Field Triage Of Injured Patients Research Articles

Patient Outcomes Based on the 2011 CDC Guidelines for Field Triage of Injured Patients.

The Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients drive the destination decision for millions of emergency medical services (EMS)-transported trauma patients annually, yet limited information exists regarding performance and relationship with patient outcomes as a whole. To evaluate the association of positive findings on Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients with hospitalization and mortality. This retrospective study included all 911 responses from the 2019 ESO Data Collaborative research dataset with complete Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients and linked emergency department dispositions, excluding children and cardiac arrests prior to EMS arrival. Patients were categorized by Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients step(s) met. Outcomes were hospitalization and emergency department or inhospital mortality. There were 86,462 records included: n = 65,967 (76.3%) met no criteria, n = 16,443 (19.0%) met one step (n = 1,571 [9.6%] vitals, n = 1,030 [6.3%] anatomy of injury, n = 993 [6.0%] mechanism of injury, and n = 12,849 [78.1%] special considerations), and n = 4,052 (4.7%) met multiple. Compared with meeting no criteria, hospitalization odds increased threefold for vitals (odds ratio [OR]: 3.07, 95% confidence interval [CI]: 2.77-3.40), fourfold for anatomy of injury (OR: 3.94, 95% CI: 3.48-4.46), twofold for mechanism of injury (OR: 2.00, 95% CI: 1.74-2.29), or special considerations (OR: 2.46, 95% CI: 2.36-2.56). Hospitalization odds increased ninefold when positive in multiple steps (OR: 8.97, 95% CI: 8.37-9.62). Overall, n = 84,473 (97.7%) had mortality data available, and n = 886 (1.0%) died. When compared with meeting no criteria, mortality odds increased 10-fold when positive in vitals (OR: 9.58, 95% CI: 7.30-12.56), twofold for anatomy of injury (OR: 2.34, 95% CI: 1.28-4.29), or special considerations (OR: 2.10, 95% CI: 1.71-2.60). There was no difference when only positive for mechanism of injury (OR: 0.22, 95% CI: 0.03-1.54). Mortality odds increased 23-fold when positive in multiple steps (OR: 22.7, 95% CI: 19.7-26.8). Patients meeting multiple Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients steps were at greater risk of hospitalization and death. When meeting only one step, anatomy of injury was associated with greater risk of hospitalization; vital sign criteria were associated with greater risk of mortality.

Patient Outcomes Based on the 2011 CDC Guidelines for Field Triage of Injured Patients.

Patient Outcomes Based on the 2011 CDC Guidelines for Field Triage of Injured Patients.

National guideline for the field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2021.

National guideline for the field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2021.

66 Prediction of Hospitalization and Mortality Based on Emergency Medical Services-Recorded Criteria from the 2011 Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients

Our study objective was to evaluate hospitalization and mortality of injured patients transported by emergency medical services (EMS) based upon the 2011 Centers for Disease Control and Prevention (CDC) Guidelines for Field Triage of Injured Patients.

Validation of Guidelines for Field Triage of Injured Patients for major trauma in patients of brain and spinal injury.

Validation of Guidelines for Field Triage of Injured Patients for major trauma in patients of brain and spinal injury.

Undertriage of major trauma patients at a university hospital: a retrospective cohort study

BackgroundStudies show increased mortality among severely injured patients not met by trauma team. Proper triage is important to ensure that all severely injured patients receive vital trauma care. In 2017 a new national trauma plan was implemented in Norway, which recommended the use of a modified version of “Guidelines for Field Triage of Injured Patients” to identify severely injured patients.MethodsA retrospective study of 30,444 patients admitted to Haukeland University Hospital in 2013, with ICD-10 injury codes upon discharge. The exclusion criteria were department affiliation considered irrelevant when identifying trauma, patients with injuries that resulted in Injury Severity Score < 15, patients that did receive trauma team, and patients admitted > 24 h after time of injury. Information from patient records of every severely injured patient admitted in 2013 was obtained in order to investigate the sensitivity of the new guidelines.ResultsTrauma team activation was performed in 369 admissions and 85 patients were identified as major trauma. Ten severely injured patients did not receive trauma team resuscitation, resulting in an undertriage of 10.5%. Nine out of ten patients were men, median age 54 years. Five patients were 60 years or older. All of the undertriaged patients experienced fall from low height (< 4 m). Traumatic brain injury was seen in six patients. Six patients had a Glasgow Coma Scale score ≤ 13. The new trauma activation guidelines had a sensitivity of 95.0% in our 2013 trauma population. The degree of undertriage could have been reduced to 4.0% had the guidelines been implemented and correctly applied.ConclusionsThe rate of undertriage at Haukeland University Hospital in 2013 was above the recommendations of less than 5%. Use of the new trauma guidelines showed increased triage precision in the present trauma population.

