Hospital overhauls guidelines after review reveals injured are wrongly classified Prince of Wales Hospital has overhauled its guidelines for classifying severely injured patients after finding that nearly a third of those whose condition should have prompted attention by a specialised trauma team did not receive the required treatment. Although no one died as a result, severely injured patients spent up to 23 minutes longer in the emergency unit than they would have if correctly classified, according to a review covering 2001 to 2005. For some patients, the misclassification delayed surgery or admission to intensive care, increasing the possibility of death seven-fold. Timothy Rainer, of the hospital's accident and emergency department, admitted that a lack of training resources, vague guidelines and a heavy workload were among the reasons for the deficiency. Under the trauma system introduced by the Sha Tin hospital in 2001, a team comprising general surgeons, an orthopaedic surgeon and a physician from the intensive-care unit was brought in if certain criteria were met. Led by Dr Rainer, the hospital review found that about 28 per cent of 674 patients whose conditions should have triggered a trauma call were deemed not to merit immediate attention by the team. Dr Rainer admitted that the proportion was quite high. 'The department, on average, holds an internal clinical audit to review every trauma case every two months. The doctors will be informed if they have missed a trauma call.' He said the misclassification made little difference in patients with a very low or very high probability of survival. The real impact was in the group with a 50 to 75 per cent chance of survival. Dr Rainer believed the core reason was that some of the trauma criteria were not specific enough. For instance, 'haemodynamic instability' (unstable blood pressure) and 'respiratory distress' were open to interpretation. Also, many of the criteria may be met only for a short period, and doctors had been encouraged not to follow guidelines rigidly and use their judgment. 'Based on the research, we revised some criteria in June, making them more precise and quantitative. So far, the compliance rate to correct a trauma call has been over 95 per cent,' he said. Dr Rainer has shared the research result, published in the latest issue of the medical journal Resuscitation, with other accident and emergency departments that do not yet have standardised trauma-call guidelines. A frontline emergency doctor who refused to be named said that in some hospitals, there were no criteria for trauma and so it depended on the clinical judgment of the emergency doctors to decide whether a multidisciplinary team would be needed. He said a set of criteria might provide some guidelines to the doctors, but could not solve all the problems involved. He believed increasing resources could reduce the chance of mistakes. A Hospital Authority spokeswoman said each trauma centre would have minor variations in the activation guidelines according to their operational needs.