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Despite major improvements in the United States trauma system over the past two decades, prehospital trauma triage is a significant challenge. Undertriage is associated with increased mortality, and overtriage results in significant resource overuse. The American College of Surgeons Committee on Trauma benchmarks for undertriage and overtriage are not being met. Many barriers to appropriate field triage exist, including lack of a formal definition for major trauma, absence of a simple and widely applicable triage mode, and emergency medical service adherence to triage protocols. Modern trauma triage systems should ideally be based on the need for intervention rather than injury severity. Future studies should focus on identifying the ideal definition for major trauma and creating triage models that can be easily deployed. This narrative review article presents challenges and potential solutions for prehospital trauma triage.

Background In New South Wales (NSW), Australia, trauma accounts for 6% of deaths. Trauma patients receiving definitive care in regional trauma centres are 34% more likely to have a fatal outcome compared to level 1 centres. Following the implementation of the NSW State Trauma Plan where patients with major trauma are fast tracked to regional trauma services, should NSW rural surgeons and retrieval doctors continue to receive surgical training in neurotrauma? Methods The study's primary objective was to ascertain which NSW regional and rural hospitals have the equipment to perform neurotrauma and when it was last used. The study also examined the outcome of those patients who had undergone an emergency neurosurgical procedure. Results Of the 149 regional and rural hospitals in NSW, 16 stored a Hudson brace, perforator, burr and Gigli saw sterile and ready to use in the operating theatre. Only one hospital utilised the equipment in the last year and 11 in the last 10 years. Of those patients who had undergone an emergency neurosurgical procedure, two patients died prior to transfer and three were confirmed deceased after transfer to a tertiary centre. Conclusion The implementation of the NSW State Trauma Plan has streamlined the trauma triage process and transport of neurotrauma patients to regional and major trauma services. However, it is likely that knowledge of how to perform burr hole and craniectomy for the evacuation of extradural haematoma remains a useful skill for the rural surgeon and retrieval doctor if transport is delayed.

Background Due to the overwhelming demand for trauma services, resulting from increasing emergency department attendances over the past decade, virtual fracture clinics (VFCs) have become the fashion to keep up with the demand and help comply with the BOA Standards for Trauma and Orthopaedics (BOAST) guidelines. In this article, we perform a systematic review asking, “How useful are VFCs?”, and what injuries and conditions can be treated safely and effectively, to help decrease patient face to face consultations. Our primary outcomes were patient satisfaction, clinical efficiency and cost analysis, and clinical outcomes. Methods We performed a systematic literature search of all papers pertaining to VFCs, using the search engines PubMed, MEDLINE, and the Cochrane Database, according to the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) checklist. Searches were carried out and screened by two authors, with final study eligibility confirmed by the senior author. Results In total, 21 records were relevant to our research question. Six orthopaedic injuries were identified as suitable for VFC review, with a further four discussed in detail. A reduction of face to face appointments of up to 50% was reported with greater compliance to BOAST guidelines (46.4%) and cost saving (up to £212,000). Conclusions This systematic review demonstrates that the VFC model can help deliver a safe, more cost-effective, and more efficient arm of the trauma service to patients. Cite this article: Bone Joint Open 2020;1-11:683–690.

In Tactical Combat Casualty Care (TCCC), medics perform Role 1 care for battlefield casualties at point of injury by stabilizing them and transporting them to field care facilities such as a Battalion Aid Station (Role 2) or Field Hospital (Role 3) where clinicians provide critical care. Care provider experience and ability vary, and training in the field can help to improve recall and performance of infrequently used critical care skills. This becomes more necessary during Prolonged Field Care (PFC) when evacuation is not immediately available and more complex treatment may be required. Our Trauma Triage Treatment and Training Decision Support (4TDS) project has developed a decision support system (DSS) for Roles 1 and 2. As an application on a Android smart phone and tablet, 4TDS includes training scenarios in skills such as shock identification and management. 4TDS pairs with various vital signs sensors that can stream data for a machine learning algorithm that can detect the probability of shock in a casualty. A "silent test" is comparing algorithm performance with actual clinical diagnoses at Mayo Clinic, Rochester, MN. Usability assessment in an austere field setting will enable us to determine medic and clinician acceptance of 4TDS and how well it supports their decision making. Faster, more accurate decisions can improve TCCC patient care under conditions in which delays can increase morbidity and mortality.

