Prehospital Triage of Trauma Patients: A Trauma Surgeon's Perspective

A number of triage tools have been developed andused to make triage decisions. Studies have demonstrated better outcomes in patients who receive care in trauma centers. The field triage decision scheme from the American College of Surgeons Committee on Trauma involves patient triage based on the presence of physiologic derangement, specific anatomic injuries, mechanism of injury, andcomorbid factors. Issues such as distance to a trauma center (rural areas) andmethods of transport (e.g., air, ground) complicate the prehospital triage of trauma patients. The best system for a given community or region is one that begins with a triage scheme that is evidence based to the greatest extent possible but is then modified based on community or regional resources andgeography. Delivering the severely injured trauma patient to a facility that can provide optimal care, in the shortest amount of the time, remains the overarching principle.     

Field triage and patient maldistribution in a mass-casualty incident

INTRODUCTION: Management of mass-casualty incidents should optimize outcomes by appropriate prehospital care, and patient triage to the most capably facilities. The number of patients, the nature of injuries, transportation needs, distances, and hospital capabilities and availabilities are all factors to be considered. Patient maldistributions such as overwhelming individual facilities, or transport to facilities incapable of providing appropriate care should be avoided. This report is a critical view of the application of the START triage nomenclature in the prehospital arena following a train crash in Los Angeles County on 26 January 2005. METHODS: A scheduled debriefing was held with the major fire and emergency medical services responders, Medical Alert Center staff, and hospitals to assess and review the response to the incident. Site visits were made to all of the hospitals involved. Follow-up questions were directed to emergency department staff that were on duty during the day of the incident. RESULTS: The five Level-I Trauma Centers responded to the poll with the capacity to receive a total of 12 "Immediate" patients, 2.4 patients per center, the eight Level-II Trauma Centers responded with capacity to receive 17 "Immediate" patients, two patients per center, while the 25 closest community hospitals offered to accept 75 "Immediate" patients, three patients per hospital. These community hospitals were typically about one-half of the size of the trauma centers (average 287 beds versus 548, average 8.7 operating rooms versus 16.6). Twenty-six patients were transported to a community hospital >15 miles from the scene, while eight closer community hospitals did not receive any patients. CONCLUSIONS: The debriefing summary of this incident concluded that there were no consistently used criteria to decide ultimate destination for "Immediates", and that they were distributed about equally between community hospitals and trauma centers.     

Trauma victims: field triage guidelines

Trauma kills more Americans from age 1 to 34 than all diseases combined. Until recently, trauma care in the United States was delivered in a nonorganized, nonintegrated fashion, with trauma victims being transported to the medical facility closest to the scene of the accident. Many recent studies confirm an unacceptably high incidence--up to 75% in some studies--of preventable deaths in trauma victims treated under the nearest hospital system. This has resulted in the development of specialized trauma centers. The concept of a regional trauma center requires restrictive medical practice in which a limited number of hospitals and physicians provide care for those 5% to 12% of patients who are critically injured. The decision on whether to take a patient to the closest hospital or to the regional trauma center is a form of triage, with far-reaching consequences medically, ethically, and financially. Various triage instruments have been developed to try to identify those patients who would benefit from the resources of a trauma center, and to avoid overcrowding those centers with patients having less serious injuries. These triage tools are based on a combination of mechanism of injury, anatomic criteria, physiologic criteria, and co-morbidity factors.     

Effectiveness of prehospital trauma triage guidelines for the identification of major trauma in elderly motor vehicle crash victims.

INTRODUCTION: Undertriage of older trauma victims has been a persistent and serious problem. Because of physiologic changes and pre-existing disease, blunt trauma in older persons is often covert. Prehospital trauma triage guidelines developed for use with a general adult population may not be sensitive enough to detect covert injuries in elderly trauma patients. This study examined the sensitivity and specificity of one state's prehospital trauma triage guidelines for adults, with a particular focus on the triage of elderly persons. METHODS: This retrospective study used patient discharge data to examine the sensitivity (a measure of undertriage) and specificity (a measure of overtriage) of the adult prehospital trauma triage guidelines in 3 counties with level I trauma centers. Sensitivity and specificity of young and middle-aged adults was compared with that of older adults. RESULTS: Undertriage was 8% for young and middle-aged men, 12% for young and middle-aged women, 18% for older men, and 15% for older women. Overtriage was present in all age groups, indicating that many motor vehicle crash victims who were admitted to trauma centers could have been admitted to nontrauma center hospitals. DISCUSSION: Low sensitivity and specificity of trauma triage guidelines results in undertriage and overtriage. These guidelines should include age as a decision point to avoid placing older persons at risk for undertriage. Although some degree of overtriage is unavoidable without increasing undertriage, efforts should be made to minimize this costly occurrence.     

