Variation in Prehospital Use and Uptake of the National Field Triage Decision Scheme

Barnett, Andy Stuart; Wang, N Ewen; Sahni, Ritu; Hsia, Renee Y.; Haukoos, Jason S.; Barton, Erik D.; Holmes, James F.; Newgard, Craig D.; Investigators, Westrn

doi:10.3109/10903127.2012.749966

Cited by 32 publications

(24 citation statements)

References 28 publications

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“…Similarly, a recent study found that the most commonly cited criterion for triage decisions was EMS provider judgment. 23 Another study also found that EMS provider judgment was frequently cited as a criterion for transport and was associated with a 23% increased odds of having a severe injury. 24 However, a literature review concluded that the evidence-base to support paramedic judgment as an accurate triage criterion is lacking.…”

Section: Discussionmentioning

confidence: 98%

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

Jones¹,

Cushman²,

Lerner³

et al. 2015

Prehospital Emergency Care

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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.

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Section: Discussionmentioning

confidence: 98%

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

Jones¹,

Cushman²,

Lerner³

et al. 2015

Prehospital Emergency Care

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“…We also collected field triage status (a dichotomous measure termed “field trauma activation” in this study) and all individual triage criteria used by field providers in these regions. 16 Because missing values for individual triage criteria are common in EMS charts, we increased the capture of triage status and minimized misclassification bias by triangulating data sources (EMS charts, matched trauma registry records, and matched EMS phone records from base hospitals). All other patients were considered triage-negative (nontrauma activations).…”

Section: Methodsmentioning

confidence: 99%

Physiologic Field Triage Criteria for Identifying Seriously Injured Older Adults

Newgard

Richardson

Holmes

et al. 2014

Prehospital Emergency Care

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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 under-triage 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 over-triage to major trauma centers.

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“…The criteria attempt to find a balance between overtriage (in which patients are taken to a center that provides higher-level care than is needed) and undertriage (in which patients are taken to a facility with inadequate resources for the level of injury). 14 The goal is to ensure optimal outcomes while limiting the potential to overwhelm Level I and Level II centers with minimally injured patients. Effective communication among EMS agencies (including 911 call centers, dispatch agencies, and transport agencies) and between EMS providers and hospitals is critical in achieving this goal.…”

Section: Critical Elements Of a Regionalized Trauma Systemmentioning

confidence: 99%

Sustaining A Coordinated, Regional Approach To Trauma And Emergency Care Is Critical To Patient Health Care Needs

2013

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Trauma systems provide an organized approach to the care of injured patients within a defined geographic region. When fully operational, the systems ensure a continuum of care involving public access through 911 calls, emergency medical services, timely triage and transport to acute care, and transfer to rehabilitation services. Substantial progress has been made in establishing statewide trauma systems, which are seen as the prototype for regionalized care for other time-sensitive, emergency conditions such as stroke. Trauma systems provide a model of care that is consistent with the goals of the Affordable Care Act, which authorizes $100 million in annual grants to ensure the continued availability of trauma services. Full funding of these provisions is needed to stabilize statewide systems that are struggling to survive. We describe the components of a regionalized trauma system, review the evidence in support of this approach, and discuss the challenges to sustaining systems that are accountable and affordable.

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Variation in Prehospital Use and Uptake of the National Field Triage Decision Scheme

Cited by 32 publications

References 28 publications

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

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

Physiologic Field Triage Criteria for Identifying Seriously Injured Older Adults

Sustaining A Coordinated, Regional Approach To Trauma And Emergency Care Is Critical To Patient Health Care Needs

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