Background In the trauma triage procedure, nurses with good knowledge and skills can start initial treatment immediately pending doctors availability, and before a final diagnosis is made. The Advanced Trauma Life Support/ Advanced Trauma Care for Nurses is one of the most important trauma education programmes to enhance the knowledge and skills of emergency nurses. This systematic review of the literature attempts to investigate the implications of introducing an Advanced Trauma Life Support/Advanced Trauma Care for Nurses’ knowledge and skills related to trauma triage. Methods A systematic review was carried out using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The included sites and databases are Web of Science, Scopus, PubMed, ScienceDirect, Cochrane Library, and Bielefeld Academic Search Engine (BASE) from 1994 to 2019. The quality of the selected studies was evaluated using a standard quality rating tool (SQRT). The quality of the criteria for inclusion and exclusion was independently reviewed by three researchers. Results This study evaluated 5266 records in the identification stage. In the included stage, only four studies were included in this review. In the standard quality assessment, none of the included studies were evaluated as being a strong study, none used an experimental design at three points in time (pre, post and follow-up), and all showed a moderate to high risk of bias. There is a lack of knowledge and skills related to trauma triage among emergency nurses in the included studies. Conclusion A lack of knowledge and skills concerning trauma triage among emergency nurses could potentially have an adverse effect on the outcomes of the patients in trauma cases.

Purpose Severely injured patients should be treated at higher-level trauma centres, to improve chances of survival and avert life-long disabilities. Emergency medical service (EMS) providers must try to determine injury severity on-scene, using a prehospital trauma triage protocol, and decide the most appropriate type of trauma centre. The objective of this study is to investigate the role of EMS provider judgment in the prehospital triage process of trauma patients, by analysing the compliance rate to the protocol and administering a questionnaire among EMS providers. Methods All trauma patients transported to a trauma centre in two different regions of the Netherlands were analysed. Compliance rate was based on the number of patients meeting the triage criteria and transported to the corresponding level trauma centre. The questionnaire was administered among EMS providers. Descriptive statistics were used to analyse the data. Results For adult patients, the compliance rate to the level I criteria of the triage protocol was 72% in Central Netherlands and 42% in Brabant. For paediatric patients, this was 63% and 38% in Central Netherlands and Brabant, respectively. The judgment on injury severity was mostly based on the injury-type criteria. Additionally, the distance to a level I trauma centre influenced the decision for destination facility in the Brabant region. Conclusion The compliance rate varied between regions. Improvement of prehospital trauma triage depends on the accuracy of the protocol and compliance rate. A new protocol, including EMS provider judgment, might be the key to improvement in the prehospital trauma triage quality.

BACKGROUND: Prehospital trauma triage ensures proper transport of patients at risk of severe injury to hospitals with an appropriate corresponding level of trauma care. Incorrect triage results in undertriage and overtriage. The American College of Surgeons Committee on Trauma recommends an undertriage rate below 5% and an overtriage rate below 50% for prehospital trauma triage protocols. To find the most accurate prehospital trauma triage protocol, a clear overview of all currently available protocols and corresponding outcomes is necessary. OBJECTIVES: The aim of this systematic review was to evaluate the current literature on all available prehospital trauma triage protocols and determine accuracy of protocol-based triage quality in terms of sensitivity and specificity. METHODS: A search of Pubmed, Embase, and Cochrane Library databases was performed to identify all studies describing prehospital trauma triage protocols before November 2016. The search terms included "trauma," "trauma center," or "trauma system" combined with "triage," "undertriage," or "overtriage." All studies describing protocol-based triage quality were reviewed. To assess the quality of these type of studies, a new critical appraisal tool was developed. RESULTS: In this review, 21 articles were included with numbers of patients ranging from 130 to over 1 million. Significant predictors for severe injury were: vital signs, suspicion of certain anatomic injuries, mechanism of injury, and age. Sensitivity ranged from 10% to 100%; specificity from 9% to 100%. Nearly all protocols had a low sensitivity, thereby failing to identify severely injured patients. Additionally, the critical appraisal showed poor quality of the majority of included studies. CONCLUSION: This systematic review shows that nearly all protocols are incapable of identifying severely injured patients. Future studies of high methodological quality should be performed to improve prehospital trauma triage protocols. LEVEL OF EVIDENCE: Systematic review, level III.