P REHOSPITAL E MERGENCY C ARE , 6 TH E DITION

Abstract

Background. Traumatic brain injury (TBI) represents a serious subset of injuries among persons in the United States, and prehospital care of these injuries can mitigate both the morbidity and the mortality in patients who suffer from these injuries. Guidelines for triage of injured patients have been set forth by the American College of Surgeons Committee on Trauma (ACS-COT) in cooperation with the Centers for Disease Control and Prevention (CDC). These guidelines include physiologic criteria, such as the Glasgow Coma Scale (GCS) score, systolic blood pressure, and respiratory rate, which should be used in determining triage of an injured patient. Objectives. This study examined the numbers of visits at level I and II trauma centers by patients with a diagnosed TBI to determine the prevalence of those meeting physiologic criteria from the ACS-COT/CDC guidelines and to determine the extent of mortality among this patient population. Methods. The data for this study were taken from the 2007 National Trauma Data Bank (NTDB) National Sample Program (NSP). This data set is a nationally representative sample of visits to level I and II trauma centers across the United States and is funded by the American College of Surgeons. Estimates of demographic characteristics, physiologic measures, and death were made for this study population using both chi-square analyses and adjusted logistic regression modeling. Results. The analyses demonstrated that although many people who sustain a TBI and were taken to a level I or II trauma center did not meet the physiologic criteria, those who did meet the physiologic criteria had significantly higher odds of death than those who did not meet the criteria. After controlling for age, gender, race, Injury Severity Score (ISS), and length of stay in the hospital, persons who had a GCS score ≤13 were 17 times more likely to die than TBI patients who had a higher GCS score (odds ratio [OR] 17.4; 95% confidence interval [CI] 10.7–28.3). Other physiologic criteria also demonstrated significant odds of death. Conclusions. These findings support the validity of the ACS-COT/CDC physiologic criteria in this population and stress the importance of prehospital triage of patients with TBI in the hopes of reducing both the morbidity and the mortality resulting from this injury.     

Comparison of prehospital trauma triage instruments in a semirural population

An essential feature of the trauma center concept is the rapid delivery of patients with complicated injuries to a regional trauma center directly from the site of injury. A variety of triage instruments have been proposed to aid the prehospital personnel in making this difficult triage decision. We used a combination of prospective and retrospective analysis to evaluate and compare the performance of 11 recommended triage instruments on the same trauma population. Of the 130 patients evaluated by paramedics in a semirural area, 41 patients were considered desirable for trauma center triage. These patients were identified by either the absence of vital signs in the prehospital setting, death in the emergency department, immediate surgery other than for orthopedic extremity injury, or immediate admission to the intensive care unit. All subsequent in-hospital deaths occurred in the group of patients identified as deserving trauma center triage. Of the triage instruments, the Kane's "revised" checklist provided the largest improvement in odds against needing a trauma center when the triage instrument is negative. Of the triage instruments with a sensitivity greater than 70%, the respiratory/systolic pressure/Glasgow Coma Scale (RSG) score provided the largest improvement in odds for needing a trauma center when the triage instrument is positive. Although no triage instrument performed ideally, the patients missed by the triage instruments having a sensitivity greater than 70% were hemodynamically stable. Transfer of such patients to a trauma center following determination of the extent of underlying injury at a referring emergency department should be possible.     

