The Journal of TRAUMA威 Injury, Infection, and Critical Care

Trauma Team Activation and the Impact on Mortality

Robert A. Cherry, MD, Tonya S. King, PhD, Daniel E. Carney, MD, PhD, Patrick Bryant, MD,
and Robert N. Cooney, MD

Background: Trauma centers use in-
jury mechanism, physiology, and anatomic
criteria to determine the extent of trauma
team activation (TTA). We examined
whether physiologic variables in our three-
tier TTA system stratified patients appro-
priately by injury severity and mortality.
Methods: The trauma registry at
our Level I trauma center was retro-
spectively reviewed for full (level 1 or
L1), partial (level 2 or L2), and limited
(level 3) adult TTA. Data were collected
on age, injury severity score (ISS), hos-
pital length of stay, systolic blood pres-
sure (SBP), heart rate, respiratory rate
(RR), Glasgow coma score (GCS), and
intubation status. Penetrating injuries,
traumatic arrests, and interfacility
transfers were excluded. Data are me-
dian (25%–75%). Statistical analysis
included hazard ratios (HzR), Kruskal-
Wallis, ␹2, and survival analyses. The p
value overall was <0.05, and pair wise
was <0.05 versus L1.
Results: There were 494 adult TTAs
for blunt injury from the scene out of
1,969 admissions. Variables associated
with mortality (HzR; 95% confidence in-
terval) by univariate analysis include SBP
<90 (9.4; 4.2, 21.2), RR >29 or <10 (17.8;
4.8, 66.0), intubation status (4.5; 2.3, 8.9),
and GCS <8 (9.7; 4.8, 19.9). When com-
bined in a multivariate model to evaluate
multiple predictors simultaneously, SBP
<90 and GCS <8 appear to be the stron-
gest predictors of mortality (RR and intu-
bation were not significant in the presence
of SBP and GCS). The three-tier system
identified patients with increased ISS and
early (<4 weeks) mortality risk. There
was a statistically significant difference
in survival between L1 and L2 at 38
days, but not for >38 days ( p ⴝ 0.739).
Conclusions: TTA criteria selected
patients with greater ISS and early mor-
tality, but impact on long-term survival
may not be appreciated. Full TTA criteria
for blunt injury may be limited to GCS
<8, SBP <90, RR >29 or <10, and intu-
bation status.
J Trauma. 2007;63:326 –330.

T
riage criteria have long been used by prehospital personnel
at the scene to sort out patients based on immediate need
for treatment and available resources. These criteria are
mainly based on mechanism of injury, physiology, and anatomy.
Extremes of age and comorbidities also play an important role in
triage. Prehospital triage criteria have also been integrated into
triage decision schemes used to determine whether transport to
a regional trauma center is medically appropriate.1 Trauma cen-
ters often use these same criteria to determine the extent of
trauma team activation and resource utilization needed in the
emergency department.
Our trauma center uses a three-tier system of trauma
team activation (TTA) to allocate resources appropriately in
the trauma bay. This study attempts to validate our TTA
system and determine whether we are appropriately stratify-
ing potentially unstable patients by injury severity and mor-
tality through the use of physiologic criteria.
Submitted for publication Mar 2, 2007.
Accepted for publication May 15, 2007.
Copyright © 2007 by Lippincott Williams & Wilkins
From the Departments of Surgery (R.A.C., D.E.C., P.B., R.N.C.) and
Public Health Sciences (T.S.K.), Milton S. Hershey Medical Center, Her-
shey, Pennsylvania.
Presented as a poster at the 65th Annual Meeting of the American Asso-
ciation for the Surgery of Trauma, September 28 –30, 2006, New Orleans,
Louisiana.
Address for reprints: Dr. Robert A. Cherry, MD, FACS, The Milton S.
Hershey Medical Center, MC H075, Hershey PA 17033; email: rcherry@
psu.edu.
DOI: 10.1097/TA.0b013e31811eaad1
MATERIALS AND METHODS
The trauma registry (Collector, Digital Innovation, For-
est Hill, MD) at our Level I state-designated trauma center
was retrospectively reviewed during the 2004 calendar year.
Trauma patients who met criteria for trauma team activation
were enrolled.
Our three-tier system of trauma team activation is de-
fined as follows: full (level 1 [L1]), partial (level 2 [L2]), and
limited (level 3 [L3]). The composition of the team is shown
in Table 1. The trauma attending is required to be present for
L1 activations. Physiologic variables from the prehospital
setting and upon arrival to the emergency department (ED)
are used to determine the level of trauma team activation. We
first determined the incidence of physiologic instability by
TTA. These variables included systolic blood pressure (SBP)
⬍90 mm Hg, heart rate (HR) ⬎120 beats per minute (bpm),
respiratory rate (RR) ⬎29 or ⬍10 breaths per minute
(breaths/min), and Glasgow coma score (GCS) ⬍8. In addi-
tion, intubation status and prehospital fluid infusion informa-
tion were obtained. We then investigated the relationship
between specific physiologic variables and mortality.
Finally, the relationship between activation level, age,
injury severity score (ISS), hospital length of stay (LOS), and
mortality was examined. Penetrating injuries, traumatic ar-
rests, and interfacility transfers were excluded. The destina-
tion of patients leaving the ED was also ascertained.
For the statistical analysis, Kaplan-Meier survival esti-
mates and piecewise proportional hazards model was used for
mortality variables. Nonparametric Kruskal-Wallis analyses

