Field Triage Research Articles

Under-Triage and Over-Triage Using the Field Triage Guidelines for Injured Patients: A Systematic Review

Objectives The Field Triage Guidelines (FTG) are used across North America to identify seriously injured patients for transport to appropriate level trauma centers, with a goal of under-triaging no more than 5% and over-triaging between 25% and 35%. Our objective was to systematically review the literature on under-triage and over-triage rates of the FTG. Methods We conducted a systematic review of the FTG performance. Ovid Medline, EMBASE, and the Cochrane databases were searched for studies published between January 2011 and February 2021. Two investigators dual-reviewed eligibility of abstracts and full-text. We included studies evaluating under- or over-triage of patients using the FTG in the prehospital setting. We excluded studies not reporting an outcome of under- or over-triage, studies evaluating other triage tools, or studies of triage not in the prehospital setting. Two investigators independently assessed the risk of bias for each included article. The primary accuracy measures to assess the FTG were under-triage, defined as seriously injured patients transported to non-trauma hospitals (1-sensitivity), and over-triage, defined as non-injured patients transported to trauma hospitals (1-specificity). Due to heterogeneity, results were synthesized qualitatively. Results We screened 2,418 abstracts, reviewed 315 full-text publications, and identified 17 studies that evaluated the accuracy of the FTG. Among eight studies evaluating the entire FTG (steps 1–4), under-triage rates ranged from 1.6% to 72.0% and were higher for older (≥55 or ≥65 years) adults (20.1–72.0%) and pediatric (<15 years) patients (15.9–34.8%) compared to all ages (1.6–33.8%). Over-triage rates ranged from 9.9% to 87.4% and were higher for all ages (12.2–87.4%) compared to older (≥55 or ≥65 years) adults (9.9–48.2%) and pediatric (<15 years) patients (28.0–33.6%). Under-triage was lower in studies strictly applying the FTG retrospectively (1.6–34.8%) compared to as-practiced (10.5–72.0%), while over-triage was higher retrospectively (64.2–87.4%) compared to as-practiced (9.9–48.2%). Conclusions Evidence suggests that under-triage, while improved if the FTG is strictly applied, remains above targets, with higher rates of under-triage in both children and older adults.

The diagnostic accuracy of prehospital triage tools in identifying patients with traumatic brain injury: A systematic review

IntroductionPrehospital care providers are usually the first responders for patients with traumatic brain injury (TBI). Early identification of patients with TBI enables them to receive trauma centre care, which improves outcomes. Two recent systematic reviews concluded that prehospital triage tools for undifferentiated major trauma have low accuracy. However, neither review focused specifically on patients with suspected TBI. Therefore, we aimed to systematically review the existing evidence on the diagnostic performance of prehospital triage tools for patients with suspected TBI. MethodsA comprehensive search of the current literature was conducted using Medline, EMBASE, CINAHL Plus and the Cochrane library (inception to 1st June 2021). We also searched Google Scholar, OpenGrey, pre-prints (MedRxiv) and dissertation databases. We included all studies published in English language evaluating the accuracy of prehospital triage tools for TBI. We assessed methodological quality and risk of bias using a modified Quality Assessment of Diagnostic Studies (QUADAS-2) tool. Two reviewers independently performed searches, screened titles and abstracts and undertook methodological quality assessments. Due to the heterogeneity in the population of interest and prehospital triage tools used, a narrative synthesis was undertaken. ResultsThe initial search identified 1787 articles, of which 8 unique eligible studies met the inclusion criteria (5 retrospective, 2 prospective, 1 mixed). Overall, sensitivity of triage tools studied ranged from 19.8% to 87.9% for TBI identification. Specificity ranged from 41.4% to 94.4%. Two decision tools have been validated more than once: HITS-NS (2 studies, sensitivity 28.3–32.6%, specificity 89.1–94.4%) and the Field Triage Decision Scheme (4 studies, sensitivity 19.8–64.5%, specificity 77.4%-93.1%). Existing tools appear to systematically under-triage older patients. ConclusionFurther efforts are needed to improve and optimise prehospital triage tools. Consideration of additional predictors (e.g., biomarkers, clinical decision aids and paramedic judgement) may be required to improve diagnostic accuracy.

