vehicle collision was the predominant mechanism in both groups, followed by falls from height.

Table 1

Data for patients who activated hospital and emergency department (ED) trauma teams

There was a significant difference in resource use between the two groups. Presence of an ED Consultant was achieved in 98% of HTT activations compared with 71% of the EDTT activations (p<0.01). Median time to whole-body CT was 41 min for HTT vs 51 min for EDTT (p<0.01). Endotracheal intubation was performed in 21% of HTT activations vs 1% of EDTT calls (p<0.01). Thirteen per cent of HTT activations required blood products within the initial resuscitation, while no EDTT activations required blood in the resuscitation phase.

Severity of injury differed between the groups. Sixty-three per cent of the HTT cohort met TARN eligibility criteria compared with only 20% of the EDTT cohort (p<0.01). For cases that were TARN eligible, median ISS was 22 in the HTT group vs 13 in the EDTT group (p<0.01). Only 9% of all EDTT calls had major trauma (ISS of 16 or more) compared with 43% of HTT calls and 85% of EDTT patients had an ISS 0–8 compared with 46% of HTT (p<0.01).

Forty per cent of patients who activated an EDTT call were discharged home from the ED compared with 7% of HTT calls. Thirty-seven per cent of HTT calls were admitted to theatre or ICU compared with 4% of EDTT patients (p<0.01). There was a small, non-significant difference in mortality between the two groups with 98.3% of EDTT calls surviving to discharge compared with 95.3% of HTT calls (p=0.15).

Thirty-three major trauma patients identified by the TARN database did not receive any trauma team response. Twenty-four (73%) were elderly patients (>65 years) with low-energy falls. Five of these patients had suffered complex intracranial injury, were treated expectantly and died.


This study shows that a two-tier trauma team activation system can accurately discriminate between higher and lower acuity trauma patients. Patients who activated the EDTT were significantly less likely to have severe injury or require hospital admission, intubation, emergency operation or blood transfusion.

There is no consensus as to what criteria should be used for trauma team activation, and little evidence to support the different systems used in the UK, most of which are based on guidance from the Royal College of Surgeons.9 Over-triage and under-triage are measures of the accuracy of any activation criteria. While over-triage is a lesser evil from a patient perspective, it burdens the trauma centre and system, affecting the treatment of other patients in the hospital, and it constitutes a poor use of resources.12 To achieve an under-triage rate of 5–10%, an over-triage rate of 30–50% may be needed.4 However, a critical part of any system using activation criteria is continuous peer review and refinement.13 ,14

However, by using a two-tiered TTA system, the impact of over-triage can be minimised to affect mainly the ED rather than the whole hospital, while under-triage can be minimised by refinement of criteria based on data from studies such as this.

For patients who received a trauma response, the under-triage rate in this study is 10.9% (39 patients who were ISS >15, required ICU admission, were admitted directly to the operating theatre, died in the ED or were immediately transferred out, who received an EDTT rather than HTT). This is consistent with other studies,15 ,16 and through continuous refinement of the trauma process and two-tier activation criteria this could be lowered further. This under-triage rate may be an overestimate, however, as 29 of these patients were admitted to ward environments for management of their injuries without further intervention in the ED, suggesting that the majority would have had their immediate needs met by the skills available within an EDTT. There was very little difference between the groups in time to key process steps such as primary survey X-rays or CT, and the rate of CT imaging in both groups was high, suggesting that access to resources was not inferior for patients met by an EDTT. The increasing rate of pan-CT in trauma patients is supported by evidence of a survival benefit.17 Mortality in both groups was low. Multidisciplinary review of the six deaths in the EDTT group found that outcome was not influenced by the lack of a HTT. In the HTT group, 55.1% of patients were appropriately triaged using the above definition with an over-triage rate of 44.9%.

In the EDTT group, the rate of over-triage would seem much higher (89.1%). However, all these patients would routinely require assessment by medical and nursing staff in the ED. The formal process of activating a trauma response for them simply front-loads this assessment using a small team led by a senior emergency physician, in keeping with the principles of early rapid assessment and without disrupting the wider hospital.18

This two-tiered trauma response allows patients who do not meet the criteria for a full HTT activation to still benefit from rapid assessment and expert decision making by a senior emergency physician with prompt access to radiology and laboratory investigations. The system should be flexible enough to allow escalation of the response to full HTT activation if it becomes apparent that the patient would benefit from the full multidisciplinary team.

Activating a HTT is disruptive to the wider hospital. Surgical and anaesthetic staff must suspend theatre lists, clinics and ward rounds to respond to the ED for an unpredictable amount of time. Plaisier et al3 quantified the financial cost of this disruption in an American MTC in 1998. In their institution, the introduction of a two-tiered system saved around 578 physician hours during the 6-month study period, which equated to savings of around £400 000 per annum. Using a similar economic model and data from this study, it is estimated that the cost saving of avoiding hospital team activation for those patients not requiring specialist care in our system could be £180 663 per annum.

Appropriate passage of prehospital information to the ED is key to the success of this system. In our institution, the ATMIST format is used to convey the necessary information both from the prehospital phase and on patient handover in the resuscitation room.8 Accurate vital signs, in particular, are necessary if an appropriate response is to be mounted.

Thirty-three major trauma patients (ISS >15) on the TARN database did not activate any trauma team response. These patients were scrutinised to identify reasons for non-activation of the two-tier system; 27 were caused by falls from standing height, a mechanism of injury not traditionally associated with major trauma.19 ,20 The remaining six were analysed in detail; two patients presented with a head injury following intoxication; one patient presented with a seizure with associated head injury; one patient presented with burn injuries following a house fire; one patient fell from a bicycle related to alcohol use; and an 86-year-old patient sustained a fall >2 m. Of these six patients, none died as a result of delayed care. Also, 5 of the 33 patients did not survive to discharge, all of whom were elderly patients with complex intracranial injury. All cases were subject to peer review through a weekly trauma review meeting, which concluded that mounting a full HTT response would be unlikely to have altered the outcome.

One addition to the EDTT activation criteria in our hospital, as a result of this work, has been to include head or torso injury in the elderly, who fall from standing height. This is in line with suggestions from other authors who have found that low-energy falls in the elderly were a common source of under-triage.20


Using a two-tiered trauma team activation system appears to be an effective and appropriate use of trauma resources. We have demonstrated that in a UK MTC, two-tiered trauma team activation criteria can accurately discriminate between more and less severely injured patients in terms of anatomical injury severity, requirement for hospital admission and use of hospital resources, thus allowing a more tailored response. Time and cost savings associated with avoiding disruptive HTT activation may be considerable.


The authors would like to thank the trauma nurse coordinators at Derriford Hospital for their help in collecting the data used in this study and the Trauma Audit Research Network (TARN).


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  • Contributors PJ and JR undertook the data collection, and wrote the initial manuscript. JES and AK conceived the study and revised subsequent versions of the manuscript. AK undertook the data analysis. All authors have seen and approved the final version of the manuscript.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.