Field Triage Research Articles

A Mobile Stroke Treatment Unit for Field Triage of Patients for Intraarterial Revascularization Therapy.

Favorable outcomes in intraarterial therapy (IAT) for acute ischemic stroke (AIS) are related to early vessel recanalization. The mobile stroke treatment unit (MSTU) is an on-site, prehospital, treatment team, laboratory, and CT scanner that reduces time to treatment for intravenous thrombolysis and may also shorten time to IAT. Using our MSTU database, we identified patients that underwent IAT for AIS. We compared the key time metrics to historical controls, which included patients that underwent IAT at our institution six months prior to implementation of the MSTU. We further divided the controls into two groups: (1) transferred to our institution for IAT and (2) directly presented to our emergency room and underwent IAT. After 164 days of service, the MSTU transported 155 patients of which 5 underwent IAT. We identified 5 historical controls that were transferred to our center for IAT. Substantial reduction in times including median door to initial CT (12minute vs. 32minute), CT to IAT (82minute vs. 165minute), and door to MSTU/primary stroke center departure (37minute vs. 106minute) were noted among the two groups. Compared to the 6 patients who presented to our institution directly, the MSTU process times were also shorter. Our initial experience shows that MSTU may help in early triage and shorten the time to IAT for AIS.

Prehospital Trauma Triage Decision-making: A Model of What Happens between the 9-1-1 Call and the Hospital

We describe the decision-making process used by emergency medical services (EMS) providers in order to understand how 1) injured patients are evaluated in the prehospital setting; 2) field triage criteria are applied in-practice; and 3) selection of a destination hospital is determined. We conducted separate focus groups with advanced and basic life support providers from rural and urban/suburban regions. Four exploratory focus groups were conducted to identify overarching themes and five additional confirmatory focus groups were conducted to verify initial focus group findings and provide additional detail regarding trauma triage decision-making and application of field triage criteria. All focus groups were conducted by a public health researcher with formal training in qualitative research. A standardized question guide was used to facilitate discussion at all focus groups. All focus groups were audio-recorded and transcribed. Responses were coded and categorized into larger domains to describe how EMS providers approach trauma triage and apply the Field Triage Decision Scheme. We conducted 9 focus groups with 50 EMS providers. Participants highlighted that trauma triage is complex and there is often limited time to make destination decisions. Four overarching domains were identified within the context of trauma triage decision-making: 1) initial assessment; 2) importance of speed versus accuracy; 3) usability of current field triage criteria; and 4) consideration of patient and emergency care system-level factors. Field triage is a complex decision-making process which involves consideration of many patient and system-level factors. The decision model presented in this study suggests that EMS providers place significant emphasis on speed of decisions, relying on initial impressions and immediately observable information, rather than precise measurement of vital signs or systematic application of field triage criteria.

On scene injury severity prediction (OSISP) algorithm for car occupants

Many victims in traffic accidents do not receive optimal care due to the fact that the severity of their injuries is not realized early on. Triage protocols are based on physiological and anatomical criteria and subsequently on mechanisms of injury in order to reduce undertriage. In this study the value of accident characteristics for field triage is evaluated by developing an on scene injury severity prediction (OSISP) algorithm using only accident characteristics that are feasible to assess at the scene of accident. A multivariate logistic regression model is constructed to assess the probability of a car occupant being severely injured following a crash, based on the Swedish Traffic Accident Data Acquisition (STRADA) database. Accidents involving adult occupants for calendar years 2003–2013 included in both police and hospital records, with no missing data for any of the model variables, were included. The total number of subjects was 29128, who were involved in 22607 accidents. Partition between severe and non-severe injury was done using the Injury Severity Score (ISS) with two thresholds: ISS>8 and ISS>15. The model variables are: belt use, airbag deployment, posted speed limit, type of accident, location of accident, elderly occupant (>55 years old), sex and occupant seat position. The area under the receiver operator characteristic curve (AUC) is 0.78 and 0.83 for ISS>8 and ISS>15, respectively, as estimated by 10-fold cross-validation. Belt use is the strongest predictor followed by type of accident. Posted speed limit, age and accident location contribute substantially to increase model accuracy, whereas sex and airbag deployment contribute to a smaller extent and seat position is of limited value. These findings can be used to refine triage protocols used in Sweden and possibly other countries with similar traffic environments.

Outcomes by day and night for patients bypassing the emergency department presenting with ST-segment elevation myocardial infarction identified with a pre-hospital electrocardiogram.

