Impact of Increasing Numbers of Trauma Activation Criteria on Outcomes and Resource Utilization: A Multicenter Study

BACKGROUND: The American College of Surgeons mandates eight trauma activation criteria for full trauma activations, yet many centers exceed this number to minimize undertriage. The association between trauma activation criteria and triage accuracy and resource use is poorly studied. OBJECTIVE: To assess the relationship between the number of criteria for full trauma activation and rates of activation, undertriage, overtriage, mortality, and hospital length of stay. METHODS: This multicenter retrospective cohort study analyzed survey and trauma registry data from 36 trauma centers across 16 U.S. states and the District of Columbia. Centers reported their activation criteria used for full trauma activation from 2017 to 2019, and outcomes were evaluated using multivariable negative binomial regression and weighted linear regression. RESULTS: Among 218,832 patients, the number of trauma activation criteria per center ranged from 8 to 28, with a mean of 16.75 and an SD of 4.47. The number of criteria was not significantly associated with the proportion of full trauma activation (adjusted incidence rate ratio [aIRR] = 1.02 [95% CI 0.996, 1.05], p = .097), undertriage (aIRR = 0.98 [95% CI 0.96, 1.003], p = .081), mortality (aIRR = 1.00 [95% CI 0.99, 1.01]; p = .952), or length of stay ( b = -0.001 [95% CI -0.059, 0.058], p = .985). However, more criteria were significantly associated with greater overtriage (aIRR = 1.02 [95% CI 1.003, 1.03], p = .010). CONCLUSION: Increasing the number of trauma activation criteria was not linked to improved undertriage or clinical outcomes, but was associated with higher overtriage, suggesting a greater burden on trauma resources without clinical benefit.