Field Triage Protocol Research Articles

Proof of principle: An animal field triage protocol for livestock and horses caught in natural disasters and major incidents

Field triage systems are available to address mass casualty incidents involving humans, but lack for animals caught in disasters. This study aimed to develop, as a proof of principle, an animal field triage protocol for livestock, horses and wildlife based on an existing human triage system. A literature review was completed, resulting in choosing the human SALT triage algorithm as a starting point, followed by an expert consultation using a two-round Delphi study to evaluate and create the final version of the triage protocol. Finally, a group of first responders were familiarized with the protocol and triage injured animals in a simulated disaster environment using a purpose-built training game and provide written feedback. For livestock and horses, consensus was reached on the use of global sorting based on the criteria ‘autonomously mobile without obvious major injuries’, and on five of six appropriate physiological criteria applied for individual health state assessment. Triaged animals were placed in one of four categories developed for applicable veterinary care, being beyond saving (black), immediate/urgent (red), delayed (yellow) and minor (green). The expert panel agreed that the veterinary triage model is probably workable for livestock and horses but not for wildlife, and has added value in natural disasters and mass casualty incidents involving animals. Validation of the protocol with first responders on the usability of the triage protocol as a proof of principle warrants a careful introduction for practical use and further evaluation during disasters affecting livestock and horses in the field.

On Scene Injury Severity Prediction (OSISP) model for trauma developed using the Swedish Trauma Registry

BackgroundProviding optimal care for trauma, the leading cause of death for young adults, remains a challenge e.g., due to field triage limitations in assessing a patient’s condition and deciding on transport destination. Data-driven On Scene Injury Severity Prediction (OSISP) models for motor vehicle crashes have shown potential for providing real-time decision support. The objective of this study is therefore to evaluate if an Artificial Intelligence (AI) based clinical decision support system can identify severely injured trauma patients in the prehospital setting.MethodsThe Swedish Trauma Registry was used to train and validate five models – Logistic Regression, Random Forest, XGBoost, Support Vector Machine and Artificial Neural Network – in a stratified 10-fold cross validation setting and hold-out analysis. The models performed binary classification of the New Injury Severity Score and were evaluated using accuracy metrics, area under the receiver operating characteristic curve (AUC) and Precision-Recall curve (AUCPR), and under- and overtriage rates.ResultsThere were 75,602 registrations between 2013–2020 and 47,357 (62.6%) remained after eligibility criteria were applied. Models were based on 21 predictors, including injury location. From the clinical outcome, about 40% of patients were undertriaged and 46% were overtriaged. Models demonstrated potential for improved triaging and yielded AUC between 0.80–0.89 and AUCPR between 0.43–0.62.ConclusionsAI based OSISP models have potential to provide support during assessment of injury severity. The findings may be used for developing tools to complement field triage protocols, with potential to improve prehospital trauma care and thereby reduce morbidity and mortality for a large patient population.

On Scene Injury Severity Prediction (OSISP) machine learning algorithms for motor vehicle crash occupants in US

A significant proportion of motor vehicle crash fatalities are potentially preventable with improved acute care. By increasing the accuracy of triage more victims could be transported directly to the best suited care facility and be provided optimal care. We hypothesize that On Scene Injury Severity Prediction (OSISP) algorithms, developed utilizing machine learning methods, have potential to improve triage by complementing the field triage protocol. In this study, the accuracy of OSISP algorithms based on the “National Automotive Sampling System - Crashworthiness Data System” (NASS-CDS) of crashes involving adult occupants for calendar years 2010–2015 was evaluated. Severe injury was the dependent variable, defined as Injury Severity Score (ISS) > 15. The dataset contained 37873 subjects, whereof 21589 included injury data and were further analyzed. Selection of model predictors was based on potential for injury severity prediction and perceived feasibility of assessment by first responders. We excluded vehicle telemetry data due to the limited availability of these systems in the contemporary vehicle fleet, and because this data is not yet being utilized in prehospital care. The machine learning algorithms Logistic Regression, Ridge Regression, Bernoulli Naïve Bayes, Stochastic Gradient Descent and Artificial Neural Networks were evaluated. Best performance with small margin was achieved with Logistic Regression, achieving area under the receiver operator characteristic curve (AUC) of 0.86 (95% confidence interval 0.82–0.90), as estimated by 10-fold stratified cross-validation. Ejection, Entrapment, Belt use, Airbag deployment and Crash type were good predictors. Using only a subset of the 5–7 best predictors approached the prediction accuracy achieved when using the full set (14 predictors). A simplified benefit analysis indicated that nationwide implementation of OSISP in the US could bring improved care for 3100 severely injured patients, and reduce unnecessary use of trauma center resources for 94000 non-severely injured patients, every year.