Emergency Medical Treatment andActive Labor Act andTrauma Triage

The Emergency Medical Treatment andActive Labor Act (EMTALA) was conceived as a means to ensure that patients with emergent conditions would receive stabilizing care andto avert the potentially dangerous, economically driven, interhospital transfer of patients. This legislation andits subsequent application arrived near the time that regional andstatewide trauma systems were established. Trauma systems were developed to guide optimal resource use for the injured patient regardless of the patient's ability to pay. Unfortunately, when coupled with current economic andlitigation threats to community emergency andsurgical practitioners, EMTALA represents a threat to the continuation of the trauma system concept. Trauma systems are dependent on a tiered hospital network where severely injured patients are taken to a hospital with resources aligned to manage the worst of injuries. When primary triage from the field cannot accomplish this task, secondary triage from a nondesignated or lower-level hospital to the higher-level trauma center is needed. EMTALA has served as a driver to change the priority for secondary triage from addressing the needs of the severely injured patient to filling community hospital surgical specialist emergency department on-call coverage gaps for less severely injured patients. Further, legal action associated with claims of EMTALA violations has needlessly extended medical examination and“stabilization” efforts at community emergency departments prior to needed secondary triage. Higher-level trauma centers will benefit from codifying system-wide emergency medical services practices related to primary andsecondary triage, establishing trauma center capacity anddivert practices, andinitiating “transfer center” operations that control transfer of patients to these centers.     

Geriatric trauma patients at a suburban level-I trauma center in Japan

BACKGROUND: Despite the increases in the aged population in Japan, there are little data on geriatric patients with traumatic injuries. A prospective clinical study was carried out to evaluate the use of the emergency medical services (EMS) system, mechanisms of injury, and prehospital assessment and triage of elderly victims of trauma. PATIENTS AND METHODS: From July 1996 through June 1997, a group of geriatric trauma (Group G, n = 22) and a control group of younger trauma patients (n = 173) were compared with respect to transfer method to an Emergency Center (direct or indirect), Revised Trauma Scores on the scene of the accident (RTS-1) and on admission to the Emergency Center (RTS-2), and outcome (survival). RESULTS: The mean values for RTS-1 in the Control Group (Group C) were not different from those in Group G, but RTS-2 of the indirect-transfer patients (IP) in Group G were significantly lower than were those for Group C. Group G mortality rates were significantly higher than were the control rates (p = 0.0001). The mortality rate of the IP subgroup was significantly lower than that of the direct transfer subgroup (DP) (30/68 vs. 5/70, p < 0.0001) in the Group C, but mortality rate of the IP subgroup exceeded that of the DP subgroup of Group G (8/14 vs. 5/8). CONCLUSION: The data suggest that in geriatric-age patients, direct transfer patients have a lower mortality rate than do indirect transfer patients when controlled for ISS. Therefore, it seems that a different set of triage criteria should be developed and implemented for geriatric-age victims with trauma-induced injuries and that those who meet these more stringent criteria should be transferred directly to a Trauma Center.     

Effectiveness of prehospital trauma triage systems in selecting severely injured patients: Is comparative analysis possible?

Introduction

In an optimal trauma system, prehospital trauma triage ensures transport of the right patient to the right hospital. Incorrect triage results in undertriage and overtriage. The aim of this systematic review is to evaluate and compare prehospital trauma triage system quality worldwide and determine effectiveness in terms of undertriage and overtriage for trauma patients.

The Impact of Distance on Triage to Trauma Center Care in an Urban Trauma System

Abstract Background. Urban trauma systems are characterized by high population density, availability of trauma centers, and acceptable road transport times (within 30 minutes). In such systems, patients meeting field trauma triage (FTT) criteria should be transported directly to a trauma center, bypassing closer non-trauma centers. Objective. We evaluated emergency medical services (EMS) triage practices to identify opportunities for improving care delivery. Objective. Specifically, we evaluated the effect of the additional distance to a trauma center, compared with a closer non-trauma center, on the noncompliance with trauma destination criteria by EMS personnel in an urban environment. Methods. This was a retrospective cohort study of adults having at least one physiologic derangement and meeting Toronto EMS field trauma triage criteria from 2005 to 2010. Road travel distances between the site of injury, the closest non-trauma center, and the closest trauma center were estimated using geographic information systems. For patients who were transported to non-trauma centers, we estimated "differential distance": the additional travel distance required to transport directly to a trauma center. Logistic regression was used to analyze the effect of differential distance on triage decisions, adjusting for other patient characteristics. Results. Inclusion criteria identified 898 patients; 53% were transported directly to a trauma center. Falls, female gender, and age greater than 65?years were associated with transport to non-trauma centers. Differential distances greater than 1 mile were associated with a decreased likelihood of triage to a trauma center. Conclusion. Differential distance between the closest non-trauma center and the closest trauma center was associated with lower compliance with triage protocols, even in an urban setting where trauma centers can be accessed within approximately 30 minutes. Our findings suggest that there are opportunities for reducing the gap between ideal and actual application of field trauma triage guidelines through a process of education and feedback.     

