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Background: In 2011, revised Field Triage Guidelines were released jointly by the Centers for Disease Control and Prevention (CDC) and the American College of Surgeons - Committee on Trauma (ACS-COT). It is unknown how the modifications will affect the number of injured children identified by EMS providers as needing transport to a trauma center., Objective: To determine the change in under- and over-triage rates when the 2011 Field Triage Guidelines are compared to the 2006 and 1999 versions., Methods: EMS providers in charge of care for injured children (<15 years) transported to pediatric trauma centers in 3 mid-sized cities were interviewed immediately after completing transport. Patients were included regardless of injury severity. The interview included patient demographics and each criterion from the Field Triage Guidelines' physiologic status, anatomic injury, and mechanism of injury steps. Included patients were followed through hospital discharge. The 1999, 2006, and 2011 Guidelines were each retrospectively applied to the collected data. Children were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. Data were analyzed using descriptive statistics., Results: EMS interviews were conducted for 5,610 children and outcome data was available for 5,594 (99.7%). Average age was 7.6 years; 5% of children were identified as needing a trauma center using the study outcome. Applying the 1999, 2006, or 2011 Guidelines to the EMS interview data the over-triage rate was 32.6%, 27.9%, and 28.0%, respectively. The under-triage rate was 26.5%, 35.1%, and 34.8%, respectively. The 2011 Guidelines resulted in an 8.2% (95% CI 0.6-15.9%) absolute increase in under-triage and a 4.6% (95% CI 2.8-6.3%) decrease in over-triage compared to 1999 Guidelines., Conclusion: Use of the Field Triage Guidelines for children resulted in an unacceptably high rate of under-triage regardless of the version used. Use of the 2011 Guidelines increased under-triage compared to the 1999 version. Research is needed to determine how to better assist EMS providers in identifying children who need the resources of a trauma center.

Background: There is limited research on how well the American College of Surgeons/Center for Disease Control and Prevention Guidelines for Field Triage of Injured Patients assist EMS providers in identifying children who need the resources of a trauma center., Objective: To determine the accuracy of the Physiologic Criteria (Step 1) of the Field Triage Guidelines in identifying injured children who need the resources of a trauma center., Methods: EMS providers who transported injured children 15 years and younger to pediatric trauma centers in 3 mid-sized cities were interviewed regarding patient demographics and the presence or absence of each of the Field Triage Guidelines criteria. Children were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. This data was obtained through a structured hospital record review. The over- and under-triage rates and positive likelihood ratios (+LR) were calculated for the overall Physiologic Criteria and each individual criterion., Results: Interviews were conducted for 5,610 pediatric patients; outcome data were available for 5,594 (99.7%): 5% of all patients needed the resources of a trauma center and 19% met the physiologic criteria. Using the physiologic criteria alone, 51% of children who needed a trauma center would have been under-triaged and 18% would have been over-triaged (+LR 2.8, 95% CI 2.4-3.2). Glasgow Coma Score (GCS) < 14 had a +LR of 14.3 (95% CI 11.2-18.3), with EMS not obtaining a GCS in 4% of cases. 54% of those with an EMS GCS < 14 had an initial ED GCS < 14. Abnormal respiratory rate (RR) had a +LR of 2.2 (95% CI 1.8-2.6), with EMS not obtaining a RR in 5% of cases. 41% of those with an abnormal EMS RR had an abnormal initial ED RR. Systolic blood pressure (SBP) < 90 had a +LR of 3.5 (95% CI 2.5-5.1), with EMS not obtaining a SBP in 20% of cases. SBP was not obtained for 79% of children <1 year, 46% 1-4 years, 7% 5-9 years, and 2% 10-15 years. A total of 19% of those with an EMS SBP < 90 had an initial ED SBP < 90., Conclusions: The Physiologic Criteria are a moderate predictor of trauma center need for children. Missing or inaccurate vital signs may be limiting the predictive value of the Physiologic Criteria.

