1002 EMT-P JUDGMENT
EM"-P JUDGMENT
Paramedic Judgment of the Need for Trauma Team
Activation for Pediatric Patients
A. KEMPF, DO,
KHAJISTA QAZI, MD, MS, JEFFREY
NORMANC. CHRISTOPHER,MD, LOWELLW. GERSON,PHD
Abstract. Objective: To determine the value of
paramedic judgment in determining the need for
trauma team activation (TTA) for pediatric blunt
trauma patients. Methods: A prospective, observa-
tional study was conducted a t the ED of Children's
Hospital Medical Center of Akron between July 12,
1996, and February 28,1997, in cooperation with Ak-
ron Fire Department emergency medical techni-
cian-paramedics (EMT-Ps). The ED provides on-line
and off-line medical control for pediatric transports.
Patients with minor or no identifiable injuries are re-
leased a t the scene with the instructions to see a phy-
sician. The remainder are transported to the ED. The
decision for TTA is based on ED trauma protocols a s
well a s emergency physician judgment of injury se-
verity in combination with the judgment of the treat-
ing paramedic. During the study, EMT-Ps were asked
(before physician input) whether, based solely on
their judgment, a patient needed TTA. Patients 0-14
years old who were involved in motor vehicle crashes,
bike crashes, or falls from a height of 210 feet were
included in the study. TTA was defined as necessary
if the patient was admitted to the intensive care unit
(ICU) or operating room (OR) for nonorthopedic sur-
gical procedures. Out-of-hospital, ED, and hospital
records were reviewed. Coroners' records as well a s
medical records of all trauma admissions during the
study period were reviewed to ensure that the pa-
tients released a t the scene were not mistriaged. Re-
sults: One hundred ninety-two patients met study
criteria. Eighty-five patients (44%) were transported
to the ED, of whom 12 had TTA. EMT-Ps requested
TTA for 10 of these patients, and 2 patients had TTA
per ED trauma protocol. Two of the patients who
were judged by EMT-Ps to need TTA were admitted
T RAUMA triage protocols that are used to de-
termine the need for trauma team activation
From the Division of Emergency and Trauma Services, Chil-
dren's Hospital Medical Center of Akron (KQ, JAK, NCC), Ak-
ron, OH, and Division of Community Health Sciences (LWG),
Northeastern Ohio Universities College of Medicine, Roots-
town, OH.
Received J a n u a r y 1, 1998; revision received May 27, 1998; ac-
cepted J u n e 3, 1998. Presented a t the American Academy of
Pediatrics annual meeting, New Orleans, LA,October 1997.
Supported in p a r t by a grant from Akron Children's Hospital
Foundation.
Address for correspondence and reprints: Khajista Qazi, MD,
Children's Hospital Medical Center of Akron, One Perkins
Square, Akron, O H 44308-1062. Fax: 330-258-3761; e-mail:
kqazi@chmca.org
Qazi et al.
to the ICU/OR, and neither of the patients identified
by ED trauma protocol to require TTA were admitted
to the ICU/OR. Two initially stable patients who did
not have ITA deteriorated after arrival to the ED.
Both were admitted to the ICU. The sensitivity and
specificity of paramedic judgment of the need for "A
for pediatric blunt trauma patients were 50% (95%
CI 9.2-90.8) and 87.7% (95% CI 78.0-93.6), respec-
tively. The positive and negative predictive values
were 16.7% (95% CI 2.9-49.1) and 97.3% (95% CI
89.6-99.5). None of the patients released a t the scene
was mistriaged based on the review of the coroners'
and trauma admission records. Conclusion: Results
of this investigation indicate that a small percentage
of pediatric blunt trauma patients require TTA. EMT-
P judgment alone of the need for TTA for pediatric
blunt trauma patients is not sufficiently sensitive to
be of clinical use. The low sensitivity is explained by
the deterioration in the clinical condition of 2 initially
stable patients. The paramedic disposition decisions
from the scene were always accurate. Nontransport
by emergency medical services (EMS) may be accept-
able in some uninjured pediatric trauma patients. In-
jured pediatric trauma patients who appear to be sta-
ble may deteriorate shortly after injury. However, if
a pediatric patient appears injured, transport from
the scene and examination by a trauma specialist are
needed. Finally, the role of paramedic judgment must
be further defined by larger studies with urban, ru-
ral, and suburban EMS systems before it can be used
as a sole predictor of "A. Key words: emergency
medical technicians; trauma; judgment; assessment;
pediatrics. ACADEMIC EMERGENCY MEDICINE
1998; 5:1002-1007
"M'A) consider physiologic, anatomic, and mecha-
nism of injury This protocol-based ap-
proach to trauma care may lead to over- or under-
triage of trauma victims. An ideal trauma triage
system with no undertriage and minimum overtri-
age does not exist for adult or pediatric trauma
patients. Physiologic and anatomic trauma triage
criteria may not be obvious or readily available on
the scene, resulting in transport of patients to fa-
cilities not properly equipped for their manage-
ment. Such undertriage may delay appropriate pa-
tient care and adversely affect patient outcome.
