j o u r n a l o f s u r g i c a l r e s e a r c h  n o v e m b e r 2 0 2 2 ( 2 7 9 ) 5 0 5 e5 1 0

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.JournalofSurgicalResearch.com

Predicting Unplanned Intensive Care Unit

Admission for Trauma Patients: The CRASH Score

Louis Prado, BS,a Stephen Stopenski, MD,a Areg Grigorian, MD,b

Sebastian Schubl, MD,a Cristobal Barrios, MD,a Catherine Kuza, MD,c
Kazuhide Matsushima, MD,b Damon Clark, MD,b
and Jeffry Nahmias, MD, MHPEa,*
a
Department of Surgery, University of California, Irvine, Orange, California
b
Department of Surgery, University of Southern California, Los Angeles, California
c
Department of Anesthesia, University of Southern California, Los Angeles, California

article info abstract

Article history: Introduction: Unplanned transfer of trauma patients to the intensive care unit (ICU) carries
Received 27 February 2022 an associated increase in mortality, hospital length of stay, and cost. Trauma teams need
Received in revised form to determine which patients necessitate ICU admission on presentation rather than
10 May 2022 waiting to intervene on deteriorating patients. This study sought to develop a novel Clinical
Accepted 11 June 2022 Risk of Acute ICU Status during Hospitalization (CRASH) score to predict the risk of un-
Available online 14 July 2022 planned ICU admission.
Methods: The 2017 Trauma Quality Improvement Program database was queried for pa-
Keywords: tients admitted to nonICU locations. The group was randomly divided into two equal sets
Risk calculator (derivation and validation). Multiple logistic regression models were created to determine
TQIP the risk of unplanned ICU admission using patient demographics, comorbidities, and in-
Trauma triage juries. The weighted average and relative impact of each independent predictor were used
Unplanned ICU admission to derive a CRASH score. The score was validated using area under the curve.
Results: A total of 624,786 trauma patients were admitted to nonICU locations. From 312,393
patients in the derivation-set, 3769 (1.2%) had an unplanned ICU admission. A total of 24
independent predictors of unplanned ICU admission were identified and the CRASH score
was derived with scores ranging from 0 to 32. The unplanned ICU admission rate increased
steadily from 0.1% to 3.9% then 12.9% at scores of 0, 6, and 14, respectively. The area under
the curve for was 0.78.
Conclusions: The CRASH score is a novel and validated tool to predict unplanned ICU
admission for trauma patients. This tool may help providers admit patients to the
appropriate level of care or identify patients at-risk for decompensation.
ª 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC
BY license (http://creativecommons.org/licenses/by/4.0/).

* Corresponding author. Department of Surgery, University of California, Irvine Medical Center, 333 The City Blvd West, Suite 1600,
Orange, CA. Tel.: þ1 714 456 5890; fax: þ1 714 456 6048.
E-mail address: jnahmias@hs.uci.edu (J. Nahmias).
0022-4804/$ e see front matter ª 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
https://doi.org/10.1016/j.jss.2022.06.039
506 j o u r n a l o f s u r g i c a l r e s e a r c h  n o v e m b e r 2 0 2 2 ( 2 7 9 ) 5 0 5 e5 1 0