Background: An estimated 20% of patients arriving by ambulance to the emergency department are in moderate to severe pain. However, the management of pain in the prehospital setting has been shown to be inadequate. Untreated pain may have negative physiologic and psychological consequences. The prehospital community has acknowledged this inadequacy and made treatment of pain a priority., Objectives: To determine if system-wide pain management improvement efforts (i.e. education and protocol implementation) improve the assessment of pain and treatment with opioid medications in the prehospital setting and to determine if improvements are maintained over time., Methods: This was a retrospective before and after study of a countywide prehospital patient care database. The study population included all adult patients transported by EMS between February 2004 and February 2012 with a working assessment of trauma or burn. EMS patient care records were searched for documentation of pain scores and opioid administration. Four time periods were examined: 1) before interventions, 2) after pediatric specific pain management education, 3) after pain management protocol implementation, and 4) maintenance phase. Frequencies and 95% confidence intervals were calculated for all patients meeting the inclusion criteria in each time period and Chi-square was used to compare frequencies between time periods., Results: 15,228 adult patients transported by EMS during the study period met the inclusion criteria. Subject demographics were similar between the four time periods. Pain score documentation improved between the time periods but was not maintained over time (13% [95%CI 12-15%] to 32% [95%CI 31-34%] to 29% [95 CI 27-30%] to 19% [95%CI 18-21%]). Opioid administration also improved between the time periods and was maintained over time (7% [95%CI 6-8%] to 18% [95%CI 16-19%] to 24% [95%CI 22-25%] to 23% [95% CI 22-24%])., Conclusions: In adult patients both pediatric-focused education and pain protocol implementation improved the administration of opioid pain medications. Documentation and assessment of pain scores was less affected by specific pain management improvement efforts.

Background: The National Association of Emergency Medical Services Physicians' (NAEMSP) Position Statement on Prehospital Pain Management and the joint National Highway Traffic Safety Administration (NHTSA) and Emergency Medical Services for Children (EMSC) Evidence-based Guideline for Prehospital Analgesia in Trauma aim to improve the recognition, assessment, and treatment of prehospital pain. The impact of implementation of these guidelines on pain management in children by emergency medical services (EMS) agencies has not been assessed., Objective: Determine the change in frequency of documented pain severity assessment and opiate administration among injured pediatric patients in three EMS agencies after adoption of best practice recommendations., Methods: This is a retrospective study of children <18 years of age with a prehospital injury-related primary impression from three EMS agencies. Each agency independently implemented pain protocol changes which included adding the use of age-appropriate pain scales, decreasing the minimum age for opiate administration, and updating fentanyl dosing. We abstracted data from prehospital electronic patient records before and after changes to the pain management protocols. The primary outcomes were the frequency of administration of opioid analgesia and documentation of pain severity assessment as recorded in the prehospital patient care record., Results: A total of 3,597 injured children were transported prior to pain protocol changes and 3,743 children after changes. Opiate administration to eligible patients across study sites regardless of documentation of pain severity was 156/3,089 (5%) before protocol changes and 175/3,509 (5%) after (p = 0.97). Prior to protocol changes, 580 (18%) children had documented pain assessments and 430 (74%) had moderate-to-severe pain. After protocol changes, 644 (18%) patients had pain severity documented with 464 (72%) in moderate-to-severe pain. For all study agencies, pain severity was documented in 13%, 19%, and 22% of patient records both before and after protocol changes. There was a difference in intranasal fentanyl administration rates before (27%) and after (17%) protocol changes (p = 0.02)., Conclusion: The proportion of injured children who receive prehospital opioid analgesia remains suboptimal despite implementation of best practice recommendations. Frequency of pain severity assessment of injured children is low. Intranasal fentanyl administration may be an underutilized modality of prehospital opiate administration.

Objective: Prior studies have identified provider and system characteristics that impede pain management in children, but no studies have investigated the effect of changing these characteristics on prehospital opioid analgesia. Our objectives were to determine: 1) the frequency of opioid analgesia and pain score documentation among prehospital pediatric patients after system wide changes to improve pain treatment, and 2) if older age, longer transport times, the presence of vascular access and pain score documentation were associated with increased prehospital administration of opioid analgesia in children., Methods: This was a retrospective cross-sectional study of pediatric patients aged 3-18 years assessed by a single EMS system between October 1, 2011 and September 30, 2013. Prior to October 2011, the EMS system had implemented 3 changes to improve pain treatment: (1) training on age appropriate pain scales, (2) protocol changes to allow opioid analgesia without contacting medical control, and (3) the introduction of intranasal fentanyl. All patients with working assessments of blunt, penetrating, lacerating, and/or burn trauma were included. We used descriptive statistics to determine the frequency of pain score documentation and opioid analgesia administration and logistic regression to determine the association of age, transport time, and the presence of intravenous access with opioid analgesia administration., Results: Of the 1,368 eligible children, 336 (25%) had a documented pain score. Eleven percent (130/1204) of children without documented contraindications to opioid administration received opioids. Of the children with no documented pain score and no protocol exclusions, 9% (81/929) received opioid analgesia, whereas 18% (49/275) with a documented pain score ≥4 and no protocol exclusions received opioids. Multivariate analysis revealed that vascular access (OR = 11.89; 95% CI: 7.33-19.29), longer patient transport time (OR = 1.07; 95% CI: 1.04-1.11), age (OR 0.93; 95% CI: 0.88-0.98) and pain score documentation (OR 2.23; 95% CI: 1.40-3.55) were associated with opioid analgesia., Conclusions: Despite implementation of several best practice recommendations to improve prehospital pain treatment, few children have a documented pain score and even fewer receive opioid analgesia. Children with longer transport times, successful IV placement, and/or documentation of pain score(s) were more likely to receive prehospital analgesia.