Evaluation of the Implementation of the Trauma Triage and Destination Plan on the Field Triage of Injured Patients in North Carolina

Objective: Timely triage and appropriate destination decision making for injured patients are central challenges faced by emergency medical services (EMS) systems. In 2010, North Carolina (NC) adopted a statewide Trauma Triage and Destination Plan (TTDP) based on the CDC's Field Triage Guidelines to better address these challenges. We sought to characterize the implementation of these guidelines by quantifying their effect on multiple metrics of patient care. Methods: We employed a retrospective pre-post study design utilizing a statewide EMS medical record database. We assessed several metrics of patient care—including changes in destination choice, appropriateness of EMS destination, transit time to first hospital, transit time to definitive care, and others—in a six-month period in the year before and after the implementation of the guidelines. Results: We evaluated a total of 190,307 EMS encounters pre- (n = 93,927) and post-implementation (n = 96,380). Among all patients, there was not a significant difference in the percentage transported to a community hospital or Level I, II, or III trauma center as their first destination. Among those patients meeting TTDP guidelines for transport to a trauma center, the number transported to a Level I or II trauma center decreased 1.0% from 30.6% (n = 2,911) to 29.6% (n = 2,954) (95% CI: −0.2%, 2.2%). Those transported to a Level I trauma center decreased 0.4% from 21.2% to 20.8% in the post-period (95% CI: −0.7%, 1.5%). There were also no significant changes in EMS scene times (14.0 pre-, 14.1 post-) and transport times (12.9 pre-, 13.0 post-). While scene distance from a Level I trauma center showed a decreased likelihood of transport to that center, there was an overall post-implementation increase of 2.5% from 18.0% to 20.5% (95% CI: −3.6%, −1.3%) in transport to a Level I trauma center among patients meeting anatomic criteria across all distance ranges. Conclusions: We found that implementation of region-specific destination plans based on the Field Triage Guidelines had little effect on selected hospital destination, scene times, transport times, and other metrics of EMS decision making and effectiveness. We suspect this is due to delays in information dissemination and adoption by field providers.

Undertriage of Firearm Injuries in Chicago Area

CDC guidelines for field triage of injured patients recommend that patients with firearm injuries of the head, trunk, or extremities proximal to the elbow or knee should be taken to a designated trauma center, even if this requires bypassing a closer, nondesignated center. These authors retrospectively examined triage patterns and outcomes for 9886 firearm-related injuries treated in Cook County, Illinois, …

Ability of the Physiologic Criteria of the Field Triage Guidelines to Identify Children Who Need the Resources of a Trauma Center