Introduction deemed exempt by the Institutional Review Board of the

Early recognition of critical illness in trauma, and prompt
admission to the intensive care unit (ICU) is an important goal
of triage and management. Patients sent to the general wards
and subsequently transferred to the ICU are designated as
“unplanned” ICU admissions and have demonstrated worse
outcomes in multiple studies.1-6 However, few reports focus
on unplanned ICU admissions for the trauma population.7-9
Patients inappropriately triaged to lower acuity levels of
care are associated with “avoidable cardiac arrests, higher
rates of complications, and mortality”.10-13 Several risk factors
for unplanned ICU admission and patient decompensation
have previously been identified including older age, abnormal
vitals on admission, history of comorbid conditions (i.e., dia-
betes and liver or renal disease), and higher acuity triage
category.7,8,14-17 Utilizing these and other variables, prior
scoring systems such as the APACHE II, Modified Early
Warning Score (MEWS), and Predisposition, Infection,
Response, and Organ dysfunction score have been developed
to aid clinicians in evaluating the severity of illness to merit
ICU admission.18-20 However, none are specifically designed
with the purpose of predicting unplanned ICU admission for
the trauma population. In addition, some of these tools are
cumbersome and thus more useful for only research
purposes.21
Allocating patients to the appropriate level of care and
giving providers the objective foresight of which trauma pa-
tients are most likely to decompensate may decrease the rate
of rescue failure as well as unnecessary healthcare expendi-
tures. Thus, the ability to identify trauma patients who
necessitate ICU level of care and/or more closely monitor
high-risk patients would be helpful.
University of California, Irvine, and a waiver of consent was
granted as it utilized a deidentified national database.
The CRASH score was then derived using a three-step
methodology. First, univariate analyses of known risk fac-
tors for unplanned ICU admission were performed. These
variables were selected based on an in-depth literature review
and consensus among authors.7,8 All variables selected are
readily available after initial trauma workup and are consis-
tently reported within TQIP. The variables examined included
age, alcohol abuse, current anticoagulation use, medical
comorbidities (cirrhosis, dementia, chronic heart failure, hy-
pertension, peripheral arterial disease, renal disease, and
mental disorders), traumatic injuries (multiple rib fractures,
hemopneumothorax, pelvic fracture, traumatic brain injury ,
spinal injuries, injuries to the small bowel or bladder, and long
Table 1 e Development of the Clinical Risk of Acute ICU
Status during Hospitalization (CRASH) score using
regression coefficients of the variables significant for
unplanned intensive care unit admissions.
Variable Points
Demographics
Age 65 1
Comorbidities
Alcoholism 2
Anticoagulant use 1
Cirrhosis 2
Dementia 1

This study aimed to develop an objective and user-friendly Chronic heart failure 1
scoring system to help predict unplanned ICU admissions for Hypertension 1
trauma patients using clinical variables readily available at Peripheral arterial disease 1
admission to the practicing trauma surgeon including in- Mental disorder 1
juries, comorbidities, and vital signs.
Chronic renal failure 2
Injury
Multiple rib fractures 2
Methods
Pneumothorax 1

The 2017 Trauma Quality Improvement Program (TQIP) data- Hemothorax 1

base was queried to derive the Clinical Risk of Acute ICU Pelvis fracture 1
Status during Hospitalization (CRASH) score. TQIP is a multi- Small intestine 1
center database created by the American College of Surgeons Bladder 1
that collects comprehensive prospective trauma data.22 All Spinal cord 1
adult (18 y old) trauma patients admitted from the emer-
Lower extremity long bone fracture 1
gency department to nonICU levels of care (i.e., observation,
Traumatic brain injury 2
general floor, telemetry, or step-down unit) were included for
Cervical fracture 1
analysis. Patients admitted to the ICU or patients that were
transferred from another hospital were excluded. Patients Major surgery for respiratory system 3
were then randomized using the Markov chain approach23 Major surgery for gastrointestinal system 2
into two equal-sized groups. One group was used to derive Major surgery for hepatobiliary system 1
the CRASH score and the other group was used to validate the Major surgery for urinary system 1
score. The primary outcome was an unplanned admission to Maximum score 32
the ICU defined by TQIP as “Patients admitted to the ICU after
AUROC 0.78
initial transfer to the floor, and/or patients with an unplanned
95% CI for ROC 0.77-0.79
return to the ICU after initial ICU discharge”. This study was
 prado et al  risk of unplanned trauma icu admission 507