Research on field triage of injured patients is limited by the lack of a widely used criterion standard for defining trauma center need. Injury Severity Score (ISS) >15 has been a commonly used outcome measure in research for determining trauma center need that has never been validated. A multidisciplinary team recently published a consensus-based criterion standard definition of trauma center need, but this measure has not yet been validated. The objective was to determine if the consensus-based criterion standard can be obtained by medical record review and compare patients identified as needing a trauma center by the consensus-based criterion standard vs. ISS >15. A subanalysis of data collected during a 2-year prospective cohort study of 4,528 adult trauma patients transported by EMS to a single trauma center was conducted. These data included ICD-9-CM codes, treatment times, and other patient care data. Presence of the consensus-based criterion standard was determined for each patient. ISS was calculated based on ICD-9-CM codes assigned for billing. The consensus-based criterion standard could be applied to 4,471 (98.7%) cases. ISS could be determined for 4,506 (99.5%) cases. Based on an ISS >15, 8.9% of cases were identified as needing a trauma center. Of those, only 48.2% met the consensus-based criterion standard. Almost all patients that did not meet the consensus-based criterion standard, but had an ISS >15 were diagnosed with chest (rib fractures (100/205 cases)/pneumothorax (57/205 cases), closed head (without surgical intervention 88/205 cases), vertebral (without spinal cord injury 45/205 cases), and/or extremity injuries (39/205 cases). There were 4,053 cases with an ISS <15. 5.0% of those with an ISS <15 met the consensus-based criterion standard with the majority requiring surgery (139/203 cases) or a blood transfusion (60/203 cases). The kappa coefficient of agreement for ISS and the consensus-based criterion standard was 0.43. We determined that the consensus-based criterion standard could be identified through a medical record review. Use of the consensus-based criterion standard for field triage research will more accurately identify injured patients who need the resources of a trauma center when compared to ISS.

Objective: Pediatric transports comprise approximately 10% of emergency medical services (EMS) requests for aid, but little is known about the clinical characteristics of pediatric EMS patients and the interventions they receive. Our objective was to describe the pediatric prehospital patient cohort in a large metropolitan EMS system., Methods: This retrospective analysis of all pediatric (age <19 years) EMS patients transported from October 2011 to September 2013 was conducted by reviewing a system-wide National EMS Information System (NEMSIS)-compliant database of all EMS patient encounters. We identified the most common primary working assessments, the frequency of abnormal initial vital signs, and the interventions provided. Vital signs included systolic blood pressure (SBP), respiratory (RR) and pulse rate, Glasgow Coma Scale (GCS), pulse oximetry (Pox), and respiratory effort. We defined abnormal vital signs using previously reported age-specific standards. We identified the working assessments most frequently associated with abnormal vital signs and the working assessments associated with the most commonly performed interventions. Data were analyzed using descriptive statistics., Results: There were 9,956 pediatric transports, 8.7% of the total call volume. The most common working assessments were "other" (16.1%), respiratory distress (13.7%), seizure (12.4%), and blunt trauma (12.0%). Vital signs were documented at variable rates: RR (91.1%), GCS (82.9%), SBP (71.3%), pulse (69.4%), respiratory effort (49.7%), and Pox (33.5%). Of all transported patients, 61.5% had a documented abnormal initial vital sign. Patients with an abnormal vital sign had the same most common working assessments as those with normal vital signs. Glucometry (16.9%), medication delivery (13.6%), and IV placement (11.5%) were the most common interventions and were most often provided to patients with working assessments of seizure, asthma, trauma, altered consciousness, or "other." Cardiopulmonary resuscitation (0.4%), bag mask ventilation (0.4%), and advanced airway (0.4%) occurred rarely and were most often performed for cardiac arrest and trauma., Conclusions: Children made up a small part of EMS providers' clinical practice; those encountered most frequently had respiratory distress, seizures, trauma, or an undefined assessment (i.e., "other"). EMS providers frequently encounter children with physiologic evidence of acute illness, although vital sign documentation was incomplete. Prehospital providers infrequently perform pediatric interventions. Describing EMS providers' interaction with children provides the opportunity to target improvements in pediatric prehospital treatment, training, and research.

