Guidelines for Field Triage of Injured Patients: In conjunction with the Morbidity and Mortality Weekly Report published by the Center for Disease Control and Prevention.
01 Feb 2013-Western Journal of Emergency Medicine (California Chapter of the American Academy of Emergency Medicine (Cal/AAEM))-Vol. 14, Iss: 1, pp 69-76
TL;DR: The methodology, findings and updated guidelines from the Morbidity & Mortality Weekly Report (MMWR) from the 2011 Panel are presented along with commentary on the burden of injury in the U.S., and the role emergency physicians have in impacting morbidity and mortality at the population level.
Abstract: The Centers for Disease Control and Prevention (CDC) has published significant data and trends related to the national public health burden associated with trauma and injury. In the United States (U.S.), injury is the leading cause of death for persons aged 1–44 years. In 2008, approximately 30 million injuries resulted in an emergency department (ED) evaluation; 5.4 million (18%) of these patients were transported by Emergency Medical Services (EMS).1 EMS providers determine the severity of injury and begin initial management at the scene. The decisions to transport injured patients to the appropriate hospital are made through a process known as “field triage.” Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process though its “Field Triage Decision Scheme.” In 2005, the CDC, with financial support from the National Highway Traffic Safety Administration (NHTSA), collaborated with ASC-COT to convene the initial meeting of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme. This revised version was published in 2006 by ASC-COT, and in 2009 the CDC published a detailed description of the scientific rational for revising the field triage criteria entitled, “Guidelines for Field Triage of Injured Patients.”2–3 In 2011, the CDC reconvened the Panel to review the 2006 Guidelines and recommend any needed changes. We present the methodology, findings and updated guidelines from the Morbidity & Mortality Weekly Report (MMWR) from the 2011 Panel along with commentary on the burden of injury in the U.S., and the role emergency physicians have in impacting morbidity and mortality at the population level.
Citations
More filters
TL;DR: To reduce of the burden and mitigate the impact of TBI in the United States, an improved state- and territory-specific TBI surveillance system that accurately measures burden and includes information on the acute and long-term outcomes is needed.
368 citations
TL;DR: More studies are required to elucidate the safest and most cost-effective strategies for the management of trauma in pregnancy and to avoid underdiagnosis or undertreatment of trauma due to unfounded fears of fetal effects.
188 citations
Book•
02 Apr 2013
TL;DR: Crisis Standards of Care provides a framework for a systems approach to the development and implementation of CSC plans, and addresses the legal issues and the ethical, palliative care, and mental health issues that agencies and organizations at each level of a disaster response should address.
Abstract: Catastrophic disasters occurring in 2011 in the United States and worldwide--from the tornado in Joplin, Missouri, to the earthquake and tsunami in Japan, to the earthquake in New Zealand--have demonstrated that even prepared communities can be overwhelmed. In 2009, at the height of the influenza A (H1N1) pandemic, the Assistant Secretary for Preparedness and Response at the Department of Health and Human Services, along with the Department of Veterans Affairs and the National Highway Traffic Safety Administration, asked the Institute of Medicine (IOM) to convene a committee of experts to develop national guidance for use by state and local public health officials and health-sector agencies and institutions in establishing and implementing standards of care that should apply in disaster situations-both naturally occurring and man-made-under conditions of scarce resources. Building on the work of phase one (which is described in IOM's 2009 letter report, Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations), the committee developed detailed templates enumerating the functions and tasks of the key stakeholder groups involved in crisis standards of care (CSC) planning, implementation, and public engagement-state and local governments, emergency medical services (EMS), hospitals and acute care facilities, and out-of-hospital and alternate care systems. Crisis Standards of Care provides a framework for a systems approach to the development and implementation of CSC plans, and addresses the legal issues and the ethical, palliative care, and mental health issues that agencies and organizations at each level of a disaster response should address. Please note: this report is not intended to be a detailed guide to emergency preparedness or disaster response. What is described in this report is an extrapolation of existing incident management practices and principles. Crisis Standards of Care is a seven-volume set: Volume 1 provides an overview; Volume 2 pertains to state and local governments; Volume 3 pertains to emergency medical services; Volume 4 pertains to hospitals and acute care facilities; Volume 5 pertains to out-of-hospital care and alternate care systems; Volume 6 contains a public engagement toolkit; and Volume 7 contains appendixes with additional resources.
164 citations
Cites background from "Guidelines for Field Triage of Inju..."
..., triage upon entry to the emergency department or by EMS providers at a disaster scene) (Benson et al., 1996; Lerner et al., 2008; Sasser et al., 2009); • secondary triage—performed after additional assessments and initial interventions (e....
[...]
TL;DR: This article reviews key concepts from the disaster literature, providing the emergency physician with a framework of ethical and operational principles on which medical interventions provided may be adjusted according to demand and the resources available.
154 citations
TL;DR: SBP of less than 110 mm Hg has discrimination as good as that of SBP of more than 90mm Hg, with superior improvements in undertriage relative to overtriage in geriatric patients.