Pre-hospital ECG and emergency department (ED) bypass direct to the catheter laboratory may optimize reperfusion times for patients with ST-segment elevation myocardial infarction. Questions remain over feasibility and safety during off hours. To determine if presenting time of day is associated with differences in in-hospital and 30-day mortality and key reperfusion times. Seven hundred and twenty consecutive patients with STEMI triaged directly from the field to the catheter laboratory between June 2004-May 2013. Vital status was reported as of August 2013. The mean age was 65 ± 14 years, and 75.1% were male. Overall mortality (in-hospital/30 days) did not significantly differ for patients (3.4% in hours and 3.1% off hours; P = N/S). Symptom onset-to-arrival to the heart attack was non-significantly lower (100 minutes off hours (IQR 78-174) versus 110 minutes in hours (IQR 75-199), P = N/S). Call-to-balloon time was not significantly affected by the time of presentation: 150 min in hours (IQR 111-239) versus 154 minutes during off hours (IQR 115-225) P = N/S. Overall door-to-balloon time was 36 minutes (IQR 25-51), 34 minutes in hours (IQR 24-49) versus 40 minutes off hours (IQR 29-55) P = N/S. The overall false positive activation rate was only 13.1%, (in hours 12.2% vs. off hours 14.6%, respectively, P = N/S). In a unit with an established field triage system facilitating ED bypass, reperfusion times and mortality are not significantly influenced by whether the patient presents during standard working hours or outside of these hours.

Close, but not close enough.

Close, but not close enough.

The influence of residential distance on time to treatment in ST-elevation myocardial infarction patients.

AimsTo evaluate the relation between residential distance and total ischaemic time in patients with acute ST-elevation myocardial infarction (STEMI).MethodsSTEMI patients were transported to the Isala Hospital Zwolle with the intention to perform primary percutaneous coronary intervention PCI (pPCI) from 2004 until 2010 (n = 4149). Of these, 1424 patients (34 %) were referred via a non-PCI ‘spoke' centre (‘spoke’ patients) and 2725 patients (66 %) were referred via field triage in the ambulance (ambulance patients).ResultsA longer residential distance increased median total ischaemic time in ‘spoke’ patients (0–30 km: 228 min, >30-60 km: 235 min, >60-90 km: 264 min, p < 0.001), however not in ambulance patients (0–30 km: 179 min, >30-60 km: 175 min, >60-90 km: 186 min, p = 0.225). After multivariable linear regression analysis, in ‘spoke’ patients residential distance of >30-60 km compared with 0–30 km was not independently associated with ischaemic time; however, a residential distance of >60-90 km (exp (B) = 1.11, 95 % CI 1.01-1.12) compared with 0–30 km was independently related with ischaemic time. In ambulance patients, residential distance of >30-60 and >60-90 km compared with 0–30 km was not independently associated with ischaemic time.ConclusionA longer distance from the patient’s residence to a PCI centre was associated with a small but significant increase in time to treatment in ‘spoke’ patients, however not in ambulance patients. Therefore, referral via field triage in the ambulance did not lead to a significant increase in time to treatment, especially at long distances (up to 90 km).

The Centers for Disease Control (CDC) field triage criteria do not accurately predict the need for trauma team activation in the pediatric population

Wyrick, Deidre L. MD; Duke, Julie MD; Joubert, Kyla MD; Recicar, John RN; Maxson, Todd R MD Author Information

Physiologic Field Triage Criteria for Identifying Seriously Injured Older Adults

Objective. To evaluate the ability of out-of-hospital physiologic measures to predict serious injury for field triage purposes among older adults and potentially reduce the undertriage of seriously injured elders to non-trauma hospitals. Methods. This was a retrospective cohort study involving injured adults 55 years and older transported by 94 emergency medical services (EMS) agencies to 122 hospitals (trauma and non-trauma) in 7 regions of the western United States from January 1, 2006 to December 31, 2008. We evaluated initial out-of-hospital Glasgow Coma Scale (GCS) score, systolic blood pressure (SBP), respiratory rate, heart rate, shock index (SBP ÷ heart rate), out-of-hospital procedures, mechanism of injury, and patient demographics. The primary outcome was “serious injury,” defined as Injury Severity Score (ISS) ≥ 16, as a measure of trauma center need. We used multivariable regression models, fractional polynomials and binary recursive partitioning to evaluate appropriate physiologic cut-points and the value of different physiologic triage criteria. Results. A total of 44,890 injured older adults were evaluated and transported by EMS, of whom 2,328 (5.2%) had ISS ≥ 16. Nonlinear associations existed between all physiologic measures and ISS ≥ 16 (unadjusted and adjusted p ≤ 0.001 for all,), except for heart rate (adjusted p = 0.48). Revised physiologic triage criteria included GCS score ≤ 14; respiratory rate < 10 or > 24 breaths per minute or assisted ventilation; and SBP < 110 or > 200 mmHg. Compared to current triage practices, the revised criteria would increase triage sensitivity from 78.6 to 86.3% (difference 7.7%, 95% CI 6.1–9.6%), reduce specificity from 75.5 to 60.7% (difference 14.8%, 95% CI 14.3–15.3%), and increase the proportion of patients without serious injuries transported to major trauma centers by 60%. Conclusions. Existing out-of-hospital physiologic triage criteria could be revised to better identify seriously injured older adults at the expense of increasing overtriage to major trauma centers.