Objective: Our objective was to determine the predictive value of the anatomic step of the 2011 Field Triage Decision Scheme for identifying trauma center need., Methods: Emergency medical services (EMS) providers caring for injured adults transported to regional trauma centers in three midsized communities were interviewed over two years. Patients were included, regardless of injury severity, if they were at least 18 years old and were transported by EMS with a mechanism of injury that was an assault, motor vehicle or motorcycle crash, fall, or pedestrian or bicyclist struck. The interview was conducted upon emergency department (ED) arrival and collected physiologic condition and anatomic injury data. Patients who met the physiologic criteria were excluded. Trauma center need was defined as nonorthopedic surgery within 24 hours, intensive care unit admission, or death prior to hospital discharge. Data were analyzed by calculating descriptive statistics, including positive likelihood ratios (+LRs) with 95% confidence intervals (CIs)., Results: A total of 11,892 interviews were conducted. One was excluded because of missing outcome data and 1,274 were excluded because they met the physiologic step. EMS providers identified 1,167 cases that met the anatomic criteria, of which 307 (26%) needed the resources of a trauma center (38% sensitivity, 91% specificity, +LR 4.4; CI: 3.9-4.9). Criteria with a +LR ≥5 were flail chest (9.0; CI: 4.1-19.4), paralysis (6.8; CI: 4.2-11.2), two or more long-bone fractures (6.3; CI: 4.5-8.9), and amputation (6.1; CI: 1.5-24.4). Criteria with a +LR >2 and <5 were penetrating injury (4.8; CI: 4.2-5.6) and skull fracture (4.8; CI: 3.0-7.7). Only pelvic fracture (1.9; CI: 1.3-2.9) had a +LR less than 2., Conclusions: The anatomic step of the Field Triage Guidelines as determined by EMS providers is a reasonable tool for determining trauma center need. Use of EMS perceived pelvic fracture as an indicator for trauma center need should be reevaluated. Key words: wounds and injury; triage; emergency medical services; emergency medical technicians.

Objective: To determine the predictive value of the mechanism-of-injury step of the American College of Surgeons Field Triage Decision Scheme for determining trauma center need., Methods: Emergency medical services (EMS) providers caring for injured adult patients transported to the regional trauma center in three midsized communities over two years were interviewed upon emergency department (ED) arrival. Included was any injured patient, regardless of injury severity. The interview collected patient physiologic condition, apparent anatomic injury, and mechanism of injury. Using the 1999 Scheme, patients who met the physiologic or anatomic steps were excluded. Patients were considered to need a trauma center if they had nonorthopedic surgery within 24 hours, had intensive care unit admission, or died prior to hospital discharge. Data were analyzed by calculating positive likelihood ratios (+LRs) and 95% confidence intervals (CIs) for each mechanism-of-injury criterion., Results: A total of 11,892 provider interviews were conducted. Of those, one was excluded because outcome data were not available, and 2,408 were excluded because they met the other steps of the Field Triage Decision Scheme. Of the remaining 9,483 cases, 2,363 met one of the mechanism-of-injury criteria, 204 (9%) of whom needed the resources of a trauma center. Criteria with a +LR ≥ 5 were death of another occupant in the same vehicle (6.8; CI: 2.7-16.7), fall >20 feet (5.3; CI: 2.4-11.4), and motor vehicle crash (MVC) extrication time >20 minutes (5.1; CI: 3.2-8.1). Criteria with a +LR between >2 and <5 were intrusion >12 inches (4.2; CI: 2.9-5.9), ejection (3.2; CI: 1.3-8.2), and deformity >20 inches (2.5; CI: 1.9-3.2). The criteria with a +LR ≤ 2 were MVC speed >40 mph (2.0; CI: 1.7-2.4), pedestrian/bicyclist struck at a speed >5 mph (1.2; CI:1.1-1.4), bicyclist/pedestrian thrown or run over (1.2; CI: 0.9-1.6), motorcycle crash at a speed >20 mph (1.2; CI: 1.1-1.4), rider separated from motorcycle (1.0; CI: 0.9-1.2), and MVC rollover (1.0; CI: 0.7-1.5)., Conclusion: Death of another occupant, fall distance, and extrication time were good predictors of trauma center need when a patient did not meet the anatomic or physiologic conditions. Intrusion, ejection, and vehicle deformity were moderate predictors. Key words: wounds and injury; triage; emergency medical services; emergency medical technicians; predictors; mechanism of injury; trauma center.