ABSTRACTBackground: There is limited research on how well the American College of Surgeons/Center for Disease Control and Prevention Guidelines for Field Triage of Injured Patients assist EMS providers in identifying children who need the resources of a trauma center. Objective: To determine the accuracy of the Physiologic Criteria (Step 1) of the Field Triage Guidelines in identifying injured children who need the resources of a trauma center. Methods: EMS providers who transported injured children 15 years and younger to pediatric trauma centers in 3 mid-sized cities were interviewed regarding patient demographics and the presence or absence of each of the Field Triage Guidelines criteria. Children were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. This data was obtained through a structured hospital record review. The over- and under-triage rates and positive likelihood ratios (+LR) were calculated for the overall Physiologic Criteria and each individual criterion. Results: Interviews were conducted for 5,610 pediatric patients; outcome data were available for 5,594 (99.7%): 5% of all patients needed the resources of a trauma center and 19% met the physiologic criteria. Using the physiologic criteria alone, 51% of children who needed a trauma center would have been under-triaged and 18% would have been over-triaged (+LR 2.8, 95% CI 2.4–3.2). Glasgow Coma Score (GCS) < 14 had a +LR of 14.3 (95% CI 11.2–18.3), with EMS not obtaining a GCS in 4% of cases. 54% of those with an EMS GCS < 14 had an initial ED GCS < 14. Abnormal respiratory rate (RR) had a +LR of 2.2 (95% CI 1.8–2.6), with EMS not obtaining a RR in 5% of cases. 41% of those with an abnormal EMS RR had an abnormal initial ED RR. Systolic blood pressure (SBP) < 90 had a +LR of 3.5 (95% CI 2.5–5.1), with EMS not obtaining a SBP in 20% of cases. SBP was not obtained for 79% of children <1 year, 46% 1–4 years, 7% 5–9 years, and 2% 10–15 years. A total of 19% of those with an EMS SBP < 90 had an initial ED SBP < 90. Conclusions: The Physiologic Criteria are a moderate predictor of trauma center need for children. Missing or inaccurate vital signs may be limiting the predictive value of the Physiologic Criteria.

Collecting information from the scene of a motor vehicle collision: The mechanism of injury

While dealing with motor vehicle collision (MVC) victims, the Paramedics on-scene make patient management decisions based on assessment of the physiological parameters, anatomic site of injury, mechanism of injury (MOI), and some special considerations (age and underlying illnesses). In victims with normal physiological and anatomical parameters, and no alarming consideration, the MOI alone is found to be an independent predictor of mortality and functional impairment (2, 3); the Emergency Physician can utilize such information to guide further management of the MVC victims. Information concerning the MOI mostly comes from the Paramedics who retrieved the patient from the crash scene. The purpose of this review is to explore the injury-predictive mechanisms of MVC and to guide the Paramedics in conveying such vital information to the Emergency Physician during handover process. A literature search was made using the online search engine PubMed to identify studies exploring the injury-predictive mechanisms of MVC. Keyword combinations were used that included: Motor/Vehicle/Collision/Road/Traffic/Accidents/Trauma/Mechanism of injury. Auto vs. pedestrian and Motorcycle crashes were excluded. A total of 8 articles were found to be relevant. The mechanisms of MVC which are highly predictive of a significant occult injury include ejection from vehicle (1,4,5), intrusion of the passenger compartment more than 12 inches (1,2,4), prolonged extrication time &gt;20 minutes (4,5), death in the same passenger compartment (1,5), high speed crashes (4), deformity of the steering wheel (2), and rollover causing significant intrusion or ejection of the victim (1). Paramedics reporting the aforementioned crash-specific variables would alert the Emergency Physician and help him better deal with MVC victims who have normal physiological and anatomical parameters, and no alarming considerations. Provision of MVC scene photographs to the emergency physician could be a future research project to assess its impact on altering patient management and outcome.

Evaluation of a Consensus-Based Criterion Standard Definition of Trauma Center Need for Use in Field Triage Research

Research on field triage of injured patients is limited by the lack of a widely used criterion standard for defining trauma center need. Injury Severity Score (ISS) >15 has been a commonly used outcome measure in research for determining trauma center need that has never been validated. A multidisciplinary team recently published a consensus-based criterion standard definition of trauma center need, but this measure has not yet been validated. The objective was to determine if the consensus-based criterion standard can be obtained by medical record review and compare patients identified as needing a trauma center by the consensus-based criterion standard vs. ISS >15. A subanalysis of data collected during a 2-year prospective cohort study of 4,528 adult trauma patients transported by EMS to a single trauma center was conducted. These data included ICD-9-CM codes, treatment times, and other patient care data. Presence of the consensus-based criterion standard was determined for each patient. ISS was calculated based on ICD-9-CM codes assigned for billing. The consensus-based criterion standard could be applied to 4,471 (98.7%) cases. ISS could be determined for 4,506 (99.5%) cases. Based on an ISS >15, 8.9% of cases were identified as needing a trauma center. Of those, only 48.2% met the consensus-based criterion standard. Almost all patients that did not meet the consensus-based criterion standard, but had an ISS >15 were diagnosed with chest (rib fractures (100/205 cases)/pneumothorax (57/205 cases), closed head (without surgical intervention 88/205 cases), vertebral (without spinal cord injury 45/205 cases), and/or extremity injuries (39/205 cases). There were 4,053 cases with an ISS <15. 5.0% of those with an ISS <15 met the consensus-based criterion standard with the majority requiring surgery (139/203 cases) or a blood transfusion (60/203 cases). The kappa coefficient of agreement for ISS and the consensus-based criterion standard was 0.43. We determined that the consensus-based criterion standard could be identified through a medical record review. Use of the consensus-based criterion standard for field triage research will more accurately identify injured patients who need the resources of a trauma center when compared to ISS.