326 August 2007

 Trauma Team Activation Impact on Mortality

Table 1 Composition of Trauma Teams by Level of Table 2 Analysis of Differences Between Row
Activation Percentages for Physiologic Variables
Level 1 trauma team Level 1 Level 2 Level 3 p Value
Trauma surgery attending Scene HR ⬎120 bpm 18.4% 1.5% 0% ⬍0.001
Emergency medicine attending ED HR ⬎120 bpm 17.3% 5.0% 9.1% ⬍0.001
PGY4 or PGY5 surgical resident Scene SBP ⬍90 mm Hg 7.1% 0.9% 0% 0.062
1–2 Junior surgical residents ED SBP ⬍90 mm Hg 8.9% 1.4% 3.0% ⬍0.001
Anesthesiology attending Scene RR ⬎29 or ⬍10 27.0% 7.8% 5.9% ⬍0.001
Anesthesiology resident breaths/min
PGY3 radiology resident or attending ED RR ⬎29 or ⬍10 17.9% 9.1% 6.1% 0.023
2 Emergency department nurses breaths/min
1 Chaplain Prehospital fluid 48.1% 26.5% 20.7% ⬍0.001
X-ray personnel ⬎500 mL
EMT
Level 2 trauma team Data was evaluated using Cochran-Mantel-Haenszel ␹2 test.
Emergency medicine attending HR, heart rate; ED, Emergency Department; SBP, Systolic blood
PGY4 or PGY5 surgical resident pressure; RR, respiration rate.
1–2 Junior surgical residents
Anesthesiology attending
Anesthesiology resident Table 3 Variables Predictive of Mortality by
PGY3 radiology resident or attending Univariate Mortality
2 Emergency department nurses
1 Chaplain p Value Hazard Ratio 95% CI
X-ray personnel ED SBP ⬍90 mm Hg ⬍0.01 9.4 4.2, 21.2
EMT Scene RR ⬎29, ⬍10 ⬍0.01 17.8 4.8, 66.0
Level 3 trauma team breaths/min
Emergency medicine attending Intubation ⬍0.01 4.5 2.3, 8.9
Emergency medicine PGY 3 resident ED GCS ⬍8 ⬍0.01 9.7 4.8, 19.9
Emergency medicine PGY 2 resident
Trauma services PGY4 resident ED, Emergency Department; SBP, Systolic blood pressure; RR,
1 Emergency department nurse respiration rate; GCS, Glasgow Coma Scale.
1 Chaplain
X-ray personnel intubation status (⬍0.01; 4.5; 2.3, 8.9), and GCS ⬍8 (⬍0.01;
EMT 9.7; 4.8, 19.9) (Table 3). The amount of prehospital fluid
EMT, Emergency Medical Technician. volume infused was also shown to be significantly associated
with mortality (0.03; 1.5; 0.91, 2.6). Survival was found to be
were required for continuous or ordinal variables. ␹2 analyses 66.7% for patients infused with more than 2,000 mL of
were used to evaluate categorical variables. The median and crystalloid (n ⫽ 16), compared with 91.9% for patients with
25th and 75th percentiles were reported as summary statistics infusions of 500 to 2,000 mL (n ⫽ 146), 94.4% for those with
for quantities with skewed distributions. Statistical analyses less than 500 mL (n ⫽ 62), and 94.6% if there was no
were performed using SAS Version 9 (SAS Institute Inc., crystalloid given (n ⫽ 39). This was not true for scene SBP
Cary, NC). All p values ⬍0.05 were used to denote signifi- ( p ⫽ 0.17), ED HR ( p ⫽ 0.66), scene HR ( p ⫽ 0.45), and ED
cant differences between study groups. RR ⬎29 or ⬍10 breaths/min ( p ⫽ 0.12). However, it was
The Institutional Review Board at the Penn State Milton noted that RR ⬎29 or ⬍10 breaths/min at the scene was
S. Hershey Medical Center approved the study with a waiver significantly associated with mortality (⬍0.01; 17.8; 4.8,
of informed consent. 66.0).
When combined in a multivariate model to evaluate
RESULTS multiple predictors simultaneously, ED SBP ⬍90 mm Hg and
During the calendar year 2004, our trauma center eval- GCS ⬍8 appear to be the strongest predictors of mortality.
uated 1,969 patients. There were 494 adult trauma team Those with an ED SBP ⬍90 mm Hg were 6.6 times more
activations that met criteria for the study. All of these patients likely to die (95% CI 2.8,15.8) and those with a GCS ⬍8
had blunt trauma and were direct transfers from the scene. were 9.9 times more likely to die (95% CI 4.6,15.8). RR and
The three-tier system selected out patients who presented intubation were not significant in the presence of SBP and
with scene and ED HR ⬎120 bpm, ED SBP ⬍90 mm Hg, GCS.
scene and ED RR ⬎29 or ⬍10 breaths per minute, and A general association statistic was generated using the
volume of prehospital fluid infused (Table 2). Cochran-Mantel-Haenszel ␹2 analysis to evaluate the distri-
Physiologic variables associated with mortality ( p value; bution of patients leaving the ED. There was a statistically
hazard ratios [HzR]; 95% confidence interval [CI]) by uni- significant difference in the destination of patients leaving the
variate analysis include ED SBP ⬍90 (⬍.01; 9.4; 4.2, 21.2), ED by level of trauma activation ( p ⬍0.01) (Table 4).

Volume 63 • Number 2 327

 The Journal of TRAUMA威 Injury, Infection, and Critical Care

Table 4 Distribution of Patients Leaving the Emergency Department Based on Level of Trauma Activation
Floor SICU OR IMC Died Burn Center Home Total

Level 1 25 74 50 14 8 2 1 174
14.4% 42.5% 28.7% 8.1% 4.6% 1.2% 0.57%
Level 2 109 50 52 74 0 2 0 287
38.0% 17.4% 18.1% 25.8% 0% 0.7% 0%
Level 3 20 1 9 3 0 0 0 33
60.6% 3.0% 27.35 9.1% 0% 0% 0%
Total 154 125 111 91 8 4 1 494
SICU, Surgical intensive care unit; OR, operating room; IMC, intermediate care.