bone fractures), and requirement for major surgery. The need
for major surgery was defined within TQIP by ICD-10 codes.
Next, a multivariable forward stepwise logistic regression
model was performed using univariate analysis variables with
a P-value < 0.2. Within this model, risk factors with a P < 0.05
were identified for inclusion in the CRASH score. The odds
ratio of each risk factor was used to access the relative impact
and assign a point value, this was done by dividing by the
lowest common denominator (e.g., the lowest odds ratio) and
rounding off to the nearest whole integer. However, this
yielded noninteger numbers that were rounded to the nearest
whole number. Several iterations were developed to account
for small differences in rounding and error. For each iteration,
a receiver operating curve was generated and the area under
the receiver operating characteristic (AUROC) curve was
examined to assure consistency. In this study, the AUROC
measures the ability of the model to discriminate between the
presence of unplanned ICU admission versus its absence.
Last, the validation set was used to test the CRASH score
generated from the derivation set. The AUROC was calculated
and compared to the derivation set. All analyses were
performed with IBM SPSS Statistics for Windows (Version 24,
IBM Corp., Armonk, NY).
Results
A total of 624,786 trauma patients admitted to nonICU loca-
tions were identified. This was divided into two groups of
312,393 patients. The characteristics chosen for the derivation
and validation sets are shown in Table 1. There were no sig-
nificant differences between the two cohorts (P < 0.05). Within
the derivation set, the incidence of unplanned ICU admission
was 3769 (1.2%). A total of 24 independent risk factors of un-
planned ICU admission were identified; predictors included
age >65 y old, multiple comorbidities, trauma-related injuries,
and the need for major surgery. These independent risk fac-
tors were included in the multivariable logistic regression
(Table 2) and the CRASH score was derived with scores that
ranged from 0 to 32. In the validation set, the incidence of
unplanned ICU admission was 1.2%. The unplanned ICU
admission rate increased steadily from 0.1% to 3.9% then 9.4%