A consensus-based criterion standard for trauma center need

In civilian trauma care, field triage is the process applied by prehospital care providers to identify patients who are likely to have severe injuries and immediately need the resources of a trauma center. Studies of the efficacy of field triage have used various measures to define trauma center need because no "criterion standard" exists, making cross-study comparisons difficult. This study aimed to develop a consensus-based functional criterion standard definition of trauma center need. Local and national experts were recruited for participation. Blinded key informant interviews were conducted in order of availability until no new themes emerged. Themes identified during the interviews were used to develop a Modified Delphi survey, which was electronically delivered via Survey Monkey. The trauma center need criteria were refined iteratively based on participant responses. Participants completed additional surveys until there was at least 80% agreement for each criterion. Fourteen experts were recruited. Five participated in key informant interviews. A Modified Delphi survey was administered five times (four modifications based on the expert's responses). After the fifth round, there was at least 82% agreement on each criterion. The final definition included 10 time-specific indicators: major surgery, advanced airway, blood products, admission for spinal cord injury, thoracotomy, pericardiocentesis, cesarean delivery, intracranial pressure monitoring, interventional radiology, and in-hospital death. We developed a consensus-based functional criterion standard definition of needing the resources of a trauma center, which may help to standardize field triage research and quality assurance in trauma systems as well as allow for cross study comparisons.

Variability in California triage from 2005 to 2009: a population-based longitudinal study of severely injured patients.

Timely access to trauma care requires that severely injured patients are ultimately triaged to trauma centers. We sought to determine triage patterns for the injured population within the state of California to determine those factors associated with undertriage. We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database from January 1, 2005, and December 31, 2009. All visits associated with injury were linked longitudinally. Sixty-day and one-year mortality was determined using vital statistics data. Primary field triage was defined as field triage to a Level I/II trauma center; retriage was defined as initial triage to a non-Level I/II center followed by transfer to a Level I/II. Regions were organized by local emergency medical services agencies. The primary outcomes were triage patterns and mortality. The undertriage rate was 35% (n = 20,988) but was variable across regions (12-87%). Primary field triage ranged from 7% to 77%. Retriage rates not only were overall low (6% of all severely injured patients) but also varied by region (1-38%). In adjusted analysis, factors associated with a lower odds ratio (OR) of primary field triage included the following: age of 55 years or greater (OR, 0.78; p = 0.001), female sex (OR, 0.88; p = 0.014), greater number of comorbidities (OR, 0.92; p < 0.001), and fall mechanism versus motor vehicle collision (OR, 0.54; p < 0.001). One-year mortality was higher for undertriaged patients (25% vs. 16% and 18% for primary field and retriage, respectively, p < 0.001). This is the first study to create a longitudinal database of all emergency department visits, hospitalizations, and long-term mortality for every severely injured patient within an entire state during a 5-year period. Undertriage varied substantially by region and was associated with multiple factors including access to care and patient factors. Epidemiologic study, level III.