in survival between L1 and L2 at 38 days, but not for ⬎38

Table 5 Age, ISS, Hospital LOS, and Mortality for the
days ( p ⫽ 0.739) (Fig. 1).
3 Types of Trauma Activations
Level 1, Level 2, Level 3,
N ⫽ 174 N ⫽ 287 N ⫽ 33 DISCUSSION
Age 41 (25–55) 43 (28–58) 42 (28–57) Several studies have shown that there is a benefit to a
ISS* 22 (14–34) 14 (9–21)** 10 (5–17)* tiered trauma response system for both adult and pediatric
Hospital LOS* 7 (3–18) 4 (2–7)** 3 (2–5)* patients.2–7 Resources are mobilized and tailored to meet the
Mortality (2 wk)* 17% 3%** 0%
Mortality (4 wk)* 21% 6%** 0% needs of the injured patient based on strict criteria. The intent
Mortality (6 wk) 26% 25% 3% is to distribute relatively scarce resources in a safe and cost-
ISS, injury severity score; LOS, length of stay.
effective manner. Triage criteria are typically categorized
* Overall p ⬍ 0.05; ** pair wise p ⬍ 0.05 vs. L1. into physiologic, anatomic, and mechanism of injury criteria
Data on age (years), ISS, and hospital LOS (days) are expressed to stratify trauma patients by injury severity.
in median ⫾25th and 75th percentile. Our study demonstrated that our three-tier trauma acti-
vation protocol appropriately stratified those patients with
The trauma team activation protocol identified patients hemodynamically concerning physiologic variables. Patients
with increased injury severity and early (ⱕ4 week) mortality who presented to the ED with tachycardia (HR ⬎120 bpm),
risk (Table 5). There was a statistically significant difference hypotension (SBP ⬍90 mm Hg), respiratory insufficiency

Fig. 1. Survival curves for the three types of trauma activations.