Pediatric Facility Recognition Program and the Illinois EMSC Experience.

Emergency medical services (EMS) systems were initially developed in the United States during the late 1960s. Modeled from military experiences, EMS demonstrated that survival for prehospital patients could be improved with enhanced field triage, treatment, and transport protocols. Over the next few decades, it was identified that children and adolescents had poorer outcomes in similar acute medical situations as compared to adults. To address this, the emergency medical services for children (EMSC) program was established in 1985 as a federal initiative to ensure appropriate resources and adequately trained personnel are available to meet the emergency care needs of children who are critically ill and injured. In 1994, the Illinois EMSC program was established and a pediatric facility recognition program to improve the emergency care of pediatric patients was rolled out in 1998. This article reviews the development of EMSC facility recognition programs and discusses their unique characteristics and contributions to improved pediatric emergency care. [Pediatr Ann. 2021;50(4):e165-e171.].

Current trauma care system in Saudi Arabia: A scoping literature review

BackgroundTrauma is one of the leading causes of death worldwide with millions of people dying each year, particularly in low or middle-income countries. This paper describes and evaluates the current trauma system (TS) in Saudi Arabia (SA). MethodsA scoping literature review was performed, incorporating an extensive search of Medline and Embase databases for refereed literature, as well as a search of grey literature to locate unpublished articles or reports in English or Arabic. All publications were assessed against the World Health Organization (WHO) Trauma System Maturity Index (TSMI) and American College of Surgeon’s (ACS) criteria. ResultsDespite local injury prevention efforts, Motor Vehicle Crashes (MVC) remain the primary cause of injuries in SA. Prehospital trauma care in SA aligns with level III care as described in the WHO TSMI classification system, based on the presence of formal emergency medical services and universal access to care. With respect to the ACS classification, no clear written guidelines, either for field triage or trauma destination protocols such as trauma bypass, were identified in prehospital trauma care. The role of secondary and tertiary facilities in treating trauma patients is unclear, with no clear referral linkages, suggesting a level I to III grading of SA’s trauma care facilities. Currently, there is no national or regional electronic trauma registry, no quality assurance program, and active involvement in research projects related to injuries is limited. ConclusionThe current SA TS has strengths but there are key features missing in comparison to other systems globally. As MVCs remain a leading cause of death/ disability, efforts to reduce the prevalence and impact of MVC burden in SA through development of a stronger national TS are warranted.

Emergency medical systems education may improve knowledge of pre-hospital stroke triage protocols

BackgroundFollowing the results of randomized clinical trials supporting the use of mechanical thrombectomy (MT) with tissue plasminogen activator for emergent large vessel occlusion (ELVO), our state Stroke Task Force convened...

Trauma patients centralization for the mechanism of trauma: old questions without answers.

Centralization of trauma patients has become the standard of care. Unfortunately, overtriage can overcome the capability of Trauma Centres. This study aims to analyse the association of different mechanisms of injury with severe or major trauma defined as Injury Severity Score (ISS) greater than 15 and an estimation of overtriage upon our Trauma Centre. A retrospective review of our prospective database was undertaken from March 2014 to August 2016. Univariate and multivariable logistic regression models were used to estimate the association between covariates (gender, age, and mechanisms of injury) and the risk of major trauma. The trauma team (TT) treated 1575 patients: among the 1359 (86%) were triaged only because of dynamics or mechanism of trauma. Overtriage according to an ISS < 15, was 74.6% on all trauma team activation (TTA) and 83.2% among the TTA prompted by the mechanism of injury. Patients aged 56-70years had an 87% higher risk of having a major trauma than younger patients (OR 1.87, 95% CI 1.29-2.71) while for patients aged more than 71years OR was 3.45, 95% CI 2.31-5.15. Car head-on collision (OR 2.50, 95% CI 1.27-4.92), intentional falls (OR 5.61, 95% CI 2.43-12.97), motorbike crash (OR 1.67, 95% CI 1.06-2.65) and pedestrian impact (OR 2.68, 95% CI 1.51-4.74) were significantly associated with a higher risk of major trauma in a multivariate analysis. Significant association with major trauma was demonstrated in the multivariate analysis of different mechanisms of trauma in patients triaged only for dynamics. A revision of our field triage protocol with a prospective validation is needed to improve overtriage that is above the suggested limits.

Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients

A major component of trauma care is adequate prehospital triage. To optimize the prehospital triage system, it is essential to gain insight in the quality of prehospital triage of the entire trauma system. To prospectively evaluate the quality of the field triage system to identify severely injured adult trauma patients. Prehospital and hospital data of all adult trauma patients during 2012 to 2014 transported with the highest priority by emergency medical services professionals to 10 hospitals in Central Netherlands were prospectively collected. Prehospital data collected by the emergency medical services professionals were matched to hospital data collected in the trauma registry. An Injury Severity Score of 16 or more was used to determine severe injury. The quality and diagnostic accuracy of the field triage protocol and compliance of emergency medical services professionals to the protocol. A total of 4950 trauma patients were evaluated of which 436 (8.8%) patients were severely injured. The undertriage rate based on actual destination facility was 21.6% (95% CI, 18.0-25.7) with an overtriage rate of 30.6% (95% CI, 29.3-32.0). Analysis of the protocol itself, regardless of destination facility, resulted in an undertriage of 63.8% (95% CI, 59.2-68.1) and overtriage of 7.4% (95% CI, 6.7-8.2). The compliance to the field triage trauma protocol was 73% for patients with a level 1 indication. More than 20% of the patients with severe injuries were not transported to a level I trauma center. These patients are at risk for preventable morbidity and mortality. This finding indicates the need for improvement of the prehospital triage protocol.

Validation of the criteria for early critical care resource use in assessing the effectiveness of field triage

BackgroundThis study aimed to validate the criteria for early critical care resource (CCR) use as an outcome predictor for seriously injured patients triaged in the field by comparing the effectiveness of the criteria for early CCR use with that of criteria defined by an Injury Severity Score (ISS) >15. MethodsWe analysed data from seriously injured trauma patients who were triaged using a field triage protocol by emergency medical service providers (EMS-ST patients). Early CCR use was defined as the use of any of the following treatment modalities or outcomes: advanced airway management, blood transfusion, or interventional radiology (<4h), emergency operation or cardiopulmonary resuscitation, or thoracotomy (<24h), or admission for spinal cord injury. The primary endpoint was inhospital mortality. We generated area under the receiver operating characteristic (AUROC) curves to compare the value of the early CCR use criteria with that of the ISS >15 criteria in the discrimination between survivors and non-survivors. ResultsOf the 14,352 adult EMS-ST patients, 9299 were enrolled in this study. Approximately 19.6% required early CCR use, and 18.0% had an ISS >15. The rate of in-hospital mortality was 9.4%. The AUROC values for the performances of the early CCR use and ISS>15 criteria in the prediction of in-hospital mortality were 0.89 (95% confidence interval [CI] 0.85–0.91) and 0.84 (95% CI 0.79–0.86), respectively (p<0.01). ConclusionThe early CCR use criteria demonstrated better performance than the ISS >15 criteria in the prediction of mortality in EMS-ST patients.

Achieving timely percutaneous reperfusion for rural ST-elevation myocardial infarction patients by direct transport to an urban PCI-hospital.