An Evidence-based Guideline for the Air Medical Transportation of Prehospital Trauma Patients

Background. Decisions about the transportation of trauma patients by helicopter are often not well informed by research assessing the risks, benefits, and costs of such transport. Objective. The objective of this evidence-based guideline (EBG) is to recommend a strategy for the selection of prehospital trauma patients who would benefit most from aeromedical transportation. Methods. A multidisciplinary panel was recruited consisting of experts in trauma, EBG development, and emergency medical services (EMS) outcomes research. Representatives of the Federal Interagency Committee on Emergency Medical Services (FICEMS), the National Highway Traffic Safety Administration (NHTSA) (funding agency), and the Children's National Medical Center (investigative team) also contributed to the process. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to guide question formulation, evidence retrieval, appraisal/synthesis, and formulate recommendations. The process followed the National Evidence-Based Guideline Model Process, which has been approved by the Federal Interagency Committee on EMS and the National EMS Advisory Council. Results. Two strong and three weak recommendations emerged from the process, all supported only by low or very low quality evidence. The panel strongly recommended that the 2011 CDC Guideline for the Field Triage of Injured Patients be used as the initial step in the triage process, and that ground emergency medical services (GEMS) be used for patients not meeting CDC anatomic, physiologic, and situational high-acuity criteria. The panel issued a weak recommendation to use helicopter emergency medical services (HEMS) for higher-acuity patients if there is a time-savings versus GEMS, or if an appropriate hospital is not accessible by GEMS due to systemic/logistical factors. The panel strongly recommended that online medical direction should not be required for activating HEMS. Special consideration was given to the potential need for local adaptation. Conclusions. Systematic and transparent methodology was used to develop an evidence-based guideline for the transportation of prehospital trauma patients. The recommendations provide specific guidance regarding the activation of GEMS and HEMS for patients of varying acuity. Future research is required to strengthen the data and recommendations, define optimal approaches for guideline implementation, and determine the impact of implementation on safety and outcomes including cost.

Guidelines for Field Triage of Injured Patients

The Centers for Disease Control and Prevention (CDC) has published significant data and trends related to the national public health burden associated with trauma and injury. In the United States (U.S.), injury is the leading cause of death for persons aged 1–44 years. In 2008, approximately 30 million injuries resulted in an emergency department (ED) evaluation; 5.4 million (18%) of these patients were transported by Emergency Medical Services (EMS).1 EMS providers determine the severity of injury and begin initial management at the scene. The decisions to transport injured patients to the appropriate hospital are made through a process known as “field triage.” Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process though its “Field Triage Decision Scheme.” In 2005, the CDC, with financial support from the National Highway Traffic Safety Administration (NHTSA), collaborated with ASC-COT to convene the initial meeting of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme. This revised version was published in 2006 by ASC-COT, and in 2009 the CDC published a detailed description of the scientific rational for revising the field triage criteria entitled, “Guidelines for Field Triage of Injured Patients.”2–3 In 2011, the CDC reconvened the Panel to review the 2006 Guidelines and recommend any needed changes. We present the methodology, findings and updated guidelines from the Morbidity & Mortality Weekly Report (MMWR) from the 2011 Panel along with commentary on the burden of injury in the U.S., and the role emergency physicians have in impacting morbidity and mortality at the population level.