328 August 2007


(RR ⬎29 or ⬍10 breaths/min), and were significantly cap-
tured and evaluated by the full trauma team. This was also
true for patients who were infused larger volumes of crystal-
loid during the prehospital phase of care.
Furthermore, some of these variables, such as ED hypo-
tension, intubation, GCS ⬍8, and respiratory insufficiency at
the scene, were predictive of mortality using a univariate
model. The strongest predictors were ED hypotension and
GCS ⬍8 in the multivariate analysis. Based on this study, we
did change HR ⬎120 bpm from an L1 trauma team criterion
to L2. Our trauma performance improvement committee is
monitoring this change carefully.
The most sensitive criteria for stratifying patients include
physiologic criteria, such as hypotension.8 –11 Our study did
demonstrate that SBP ⬍90 mm Hg was one of the strongest
predictors for mortality. According to Wuerz et al.,12 despite
the high sensitivity of physiologic criteria, other criteria
should be used in conjunction with physiologic criteria to
increase specificity. We recommend that SBP ⬍90 mm Hg
and GCS ⬍8 be used in combination to stratify patients.
Several studies have found that combining both physio-
logic and anatomic criteria are particularly useful criteria in
the triage scheme decision for trauma patients.13–15 In one
study, physiologic criteria were combined with mechanism of
injury to identify the most severely injured patients.16 Mech-
anism of injury alone, however, does not appear to be helpful
in identifying severely injured patients.1,5,11
Tinkoff et al.9 found that endotracheal tube intubation
predicted intensive care unit admission, operative interven-
tion, and mortality. In our study, endotracheal intubation was
predictive of mortality by univariate analysis, but we were
unable to demonstrate this finding when using a multivariate
model to evaluate multiple predictors simultaneously. Husum
et al.10 found respiratory rate to be predictive of mortality.
However, this study was conducted in an area with minefields
in two developing countries and results. This result was not
shown in our study.
A GCS of less than 8 and, more specifically, the GCS
motor response component, has been shown to predict
mortality.9,17 Prehospital GCS also predicts hospital admis-
sion after motor vehicle crashes.18 Our investigation showed
that GCS and SBP ⬍90 mm Hg were the strongest predictors
of mortality.
L2 and L3 trauma patients were most commonly admit-
ted to the floor (38% and 61%, respectively), but L1 trauma
patients were admitted to the intensive care unit (43%). Al-
though L1 and L3 trauma patients had equivalent admission
rates to the operating room from the ED (28.7% vs. 27.4%),
the cases involving L3 patients were nonemergent, orthope-
dic procedures.
Based on the above analyses, our trauma center modified
our trauma team activation protocol. Although intubation
status was associated with mortality on univariate analysis
only, we moved this criterion from an L2 to an L1 TTA.
There were relatively few intubated patients activated as an
Volume 63 • Number 2
Trauma Team Activation Impact on Mortality
L2 TTA at our institution (n ⫽ 15). We therefore did not
think this would place undue stress on our resources relative
to our patient safety needs. In addition, GCS ⬍8 was clearly
defined as an L1 trauma team activation. Because HR ⬎120
bpm was not associated with mortality, this criterion was
changed from an L1 to an L2 TTA.
Interestingly, the three-tier trauma activation system did
select out patients appropriately by ISS. This was reflected in
the statistically significant differences in early (4-week) mor-