Table 2 e Multivariable logistic regression analysis for derivation of the CRASH score.
Characteristic OR CI P-value
Demographics
Age 65 1.54 1.42-1.67 <0.001
Comorbidities
Alcoholism 2.18 1.96-2.41 <0.001
Anticoagulant use 1.73 1.57-1.91 <0.001
Cirrhosis 2.34 1.90-2.65 <0.001
Dementia 1.21 1.06-1.38 0.005
Chronic heart failure 1.74 1.54-1.96 <0.001
Hypertension 1.63 1.51-1.76 <0.001
Peripheral arterial disease 1.53 1.16-2.02 0.003
Mental disorder 1.55 1.32-1.58 <0.001
Chronic renal failure 2.20 1.84-2.52 <0.001
Injury
Multiple rib fractures 2.42 1.96-2.88 <0.001
Pneumothorax 1.11 1.01-1.34 0.009
Hemothorax 1.24 1.05-1.48 0.013
Pelvis fracture 1.13 1.03-1.26 0.008
Small intestine 1.31 1.05-1.64 0.015
Bladder 1.12 1.02-1.24 0.009
Spinal cord 1.85 1.55-2.20 <0.001
Lower extremity long bone fracture 1.55 1.44-1.66 <0.001
Traumatic brain injury 2.39 1.89-2.71 <0.001
Cervical fracture 1.18 1.04-1.33 0.010
Major surgery for respiratory system 3.99 3.59-4.44 <0.001
Major surgery for gastrointestinal system 2.42 2.17-2.71 <0.001
Major surgery for hepatobiliary system 1.70 1.36-2.11 <0.001
Major surgery for urinary system 1.51 1.38-1.66 <0.001
508 j o u r n a l o f s u r g i c a l r e s e a r c h  n o v e m b e r 2 0 2 2 ( 2 7 9 ) 5 0 5 e5 1 0
at scores of 0, 6, and 12, respectively. The AUROC for both the
derivation and validation sets was 0.78 (Fig.).
Discussion
Unplanned ICU admission is a harbinger of adverse outcomes
and should be prevented when possible. Unplanned ICU ad-
missions constituting approximately 1%-9% of all ICU ad-
missions signifying an important metric for quality
improvement and further research.24 However, there are
limited resources to triage and guide admission disposition for
complex trauma patients with multi-system injuries. This
national analysis of trauma patients identified significant
predictors of unplanned ICU admission to include age 65 y
old as well as certain comorbidities such as alcohol use,
chronic renal failure, and cirrhosis. With respect to the
AUROC from our statistical analysis, the CRASH score is
demonstrated to be a good predictor of unplanned ICU
admission in trauma patients, with a score of 12 demon-
strating a 9.4% rate of unplanned admission.25-27
Since unplanned ICU admissions are associated with
increased hospital length of stay and cost, major organiza-
tions such as the American College of Surgeons Committee on
Trauma and The Joint Commission have identified it as an
Fig. e Unplanned intensive care unit admission rates for various Clinical Risk of Acute ICU Status during Hospitalization
(CRASH) scores.
important indicator of hospital performance.9,22,28-30 As such,
prior scoring systems such as the surgical APGAR score, have
been derived for patients undergoing elective or emergency
surgery.31,32 However, this score is primarily derived intra-
operatively, limiting its use as an effective triage tool for
trauma. Similarly, a score derived by Kongkaewpaisan et al.
examined the preoperative risk of unplanned ICU admission
for either elective or emergency general surgery and thus also
does not incorporate injury data which are a known predictor
of adverse outcomes for trauma.33-35 The CRASH tool gener-
ated in this study demonstrated good predictive capability
while using a manageable number of variables and informa-
tion that is readily available on admission and thus can be
incorporated into the daily care of trauma patients.
A single center study by Rubano et al. previously reported
on unplanned ICU admission in trauma patients.7 Their
multivariate analysis included risk factors overlapping with
ours such as major abdominal surgery, neurosurgery, or or-
thopedic surgery. They identified bleeding disorders and
transfers from outside hospitals as significant risk factors, but
their sample set was derived from a single suburban regional
trauma registry and had a sample size of 5411 with <2% of
their population comprised of penetrating trauma. Also, their
model incorporated the injury severity score, which is often
not calculated until patients are discharged. On the other
 prado et al  risk of unplanned trauma icu admission
hand, the CRASH score is derived and validated using a large
national sample making it more generalizable and utilizing
specific injuries which allow this tool to be calculated imme-
diately following clinical and imaging workup.
The proper allocation of patients to appropriate levels of
care is crucial to not only conserve resources and healthcare
costs, but also to decrease the rate of failure to rescue in this
population. Misallocation of surgical patients to nonICU levels
of care is associated with an increased rate of mortality, with
similar findings for readmission to the ICU in trauma pa-
tients.2,36 Thus, it is imperative for hospitals and trauma
providers to address the issue of unplanned ICU admissions
promptly, and the formulations of scoring systems such as
CRASH may provide an effective, simple, and useable solution