Randomized Trial Comparing Two Mass Casualty Triage Systems (JumpSTART versus SALT) in a Pediatric Simulated Mass Casualty Event

Purpose. Several field triage systems have been developed to rapidly sort patients following a mass casualty incident (MCI). JumpSTART (Simple Triage and Rapid Transport) is a pediatric-specific MCI triage system. SALT (Sort, Assess, Lifesaving interventions, Treat/Transport) has been proposed as a new national standard for MCI triage for both adult and pediatric patients, but it has not been tested in a pediatric population. This pilot study hypothesizes that SALT is at least as good as JumpSTART in triage accuracy, speed, and ease of use in a simulated pediatric MCI. Methods. Paramedics were invited and randomly assigned to either SALT or JumpSTART study groups. Following randomization, subjects viewed a 15-minute PowerPoint lecture on either JumpSTART or SALT. Subjects were provided with a triage algorithm card for reference and were asked to assign triage categories to 10 pediatric patients in a simulated building collapse. The scenario consisted of 4 children in moulage and 6 high-fidelity pediatric simulators. Injuries and triage categories were based on a previously published MCI scenario. One investigator followed each subject to record time and triage assignment. All subjects completed a post-test survey and structured interview following the simulated disaster. Results. Forty-three paramedics were enrolled. Seventeen were assigned to the SALT group with an overall triage accuracy of 66% ±15%, an overtriage mean rate of 22 ± 16%, and an undertriage rate of 10 ± 9%. Twenty-six participants were assigned to the JumpSTART group with an overall accuracy of 66 ± 12%, an overtriage mean of 23 ±16%, and an undertriage rate of 11.2 ± 11%. Ease of use was not statistically different between the two systems (median Likert value of both systems = 2, p = 0.39) Time to triage per patient was statistically faster in the JumpSTART group (SALT = 34 ± 23 seconds, JumpSTART = 26 ± 19 seconds, p = 0.02). Both systems were prone to cognitive and affective error. Conclusion. SALT appears to be at least as good as JumpSTART in overall triage accuracy, overtriage, or undertriage rates in a simulated pediatric MCI. Both systems were considered easy to use. However, JumpSTART was 8 seconds faster per patient in time taken to assign triage designations. Key words: mass casualty triage; pediatric; simulation

Trauma Care for Children in the Field

Emergency medical care for children has evolved immensely over the past 30 years. During this period, much has been accomplished to improve the quality of care delivered to injured children in the United States. In this article, we will highlight specific examples of how trauma care of children has changed and improved in recent decades. Beginning with the importance of injury prevention, the article will also discuss the specific management of traumatic brain injury, blast injury, and field triage of mass casualty situations before concluding with highlights of other changes and advances that have occurred.

Validation of prehospital trauma triage criteria for motor vehicle collisions

Triage of an injured patient to an appropriate trauma center can have an impact on morbidity and mortality. We sought to validate the 2012 national field triage guidelines for motor vehicle crashes. This is a retrospective cross-sectional study using the National Automotive Sampling System Crashworthiness Data System. Vehicle damage criteria proposed as prehospital triage guidelines were correlated with injury severity. There were 85,761 individuals representing 29,397,234 occupants in car crashes from 2003 to 2008. Of the patients, 3.8% met physiologic Step 1 criteria with a mean Injury Severity Score (ISS) of 9.1 (95% confidence interval [CI], -3.1 to 20.9); Step 1 had a positive predictive value (PPV) of 20.8% (95% CI, 20.1-21.4%) for severe injury (ISS > 15). Of the patients, 0.43% met anatomic Step 2 criteria alone, with a mean ISS of 18.1 (95% CI, 16.4-19.8) and a PPV of 48.5% (95% CI, 46.8-50.1%). Step 3 criteria include injury mechanism; 3.7% of the patients met one of these criteria alone with a mean ISS of 5.1 (95% CI, 4.4-5.8) and a PPV of 9.7% (95% CI, 9.3-10.2%).Patients who met only Step 3 criteria were examined to determine crash characteristics that predict severe injury. Intrusion of greater than 12 inches had a PPV of 10.4% (95% CI, 9.5-11.3); steering wheel collapse had a PPV of 25.7% (95% CI, 23.0-28.4%). Older patients (age > 55 years) who met Step 3 mechanism criteria had higher predictive values for injury for nearly all crash characteristics. Injury mechanism criteria alone predict significant injury in a substantial proportion of patients who did not meet the physiologic or anatomic criteria. Vehicular crash data could improve the ability of emergency medical service providers to triage injured occupants. Consideration of transport to a trauma center should be given for elderly patients and drivers with steering wheel collapse. Epidemiologic study, level III.

A qualitative examination of the health workforce needs during climate change disaster response in Pacific Island Countries.