BackgroundsST-elevation myocardial infarction (STEMI) guidelines recommend reperfusion by primary percutaneous coronary intervention (PCI) ≤ 90 min from time of first medical contact (FMC). This strategy is challenging in rural areas lacking a nearby PCI-capable hospital. Recommended reperfusion times can be achieved for STEMI patients presenting in rural areas without a nearby PCI-capable hospital by ground transportation to a central PCI-capable hospital by use of protocol-driven emergency medical service (EMS) STEMI field triage protocol.MethodsSixty STEMI patients directly transported by EMS from three rural counties (Nassau, Camden and Charlton Counties) within a 50-mile radius of University of Florida Health-Jacksonville (UFHJ) from 01/01/2009 to 12/31/2013 were identified from its PCI registry. The STEMI field triage protocol incorporated three elements: (1) a cooperative agreement between each of the rural emergency medical service (EMS) agency and UFHJ; (2) performance of a pre-hospital ECG to facilitate STEMI identification and laboratory activation; and (3) direct transfer by ground transportation to the UFHJ cardiac catheterization laboratory. FMC-to-device (FMC2D), door-to-device (D2D), and transit times, the day of week, time of day, and EMS shift times were recorded, and odds ratio (OR) of achieving FMC2D times was calculated.ResultsFMC2D times were shorter for in-state STEMIs (81 ± 17 vs. 87 ± 19 min), but D2D times were similar (37 ± 18 vs. 39 ± 21 min). FMC2D ≤ 90 min were achieved in 82.7% in-state STEMIs compared to 52.2% for out-of-state STEMIs (OR = 4.4, 95% CI: 1.24–15.57; P = 0.018). FMC2D times were homogenous after adjusting for weekday vs. weekend, EMS shift times. Nine patients did not meet FMC2D ≤ 90 min. Six were within 10 min of target; all patient achieved FMC2D ≤ 120 min.ConclusionsGuideline-compliant FMC2D ≤ 90 min is achievable for rural STEMI patients within a 50 mile radius of a PCI-capable hospital by use of protocol-driven EMS ground transportation. As all patients achieved a FMC2D time ≤ 120 min, bypass of non-PCI capable hospitals may be reasonable in this situation.

Maryland’s Helicopter Emergency Medical Services Experience From 2001 to 2011: System Improvements and Patients’ Outcomes

Helicopter emergency medical services (EMS) has become a well-established component of modern trauma systems. It is an expensive, limited resource with potential safety concerns. Helicopter EMS activation criteria intended to increase efficiency and reduce inappropriate use remain elusive and difficult to measure. This study evaluates the effect of statewide field trauma triage changes on helicopter EMS use and patient outcomes. Data were extracted from the helicopter EMS computer-aided dispatch database for in-state scene flights and from the state Trauma Registry for all trauma patients directly admitted from the scene or transferred to trauma centers from July 1, 2000, to June 30, 2011. Computer-aided dispatch flights were analyzed for periods corresponding to field triage protocol modifications intended to improve system efficiency. Outcomes were separately analyzed for trauma registry patients by mode of transport. The helicopter EMS computer-aided dispatch data set included 44,073 transports. There was a statewide decrease in helicopter EMS usage for trauma patients of 55.9%, differentially affecting counties closer to trauma centers. The Trauma Registry data set included 182,809 patients (37,407 helicopter transports, 128,129 ambulance transports, and 17,273 transfers). There was an increase of 21% in overall annual EMS scene trauma patients transported; ground transports increased by 33%, whereas helicopter EMS transports decreased by 49%. Helicopter EMS patient acuity increased, with an attendant increase in patient mortality. However, when standardized with W statistics, both helicopter EMS- and ground-transported trauma patients showed sustained improvement in mortality. Modifications to state protocols were associated with decreased helicopter EMS use and overall improved trauma patient outcomes.

Accuracy of the field triage protocol in selecting severely injured patients after high energy trauma