Introduction Patients who visit emergency departments need to undergo a precise assessment to determine their priority and accurate triage category to ensure they receive the right treatment. Aim To identify the effect of triage training on the skills and accuracy of triage decisions for adult trauma patients. Method A randomized controlled trial design was conducted in ten emergency department of public hospitals. A total of 143 registered nurses and medical officer assistants who performed triage roles were recruited for the control group (n = 74) and the intervention group (n = 69). The skill and accuracy of triage decisions were measured two weeks and four weeks after the intervention group were exposed to the intervention. Results There was a significant effect on the skill of triage decision-making between the control and the intervention group p Conclusion The triage training improved the skills of the participants and the accuracy of triage decision-making across time.

Objective: We evaluated the performance of individual trauma triage criteria using data from a regional trauma registry. Methods: Los Angeles County (LAC) paramedics use triage criteria adapted fro...

In the UK, reports from the Trauma Audit Research Network (TARN)1 2 have shown that the very young and the very old now outnumber higher profile trauma groups, such as road accidents and stabbings. Other countries have seen similar demographic shifts. The very young and the very old share many societal and medical traits, including late diagnosis of severe injuries that may not be apparent on initial presentation.3 This could be described as ‘stealth trauma’. Many countries have established major trauma networks,4 5 with the English system showing incremental improvements in patient outcomes.6 However, these systems rely on early identification by prehospital services of the ‘major trauma patient’ (usually by application of a trauma triage tool by ambulance staff). This identifies patients for immediate transfer to a major trauma centre (MTC), however this system does not work at the extremes of age. The TARN reports show that the old and the very young have a delayed process of care. The mechanism of injury …

Standard triage systems result in high rates of overtriage to achieve acceptably low undertriage. We previously validated optimal triage variables and used these to implement a new simplified triage system (NEW) at our hospital.All trauma entries from May 2010 to Feb 2013 were prospectively reviewed. Calculation of the undertriage and overtriage rates was based on the need for any urgent or life-saving intervention.We identified 704 trauma patients. Level 1 activations were reduced from 32% (OLD) to 19% in the NEW system (P.05). Overtriage was reduced from 79% (OLD) to 44% in the NEW system (P.01). The undertriage rate was 1.6% in the NEW system, compared with 1.2% in the OLD system (P = nonsignificant). Of all patients, 14% (63) required a life-saving intervention. There were no deaths among undertriaged patients.The NEW simplified triage system significantly reduced the rate of overtriage, while safely maintaining a low undertriage rate.

Aims Fracture clinics are often characterised by the referral of large numbers of unselected patients with minor injuries not requiring investigation or intervention, long waiting times and recurrent unnecessary reviews. Our experience had been of an unsustainable system and we implemented a ‘Trauma Triage Clinic’ (TTC) in order to rationalise and regulate access to our fracture service. The British Orthopaedic Association’s guidelines have required a prospective evaluation of this change of practice, and we report our experience and results. Patients and Methods We review the management of all 12 069 patients referred to our service in the calendar year 2014, with a minimum of one year follow-up during the calendar year 2015. Results Following the successful introduction of the TTC, only 2836 patients (23.5%) who would previously have been reviewed in the general fracture clinic were brought back to such a clinic to be seen by a surgeon. An additional 2366 patients (19.6%) were brought back to a sub-specialist injury-specific clinic. Another 2776 patients (23%) with relatively predictable injuries were reviewed by a nurse practitioner according to an established protocol or specific consultant instructions. A further 3222 patients (26.7%) were discharged from the service without attending the clinic. No significant errors or omissions occurred with the introduction of the TTC. Conclusion We have found that our TTC allows large numbers of referrals to be reviewed and triaged safely and effectively, to the benefit and satisfaction of patients, consultants, trainees, staff and the organisation. This paper provides the first large-scale review of the instigation of a TTC, and its effect, acceptability and safety. Cite this article: Bone Joint J 2017;99-B:503–7.