Blunt injury mechanisms are poor predictors of
injury severity in adult and pediatric trauma

ACADEMIC EMERGENCY MEDICINE October 1998, Volume 5. Number 10
TTA based on mechanism of injury
alone leads to overtriage and inefficient utilization
of trauma center resources, and may prove to be
cost-ineffective.B-l1 Several studies of adult trauma
patients attempted to assess the value of emer-
gency medical technician-paramedic (EMT-P)
judgment of trauma patients as a n alternative
t o objective trauma triage instruments. EMT-P
judgment of adult trauma patients is comparable
to that of out-of-hospital trauma triage instru-
m e n t ~ . ’ * - Inclusion
’~ of EMT-P perception of injury
severity in the triage decision process increases the
sensitivity of select out-of-hospital trauma triage
criteria.16J6 No published studies have evaluated
the use of EMT-P judgment of injury severity in
pediatric blunt trauma patients. Involvement of
paramedics in the triage decision process may po-
tentially improve the quality of triage decisions by
minimizing both undertriage and overtriage. The
objective of this preliminary study was to estimate
this potential by determining the accuracy of par-
amedic judgment in predicting the need for TTA
for pediatric blunt trauma patients.
METHODS
Study Design. This prospective study was con-
ducted at the ED of Children’s Hospital Medical
Center of Akron between July 12, 1996, and Feb-
ruary 28, 1997, in cooperation with the Akron Fire
Department and Emergency Medical Services
(EMS) system. The study was approved by the in-
stitutional review board.
Setting and Population. Children’s Hospital
Medical Center of Akron serves as the sole tertiary
pediatric care center for 17 counties. The ED has
an annual census of approximately 50,000 visits
with 500 trauma admissions. Pediatric emergency
physicians supervise patient care in the ED 24
hours a day.
The Akron Fire Department has 13 EMS
squads that serve a n area of 62.2 square miles
with a relatively stable population of 223,000 peo-
ple. The system responds to approximately 4,200
pediatric calls annually. All squads are staffed ex-
clusively by EMT-Ps. The EMT-Ps are taught the
Akron Fire Department trauma protocol prior to
starting their duties as paramedics. The EMT-Ps
are required to take Pediatric Advanced Life Sup-
port (PALS) and Basic Trauma Life Support
(BTLS) courses, as well as continuing education
lectures on trauma. The PALS course includes a
lecture on trauma resuscitation; the BTLS course
was designed for out-of-hospital care providers and
emphasizes recognition and assessment of trauma
in the out-of-hospital setting. The quality assur-
ance officer at Akron Fire Department reviews all
15532712, 1998, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1998.tb02780.x by Cochrane Saudi Arabia, Wiley Online Library on [20/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1003
TABLE1. ED Protocol for Trauma Team Activation
Blunt or vehicular trauma + burn or inhalation injury
Death in the same automobile/vehicle
Fall from >20 feet
Penetrating injury to the head, neck, or torso
Paralysis
Extremity amputation proximal to the knedelbow
Pelvic fracture
T w o or more long bone fractures
Pediatric trauma score 5 8
trauma run reports regularly to provide feedback
on performance as needed. The trauma run reports
also are reviewed by the EMS coordinator at the
ED. Assessment and out-of-hospital management
of trauma patients are discussed in the monthly
run reviews. In addition, lectures are given on
trauma assessment and management in the run
reviews.
Patients 0-14 years of age injured in motor ve-
hicle crashes (MVCs), bike crashes or falls from a
height of >10 feet who were evaluated by City of
Akron EMT-Ps were eligible for study. Medical di-
rection for pediatric transports is proved on-line by
ED attending physicians and by written (off-line)
protocols.