BackgroundThere is a growing body of evidence that the impacts of climate change are affecting population health negatively. The Pacific region is particularly vulnerable to climate change; a strong health-care system is required to respond during times of disaster. This paper examines the capacity of the health sector in Pacific Island Countries to adapt to changing disaster response needs, in terms of: (i) health workforce governance, management, policy and involvement; (ii) health-care capacity and skills; and (iii) human resources for health training and workforce development.MethodsKey stakeholder interviews informed the assessment of the capacity of the health sector and disaster response organizations in Pacific Island Countries to adapt to disaster response needs under a changing climate. The research specifically drew upon and examined the adaptive capacity of individual organizations and the broader system of disaster response in four case study countries (Fiji, Cook Islands, Vanuatu and Samoa).Results‘Capacity’ including health-care capacity was one of the objective determinants identified as most significant in influencing the adaptive capacity of disaster response systems in the Pacific. The research identified several elements that could support the adaptive capacity of the health sector such as: inclusive involvement in disaster coordination; policies in place for health workforce coordination; belief in their abilities; and strong donor support. Factors constraining adaptive capacity included: weak coordination of international health personnel; lack of policies to address health worker welfare; limited human resources and material resources; shortages of personnel to deal with psychosocial needs; inadequate skills in field triage and counselling; and limited capacity for training.ConclusionFindings from this study can be used to inform the development of human resources for health policies and strategic plans, and to support the development of a coordinated and collaborative approach to disaster response training across the Pacific and other developing contexts. This study also provides an overview of health-care capacity and some of the challenges and strengths that can inform future development work by humanitarian organizations, regional and international donors involved in climate change adaptation, and disaster risk reduction in the Pacific region.

Prehospital Telemedicine Electrocardiogram Triage for a Regional Public Emergency Medical Service: Is It Worth It? A Preliminary Cost Analysis

Telemedicine has been shown to improve quality of health-care delivery in several fields of medicine; its cost-effectiveness, however, is still a matter of debate. Pre-hospital telemedicine electrocardiogram triage for regional public emergency medical service may reduce costs. An economic evaluation (cost analysis) was performed from the perspective of regional health-care system. Patients enrolled in the study and considered for cost analysis were those who called the local emergency medical service (EMS; dialing 1-1-8) during 2012 and underwent prehospital field triage with a telemedicine electrocardiogram (ECG) in the case of suspected acute cardiac disease (acute coronary syndrome, arrhythmia). The prehospital ECGs were read by a remote cardiologist, available 24/7. Cost savings associated with this method were calculated by subtracting the cost of prehospital triage with telemedicine support from the cost of conventional emergency department triage (ECG and consultation by a cardiologist). During 2012, the regional EMS performed 109 750 ECGs by telemedicine support. The associated total cost for the regional health-care system was €1 833 333, with a €16.70 cost per single ECG/consultation. Given the cost of similar conventional emergency department treatment from a regional rate list of €24.80 to €55.20, the savings was €8.10 to €38.40 per ECG/consultation (total savings, €891 759.50 to €4 219 379.50). The cost for ruling out an acute cardiac disease was €25.30; for a prehospital diagnosis of cardiovascular disease, €49.20. With 629 prehospital diagnoses of ST-elevation myocardial infarction and reported reductions in mortality thanks to prehospital diagnosis deduced from prior studies, 69 lives per year presumably could be saved, with a cost per quality-adjusted life year gained of €1927, €990/€ - 2508 after correction for potential savings. Prehospital EMS triage with telemedicine ECG in patients with suspected acute cardiac disease may reduce health-care costs.

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.

Comparison of Outcomes for Children With Cervical Spine Injury Based on Destination Hospital From Scene of Injury

Pediatric cervical spine injury is rare. As a result, evidence-based guidance for prehospital triage of children with suspected cervical spine injuries is limited. The effects of transport time and secondary transfer for specialty care have not previously been examined in the subset of children with cervical spine injuries. The primary objective was to determine if prehospital destination choice affects outcomes for children with cervical spine injuries. The secondary objectives were to describe prehospital and local hospital interventions for children ultimately transferred to pediatric trauma centers for definitive care of cervical spine injuries. The authors searched the Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury data set for children transported by emergency medical services (EMS) from scene of injury. Neurologic outcomes in children with cervical spine injuries transported directly to pediatric trauma centers were compared with those transported to local hospitals and later transferred to pediatric trauma centers, adjusting for injury severity, indicated by altered mental status, focal neurologic deficits, and substantial comorbid injuries. In addition, transport times and interventions provided in the prehospital, local hospital, and pediatric trauma center settings were compared. Multiple imputation was used to handle missing data. The PECARN cervical spine injury cohort contains 364 patients transported from scene of injury by EMS. A total of 321 met our inclusion criteria. Of these, 180 were transported directly to pediatric trauma centers, and 141 were transported to local hospitals and later transferred. After adjustments for injury severity, odds of a normal outcome versus death or persistent neurologic deficit were higher for patients transported directly to pediatric trauma centers (odds ratio [OR]= 1.89, 95% confidence interval [CI]=1.03 to 3.47). EMS transport times to first hospital did not differ and did not affect outcomes. Prehospital analgesia was very infrequent. Initial destination from scene (pediatric trauma center vs. local hospital) appears to be associated with neurologic outcome of children with cervical spine injuries. Markers of injury severity (altered mental status and focal neurologic findings) are important predictors of poor outcome in children with cervical spine injuries and should remain the primary guide for prehospital triage to designated trauma centers.