Patients with severe traumatic brain injury transferred to a Level I or II trauma center

Patients with severe traumatic brain injury (TBI), head Abbreviated Injury Scale (AIS) score of 3 or greater, who are indirectly transported from the scene of injury to a nontrauma center can experience delays to definitive neurosurgical management. Transport to a hospital with appropriate initial emergency department treatment and rapid admission has been shown to reduce mortality in a state's trauma system. This study was conducted to see if the same finding holds with a nationally representative sample of patients with severe TBI seen at Level I and II trauma centers. This study is based on adult (≥18 years), severe TBI patients treated in a nationally representative sample of Level I and II trauma centers, submitting data to the National Trauma Databank National Sample Program from 2007 to 2009. We analyzed independent variables including age, sex, primary payer, race, ethnicity, mode of transport, injury type (blunt vs. penetrating), mechanism of injury, trauma center level, head AIS, initial Glasgow Coma Scale (GCS), Injury Severity Score (ISS), and systolic blood pressure by transfer status. The primary outcome variable was inpatient death, with discharge disposition, neurosurgical procedures, and mean hospital, intensive care unit, and ventilator days serving as secondary outcomes. After exclusion criteria were applied (ISS < 16; age < 18 years; GCS motor score = 6; non-head AIS score ≥ 3; head AIS < 3; patients with missing transfer status, and death on arrival), a weighted sample of 51,300 (16%) patients was eligible for analysis. In bivariate analyses, transferred patients were older (≥60 years), white, insured, less severely injured (head AIS score ≤ 4, ISS ≤ 25), and less likely to have sustained penetrating trauma (p < 0.001). After controlling for all variables, direct transport, 1 or more comorbidities, advanced age, head AIS score, intracranial hemorrhage, and firearm injury remained significant predictors of death. Being transferred (adjusted odds ratio, 0.79; 95% confidence interval, 0.64-0.96) lowered the risk of death. Patients with severe TBI who were transferred to a Level I or II trauma center had lower injury severity, including less penetrating trauma, and, as a result, were less likely to die compared with patients who were directly admitted to a Level I or II trauma center. The results may demonstrate adherence with the current Guidelines for Prehospital Management of Traumatic Brain Injury and Guidelines for Field Triage of Injured Patients, which recommend the direct transport of patients with severe TBI to the highest level trauma center. Patients with severe TBI who cannot be taken to a trauma center should be stabilized at a nontrauma center and then transferred to a Level I or II trauma center. Regional and national trauma databases should consider collecting information on patient outcomes at referral facilities and total transport time after injury, to better address the outcomes of patient triage decisions. Prognostic study, level III; therapeutic study, level IV.

Guidelines for Field Triage of Injured Patients

Guidelines for Field Triage of Injured Patients

Motor Vehicle Intrusion Alone Does Not Predict Trauma Center Admission or Use of Trauma Center Resources

Background. The Centers for Disease Control and Prevention (CDC) published its Guidelines for Field Triage of Injured Patients in 2009. These CDC guidelines define criteria for the triage of trauma patients to trauma centers, and include physiologic, anatomic, and high-risk mechanism-of-injury criteria. One of the mechanism criteria used for motor vehicle crashes (MVCs) is intrusion >12 inches at the occupant site or >18 inches at any site. Objective. We hypothesized that motor vehicle intrusion, as the sole criterion for transport to a trauma center, is neither sensitive nor specific for predicting which patients will utilize trauma center resources. Methods. This was a retrospective, observational study of a cohort of MVC victims transported to a single trauma center. The authors extracted MVC characteristics, patient demographics, and final diagnoses from emergency medical services (EMS) and emergency department (ED) charts. Two outcomes were examined: admission to the trauma center for a traumatic injury and use of trauma center resources, defined as in-hospital death, admission to an intensive care unit, operative intervention of any type, spinal injury, or intracranial hemorrhage. Results. During the 18-month study period, 608 patients met the inclusion criteria in our study; 36 patients met the trauma center triage criteria based solely on intrusion. The sensitivity, specificity, and positive predictive value (PPV) of intrusion were 38.9%, 92.8%, and 25.5%, respectively, for trauma center admission, and 58.3%, 91.9%, and 12.7%, respectively, for trauma center resource utilization. We conducted one post hoc adjustment to modify intrusion to entrapment. This change greatly increased the PPV of the CDC guidelines for both trauma center admissions and trauma center utilization, without any reduction in sensitivity. Conclusions. Motor vehicle intrusion alone is a poor predictor of the need for trauma center admission or trauma center resource utilization. A modest change to the CDC guidelines from intrusion to entrapment may reduce overtriage while maintaining a high sensitivity for serious injury.

