In suburban and rural areas, whether to transport patients to specialized trauma facilities can be a very important decision. Long transport times could leave an area without quick coverage should another call come in. With cutbacks in staffing this may soon even become a concern in urban areas.
Additionally, proper triage is required so that the best use is made of trauma-center resources without "stealing" patients appropriate for community hospital treatment. Unneeded transfers to faraway trauma centers may also cause disruptions for patients' families. Various methods for making out-of-hospital triage decisions have been tried with some success. Most, however, fail to find the patients who initially look well but may eventually require trauma center services.
"Ideal trauma triage criteria should direct severely injured patients to trauma centers while distributing patients with minor injuries to community hospitals," said Mark Henry, M.D., an emergency physician at the University Medical Center at the State University of New York at Stony Brook. "Sensitive criteria are important to prevent transport to non-trauma hospitals where definitive care may be unavailable or delayed. Specificity of criteria is needed to prevent overtriage and an overload of trauma facilities."
New York State adopted out-of-hospital triage guidelines based on national criteria developed by the American College of Surgeons (ACS). Henry's group looked at the ability of the guidelines to predict the need for trauma center care. The ACS recommendations are in two categories. The mechanism of injury indications include falls greater than 20 feet, pedestrians struck by vehicles going more than 20 mph or motor vehicle accidents including ejection from vehicle, death of occupant in patient's vehicle, rollover and high-speed impact with severe vehicle damage.
The physiological and anatomic standards include a pulse rate more than 120 or less than 50 beats a minute, systolic blood pressures below 90 mmHg, respiratory rate more than 28 or less than 10 breaths per minute, a Glasgow Coma scale score of lower than 13, two or more long bone fractures, system trauma to two or more body systems, spinal cord injury or paralysis, flail chest and amputation other than digits. Orthopedic procedures such as open fractures were not included.
Professionally acceptable time frames before surgery provide enough leeway for evaluation at a local hospital with transfer to a trauma center if needed. The team decided to study only blunt-force trauma in patients; those with penetrating trauma, burns or falls from less than 20 feet were excluded. The study was conducted in Suffolk County, NY. The county Department of Health Services runs the EMS system. All pre-hospital care reports are sent to University Medical Center, which provides medical control services for the county.
Victims of blunt trauma treated between September 1992 and the end of January 1993 were entered into the study. Patients who sustained blunt trauma because of motor vehicle accidents, assaults or falls higher than ground level comprised the population under study. There were 912 patients identified through a review of pre-hospital run reports. Of these, 55 were unavailable for analysis. Most patients (79 percent) were victims of motor vehicle accidents, 83 were pedestrians struck by motor vehicles and 52 patients fell.
The cases were divided into four groups. In addition to a control group that met none of the criteria, other classifications included those who met only the mechanism criteria, those who met only the physiological criteria and those who met both.
"The presence of either ACS mechanism or physiological criteria predicted an increased likelihood of hospital admission compared with the control patients," Henry noted. "Once hospitalized, the patients with only the mechanism criteria were less likely to require hospitalization for more than three days, intensive care unit (ICU) treatment and operative interventions than were patients that met physiological criteria. When patients had a mechanism criterion in addition to a physiological one, the likelihood of requiring a major operative procedure increased further."
Their results were consistent with prior studies that showed physiologic signs and symptoms were predictive of the need for advanced care. All emergency department deaths occur-red in patients with at least one physiological impairment. The researchers also found an increased likelihood that an ICU stay would be required in this group. Henry noted, however, the relationship between this and the need for trauma center admission is less clear since many hospitals use ICUs for monitoring purposes.
One major difference in this study from others is that they specifically looked at how predictive of treatment mechanical indications were by themselves. The researchers found that meeting mechanism criteria alone did not improve identification of patients who died in emergency departments, required operations, ICU stays or prolonged hospitalization when compared to those without any criteria.
"The presence of the physiological criteria increased the likelihood of needing trauma center services and the patient may benefit from transport directly to such a facility," Henry said. "Because of the low need for operative intervention and ICU services, patients with no criteria or mechanism criteria only and at a long distance from a trauma center may initially be evaluated at the closest hospital and transferred to a trauma center if indicated."
Kurt Ullman, a Firehouse® contributing editor, is a registered nurse and regional chairman of the volunteer Indiana Arson and Crime Association.