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.

Abstract 208: Emergency Medical Service Resuscitative Interventions in North-Central West Virginia Trauma Activation Criteria Patients: A Ten Year Experience

Introduction: West Virginia (WV) is the second most rural state, with 51.3% of the population living in a rural area and 97.3% of the land area considered rural by the US Census Bureau. West Virginia University (WVU) MedCom provides medical command for Emergency Medical Services (EMS) in 26 north-eastern WV counties. EMS transport times often exceed 20 minutes in rural counties. However, little is known about the specific provider capabilities and interventions that occur in the rural pre-hospital setting. Methods: This was a retrospective, observational review of EMS interventions for “trauma activation criteria patients” (based on CDC Field Triage Guidelines) in the WVU MedCom database. Trauma activation criteria EMS encounters from January 1, 2002 to December 31, 2011 were analyzed for EMS provider capability, receiving hospital capability, and pre-hospital resuscitative interventions. Results: There were 11,853 patients available for analysis in the time period. Basic Life Support (BLS) providers provided 21.0% of the care. The distribution of receiving Trauma Centers was as follows: 83.2% Level I, 4.7% Level II, 3.9% Level III, 5.0% Level IV; 3.2% were taken to a facility without trauma center designation. Airway intervention occurred in 7.5% of patients; 2.3% had endotracheal tube (ETT) placement (0.88% had failed ETT placement), 0.34% had King/Combi-tube placement, and 4.0% had positive pressure ventilation with bag valve mask. Vascular access was attempted in 78.7% of the patients; 73.0% had vascular access established (72.9% by IV and 0.08% by intra-osseous access) and 5.1% had an IV fluid bolus administered. CPR was performed on 1.0% of the patients and needle thoracostomy was performed on 0.32% of the patients. Discussion: In rural north-central WV, BLS responders provided the pre-hospital care to 1 in 5 patients. Although treatment at a Level I Trauma Center has been shown to decrease patient mortality by 25%, only 83.2% of trauma patients in rural north-central WV were initially treated at a Level I Trauma Center. Pre-hospital airway intervention was needed in 7.5% of patients. Vascular access was established in only 73.0%; 5.1% received a fluid bolus. Additional studies will be needed to assess the impact of these treatments on patient outcomes.

Challenges of the management of mass casualty: lessons learned from the Jos crisis of 2001.

BackgroundJos has witnessed a series of civil crises which have generated mass casualties that the Jos University Teaching Hospital has had to respond to from time to time. We review the challenges that we encountered in the management of the victims of the 2001 crisis.MethodologyWe reviewed the findings of our debriefing sessions following the sectarian crisis of September 2001 and identified the challenges and obstacles experienced during these periods.ResultsCommunication was a major challenge, both within and outside the hospital. In the field, there was poor field triage and no prehospital care. Transportation and evacuation was hazardous, for both injured patients and medical personnel. This was worsened by the imposition of a curfew on the city and its environs. In the hospital, supplies such as fluids, emergency drugs, sterile dressings and instruments, splints, and other consumables, blood and food were soon exhausted. Record keeping was erratic. Staff began to show signs of physical and mental exhaustion as well as features of anxiety and stress. Tensions rose between different religious groups in the hospital and an attempt was made by rioters to attack the hospital. Patients suffered poor subsequent care following resuscitation and/or surgery and there was neglect of patients on admission prior to the crisis as well as non trauma medical emergencies.ConclusionMass casualties from disasters that disrupt organized societal mechanisms for days can pose significant challenges to the best of institutional disaster response plans. In the situation that we experienced, our disaster plan was impractical initially because it failed to factor in such a prolongation of both crisis and response. We recommend that institutional disaster response plans should incorporate provisions for the challenges we have enumerated and factor in peculiarities that would emanate from the need for a prolonged response.