Study Protocol. The approved procedure for dis-
position of trauma patients is that the EMT-Fs an-
alyze the information available at the scene and
establish contact with medical control. Trauma pa-
tients who are determined to have minor or no in-
juries may be released at the scene, based on par-
amedic judgment in conjunction with on-line
medical control. All scene-released patients are
given instructions to follow-up with their physi-
cians. All other injured patients are transported to
the ED. The planned level of response in the ED
is determined by a preexisting protocol (Table 1) or
on-line medical control, taking into consideration
the treating paramedic’s assessment of injury se-
verity. Those patients who qualify by either crite-
ria are evaluated by a trauma team. The leader-
ship and composition of trauma team are shown in
Table 2. When TTA is considered necessary, the
members of the trauma team are summoned to the
ED prior to patient arrival. Patients who are trans-
ported to the ED, but are judged not to need TTA,
are initially evaluated by the ED medical staff.
Surgical consultation is later obtained as appro-
priate. A senior surgery resident is available for
consultation 24 hours a day. The on-call surgery
attending is available immediately and within 15
minutes of the patient’s arrival during the regular
business hours and after hours, respectively. Dur-
ing the study, at the time the report was called by
the EMT-P to the ED, the treating paramedics
 15532712, 1998, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1998.tb02780.x by Cochrane Saudi Arabia, Wiley Online Library on [20/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1004 EMT-P JUDGMENT Qazi et al. E m - P JUDGMENT

TABLE2. Leadership and Composition of t h e Trauma Team ED. The EMT-P responses were based solely on
Leadership their judgments of severity of injury. The para-
Surgery attending* medics did not calculate a formal trauma score. No
extra training was given to the EMT-Ps or the ED
Composition dispatch officers. Standing patient care policies
ED attending* and procedures were not altered during the study.
Surgery resident
Two ED nurses
Laboratory technician Measurements. Out-of-hospital, ED, and hospi-
Respiratory therapist tal records were abstracted for patient demograph-
Radiology technician ics, disposition from the scene and ED, and final
Nursing supervisor diagnoses. Patients with incomplete records were
Anesthesia resident?
excluded (n = 1).We reviewed medical records of
OR personnelt
all trauma admissions during the study period to
*The ED attending is the t r a u m a team leader until the surgery ensure that no patient released at the scene was
attending arrives to the ED within 20 minutes after trauma mistriaged. In addition, coroners of the 17-county
team activation ('ITA).
t T h e operating room (OR) supervisor is notified of t h e patient's
referral base as well as Cuyahoga County, located
arrival. The anesthesia attending arrives to the ED within 20 directly north of Akron, were surveyed.
minutes after "A.
Data Analysis. TI'A was defined as necessary if
TABLE3. Demographics, Injury Mechanisms, and Scene the patient was admitted to the intensive care unit
Dispositions of the Study Subjects (ICU) or operating room (OR) for nonorthopedic op-
erative procedures. Admission to the ICU/OR was
Age-mean -t SD 7.6 2 4.2y r
used as a criterion standard for calculation of sen-
Sex sitivity, specificity, and predictive values. Epi Info
Male 100 (52.0%) (USD Inc., Stone Mountain, GA) was used for data
Female 92 (48.0%) analysis. Mean values a r e reported as t standard
deviation.
Injury mechanism
Motor vehicle crash 137 (71.3%)
Bicycle crash 42 (21.9%) RESULTS
Fall from a height of >10 ft 13 (6.8%)
One hundred ninety-two patients met the study
Scene disposition criteria. Fifty-two percent of the patients were
ED 85 (44.3%)
Home 107 (55.7%)
male, and the average age for all the patients was
7.6 5 4.2 years. MVCs were the leading mecha-
nism of injury, followed by bike crashes and falls
were asked to determine the level of response re- (Table 3). Eighty-five patients (44%) were trans-
quired in the ED. Their responses were recorded ported to the ED. Of these, 12 (14.1%) had TTA.