Trauma Triage: New York Experience

New York State developed a statewide trauma program in the early 1990s. Designation of trauma centers andprehospital triage of patients by emergency medical services are pillars of the system. Outcomes are evaluated as part of the quality improvement system. New York has a statewide trauma registry with population-based data for all of the state but New York City. Studies made possible because of the trauma registry provided evidence to guide revision of the emergency medical services trauma triage protocol for adult patients. For example, pulse < 50 or > 120 beats/min was retained as a physiologic criteria, while crumple zone andcrash speed were eliminated as mechanism criteria. Patients with certain physiologic criteria treated in regional centers showed a considerably reduced mortality rate when compared with patients treated in area trauma centers andnoncenters. Other “high-risk” populations were identified for special consideration by emergency medical technicians for trauma center transport because of their associated higher mortality. One “high-risk” group, patients older than 55 years or younger than 5 years, has associated 11% mortality (compare with a statewide average of 7.43%) andrepresents 41% of all registry patients. Population-based trauma registries andstructured prehospital trauma records that accurately record the presence or absence of trauma criteria are essential to evaluate trauma triage criteria; improve quality, efficiency, andaccess; andguide care.     

Scene disposition and mode of transport following rural trauma: a prospective cohort study comparing patient costs

This prospective cohort study was performed from 1994 to 1996 to compare the impact of scene disposition on prehospital and hospital costs incurred by rural trauma patients transported to a trauma center by helicopter or ground ambulance. The study included all rural adult injury victims who arrived at the tertiary trauma center by ambulance within 24 h of injury. Inclusion criteria consisted of inpatient admission or death in the emergency department, and any traumatic injury except burns. Data collected included mortality, mode of transport, Injury Severity Score (ISS), and costs from impact to discharge or death. Of 105 study patients, 52 initially went to a rural hospital, while 53 went directly to the trauma center. There was no significant difference in survival in the two groups. The ISS was significantly higher for patients taken directly to the trauma center from the scene. The ISS of trauma patients transported from the rural hospital was highest for patients sent by ground transport. The prehospital transport costs were significantly more for patients transported to a rural hospital first. The costs incurred at the trauma center were highest for those patients transported directly from the scene. Many severely injured patients were initially transported to a rural hospital rather than directly to the trauma center. At both the scene and rural hospital, consistent use of triage criteria appeared to be lacking in determining the severity of injury, appropriate destination, and mode of transport for trauma patients. Since no significant difference in prehospital helicopter and ground transport costs was demonstrated, the decision on mode of transport should be in the best interest of patient care.     

The prehospital management of pelvic fractures

Pelvic fractures are one of the potentially life-threatening injuries that should be identified during the primary survey in patients sustaining major trauma. Early suspicion, identification and management of a pelvic fracture at the prehospital stage is essential to reduce the risk of death as a result of hypovolaemia and to allow appropriate triage of the patient. The assessment and management of pelvic fractures in the prehospital environment is reviewed here. It is advocated that the pelvis should not be examined by palpation or springing, and that the patient should not be log rolled. Pelvic immobilisation should be used routinely if there is any suspicion of pelvic fracture based on the mechanism of injury, symptoms and clinical findings.     

Pelvic fractures: an analysis of factors affecting prehospital triage and patient outcome

Using an established prehospital regional triage protocol, 175 patients sustaining fractures of the pelvis were managed in a level one trauma center during a 38-month interval. The majority of injuries (51.7%) were caused by motor vehicle accidents and involved an average trauma score (TS) of 13 and an average injury severity score (ISS) of 24. The overall mortality was 16%; 43.5% had open fractures, 13.2% had closed fractures, and 30.6% had been in pedestrian accidents. Significant risk factors for mortality were age, blood pressure on admission, associated injuries, and the presence of an open pelvic fracture. It appears that TS alone is not reliable in prehospital triage of patients with pelvic fractures. Age and mechanism of injury may better identify the patient at risk for morbidity and mortality.     