to mitigate these negative outcomes.
That said, there are many limitations to this study
including those inherent to a retrospective national database
such as reporting bias, misclassification, and missing data. In
addition, it is unclear whether certain information was
available at the time of presentation or later added to the
electronic medical record (e.g., patients with initial altered
mental status). Many trauma patients upon arrival have
altered mental status and thus information regarding their
comorbid conditions may be lacking, thereby limiting this
portion of the CRASH score. Also, information regarding the
indication for unplanned ICU admission is not available
within the TQIP database and was not standardized across
participating hospitals. Finally, even at the highest CRASH
score only w10% of the patients required unplanned ICU
admission thus this may not signify that all these patients
require ICU admission. At the least, this reflects a high-risk
population that could be monitored more closely and/or this
information taken into the backdrop of each individual pa-
tient’s clinical care to guide further decision making by
trauma providers. For patients whose clinical presentation
equivocates the need for ICU care, providers can use the
CRASH cutoff score of 12 to aid decision-making, knowing that
nearly 10% of those patients will worsen and necessitate
higher care if not admitted to the ICU upon presentation. In
addition, as technologies such as artificial intelligence are
developed and other variables are incorporated into medical
decision tools, the potential for further honing the risk pre-
diction ability of this tool is high. We recommend that cutoffs
for triage in other healthcare facilities be determined by local
population data, facility resources, and tolerance for and/or
ability to rescue following mis-triage.
Conclusions
CRASH is a novel and validated scoring tool derived from a
nationwide population that predicts unplanned ICU admis-
sion. This tool warrants further prospective validation and
assessment for its clinical utility to properly triage trauma
patients to ICU admission and/or improve clinical vigilance for
the early rescue of high-risk patients not admitted to an ICU.
Supplementary Materials
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.jss.2022.06.039.
509
Author Contributions
Drs Prado, Stopenski, Grigorian, and Nahmias had full access
to the data in the study and take responsibility for the integrity
and accuracy of the analysis. Dr Grigorian conceptualized and
designed the study together with the other coauthors. Drs
Stopenski, Grigorian, and Nahmias contributed to study
design, statistical analysis, and scientific interpretation of the
results. Dr Prado contributed to the manuscript with scientific
interpretation, drafting, and revision. All authors contributed
to critical revisions of the manuscript and approve the final
manuscript as submitted.
Disclosure
None declared.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Statement of Ethics
This research complies with the guidelines for human subject
research and was exempt from institutional review board re-
view at the University of California, Irvine.
references
1. American college of surgeon national trauma data bank
national trauma data standard: data dictionary.
2. Fakhry SM, Leon S, Derderian C, Al-Harakeh H, Ferguson PL.
Intensive care unit bounce back in trauma patients: an
analysis of unplanned returns to the intensive care unit. J
Trauma Acute Care Surg. 2013;74:1528e1533.
3. Ho KM, Dobb GJ, Lee KY, Finn J, Knuiman M, Webb SA. The
effect of comorbidities on risk of intensive care readmission
during the same hospitalization: a linked data cohort study. J
Crit Care. 2009;24:101e107.
4. Lee JY, Park SK, Kim HJ, Hong SB, Lim CM, Koh Y. Outcome of
early intensive care unit patients readmitted in the same
hospitalization. J Crit Care. 2009;24:267e272.
5. Kastrup M, Powollik R, Balzer F, et al. Predictive ability of the
stability and workload index for transfer score to predict
unplanned readmissions after ICU discharge. Crit Care Med.
2013;41:1608e1615.
6. Kramer AA, Higgins TL, Zimmerman JE. Intensive care unit
readmissions in U.S. hospitals: patient characteristics, risk
factors, and outcomes. Crit Care Med. 2012;40:3e10.
7. Rubano JA, Vosswinkel JA, McCormack JE, Huang EC,
Shapiro MJ, Jawa RS. Unplanned intensive care unit
admission following trauma. J Crit Care. 2016;33:174e179.
8. Mulvey HE, Haslam RD, Laytin AD, Diamond CA, Sims CA.
Unplanned ICU admission is associated with worse clinical
outcomes in geriatric trauma patients. J Surg Res.
2020;245:13e21.
510 j o u r n a l o f s u r g i c a l r e s e a r c h  n o v e m b e r 2 0 2 2 ( 2 7 9 ) 5 0 5 e5 1 0
9. Dahn CM, Manasco AT, Breaud AH, et al. A critical analysis of
unplanned ICU transfer within 48 hours from ED admission
as a quality measure. Am J Emerg Med. 2016;34:1505e1510.
