3.2 Trauma Team Activation (TTA)

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Description of Indicator

Relationship to Quality Medical care should be safe
Type of Indicator Hospital process, Hospital Level
Proposed Data Source Hospital Medical Records
Definition Number of injured patients admitted to ED who satisfy local TTA guidelines AND for whom there is a TTA per 100 patients*
Numerator All injured patients age 18 years and older admitted to the ED who satisfy local TTA guidelines AND for whom there is a TTA*
Denominator All injured patients age 18 years and older admitted to the ED who satisfy local TTA guidelines*
Benchmark Not specified at present
Risk Adjustment Not applicable

* Ideally local TTA guidelines should be employed. Alternatively presence of physiological compromise (RR < 10 or > 29 breaths per minute or intubated or GCS < 9 or SBP < 90 mmHg) or a major anatomic injury (penetrating injury to head, neck, torso, extremities proximal to elbow or knee, flail chest, > 2 proximal long-bone fractures, crush, degloved or mangled extremity, amputation proximal to wrist and ankle, pelvic fracture, open or depressed skull fracture, paralysis) derived from the field triage published by the CDC9,10 may be employed.

This indicator is intended to monitor TTA and identify deviations from local guidelines that warrant individual patient review.

Panel Review
Panelists expressed that this indicator may allow for opportunities to review situations in which the trauma team is not activated for patients satisfying TTA criteria. They noted that there are some issues that will make implementation of this indicator difficult as it is unclear if there is a common trigger that could be used across centers. Panelists noted that each institution has their own scoring mechanism for activating a trauma team and often physicians and EMS simply use their own judgment. It was discussed that a common trigger could be based on physiological criteria (e.g. intubated, GCS < 9 or SBP < 90mmHg) or alternatively remain based on local guidelines. Panelists noted ISS to be an inappropriate trigger as it is calculated retrospectively.

Trauma Center Review
The trauma centers specified that this indicator helps to measure timeliness of trauma care, resuscitation and diagnostics. Like the previous indicator, the trauma centers noted that it is already in place in some systems and therefore the definition should be consistent with previously established guidelines (e.g. ASCOT)2. It was reported that this indicator must allow for local protocols to be used for TTA but recognized that this may complicate comparison between centers. Lastly, trauma centers noted there is a need to ensure that documentation is completed and consistent in order to evaluate this indicator.

Review of Literature & Evidence
Face Validity: No studies identified.
Construct Validity: One study demonstrated that the quality indicator was associated with reduced risk of ICU admission, but was not associated with hospital mortality36.
Reliability: No studies identified.
Risk Adjustment: Age, GCS, SBP, ISS and level of trauma care have been employed as variables for risk adjustment in studies examining this indicator for tiered TTA protocols37.
Utilization: Trauma Team Activation is as an indicator used by a large number of trauma centers: USA 49% (97/200), Canada 66% (23/35), Australasia 33% (4/12).
One study showed that GCS < 8 and SBP < 90 mmHg were predictors of mortality and should be taken into consideration for TTA in cases of adult blunt trauma38. Franklin et al. showed that prehospital hypotension (SBP < 90 mmHg) remains a valid indicator for TTA39. Sava et al. suggested the addition of truncal gunshot to TTA criteria40. One study described how a 3-tiered TTA protocol allowed for safe patient care with improved utilization of hospital resources41. Another study suggested that age > 70 years alone should be a criterion for TTA42. Rainer et al. suggested that compliance with TTA protocols optimized process of care and improved survival43. For the most part, studies in the literature have evaluated criteria incorporated into the field triage decision scheme proposed by the CDC9,10.

The quality indicator was proposed by Ruchholtz et al.35 and Willis et al.36.


2. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient 2006. Chicago: American College of Surgeons; 2006.
9. Centers for Disease Control and Prevention (CDC). CDC - Injury Prevention and Control: Field Triage - Guidelines for the Field Triage of Injured Patients. 2011; http://www.cdc.gov/fieldtriage/index.html. Accessed July 8, 2012.
10. Sasser SM, Hunt RC, Sullivent EE, et al. Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep. 2009;58(RR-1):1-35.
35. Ruchholtz S, Waydhas C, Lewan U, et al. A multidisciplinary quality management system for the early treatment of severely injured patients: implementation and results in two trauma centers. Intensive Care Med. 2002;28(10):1395-1404.
36. Willis CD, Stoelwinder JU, Cameron PA. Interpreting process indicators in trauma care: construct validity versus confounding by indication. Int J Qual Health Care. 2008;20(5):331-338.
37. Davis T, Dinh M, Roncal S, et al. Prospective evaluation of a two-tiered trauma activation protocol in an Australian major trauma referral hospital. Injury. 2010;41(5):470-474.
38. Cherry RA, King TS, Carney DE, Bryant P, Cooney RN. Trauma team activation and the impact on mortality. J Trauma. 2007;63(2):326-330.
39. Franklin GA, Boaz PW, Spain DA, Lukan JK, Carrillo EH, Richardson JD. Prehospital hypotension as a valid indicator of trauma team activation. J Trauma. 2000;48(6):1034-1037; discussion 1037-1039.
40. Sava J, Alo K, Velmahos GC, Demetriades D. All patients with truncal gunshot wounds deserve trauma team activation. J Trauma. 2002;52(2):276-279.
41. Claridge JA, Golob JF, Jr., Leukhardt WH, et al. Trauma team activation can be tailored by prehospital criteria. Am Surg. 2010;76(12):1401-1407.
42. Demetriades D, Chan LS, Velmahos G, et al. TRISS methodology in trauma: the need for alternatives. Br J Surg. 1998;85(3):379-384.
43. Rainer TH, Cheung NK, Yeung JH, Graham CA. Do trauma teams make a difference? A single centre registry study. Resuscitation. 2007;73(3):374-381.