Characteristics of Pediatric Trauma Transfers to a Level I Trauma Center: Implications for Developing a Regionalized Pediatric Trauma System in California

Background: Since California lacks a statewide trauma system, there are no uniform interfacility pediatric trauma transfer guidelines across local emergency medical services (EMS) agencies in California. This may result in delays in obtaining optimal care for injured children. Objectives: This study sought to understand patterns of pediatric trauma patient transfers to the study trauma center as a first step in assessing the quality and efficiency of pediatric transfer within the current trauma system model. Outcome measures included clinical and demographic characteristics, distances traveled, and centers bypassed. The hypothesis was that transferred patients would be more severely injured than directly admitted patients, primary catchment transfers would be few, and out‐of‐catchment transfers would come from hospitals in close geographic proximity to the study center. Methods: This was a retrospective observational analysis of trauma patients ≤ 18 years of age in the institutional trauma database (2000–2007). All patients with a trauma International Classification of Diseases, 9th revision (ICD‐9) code and trauma mechanism who were identified as a trauma patient by EMS or emergency physicians were recorded in the trauma database, including those patients who were discharged home. Trauma patients brought directly to the emergency department (ED) and patients transferred from other facilities to the center were compared. A geographic information system (GIS) was used to calculate the straight‐line distances from the referring hospitals to the study center and to all closer centers potentially capable of accepting interfacility pediatric trauma transfers. Results: Of 2,798 total subjects, 16.2% were transferred from other facilities within California; 69.8% of transfers were from the catchment area, with 23.0% transferred from facilities ≤ 10 miles from the center. This transfer pattern was positively associated with private insurance (risk ratio [RR] = 2.05; p < 0.001) and negatively associated with age 15–18 years (RR = 0.23; p = 0.01) and Injury Severity Score (ISS) > 18 (RR = 0.26; p < 0.01). The out‐of‐catchment transfers accounted for 30.2% of the patients, and 75.9% of these noncatchment transfers were in closer proximity to another facility potentially capable of accepting pediatric interfacility transfers. The overall median straight‐line distance from noncatchment referring hospitals to the study center was 61.2 miles (IQR = 19.0–136.4), compared to 33.6 miles (IQR = 13.9–61.5) to the closest center. Transfer patients were more severely injured than directly admitted patients (p < 0.001). Out‐of‐catchment transfers were older than catchment patients (p < 0.001); ISS > 18 (RR = 2.06; p < 0.001) and age 15–18 (RR = 1.28; p < 0.001) were predictive of out‐of‐catchment patients bypassing other pediatric‐capable centers. Finally, 23.7% of pediatric trauma transfer requests to the study institution were denied due to lack of bed capacity. Conclusions: From the perspective an adult Level I trauma center with a certified pediatric intensive care unit (PICU), delays in definitive pediatric trauma care appear to be present secondary to initial transport to nontrauma community hospitals within close proximity of a trauma hospital, long transfer distances to accepting facilities, and lack of capacity at the study center. Given the absence of uniform trauma triage and transfer guidelines across state EMS systems, there appears to be a role for quality monitoring and improvement of the current interfacility pediatric trauma transfer system, including defined triage, transfer, and data collection protocols. ACADEMIC EMERGENCY MEDICINE 2010; 17:1364–1373 © 2010 by the Society for Academic Emergency Medicine     

Outcome of critically injured patients treated at Level I trauma centers versus full-service community hospitals

Critically injured patients were identified by a CRAMS (circulation, respiration, abdomen, motor, speech) score of 6 or less while still in the field. They were prospectively followed as they received their care at the nearest medical facility according to the then-existing district Emergency Medical Services protocols. Those cared for by Level I trauma centers had a significantly reduced mortality rate compared to those treated at the other large full-service community hospitals. The commitment to Level I trauma care improves outcome of the critically injured, and field triage of the critically injured patient to these centers is indicated.     