on the dispatch form by the dispatch officer in the Two patients who were judged not to need TTA

TABLE4.Characteristics of Patients with Trauma Team Activation (TTA) and/or Intensive Care Unitloperating Room (ICUI
OR) Admission
TT Mechanism Disposition Length of ICU
Activation of Injury ICU/OR Stay (Days) Final Diagnosis
Yes MVC* Yes Liver laceration
Yest Bike crash Yes Intracranial hematoma a n d closed head injury
No Fall Yes Liver laceration
No MVC Yes Subdural hematoma and basilar skull fracture
Yes MVC No Open fracture of tibidfibula
Yes MVC No Superficial soft-tissue injury
Yes MVC No Open fracture of tibia
Yes MVC No Open fracture of tibidfibula and open fracture of ulna
Yes MVC No Closed head injury
Yes MVC No Superficial soft-tissue injury
Yes$ MVC No Superficial soft-tissue injury
Yes Fall No Superficial soft-tissue injury
Yes$ Fall No Superficial soft-tissue injury
Yes Fall No Closed head injury
*MVC = motor vehicle crash.
tTTA per emergency medical technician (EMT) judgment and per ED trauma protocol.
ST" per ED trauma protocol; t h e remainder of the patients had TTA per EMT judgment.
 15532712, 1998, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1998.tb02780.x by Cochrane Saudi Arabia, Wiley Online Library on [20/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ACADEMIC EMERGENCY MEDICINE October 1998,Volume 5, Number 10 1005

eventually required it. TTA was a t the request of TABLE5. Accuracy of Paramedic Judgment for Dauma
the treating paramedics in 9 cases, and according Team Activation
to ED trauma protocol in 2 (Table 1). One patient Intensive Care
was judged to need TTA both by paramedics and UniUOperating
ED trauma protocol (pediatric trauma score Room Admission
18). Yes No Total
Two of the 10 patients judged by paramedics to
Paramedic recommendation
require TTA were admitted to the ICU or OR, and Yes 2 10 12
neither of the 2 patients identified by ED protocol No 2 71 73
as requiring TTA required admission. Two patients
who were not identified prospectively as requiring TOTAL 4 81 85
TTA were admitted to the ICU. Both patients were
asymptomatic with stable vital signs upon arrival
to the ED, but deteriorated within the first 30 attempted to establish the sensitivity of paramedic
minutes of their evaluation and treatment. One judgment for assessment of injury severity in order
had sustained a liver laceration as a result of a fall to determine alternatives to traditional trauma
from a height of 12 feet, the other a basilar skull scores. In a prospective study,15 the inclusion of
fracture in an MVC. EMT-P perception of injury to select anatomic,
The characteristics of the 14 patients who had physiologic, and mechanism-of-injury criteria in-
TTA and/or ICU/OR admission are shown in Table creased the sensitivity of the criteria. A prospective
4. The sensitivity and specificity of paramedic study by Emerman et a1.I2found that the EMT pre-
judgment of the need for TTA for pediatric blunt dictions of mortality and the need for emergent op-
trauma patients were 50% (95% CI 9.2-90.8) and eration were as accurate as 3 trauma scores. In a
87.7% (95% CI 78.0-93.61, respectively, and the prospective study, Fries et al.13 reported that the
positive and negative predictive values were 16.7% paramedic judgment of the need for trauma center
(95% CI 2.9-49.1) and 97.3% (95% CI 89.6-99.5) resources was more sensitive than the trauma tri-
(Table 5). No patient released at the scene was age rule proposed by Baxt e t a1.22A retrospective
later hospitalized for sustained injuries. The sur- study by Ornato et al.14 showed that paramedic
vey of coroners' records revealed no trauma deaths judgment was better at identifying patients in
among patients released by paramedics at the need of major surgery than the patients' trauma
scene of their injuries. scores. Esposito e t a1.16 found that EMT judgment
alone was a low-yield out-of-hospital triage crite-
DISCUSSION rion to identify major trauma patients. Adding
mechanism-of-injury criteria to EMT-P judgment
An accurate assessment of injury severity in the improved accuracy in identifying major trauma.
out-of-hospital setting is an essential component of These findings were corroborated by a study by
the decision-making process for TTA. The appro- Hedges et al.23Most of the studies cited had either
priate use of a trauma team is important for safe, no or inadequate numbers of pediatric patients.
efficient, and cost-effective utilization of ED and Our study suggests t h a t neither preestablished
~ ~ J ~ trauma scoring sys- criteria nor paramedic judgment may be sufficient
hospital r e s o ~ r c e s . Several
tems have been evaluated for use in the out-of-hos- in the determination of the need €or TTA in pedi-
pita1 setting. Their relatively low sensitivity pre- atric blunt trauma patients. Both over- and under-
cludes their use as out-of-hospital trauma triage triage occurred. The overtriage occurred in 83%
t o ~ l s . Application
~~J~ of the pediatric trauma score (10/12) of the patients with TTA who did not re-
(PTS)has been advocated for assessing severity of quire ICU/OR. Of greater concern, there was a n
injury of pediatric trauma victims in the out-of- undertriage rate of 14.2% (2114) for the patients
hospital setting. Proponents suggest that a PTS of who required ICU/OR but did not have TTA.