Abstract TMP26: Understanding Changes In Thrombectomy Eligibility Among Large Vessel Occlusion Stroke Transfers In A Hub-and-spoke Telestroke System

Introduction: Endovascular thrombectomy (EVT) has revolutionized the care of emergent large vessel occlusion (ELVO) stroke patients. It is, therefore, crucial to optimize its delivery to eligible candidates. Within hub-and-spoke hospital system models, some patients first present to distant spoke hospitals and require transfer to hub hospitals for EVT. We sought to understand changes in EVT eligibility during transfer. Methods: Consecutive EVT candidates presenting to 25 spokes from 2018 to 2020 with pre-transfer CTA-defined ELVO and Alberta Stroke Program Early CT Score ≥6 were identified from a prospectively maintained database. Outcomes of interest included hub EVT, reasons for EVT ineligibility, and 90-day functional independence (modified Rankin Scale, mRS ≤2). Results: Among 258 patients, the median age was 70 years (IQR 60-81) and 50% were female. Forty-four percent underwent EVT upon hub arrival, of which 87% achieved Thrombolysis in Cerebral Infarction 2b-3 reperfusion. Compared to EVT-eligible patients, ineligible patients were older (73 vs 68 years, p=0.04), had lower NIH Stroke Scale (NIHSS, 10 vs 16, p&lt;0.0001), longer LKW-hub arrival time (8.4 vs 4.6 hours, p&lt;0.0001), and received less IV alteplase (32% vs 45%, p=0.04). The clinical reasons cited for becoming EVT ineligible upon hub arrival included large established infarct (49%), mild symptoms (33%), recanalization (6%), distal occlusion location (5%), subocclusive lesion (3%), and goals of care (3%). Becoming EVT ineligible independently reduced the odds of 90-day functional independence (aOR=0.26, 95%CI=0.12,0.56; p=0.001), even when controlling for age, NIHSS, and LKW-hub arrival time. Conclusions: These data support that approaches to increase EVT eligibility among ELVO transfers may improve long term outcomes. Infarct growth represents the primary reason for ineligibility. Possible interventions include direct field triage to the hub when feasible, improving inter-hospital transfer times, supporting ischemic penumbra before EVT, and developing novel agents to slow infarct growth.

Field Trauma Triage among Older Adults: A Cost-Effectiveness Analysis.

National guidelines for prehospital trauma triage aim to identify seriously injured patients who may benefit from transport to trauma centers. These guidelines have poor sensitivity for serious injury among older adults. We evaluated the cost-effectiveness of a high-sensitivity triage strategy for older adults. We developed a Markov chain Monte Carlo microsimulation model to estimate the cost-effectiveness of high-sensitivity field triage criteria among older adults compared with current practice. The model used a retrospective cohort of 3621 community-dwelling Medicare beneficiaries who were transported by emergency medical services after an acute injury in 7 counties in the northwestern US during January to December 2011. These data informed model estimates of emergency medical services triage assessment, hospital transport patterns, and outcomes from index hospitalization up to 1 year after discharge. Outcomes beyond 1 year were modeled using published literature. Differences in cost and quality-adjusted life years (QALYs) were calculated for both strategies using a lifetime analytical horizon. We calculated the incremental cost-effectiveness ratio (cost per QALY gained) to assess cost-effectiveness, which we defined using a threshold of less than $100,000 per QALY. High-sensitivity trauma field triage for older adults would produce a small incremental benefit in average trauma system effectiveness (0.0003 QALY) per patient at a cost of $1,236,295 per QALY. Sensitivity analysis indicates that the cost of initial hospitalization and emergency medical services adherence to triage status (ie transporting triage-positive patients to a trauma center) had the largest influence on overall cost-effectiveness. High-sensitivity trauma field triage is not cost-effective among older adults.

CDC field triage criteria accurately predicts outcomes in high impact trauma.