Regionalization Patterns for Children with Serious Trauma in California (2005–2015): A Retrospective Cohort Study

Abstract

Objective

Trauma centers provide coordinated specialty care and have been demonstrated to save lives. Many states do not have a comprehensive statewide trauma system. Variable geography, resources, and population distributions present significant challenges to establishing an effective uniform system for pediatric trauma care. We aimed to identify patterns of primary (field) triage and transfer of serious pediatric trauma throughout California. We hypothesized that pediatric primary triage to trauma center care would be positively associated with younger age, increased injury severity, and local emergency medical service (EMS) regions with increased resources. We hypothesized that pediatric trauma transfer would be associated with younger age, increased injury severity, and rural regions with decreased resources. Methods: We conducted a retrospective cohort study of the California Office of Statewide Health Planning and Development emergency department and inpatient discharge data (2005–2015). All patients with serious injury, defined as Injury Severity Score (ISS) >9 were included. Demographic, injury, hospital, and regional characteristics such as distances between patient residence and destination hospitals were tabulated. Univariate and multinomial logit analyses were conducted to analyze individual, hospital, and regional characteristics associated with the outcomes of location of primary triage and transfer. Estimates were converted into predicted probabilities for ease of data interpretation. Results: Primary triage to was to either a pediatric trauma center (37.8%), adult level I/II trauma center (35.0%), adult level III/IV trauma center (1.9%), pediatric non-trauma hospital (3.4%), or an adult non-trauma hospital (21.9%).Younger age, private non-HMO insurance, motor vehicle mechanism, and rural areas were the major factors influencing primary triage to any trauma hospital. Younger age, private non-HMO insurance, higher ISS, fall mechanism, <200 bed hospital, and rural areas were the major factors influencing transfer from a non-trauma hospital to any trauma center. Conclusions: We demonstrate statewide primary triage and transfer patterns for pediatric trauma in a large and varied state. Specifically we identified previously unrecognized individual, hospital, and EMS system associations with pediatric trauma regionalization. Knowledge of these de facto trauma care access patterns has policy and process implications that could improve care for all injured children in need.     

Burn disaster response planning: an urban region's approach.

The objective of this study was to describe a draft response plan for the tiered triage, treatment, or transportation of 400 adult and pediatric victims (50/million population) of a burn disaster for the first 3 to 5 days after injury using regional resources. Review of meeting minutes and the 11 deliverables of the draft response plan was performed. The draft burn disaster response plan developed for NYC recommended: 1) City hospitals or regional burn centers within a 60-mile distance be designated as tiered Burn Disaster Receiving Hospitals (BDRH); 2) these hospitals be divided into a four-tier system, based on clinical resources; and 3) burn care supplies be provided to Tier 3 nonburn centers. Existing burn center referral guidelines were modified into a hierarchical BDRH matrix, which would vector certain patients to local or regional burn centers for initial care until capacity is reached; the remainder would be cared for in nonburn center facilities for up to 3 to 5 days until a city, regional, or national burn bed becomes available. Interfacility triage would be coordinated by a central team. Although recommendations for patient transportation, educational initiatives for prehospital and hospital providers, city-wide, interfacility or interagency communication strategies and coordination at the State or Federal levels were outlined, future initiatives will expound on these issues. An incident resulting in critically injured burn victims exceeding the capacity of local and regional burn center beds may be a reality within any community and warrants a planned response. To address this possibility within New York City, an initial draft of a burn disaster response has been created. A scaleable plan using local, state, regional, or federal health care and governmental institutions was developed.     

A decentralized trauma system design for a rural area

Most trauma-care systems are based on an urban model in which patients are found in sufficient proximity to the trauma center to allow preferential triage. The roles of other hospitals in the community are limited. In rural areas, patients may be remote from the trauma center and may require initial stabilization at a closer, nontrauma "center" designated hospital. An inclusive trauma system design is more appropriate in such situations. The Emergency Department Approved for Trauma (EDAT) is a program implemented in a rural area of northeastern California that establishes minimum standards for nontrauma center designated hospitals in remote areas. It integrates these hospitals into the trauma system through transfer guidelines and agreements and participation in systemwide quality assurance/improvement programs. The EDAT program promotes both improved initial treatment of rural trauma patients and appropriate transfer of patients to designated trauma centers.