4 8 indicates the need for treatment at a pediatric Our results also emphasize that physiologic de-
trauma center.20 Detractors suggest PTS scoring, rangements may occur after arrival to ED. The 2
including the use of this cutoff point for transport patients who deteriorated after arrival to the ED
to a pediatric trauma center, has its drawbacks. A were initially asymptomatic. The patients were
retrospective study by Aprahamian et a1.21 re- transported to the ED because the mechanism of
ported that 17% of pediatric trauma patients with injury was considered significant by the treating
a PTS of 2 8 were admitted to the OR and 9%were EMT-Ps and the on-line medical control. One child
admitted to the ICU. The accuracy of the PTS for had flipped over twice after being hit by a motor
recognizing severely injured children was shown to vehicle moving a t 25 miles per hour. The second
be only 68% in another retrospective study.20 child had fallen from a height of 12 feet. If the en-
Several studies of adult trauma patients have tire study population is taken into account (n =
 15532712, 1998, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1998.tb02780.x by Cochrane Saudi Arabia, Wiley Online Library on [20/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1006 EMT-P JUDGMENT Qazi e t al. EMT-P JUDGMENT

192), based on review of coroners' and trauma ad- and/or rural communities. In addition, level of
mission records, there was no undertriage among training and ongoing education of EMTs may vary
the patients who were not transported to the ED. from one EMS system to another. Future studies
Our tiered out-of-hospital and ED trauma response should look at the judgments of paramedics who
systems discourage overtriage. In our study, sever- serve in different practice settings. Moreover, im-
ity of injury of 2 patients who later required ICU pact of the level of training and ongoing education
admission could not be predicted in the out-of-hos- on EMT judgment of pediatric blunt trauma pa-
pita1 setting. The outcome of these patients was tients is another interesting area for future studies
unaffected because of immediate availability of re- to explore. Determination of factors that help
sources for specialized pediatric trauma care. The EM% make their decisions regarding injury sever-
resources needed by pediatric trauma patients ity of pediatric blunt trauma patients is another
differ significantly from those needed by adult interesting area for future studies.
trauma patients. Therefore, pediatric trauma tri-
age schemes should be designed to ensure timely CONCLUSIONS
care for those pediatric trauma patients who may
develop symptoms and signs consistent with major Results of this preliminary investigation indicate
trauma after arrival to the ED. Improved pediatric that a small percentage of pediatric blunt trauma
trauma triage will result from research on the con- patients require TTA. EMT-P judgment alone of
tribution of individual physiologic, anatomic, and the need for "A for pediatric blunt trauma pa-
mechanism-of-injury factors in predicting injury tients is not sufficiently sensitive to be of clinical
severity in pediatric trauma patients. Emphasis on use. The low sensitivity is explained by the dete-
improved education and training of general emer- rioration in the clinical conditions of 2 initially sta-
gency physicians in pediatric trauma care may ble patients. The paramedic disposition decisions
prove to be helpful in the appropriate initial man- from the scene were always accurate. Nontrans-
agement of pediatric patients when undertriage of port by EMS may be acceptable in some uninjured
initially stable patients does occur. Expanded pediatric trauma patients. Injured pediatric
paramedic education and training in pediatric trauma patients who appear to be stable may de-
trauma assesssment also are important in making teriorate shortly after injury. However, if a pedi-
accurate triage decisions. atric patient appears injured, transport from the
scene and examination by a trauma specialist are
LIMITATIONS AND FUTURE QUESTIONS needed. Finally, the role of paramedic judgment
must be further defined by larger studies with ur-
Our ED receives patients from 17 counties. To en- ban, rural, and suburban EMS systems before it
sure consistency, we limited our study to the Akron can be used as a sole predictor of TTA.