10. Hodgetts TJ, Kenward G, Vlackonikolis I, et al. Incidence,
location and reasons for avoidable in-hospital cardiac arrest
in a district general hospital. Resuscitation. 2002;54:115e123.
11. Hillman KM, Bristow PJ, Chey T, et al. Antecedents to hospital
deaths. Intern Med J. 2001;31:343e348.
12. Shiloh AL, Ari Eisen L, Savel RH. The unplanned intensive
care unit admission. J Crit Care. 2015;30:419e420.
13. Chalfin DB, Trzeciak S, Likourezos A, Baumann BM,
Dellinger RP, DELAY-ED Study Group. Impact of delayed
transfer of critically ill patients from the emergency
department to the intensive care unit. Crit Care Med.
2007;35:1477e1483.
14. Hillman KM, Bristow PJ, Chey T, et al. Duration of life-
threatening antecedents prior to intensive care admission.
Intensive Care Med. 2002;28:1629e1634.
15. Escarce JJ, Kelley MA. Admission source to the medical
intensive care unit predicts hospital death independent of
Apache II score. JAMA. 1990;264:2389e2394.
16. Frost SA, Alexandrou E, Bogdanovski T, Salamonson Y,
Parr MJ, Hillman KM. Unplanned admission to intensive care
after emergency hospitalisation: risk factors and
development of a nomogram for individualising risk.
Resuscitation. 2009;80:224e230.
17. Boerma LM, Reijners EPJ, Hessels RAPA, V Hooft MAA. Risk
factors for unplanned transfer to the intensive care unit after
emergency department admission. Am J Emerg Med.
2017;35:1154e1158.
18. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. Apache II:
a severity of disease classification system. Crit Care Med.
1985;13:818e829.
19. Morgan RJM, Williams F, Wright MM. An early warning
scoring system for detecting developing critical illness. Clin
Intensive Care. 1997;8:100.
20. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/
ACCP/ATS/SIS International sepsis definitions conference.
Crit Care Med. 2003;31:1250e1256.
21. Tsai JC, Weng SJ, Huang CY, Yen DH, Chen HL. Feasibility of
using the predisposition, insult/infection, physiological
response, and organ dysfunction concept of sepsis to predict
the risk of deterioration and unplanned intensive care unit
transfer after emergency department admission. J Chin Med
Assoc. 2014;77:133e141.
22. Hemmila MR, Nathens AB, Shafi S, et al. The Trauma Quality
Improvement Program: pilot study and initial demonstration
of feasibility. J Trauma. 2010;68:253e262.
23. Gionis A, Mannila H, Mielikäinen T, Tsaparas P. Assessing
data mining results via swap randomization. ACM Trans
Knowledge Discov Data. 2007;1:14.
24. Posa PJ, Yonkee DE, Fields WL. Development and implications
of an interdisciplinary quality assurance monitor on
unplanned transfers into the intensive care units. J Nurs Care
Qual. 1992;6:51e55.
25. Cohen ME, Bilimoria KY, Ko CY, Hall BL. Development of an
American College of surgeons national surgery quality
improvement Program: morbidity and mortality risk
calculator for colorectal surgery. J Am Coll Surg.
2009;208:1009e1016.
26. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The
LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis)
score: a tool for distinguishing necrotizing fasciitis from
other soft tissue infections. Crit Care Med.
2004;32:1535e1541.
27. Easterlin MC, Chang DC, Wilson SE. A practical index to
predict 30-day mortality after major amputation. Ann Vasc
Surg. 2013;27:909e917.
28. Bapoje SR, Gaudiani JL, Narayanan V, Albert RK. Unplanned
transfers to a medical intensive care unit: causes and
relationship to preventable errors in care. J Hosp Med.
2011;6:68e72.
29. Delgado MK, Liu V, Pines JM, Kipnis P, Gardner MN,
Escobar GJ. Risk factors for unplanned transfer to intensive
care within 24 hours of admission from the emergency
department in an integrated healthcare system. J Hosp Med.
2013;8:13e19.
30. Marquet K, Claes N, De Troy E, et al. One fourth of
unplanned transfers to a higher level of care are
associated with a highly preventable adverse event: a
patient record review in six Belgian hospitals. Crit Care
Med. 2015;43:1053e1061.
31. Sobol JB, Gershengorn HB, Wunsch H, Li G. The surgical Apgar
score is strongly associated with intensive care unit
admission after high-risk intraabdominal surgery. Anesth
Analg. 2013;117:438e446.
32. Glass NE, Pinna A, Masi A, et al. The surgical apgar score
predicts postoperative ICU admission. J Gastrointest Surg.
2015;19:445e450.
33. Kongkaewpaisan N, Lee JM, Eid AI, et al. Can the emergency
surgery score (ESS) be used as a triage tool predicting the
postoperative need for an ICU admission? Am J Surg.
2019;217:24e28.
34. Sobol JB, Wunsch H. Triage of high-risk surgical patients for
intensive care. Crit Care. 2011;15:217.
35. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the
TRISS method. Trauma score and the injury severity score. J
Trauma. 1987;27:370e378.
36. Vester-Andersen M, Lundstrøm LH, Møller MH, et al.
Mortality and postoperative care pathways after emergency
gastrointestinal surgery in 2904 patients: a population-based
cohort study. Br J Anaesth. 2014;112:860e870.