:Background:The precision of emergency medical services (EMS) triage criteria dictates whether an injured patient receives appropriate care. The trauma triage protocol is a decision scheme that groups patients into triage categories of major, moderate and minor. We hypothesized that there is a difference between trauma triage category and injury severity score (ISS).Methods:This retrospective, observational study was conducted to investigate a difference between trauma triage category and ISS. Bivariate analysis was used to test for differences between the subgroup means. The differences between the group means on each measure were analyzed for direction and statistical significance using ANOVA for continuous variables and chi square tests for categorical variables. Logistic and linear regressions were performed to evaluate factors predicting mortality, ICU length of stay.Results:With respect to trauma triage category, our findings indicate that minor and moderate triage categories are similar with respect to ISS, GCS, ICU LOS, hospital LOS, and mortality. However, after excluding for low impact injuries (falls), differences between the minor and moderate categories were evident when comparing to ISS, GCS, ICU LOS, and hospital LOS. Additionally, after excluding for low impact injures, ISS, ICU LOS, and hospital stay were found to correlate well with trauma triage category. Conclusions:In this retrospective, observational study significant differences were not seen when comparing ISS with the trauma triage categories of moderate and minor during our initial analysis. However, a difference was found after excluding for low impact injuries. These findings suggest that CDC criteria accurately predicts outcomes in high impact trauma.

The national trauma triage protocol: how EMS perspective can inform the guideline revision

ObjectivesThe Field Triage Guidelines (FTG) support emergency medical service (EMS) decisions regarding the most appropriate transport destination for injured patients. While the components of the algorithm are largely evidenced-based, the...

Development and Validation of a Simplified Prehospital Triage Model Using Neural Network to Predict Mortality in Trauma Patients: The Ability to Follow Commands, Age, Pulse Rate, Systolic Blood Pressure and Peripheral Oxygen Saturation (CAPSO) Model.

Objective: Most trauma scoring systems with high accuracy are difficult to use quickly in field triage, especially in the case of mass casualty events. We aimed to develop a machine learning model for trauma mortality prediction using variables easy to obtain in the prehospital setting.Methods: This was a retrospective prognostic study using the National Trauma Data Bank (NTDB). Data from 2013 to 2016 were used for model training and internal testing, and data from 2017 were used for validation. A neural network model (NN-CAPSO) was developed using the ability to follow commands (whether GCS-motor was <6), age, pulse rate, systolic blood pressure (SBP) and peripheral oxygen saturation, and a new score (the CAPSO score) was developed based on logistic regression. To achieve further simplification, a neural network model with the SBP variable removed (NN-CAPO) was also developed. The discrimination ability of different models and scores was compared based on the area under the receiver operating characteristic curve (AUROC). Furthermore, a reclassification table with three defined risk groups was used to compare NN-CAPSO and other models or scores.Results: The NN-CAPSO had an AUROC of 0.911(95% confidence interval 0.909 to 0.913) in the validation set, which was higher than the other trauma scores available for prehospital settings (all p < 0.001). The NN-CAPO and CAPSO score both reached the AUROC of 0.904 (95% confidence interval 0.902 to 0.906), and were no worse than other prehospital trauma scores. Compared with the NN-CAPO, CAPSO score, and the other trauma scores in reclassification tables, NN-CAPSO was found to more accurately classify patients to the right risk groups.Conclusions: The newly developed CAPSO system simplifies the method of consciousness assessment and has the potential to accurately predict trauma patient mortality in the prehospital setting.

Cost-effectiveness of field trauma triage among injured children transported by emergency medical services.

A pediatric field triage strategy that meets the national policy benchmark of ≥95% sensitivity would likely improve health outcomes but increase heath care costs. Our objective was to compare the cost-effectiveness of current pediatric field triage practices to an alternative field triage strategy that meets the national policy benchmark of ≥95% sensitivity. We developed a decision-analysis Markov model to compare the outcomes and costs of the two strategies. We used a prospectively collected cohort of 3507 (probability weighted, unweighted n=2832) injured children transported by 44 emergency medical services (EMS) agencies to 28 trauma and non-trauma centers in the Northwestern United States from 1/1/2011 to 12/31/2011 to derive the alternative field triage strategy and to populate model probability and cost inputs for both strategies. We compared the two strategies by calculating quality adjusted life years (QALYs) and health care costs over a time horizon from the time of injury until death. We set an incremental cost-effectiveness ratio threshold of less than $100,000 per QALY for the alternative field triage to be a cost-effective strategy. Current pediatric field triage practices had a sensitivity of 87.4% (95% confidence interval [CI] 71.9 to 95.0%) and a specificity of 82.3% (95% CI 81.0 to 83.5%) and the alternative field triage strategy had a sensitivity of 97.3% (95% CI 82.6 to 99.6%) and a specificity of 46.1% (95% CI 43.8 to 48.4%). The alternative field triage strategy would cost $476,396 per QALY gained compared to current pediatric field triage practices and thus would not be a cost-effective strategy. Sensitivity analyses demonstrated similar findings. Current field triage practices do not meet national policy benchmarks for sensitivity. However, an alternative field triage strategy that meets the national policy benchmark of ≥95% sensitivity is not a cost-effective strategy.