EMS system. This contributed to a relatively low
number of TTAs. The presence of only one tertiary The authors thank Akron Fire Department paramedics for
pediatric care center in Akron, the size of the city, their cooperation in the study.
and a relatively stable population influence our
out-of-hospital triage system. For this reason, we
have reservations about generalizing the results of References
our study to EMS systems that function in larger, 1. Emerman CL. Trauma triage: where do we go from here?
more urban communities with several hospitals [commentary]. h a d Emerg Med. 1995; 2:1025-6.
committed to pediatric trauma care. Rural EMS 2. Eastman AB, Lewis FR, Champion HR, Mattox KL. Re-
paramedics operate in areas in which transport to gional trauma system design: critical concepts. Amer J Surg.
1987; 154179-84.
a tertiary pediatric care center may be impractical 3. American College of Surgeons Committee on Trauma. Re-
because of prolonged transport time. In addition, source Document for Optimal Care of the Injured Patient. Chi-
paramedics from rural settings may not have ade- cago: ACS, 1993.
4. Long WB, Bachulis BL, Hynes GD. Accuracy and relation-
quate experience in the assessment and triage of ship of mechanisms of injury, trauma score, and injury sever-
pediatric trauma patients. These special situations ity score in identifying major trauma. Am J Surg. 1986; 151:
warrant the need for different strategies for safe 581-4.
5. Knopp R, Yanagi A, Kallsen G, Geide A, Doehring L. Mech-
pediatric trauma care for different practice set- anism of injury and anatomic injury a s criteria for prehospital
tings. trauma triage. Ann Emerg Med. 1988; 17:895-902.
This initial report suggests the need for larger 6. Walker PJ, Cass DT. Paediatric trauma: urban epidemiol-
ogy and an analysis of methods for assessing the severity of
studies in a variety of EMS systems. Since severe trauma in 598 injured children. Aust N Z J Surg. 1987; 57:
injury in pediatric blunt trauma patients is uncom- 715-22.
mon, a larger sample size is likely to include more 7. Henry MC, Alicandro JM, Hollander JE, Moldashel JG,
Cassara G, Thode HC Jr. Evaluation of American College of
patients with a need for TTA. The EMS systems in Surgeons trauma triage criteria in a suburban and rural set-
the United States operate in urban, suburban, ting. Am J Emerg Med. 1996; 14:124-9.

ACADEMIC EMERGENCY MEDICINE October 1998, Volume 5, Number 10
6. Simon BJ, Legere P, Emhoff T, Fiallo VM,Garb J . Vehicular
trauma triage by mechanism: avoidance of the unproductive
evaluation. J Trauma. 1994; 37:645-9.
9. Shatney CH, Sensaki K. Trauma team activation for ‘mech-
anism of injury‘ blunt t r a u m a victims: time for a change? J
Trauma. 1994; 37:275-82.
10. Phillips JA, Buchman TG. Optimizing prehospital triage
criteria for trauma team alerts. J Trauma. 1993; 34:127-32.
11. Hoff WS, Tinkoff GH, Lucke JF, Lehr S. Impact of minimal
injuries on a level I t r a u m a center. J Trauma. 1992; 33:408-
12.
12. Emerman CL, Shade B, Kubincanek J. A comparison of
EMT judgment and prehospital trauma triage instruments. J
Trauma. 1991; 31:1369-75.
13. Fries GR, McCalla G, Levitt MA, Cordova R. A prospective
comparison of paramedic judgment and the trauma triage rule
in the prehospital setting. Ann Emerg Med. 1994; 24:885-9.
14. Ornato J , Mlinek E J , Craren E J , Nelson N. Ineffectiveness
of the trauma score and the CRAMS scale for accurately triag-
ing patients to trauma centers. 1985; 14:1061-4.
16. Simmons E,Hedges JR, Irwin L, Maassberg W, Kirkwood
HA. Paramedic injury severity perception can aid trauma tri-
age. Ann Emerg Med. 1995; 26:461-8.