EDITORIALAn Innovative Advance in Continuing Medical Education for Emergency Physicians and Trauma Surgeons

For the past two years, we have tried to devise, unsuccessfully, a manual for physician's assistants and residents. The manual was not completed because we did not have a comprehensive field triage plan for injured patients. A landmark publication written by members of the National Center for Injury Prevention and Control of the CDC provided comprehensive and detailed information on field triage of injured patients. This work has ten continuing education questions allowing the reader to receive 2.5 CME credits. The format for this work will provide an outline for future manuals in emergency departments and trauma centers. All emergency physicians and trauma surgeons should review this work to ensure that their community has an updated field triage plan for emergency and trauma patients.

Guidelines for Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage

In the United States, injury is the leading cause of death for persons aged 1--44 years, and the approximately 800,000 emergency medical services (EMS) providers have a substantial impact on the care of injured persons and on public health. At an injury scene, EMS providers determine the severity of injury, initiate medical management, and identify the most appropriate facility to which to transport the patient through a process called "field triage." Although basic emergency services generally are consistent across hospital emergency departments (EDs), certain hospitals have additional expertise, resources, and equipment for treating severely injured patients. Such facilities, called "trauma centers," are classified from Level I (centers providing the highest level of trauma care) to Level IV (centers providing initial trauma care and transfer to a higher level of trauma care if necessary) depending on the scope of resources and services available. The risk for death of a severely injured person is 25% lower if the patient receives care at a Level I trauma center. However, not all patients require the services of a Level I trauma center; patients who are injured less severely might be served better by being transported to a closer ED capable of managing milder injuries. Transferring all injured patients to Level I trauma centers might overburden the centers, have a negative impact on patient outcomes, and decrease cost effectiveness. In 1986, the American College of Surgeons developed the Field Triage Decision Scheme (Decision Scheme), which serves as the basis for triage protocols for state and local EMS systems across the United States. The Decision Scheme is an algorithm that guides EMS providers through four decision steps (physiologic, anatomic, mechanism of injury, and special considerations) to determine the most appropriate destination facility within the local trauma care system. Since its initial publication in 1986, the Decision Scheme has been revised four times. In 2005, with support from the National Highway Traffic Safety Administration, CDC began facilitating revision of the Decision Scheme by hosting a series of meetings of the National Expert Panel on Field Triage, which includes injury-care providers, public health professionals, automotive industry representatives, and officials from federal agencies. The Panel reviewed relevant literature, presented its findings, and reached consensus on necessary revisions. The revised Decision Scheme was published in 2006. This report describes the process and rationale used by the Expert Panel to revise the Decision Scheme.

Trauma Triage

Field triage of injured patients has the objective of rapid identification of that 5-10% with injuries serious enough to pose a risk to life. The process requires not only the identification of patients with abnormal physiology, but also those whose physiology is normal despite the fact that significant anatomic injury may exist. This paper defines relationships by which vehicle damage information available at the accident may augment the physiologic measures used for triage decisions. Vehicle velocity changes of 20 m.p.h. or more in direct frontal collisions, 22 m.p.h. or more in offset frontal collisions, and 15 m.p.h. or more in side impacts captured 90% of the patients with Injury Severity Scores of 16 or greater. The amount of vehicle damage observed with these velocity changes was found to be 20 inches of crush in direct frontal collisions, 28 inches of crush in offset frontal collisions, and 15 inches of damage in side impacts. Incorporating these findings into triage of trauma patients who exhibit normal vital signs at the accident scene may provide a more structured basis for field triage.