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.

A Study on the Disaster Field Response Procedure and Triage Using Disaster Tabletop

A Study on the Disaster Field Response Procedure and Triage Using Disaster Tabletop

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.

An audit of emergency response to terrorist-related bomb blasts and gunshot injuries

Context: The management of mass casualty events caused by terrorist-related suicide bombings in densely populated areas is often challenging. Aims: This study describes the pattern of injuries, the emergency response following a suicide bombing in Nigeria in 2014 and compares the outcomes to those of other incidents. Settings and Design: A retrospective analysis of cases that presented to a major tertiary care center was done. Methods and Material: Medical records of 50 patients who experienced bomb blast or gunshot wounds during 28th November, 2014 suicide bombing of the Kano Central Mosque were reviewed and 12 eyewitnesses were interviewed. Statistical analysis used: Descriptive analysis of quantitative data was done while major themes were identified from the key informant interviews. Results: Fifty patients were admitted at the acute care center within 4 hours. There was a male predilection (98%), with a median age of 30 years (IQR, interquartile range = 37.5 years). Most injuries were the result of multiple penetrating projectiles (secondary blast injuries), primarily involving blast-energized metallic fragments like screws, nails, bolts, ball bearings, and metal scraps. Eleven patients (22%) had minor lacerations, about a quarter (n = 12; 24%) had severe hemorrhage and were transfused, five (10%) had multi-system involvement, and mortality rate was 8% (n = 4). Interventions were aimed at preserving the lives of those injured. Conclusion: Most of the victims had major injuries which were appropriately managed although the hospital lacked an existing protocol on mass casualty management. Increased awareness, organized field triage mechanisms, and capacity building in health facilities will facilitate prompt emergency response.

Integrating transportation data with emergency medical service records to improve triage decision of high-risk trauma patients

IntroductionNowadays, a leading cause of mortality and morbidity of elderly is vehicle crash. Given the vulnerability of the senior victims in crashes, the decisions of emergency vehicle services as well as triage to shock trauma centers become extremely crucial for this cohort to receive timely transport service and proper trauma care. However, many who could be saved by shock trauma centers are either not transported via emergency medical services (EMS) or treated by non-trauma hospitals. MethodThis paper explores possible ways to improve the EMS and trauma triage decision processes. First of all, transportation-related data sources, such as traffic volumes and time-dependent vehicle speeds, have been integrated with EMS and hospital records, offering measurements of exposure to crash risks. The critical transportation information is typically missing from the field triage process but becomes readily available in real-time to support decision-making. Then the integrated data has been employed to construct machine learning models with the new predictors. ResultsPredictions of EMS transport and triage to shock trauma centers have been analyzed using a Maryland dataset with records of over 55,000 elderly patients. Compared to benchmark models without transportation information as predictors, the models trained with integrated data exhibit superior prediction accuracy. ConclusionsThis paper is among the first to develop and demonstrate a methodological framework of integrating transportation-sector data with health-related data to support various decision-making scenarios in transportation safety, emergency responses, and trauma-care triage. It has empirically demonstrated that integrated transportation and health data significantly improves the recall rates of decisions of EMS and trauma triage and showcased that under triage, a major issue for high-risk trauma patients, can be significantly addressed.

An Analysis of Patients Dead on Arrival in the American College of Surgeons Trauma Quality Program Participant Use File Data Set.