16. Esposito T J , Offner PJ, Jurkovich G J , Griffith J , Maier RV.
I I
Determination of the Minimal Clinically Significant
Difference on a Patient Visual Analog
Satisfaction Scale
MD, HENRYC.THODEJR.,PHD
ADAM J. SINGER,
Abstract. Objective: To determine the minimal
clinically significant difference (MCSD) on a visual
analog patient satisfaction scale. Methods: The au-
thors prospectively collected patient satisfaction eval-
uations during a clinical trial assessing the effect of
introducing personal television sets on overall patient
satisfaction from their ED encounters. Patient satis-
faction was assessed with 2 scales: a 100-mm visual
analog scale (VAS) ( 0 = least satisfied, 100 = most
satisfied) and a 7-point categorical scale (“terrible,”
“mostly dissatisfied,” “mixed,” “partially satisfied,”
“mostly satisfied,” “pleased,” and “delighted”). The
differences between the mean VAS scores of “de-
lighted” and “pleased” patients, and between
“pleased” and “mostly satisfied” patients were used to
determine the MCSD on the VAS. Reliability of each
of the scales was determined. Results: 181 patients
From the Department of Emergency Medicine, State Univer-
sity of New York at Stony Brook, Stony Brook, NY ( A J S ,HCT).
Received February 9, 1998; revision received May 26, 1998;
accepted J u n e 3, 1998. Presented at the SAEM annual meet-
ing, Chicago, IL, May 1998.
Address for correspondence and reprints: Adam J . Singer, MD,
Department of Emergency Medicine, University Hospital and
Medical Center, ~ 4 - 5 1 5 ,Stony Brook, ~y 11794-7400, Fax:
516-444-3919; e-mail: asinger@epo.som.sunysb.edu
15532712, 1998, 10, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1998.tb02780.x by Cochrane Saudi Arabia, Wiley Online Library on [20/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1007
Do prehospital t r a u m a center triage criteria identify major
trauma victims? Arch Surg. 1995; 130:171-6.
17. Tinkoff GH, O’Connor RE, Fulda GJ. Impact of a two-
tiered trauma Response in t h e emergency department: pro-
moting efficient resource utilization. J Trauma. 1996; 41:
735-40.
18. Ochsner MG, Schmidt JA, Rozycki GS, Champion HR. The
evaluation of a two-tiered t r a u m a response system a t a major
trauma center: is it cost effective and safe? J Trauma. 1995;
39:971-7.
19. Baxt WG, Berry CC, Epperson MD, Scalzitti V. The failure
of prehospital t r a u m a prediction rules to classify trauma pa-
tients accurately. Ann Emerg Med. 1989; 18:21-8.
20. Kaufman CR, Maier RV, Rivara FP, Carrico J . Evaluation
of the pediatric t r a u m a score. JAMA. 1990; 263:69-72.
21. Aprahamian C,Cattey RP, Walker AP,Gruchow HW, Sea-
brook G. Pediatric t r a u m a score. Arch Surg. 1990; 125:1128-
31.
22. Baxt WG, Jones G, Forlage D. The trauma triage rule: a
new, resource-based approach to t h e prehospital identification
of major trauma victims. Ann Emerg Med. 1990; 19:1401-6.
23. Hedges J R , Feero S, Moore B, Haver DW, Shultz B. Com-
parison of prehospital t r a u m a triage instruments in a semi-
rural population. J Emerg Med. 1987; 5197-208.
were evaluated. Mean age was 41 years; 59% were
female. On a subset of 19 patients, the VAS yielded
an interobserver correlation of 0.93. The kappa mea-
surement of agreement on the categorical scale was
0.77. The mean difference between “delighted” and
“pleased” patient VAS satisfaction scores was 6.8 mm
(95% CI, 1.3-12.3 mm). The mean difference between
“pleased” and “mostly satisfied” patient VAS satisfac-
tion scores was 10.7 mm (95% CI, 5.5-15.8 mm).
Conclusion: The MCSD in patient satisfaction scores
measured with a 100-mm VAS was approximately
7-11 mm. Future studies evaluating differences in
patient satisfaction should be designed to detect this
difference. Key words: patient satisfaction; visual an-
alog scale; clinical significance; reliability; validity.
ACADEMIC EMERGENCY MEDICINE 1998; 5:
1007-1011
1 N TODAY’S consumer-oriented health care
marketplace, it is more important than ever to
develop reliable and valid measures of patient sat-
isfaction. Currently, most measurements of patient
satisfaction are based on verbal-rating Likert-type
categorical scales.’-” One of the problems associ-
ated with these semantic differential scales is a re-
sponse bias known as acquiescent bias. This is the