Background: In 2006, the Centers for Disease Control and Prevention (CDC) released a revised Field Triage Decision Scheme. It is unknown how this modified scheme will affect the number of patients identified by emergency medical services (EMS) for transport to a trauma center., Objectives: To determine the change in the number of patients transported by EMS who meet the 2006 scheme, compared with the 1999 scheme, and to determine how the scheme change would affect under- and overtriage rates., Methods: The EMS providers in charge of care for injured adult patients transported to a regional trauma center in three mid-sized cities were interviewed immediately after completing transport. All injured patients were included, regardless of severity. The interview included patient demographics, vital signs, apparent anatomic injury, and the mechanism of injury. Included patients were then followed through hospital discharge. The 1999 and 2006 scheme criteria were each retrospectively applied to the collected data. The numbers of patients identified by the two schemes were determined. Patients were considered to have needed a trauma center if they had nonorthopedic surgery within 24 hours, were admitted to an intensive care unit (ICU), or died. Data were analyzed using descriptive statistics including 95% confidence intervals., Results: EMS interviews were conducted for 11,892 patients and outcome data were unavailable for one patient. The average patient age was 48 years; 51% of the patients were men. Providers reported bringing 54% of the enrolled patients to the trauma center based on their local trauma protocol. Medical record review identified 12% of the enrolled patients as needing a trauma center. Use of the 2006 scheme would have resulted in 1,423 fewer patients (12%; 95% confidence interval [CI]:11%-13%) being identified as needing a trauma center by EMS providers (40%; 95% CI: 39%-41% versus 28%; 95% CI: 27%-29%). Of those patients, 1,344 (94%) did not actually need the resources of a trauma center, whereas 78 (6%) actually needed the resources of a trauma center and would have been undertriaged., Conclusion: Use of the 2006 Field Triage Decision Scheme would have resulted in a significant decrease in the number of patients identified as needing the resources of a trauma center. These changes reduced overtriage while causing a small increase in the number of patients who would have been undertriaged.

Objective: Competency is affected by skill exposure, skill complexity, and training program quality. The purpose of this study was to reevaluate the biennial (24-month) critical care skill and experience benchmark thresholds established by the Milwaukee County Emergency Medical Services (MCEMS) system in 1997., Methods: This was a retrospective review of annual experience profiles for paramedics working during 2001-2005 using the MCEMS patient care record (PCR) database. The number of patient contacts, role as team leader/report writer, adult and pediatric endotracheal intubations, adult and pediatric intravenous (IV) access initiations, medication administration, and 12-lead electrocardiogram (ECG) acquisitions were analyzed. t-tests and descriptive statistics were performed for comparison with the 1997 study., Results: Over the five-year study period, 1,215 paramedic profiles gleaned from 107,524 PCRs documented a total of 297,900 patient contacts. Annual means+/-standard deviations [ranges] were as follows: patient contacts 245+/-133 [12-788]; team leader: 106+/-119 [0-739]; intubations: adult 2.57+/-2.54 [0-20], pediatric 0.1+/-0.3 [0-3]; IV starts: adult 44+/-37 [0-267], pediatric 0.34+/-0.77 [0-5]; treated cardiac arrests: adult 8+/-6 [0-34], pediatric 0.26+/-0.61 [0-4]; treated hypotensive trauma: 5+/-6 [0-42]; and ECGs acquired: 31+/-19 [0-144]. The 1997 analysis (1987-1996 data) included 1,450 paramedic profiles representing 467,559 patient contacts generated from 172,131 filed PCRs. All comparable experiences decreased significantly between the 1997 analysis and the current study, except medication administration, which increased 25%., Conclusion: These data show a decreased opportunity and a wide variability in the frequency of successfully completed paramedic technical skills and experiences in this EMS system. Limited exposure to critically ill adult and pediatric patients reaffirms that high-risk skills are performed infrequently. A multifaceted approach should be considered for maintaining provider competency.