Trauma patient care begins on-scene as field triage and mode of transportation are determinants of patient outcomes. This study evaluates the US national patterns of dead on arrival (DOA) among the trauma population. A cross-sectional review of the American College of Surgeons (ACS) Trauma Quality Program Participant Use File (TQP-PUF) data set (2013-2017) was performed. Trauma patients reported as DOA were stratified by ISS into low (<15), intermediate (15-24), or high (≥25) severity. Each group was then subdivided by patient demographics, mechanism, type of injury, and mode of transportation. Of the 4336816 injury cases in the TQP-PUF data set, 33199 were DOA (.77%). 77.1% (25604/33199) of DOAs were male. In the low-ISS group, .36% (13272/3639811) were DOA; in the intermediate-ISS group, 1.2% (4868/421994) were DOA; and in the high-ISS group, 5.5% (15059/275011) were DOA. Motor vehicle collisions (MVCs) (11262) and firearms (8894) were the most common injury types, equating to 60.7% of DOAs. Falls accounted for 9.1% of all DOAs. The most common DOA age-group was 18-64 years, followed by ≥65years. DOA trauma patients are predominately adult men suffering fatal blunt force injuries most frequently via MVC. DOAs are caused by all ranges of injury severity. We recommend further development of prevention programs thereby reducing the prevalence of common traumatic injuries, notably MVC, falls, and firearms to improve survival. Future studies should also investigate the access to and distribution of trauma centers and the role of helicopter, ground, and police transport modalities and transport time on and reducing DOAs and improving trauma patient outcomes.

Evaluation of a standardized instrument for post hoc analysis of trauma-team-activation-criteria in 75,613 injured patients an analysis of the TraumaRegister DGU\xae

IntroductionTo improve the quality of criteria for trauma-team-activation it is necessary to identify patients who benefited from the treatment by a trauma team. Therefore, we evaluated a post hoc criteria catalogue for trauma-team-activation which was developed in a consensus process by an expert group and published recently.The objective was to examine whether the catalogue can identify patients that died after admission to the hospital and therefore can benefit from a specialized trauma team mostly.Materials and methodsThe catalogue was applied to the data of 75,613 patients from the TraumaRegister DGU® between the 01/2007 and 12/2016 with a maximum abbreviated injury score (AIS) severity ≥ 2. The endpoint was hospital mortality, which was defined as death before discharge from acute care.ResultsThe TraumaRegister DGU® dataset contains 18 of the 20 proposed criteria within the catalogue which identified 99.6% of the patients who were admitted to the trauma room following an accident and who died during their hospital stay. Moreover, our analysis showed that at least one criterion was fulfilled in 59,785 cases (79.1%). The average ISS in this group was 21.2 points (SD 9.9). None of the examined criteria applied to 15,828 cases (average ISS 8.6; SD 5). The number of consensus-based criteria correlated with the severity of injury and mortality. Of all deceased patients (8,451), only 31 (0.37%) could not be identified on the basis of the 18 examined criteria. Where only one criterion was fulfilled, mortality was 1.7%; with 2 or more criteria, mortality was at least 4.6%.DiscussionThe consensus-based criteria identified nearly all patients who died as a result of their injuries. If only one criterion was fulfilled, mortality was relatively low. However, it increased to almost 5% if two criteria were fulfilled. Further studies are necessary to analyse and examine the relative weighting of the various criteria.SummaryOur instrument is capable to identify severely injured patients with increased in-hospital mortality and injury severity. However, a minimum of two criteria needs to be fulfilled. Based on these findings, we conclude that the criteria list is useful for post hoc analysis of the quality of field triage in patients with severe injury.

Prehospital Response Time of the Emergency Medical Service during Mass Casualty Incidents and the Effect of Triage: A Retrospective Study.

Prehospital time affects survival in trauma patients. Mass casualty incidents (MCIs) are overwhelming events where medical care exceeds available resources. This study aimed at evaluating the prehospital time during MCIs and investigating the effect of triage. A retrospective analysis was performed using Florida's Event Medical Services Tracking and Reporting System database. All patients involved in MCIs during 2018 were accessed, and prehospital time intervals were evaluated and compared to that of non-MCIs. The effect of MCI triage and field triage (Field Triage Criteria) on prehospital time was evaluated. In 2018, it was estimated that 2236 unique MCIs occurred in Florida, with a crude incidence of 10.1-10.9/100000 people. 2180 EMS units arrived at the hospital for patient disposition with a median alarm-to-hospital time of 43.74 minutes, significantly longer than non-MCIs (39.15 min; P < 0.001). MCI triage and field triage were both associated with shorter alarm-to-hospital time (39.37 min and 37.55 min, respectively). MCIs resulted in longer prehospital time intervals than non-MCIs. This finding suggests that additional efforts are needed to reduce the prehospital time for MCI patients. MCI triage and field triage were both associated with shorter alarm-to-hospital times. Widespread use may improve prehospital MCI care.