BackgroundFor optimal treatment of trauma patients it is of great importance to identify patients who are at risk for severe injuries. The Dutch field triage protocol for trauma patients, the LPA (National Protocol of Ambulance Services), is designed to get the right patient, in the right time, to the right hospital. Purpose of this study was to determine diagnostic accuracy and compliance of this triage protocol. Study designTriage criteria were categorised into physiological condition (P), mechanism of trauma (M) and injury type (I). A retrospective analysis of prospectively collected data of all high-energy trauma patients from 2008 to 2011 in the region Central Netherlands is performed. Diagnostic parameters (sensitivity, specificity, negative predictive value, positive predictive value) of the field triage protocol for selecting severely injured patients were calculated including rates of under- and overtriage. Undertriage was defined as the proportion of severely injured patients (Injury Severity Score (ISS)≥16) who were transported to a level two or three trauma care centre. Overtriage was defined as the proportion of non-severely injured patients (ISS<16) who were transported to a level one trauma care centre. ResultsOverall sensitivity and specificity of the field triage protocol was 89.1% (95% confidence interval (CI) 84.4–92.6) and 60.5% (95% CI 57.9–63.1), respectively. The overall rate of undertriage was 10.9% (95%CI 7.4–15.7) and the overall rate of overtriage was 39.5% (95%CI 36.9–42.1). These rates were 16.5% and 37.7%, respectively for patients with M+I−P−. Compliance to the triage protocol for patients with M+I−P− was 78.7%. Furthermore, compliance in patients with either a positive I+ or positive P+ was 91.2%. ConclusionThe overall rate of undertriage (10.8%) was mainly influenced by a high rate of undertriage in the group of patients with only a positive mechanism criterion, therefore showing low diagnostic accuracy in selecting severely injured patients. As a consequence these patients with severe injury are undetected using the current triage protocol. As it has been shown that severely injured patients have better outcome in level one trauma care centres further optimisation of this protocol aiming at lowering undertriage is therefore essential, preferably without incrementing overtriage too much.

Patient Choice in the Selection of Hospitals by 9-1-1 Emergency Medical Services Providers in Trauma Systems

Reasons for undertriage (transporting seriously injured patients to nontrauma centers) and the apparent lack of benefit of trauma centers among older adults remain unclear; understanding emergency medical services (EMS) provider reasons for selecting certain hospitals in trauma systems may provide insight to these issues. In this study, the authors evaluated reasons cited by EMS providers for selecting specific hospital destinations for injured patients, stratified by age, injury severity, field triage status, and prognosis. This was a retrospective cohort study of injured children and adults transported by 61 EMS agencies to 93 hospitals (trauma and nontrauma centers) in five regions of the western United States from 2006 through 2008. Hospital records were probabilistically linked to EMS records using trauma registries, state discharge data, and emergency department data. The seven standardized reasons cited by EMS providers for selecting hospital destinations included closest facility, ambulance diversion, physician choice, law enforcement choice, patient or family choice, specialty resource center, and other. "Serious injury" was defined as an Injury Severity Score (ISS) ≥ 16, and unadjusted in-hospital mortality was considered as a marker of prognosis. All analyses were stratified by age in 10-year increments, and descriptive statistics were used to characterize the findings. A total of 176,981 injured patients were evaluated and transported by EMS over the 3-year period, of whom 5,752 (3.3%) had ISS ≥ 16 and 2,773 (1.6%) died. Patient or family choice (50.6%), closest facility (20.7%), and specialty resource center (15.2%) were the most common reasons indicated by EMS providers for selecting destination hospitals; these frequencies varied substantially by patient age. The frequency of patient or family choice increased with increasing age, from 36.4% among 21- to 30-year-olds to 75.8% among those older than 90years. This trend paralleled undertriage rates and persisted when restricted to patients with serious injuries. Older patients with the worst prognoses were preferentially transported to major trauma centers, a finding that was not explained by field triage protocols. Emergency medical services transport patterns among injured patients are not random, even after accounting for field triage protocols. The selection of hospitals appears to be heavily influenced by patient or family choice, which increases with patient age and involves inherent differences in patient prognosis.

Reliability of the Primary Triage Process after the Volendam Fire Disaster

In a major incident, correct triage is crucial to emergency treatment and transportation priority. The aim of this study was to evaluate the triage process pursued at the site of the fire disaster in Volendam, the Netherlands on January 1, 2001. On-site (OS) and Emergency Department (ED) data regarding total body surface area burned (TBSA) and inhalation injury (INH) were compared with the final (FIN) assessment of these two parameters after hospital admission. Finally, the effect of OS intubation and the time of arrival at a hospital were evaluated. There were 245 injured. Mean age was 17.3 years. Final median TBSA was 12%; 96 patients (39%) had inhalation injury. Agreement between TBSA-OS (n = 46) and TBSA-FIN was poor (Pearson's correlations coefficient [PCC] = 0.77; R 2 = 0.60). TBSA-ED (n = 78) was more accurate (PCC = 0.96; R 2 = 0.93). INH-OS (n = 79, sensitivity 100%, specificity 24%) and INH-ED (n = 198, sensitivity 99%, specificity 36%) were sensitive but not specific. Eight patients were intubated on-site. No differences in outcome were found between this group and the patients who were intubated in the hospital. There was no difference in time of arrival at a hospital ( p = 0.55). TBSA was not estimated reliably in a non-clinical environment. The diagnosis of inhalation injury was adequate but resulted in over-triage on-site and at the ED. Triage did not lead to transport priorities for the severely wounded. In a major burn accident, a field triage protocol for rapid evaluation of burn injuries may be useful. Detailed assessment of injuries of burn casualties is practical only in a specialized clinical setting.