Abstract: BACKGROUND: Undertriage is a concern in geriatric patients. The National Trauma Triage Protocol (NTTP) recognized that systolic blood pressure (SBP) less than 110 mm Hg may represent shock in those older than 65 years. The objective was to evaluate the impact of substituting an SBP of less than 110 mm Hg for the current SBP of less than 90 mm Hg criterion within the NTTP on triage performance and mortality. METHODS: Subjects undergoing scene transport in the National Trauma Data Bank (2010-2012) were included. The outcome of trauma center need was defined as Injury Severity Score (ISS) greater than 15, intensive care unit admission, urgent operation, or emergency department death. Geriatric (age > 65 years) and adult (age, 16-65 years) cohorts were compared. Triage characteristics and area under the curve (AUC) were compared between SBP of less than 110 mm Hg and SBP of less than 90 mm Hg. Hierarchical logistic regression was used to determine whether geriatric patients newly triaged positive under this change (SBP, 90-109 mm Hg) have a risk of mortality similar to those triaged positive with SBP of less than 90 mm Hg. RESULTS: There were 1,555,944 subjects included. SBP of less than 110 mm Hg had higher sensitivity but lower specificity in geriatric (13% vs. 5%, 93% vs. 99%) and adult (23% vs. 10%, 90% vs. 98%) cohorts. AUC was higher for SBP of less than 110 mm Hg individually in both geriatric and adult (p CONCLUSION: SBP of less than 110 mm Hg increases sensitivity. SBP of less than 110 mm Hg has discrimination as good as that of SBP of less than 90 mm Hg, with superior improvements in undertriage relative to overtriage in geriatric patients. Geriatric patients newly triaged to be positive under this change have a risk of mortality similar to those under the current SBP criterion. This change in SBP criteria may be merited in geriatric patients, warranting further study to consider elevation to a Step 1 criterion in the NTTP. LEVEL OF EVIDENCE: Diagnostic study, level IV. Language: en
105 citations
Cites background or result from "Guidelines for Field Triage of Inju..."
...older than 65 years under the older adults criterion in the special considerations step.(4) Modifications of triage criteria in the geriatric population have demonstrated promise in previous studies and are consistent with the data presented here....
[...]
...1).(4)These includephysiologic, anatomic, mechanism of injury, and special consideration criteria, which are evaluated in a sequential fashion to identify patients that should be transported to a trauma center....
[...]
...The ACS COT has set a goal overtriage rate between 25% and 50%, which the current NTTP criteria seem to achieve.(4,25) Thus, any further increases in overtriage must be justified by comparable reductions in undertriage and improved outcomes....
[...]
References
More filters
TL;DR: It is shown that the risk of death is significantly lower when care is provided in a trauma center than in a non-trauma center and argue for continued efforts at regionalization.
Abstract: BACKGROUND Hospitals have difficulty justifying the expense of maintaining trauma centers without strong evidence of their effectiveness. To address this gap, we examined differences in mortality between level 1 trauma centers and hospitals without a trauma center (non-trauma centers). METHODS Mortality outcomes were compared among patients treated in 18 hospitals with a level 1 trauma center and 51 hospitals non-trauma centers located in 14 states. Patients 18 to 84 years old with a moderate-to-severe injury were eligible. Complete data were obtained for 1104 patients who died in the hospital and 4087 patients who were discharged alive. We used propensity-score weighting to adjust for observable differences between patients treated at trauma centers and those treated at non-trauma centers. RESULTS After adjustment for differences in the case mix, the in-hospital mortality rate was significantly lower at trauma centers than at non-trauma centers (7.6 percent vs. 9.5 percent; relative risk, 0.80; 95 percent confidence interval, 0.66 to 0.98), as was the one-year mortality rate (10.4 percent vs. 13.8 percent; relative risk, 0.75; 95 percent confidence interval, 0.60 to 0.95). The effects of treatment at a trauma center varied according to the severity of injury, with evidence to suggest that differences in mortality rates were primarily confined to patients with more severe injuries. CONCLUSIONS Our findings show that the risk of death is significantly lower when care is provided in a trauma center than in a non-trauma center and argue for continued efforts at regionalization.
2,222 citations
Journal Article•
TL;DR: In this paper, the authors present the dissemination and impact of the 2006 Guidelines for field triage of injured patients; outlines the methodology used by the Panel for its 2011 review; explains the revisions and modifications to the physiologic, anatomic, mechanism-of-injury, and special considerations criteria; and provides the rationale used by Panel for these changes.