tality. However, at 39 days postinjury, there were no statis-
tically significant differences between mortality of L1 and L2
trauma patients (26% vs. 25%, respectively) despite signifi-
cant differences in ISS (22 vs. 14, respectively). Trauma
attending presence is required for L1 TTA, but not for L2
activations.
The impact of trauma attending presence during the
initial resuscitation has been studied previously. Khetarpal et
al.19 conducted a comparative study of two American College
of Surgeons Level I trauma centers. One of the centers had
in-house attending call coverage and mandatory presence for
all trauma activations. The other trauma center had out-of-
house coverage and the attending was not required to be
present for all trauma activations. In-house trauma attending
coverage was associated with shorter resuscitations times and
reduced times to incision for emergency operations. The
study did not demonstrate a difference in mortality between
the two trauma centers.
In another study comparing two designated trauma cen-
ters, one with in-house 24-hour coverage and the other with
a 15-minute trauma attending response from home, the
trauma attending response was found to be equivalent with no
significant differences in outcome.20 A voice-paged trauma
alert activation that allows for adequate advanced notification
and accurate prehospital information may have been respon-
sible for the favorable outcomes. On the other hand, a his-
torical control study that investigated the implementation of
in-house attending call coverage at one trauma center resulted
in a significant reduction in mortality.21
Although it is concerning that required trauma attending
presence may not be impacting late (6-week) mortality, we
have no plans to alter this part of our protocol. We think that
trauma attending presence, when used appropriately, may be
life saving in individual cases that may not be borne out in
this study. In addition, the importance of bedside teaching of
residents, physician extenders, medical student, and nurses is
invaluable in maintaining consistency and quality of care.
Finally, trauma surgeons are able to identify important op-
portunities for performance improvement, during the resus-
citations, that benefits all of our patients in the long run.
There are several limitations to this study. We did not
specifically design the study to statistically evaluate certain
subgroups based on the level of trauma activation, such as
time to operating room for truncal hemorrhage. Similarly, we
do not know if trauma team activation makes a difference in
traumatic bran injury associated with hypoxia and hypoten-
329
 The Journal of TRAUMA威 Injury, Infection, and Critical Care
sion during the resuscitative phase of care. One must also be
cautious in the use and interpretation of trauma triage criteria
that were originally designed for triaging patients from the
scene to a designated trauma center. Triage criteria that are
used instead for the purpose of selecting the level of trauma
team activation may have a different sensitivity. Finally, our
institutional experience may not be transferable to other
trauma centers in which the experience and expertise of Level
II trauma team members may be different.
In conclusion, GCS ⬍8 and SBP ⬍90 mm Hg are pre-
dictive of mortality and should be used as criteria for full
TTA in adult blunt trauma. RR ⬎29 or ⬍10 breaths/min, and
intubation status were not as strongly associated with mor-
tality. TTA criteria also stratified patients appropriately by
ISS and early mortality. Unfortunately, full TTA in cases of
adult blunt trauma did not impact late (6-week) mortality.
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