DEVELOPING RESEARCH CRITERIA TO DEFINE MEDICAL NECESSITY IN EMERGENCY MEDICAL SERVICES

“The Neely Conference: Developing Research Criteria to Define Medical Necessity in EMS” convened emergency medical services (EMS) physicians, researchers, administrators, providers, and federal agency representatives to begin the development of a set of uniform triage criteria and outcome measures that could be used to study and evaluate medical necessity among EMS patients. These standardized criteria might be used in research studies examining EMS dispatch and response (e.g., dispatch triage protocols, alternative response configurations), and EMS treatment and transport (e.g., field triage protocols, alternative care destinations). The conference process included review and analysis of the literature, expert judgment, and consensus building. There was general agreement on the following: 1. Any dispatch triage or field triage system that is developed must be designed to offer patients alternatives to EMS, not to refuse care to patients. 2. It is theoretically possible to develop a set of clinical criteria for need. Some groups of patients will clearly need a traditional EMS response and other groups will not, but this has yet to be defined. 3. In addition to clinical criteria, certain social and other nonclinical criteria such as pain or potential abuse may be used to justify a response. 4. Communication barriers, patient age, special needs, and other conditions complicate patient assessment but should not exclude patients from consideration for alternate triage or transport. 5. These research questions are important, and standard sets of outcome measures are needed so that different studies and innovative programs can be compared.

ANALYSIS OF RECURRENT PROCESS ERRORS LEADING TO PROVIDER-RELATED COMPLICATIONS ON AN ORGANIZED TRAUMA SERVICE

Complications in trauma care occur because of provider-related or patient disease-related events. Strictly defined standardized definitions of both types of complications are needed to develop strategies for problem resolution. The frequency and characteristics of 135 disease-related and provider-related complications were examined for a 3-year period in a level I university trauma service in all patients meeting Major Trauma Outcome Study (MTOS) criteria. Provider-related complications were analyzed for recurrent process errors to be targeted for corrective action. Complication events occurred in 2764 of 3327 patients, with provider-related complications in 759. Twenty-three percent (175) of complications were judged unjustified and 16 patterns of recurrent process-of-care errors were identified. Delay in trauma team activation was caused by insensitivity of field triage protocols and inadequate recognition of injury patterns. Delays in diagnosis or surgery were caused by inadequate performance of standard work-up, inadequate recognition of injury severity by providers, diagnostic procedure interpretation errors, and errors in prioritizing the order of diagnostic procedures. Errors in technique were attributed to inexperience, haste, unfamiliarity with devices, lack of developed institutional techniques, and failure of providers to use recognized endpoints. Errors in judgment were attributed to failure to access available patient information, proceeding despite available information, and failure to utilize available care guidelines. Further reduction in provider-related morbidity in an organized trauma system requires this type of analysis, which identifies the need to change the process of care through education or adjustment of protocols for standardization care delivery in addition to the traditional focus on outcomes.

New directions in the research and treatment of carbon monoxide exposure

teria for admission to the program were the patient’s rescue from a fire or a carbon monoxide incident in which the victim was unconscious at the scene or manifested mental aberration on questioning. Patients meeting these criteria were transferred via Med-Evac helicopter to MIEMSS. Most patient referrals were from Baltimore City and the five surrounding counties; a smaller number of patients came from the Baltimore/Washington corridor and the Washington beltway areas. Through the fire combustion research section of the National Bureau of Standards, a grant was obtained to develop field triage protocols for toxic inhalant victims; test the severity of toxic involvement; and develop optimal treatment programs for these cases. Studies of toxic inhalation and carbon monoxide poisoning indicate the need for field triage protocols and changes in our concepts of the clinical manifestations, treatment, and expected outcome in these cases. Members of a MIEMSS “smoke team” tested a portable