Abstract: In the United States, injury is the leading cause of death for persons aged 1-44 years. In 2008, approximately 30 million injuries were serious enough to require the injured person to visit a hospital emergency department (ED); 5.4 million (18%) of these injured patients were transported by Emergency Medical Services (EMS). On arrival at the scene of an injury, the EMS provider must determine the severity of injury, initiate management of the patient's injuries, and decide the most appropriate destination hospital for the individual patient. These destination decisions are made through a process known as "field triage," which involves an assessment not only of the physiology and anatomy of injury but also of the mechanism of the injury and special patient and system considerations. Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process through its "Field Triage Decision Scheme." This guidance was updated with each version of the decision scheme (published in 1986, 1990, 1993, and 1999). In 2005, CDC, with financial support from the National Highway Traffic Safety Administration, collaborated with ACS-COT to convene the initial meetings of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme; the revised version was published in 2006 by ACS-COT (American College of Surgeons. Resources for the optimal care of the injured patient: 2006. Chicago, IL: American College of Surgeons; 2006). In 2009, CDC published a detailed description of the scientific rationale for revising the field triage criteria (CDC. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR 2009;58[No. RR-1]). In 2011, CDC reconvened the Panel to review the 2006 Guidelines in the context of recently published literature, assess the experiences of states and local communities working to implement the Guidelines, and recommend any needed changes or modifications to the Guidelines. This report describes the dissemination and impact of the 2006 Guidelines; outlines the methodology used by the Panel for its 2011 review; explains the revisions and modifications to the physiologic, anatomic, mechanism-of-injury, and special considerations criteria; updates the schematic of the 2006 Guidelines; and provides the rationale used by the Panel for these changes. This report is intended to help prehospital-care providers in their daily duties recognize individual injured patients who are most likely to benefit from specialized trauma center resources and is not intended as a mass casualty or disaster triage tool. The Panel anticipates a review of these Guidelines approximately every 5 years.
740 citations
TL;DR: Selecting trauma centers based on geographic need, appropriately locating medical helicopter bases, and establishing formal agreements for sharing trauma care resources across states should be considered to improve access to trauma care in the United States.
Abstract: ContextPrevious studies have reported that the number and distribution of trauma
centers are uneven across states, suggesting large differences in access to
trauma center care.ObjectiveTo estimate the proportion of US residents having access to trauma centers
within 45 and 60 minutes.Design and SettingCross-sectional study using data from 2 national databases as part of
the Trauma Resource Allocation Model for Ambulances and Hospitals (TRAMAH)
project. Trauma centers, base helipads, and block group population were counted
for all 50 states and the District of Columbia as of January 2005.Main Outcome MeasuresPercentages of national, regional, and state populations having access
to all 703 level I, II, and III trauma centers in the United States by either
ground ambulance or helicopter within 45 and 60 minutes.ResultsAn estimated 69.2% and 84.1% of all US residents had access to a level
I or II trauma center within 45 and 60 minutes, respectively. The 46.7 million
Americans who had no access within an hour lived mostly in rural areas, whereas
the 42.8 million Americans who had access to 20 or more level I or II trauma
centers within an hour lived mostly in urban areas. Within 45 and 60 minutes,
respectively, 26.7% and 27.7% of US residents had access to level I or II
trauma centers by helicopter only and 1.9% and 3.1% of US residents had access
to level I or II centers only from trauma centers or base helipads outside
their home states.ConclusionSelecting trauma centers based on geographic need, appropriately locating
medical helicopter bases, and establishing formal agreements for sharing trauma
care resources across states should be considered to improve access to trauma
care in the United States.
454 citations
TL;DR: Level I trauma centers have better outcomes than lower-level centers in patients with specific injuries associated with high mortality and poor functional outcomes, and the volume of major trauma admissions does not influence outcome in either level I or II centers.
Abstract: Objective:
The objective of this study was to investigate the effect of American College of Surgeons (ACS) trauma center designation and trauma volume on outcome in patients with specific severe injuries.
370 citations
TL;DR: Establishment of a trauma system shifted the more seriously injured patients to level I trauma centers, where there was a significant reduction in the adjusted death rate.
Abstract: Objective. —To determine if risk of death for hospitalized injured patients changes when an urban trauma system is implemented. Design. —An analysis of the risk of death in hospitalized injured patients in 1984 and 1985 (pretrauma system), 1986 and 1987 (early trauma system), and 1990 and 1991 (established trauma system) using hospital discharge abstract data. Setting. —A total of 18 acute care hospitals in the four-county area encompassing Portland, Ore. Patients. —A cohort of 70 350 hospitalized patients with at least one discharge diagnosis indicating injury. Main Outcome Measure. —Death during hospitalization. Results. —After the trauma system was established, 77% of patients in the region with an Injury Severity Score (ISS) of 16 or greater were admitted to level I trauma centers. More than 72% of patients with an ISS less than 16 were hospitalized in nontrauma centers. Risk of death for injured patients hospitalized at level I trauma centers declined after the trauma system was established (odds ratio, 0.65; 95% confidence interval, 0.51 to 0.81). Patients who died in trauma centers after institution of the trauma system were younger and had more severe injuries, and the majority died within 1 day of admission, whereas patients who died in nontrauma centers died a median of 5 days after admission. Conclusion. —Establishment of a trauma system shifted the more seriously injured patients to level I trauma centers, where there was a significant reduction in the adjusted death rate. ( JAMA . 1994;271:1919-1924)
334 citations