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.].

Effect of Field Triage Training on Emergency Medical Technicians in Taipei City.

Injury is a leading cause of death among young adults. An accurately implemented fi led triage scheme (FTS) by emergency medical technicians (EMTs) is the first step for delivering right patients to the right hospital. However, the training effect of FTS on EMTs with different levels and backgrounds has scarcely been reported. We evaluated training effects of FTS among EMTs in Taipei. Standard FTS contains physiologic status, anatomical sites of injury, and mechanism of injury criteria. The intervention was a 30-minute lecture and pre-and-post tests, each containing five questions about trauma severity judgment (i.e., mechanism of injury [2 questions], anatomic sites of injury [2 questions], and physiological status [1 question]). The change in EMT accuracy was measured before and after training. Subgroup analyses were performed across EMTs with different levels and seniorities. From September 1, 2015 to March 31, 2016, 821 EMTs were enrolled, including 740 EMT-intermediates and 81 paramedics. Overall, EMT accuracy improved after the intervention in the intermediate (73.2% vs.85.5%, p < 0.05) and paramedic (76.0% vs.85.7%, p <0.01) groups. All trainees showed improvements in physiology and mechanism criteria, but paramedics showed decreased accuracy in anatomic criteria. The subgroup analysis showed that accuracy positively associated with prehospital care experience for major trauma cases 1 year before the training course, and the anatomical criterion accuracy was adversely associated with paramedic seniority. Field triage training can improve EMT accuracy for FTS. The anatomical aspect is more diffi cult to improve and should be emphasized in FTS training courses.

Field-Triage, Hospital-Triage and Triage-Assessment: A Literature Review of the Current Phases of Adult Trauma Triage.

Despite major improvements in the United States trauma system over the past two decades, prehospital trauma triage is a significant challenge. Undertriage is associated with increased mortality, and overtriage results in significant resource overuse. The American College of Surgeons Committee on Trauma benchmarks for undertriage and overtriage are not being met. Many barriers to appropriate field triage exist, including lack of a formal definition for major trauma, absence of a simple and widely applicable triage mode, and emergency medical service adherence to triage protocols. Modern trauma triage systems should ideally be based on the need for intervention rather than injury severity. Future studies should focus on identifying the ideal definition for major trauma and creating triage models that can be easily deployed. This narrative review article presents challenges and potential solutions for prehospital trauma triage.

The Whole is Greater Than the Sum of its Parts: GCS Versus GCS-Motor for Triage in Geriatric Trauma

BackgroundTrauma field triage matches injured patients to the appropriate level of care. Prior work suggests the Glasgow Coma Scale motor (GCSm) is as accurate as the total GCS (GCSt) and easier to use. However, older patients present with higher GCS for a given injury, and as such, it is unclear if this substitution is advisable. Our objective was to compare the GCS deficit patterns between geriatric and adult patients presenting with severe traumatic brain injury (TBI), as well as the diagnostic performance of the GCSm versus GCSt within the field triage criteria in these populations. Materials and MethodsWe conducted a retrospective, observational cohort study of patients ≥16 y in the National Trauma Data Bank 2007–2015. GCS deficit patterns were compared between adults (16-65) and geriatric patients (>65). Measures of diagnostic performance of GCSt≤13 versus GCSm≤5 criteria to predict trauma center need (TCN) were compared. ResultsIn total, 4,480,185 patients were analyzed (28% geriatric). Geriatric patients more frequently presented with non–motor–only deficits than adults (16.4% versus 12.4%, P < 0.001), and these patients demonstrated higher severe TBI (40.3% versus 36.7%, P < 0.001) and craniotomy (5.8% versus 5.1%, P < 0.001) rates. GCSt was more sensitive and accurate in predicting TCN for geriatric patients and had lower rates of undertriage as compared to GCSm. ConclusionsGeriatric patients more frequently present with non–motor–only deficits after injury, and this is associated with severe head injury. Substitution of GCSm for GCSt would exacerbate undertriage in geriatric patients and, thus, the total GCS should be maintained for field triage in geriatric patients.