Objective 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. Methods 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. Results 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. Conclusions 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.

Objective Determine the dimensions of traumatic brain injury (TBI) evaluation in U.S. emergency department (EDs) to inform potential application of novel diagnostic tests. Setting United States EDs. Participants National Hospital Ambulatory Medical Care Survey of ED visits in 2009 and 2010 where TBI was evaluated (1) and diagnosed clinically, or (2) with head CT scan. Design Retrospective cross-sectional. Results TBI was evaluated during 4.8 (95% CI: 4.2–5.4) million visits/year; and head CT scan was performed in 82% of TBI evaluations (3.9 [95% CI: 3.4–4.4] million visits/year). TBI was diagnosed in 52% of evaluations (2.5 [95% CI: 2.1–2.8] million visits/year). Among those who received head CTs, 9% had CT evidence of traumatic abnormalities. Among patients evaluated for TBI who had a Glasgow Coma Scale recorded, 94.5% were classified as mild TBI, 2.1% as moderate TBI and 3.5% as severe TBI. Among patients with ICD9-C-M codes permitting the calculation of Head AIS scores 9.0%, 85.0%, 2.5%, 3.2%, 0.3% and 0% had Head AIS scores of 1,2,3,4,5,6 respectively. Of patients evaluated for TBI, 31% had other head/face/neck injuries; 10% had spine and back injuries; 7% had torso injuries; and 14% had extremity injuries. Conclusion The ED is the main gateway to medical care for millions of patients evaluated for TBI each year. Novel diagnostic tests are need to improve ED diagnosis and management of TBI.

Telemedicine-enhanced emergency care is an acceptable method of providing emergency care to older adults in SLCs. Stakeholders report a number of advantages. Training and technology barriers require particular attention.

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