ObjectiveThe aim of this study was to evaluate whether bystanders with no training in triage can correctly prioritize three injured patients by using a triage instrument.MethodAn observational study was conducted. Participants performed a primary triage on three paper-based patient cases and answered 11 questions during a public event in the center of Stockholm, Sweden.ResultsA total of 69 persons participated in the study. The success rate among all the participants for correct triage of the three patient cases was 52 percent. The female participants and younger participants (ConclusionParticipants with no prior knowledge of triage instruments may be capable of triaging injured patients with the help of an easy triage instrument. The over- and under-triage percentages were low, and this may indicate that the developed triage instrument is relatively easy to use. It may also indicate that bystanders can identify a severely injured patient.NordbergM, CastrénM, LindströmV. Primary trauma triage performed by bystanders: an observation study. Prehosp Disaster Med.2016;31(4):353–357.

Background: Pre-hospital trauma triage criteria are used to expedite the transport of severely injured patients to major trauma services. The current Victorian adult pre-hospital trauma triage criteria consist of physiological, anatomical and mechanistic elements. The purpose of this study was to evaluate the performance of the current triage criteria and, if necessary propose refined criteria to improve the under and over-triage rates. Conclusions: Evaluation showed that the specificity and sensitivity of the current trauma triage criteria could be improved. The implementation of a revised triage model should identify more confirmed major trauma patients. Likewise, over-triage of non-major trauma patients to major trauma services would be significantly reduced. The refined criteria should also decrease discretionary decision-making by paramedics in the field. Methods: The study was conducted in Melbourne, Victoria, which has a fully integrated State Trauma System. Trauma data was sourced from the pre-hospital Victorian Ambulance Clinical Information System and the Victorian State Trauma Registry. Confirmed major trauma was defined at hospital discharge as one or more of death, ISS > 15, ICU ventilation or urgent surgery. Data was matched through probabilistic linkage. The triage criteria were evaluated using multivariate logistic regression and classification tree modelling. Diagnostic statistics, including sensitivity and specificity were calculated to assess triage performance. Results: Over 12-months there were 1166 'confirmed major trauma' patients and 44,166 'non-major trauma' patients. Evaluation showed the current triage criteria needed refinement, and multiple revised pre-hospital trauma triage models were constructed. Based on the best overall combination of diagnostic statistics, a revised model was chosen with a sensitivity of 97.8% (vs. 95.3% in the current model), a specificity of 82.7% (vs. 62.7%) and an accuracy of 83.0% (vs. 63.4%). The over-triage rate was 17.3% (vs. 37.3%) and the under-triage rate was 2.2% (vs. 4.7%). Refereed/Peer-reviewed

The traditional paradigm for trauma resuscitations was that a surgeon was always required for leadership. However many changes such as resident work-hour limitations, a shift toward non-operative management, improved trauma triage, and advanced imaging have raised questions about the necessity of a member of the surgical team at all resuscitations. The requirement for surgeon presence is based mostly on opinion rather than data. Our institution has over a decade of experience with pediatric emergency medicine physicians managing minor trauma resuscitations and requiring surgeon presence specifically for the major resuscitations. This has resulted in more appropriate resource allocation without sacrificing patient care in our institution. Other institutions have similarly shifted the focus away from early surgeon involvement while preserving patient safety. We recommend a critical re-evaluation of trauma protocols and systems in requiring surgeon presence as a novel mechanism to improve surgical resource utilization without compromising patient care.

This report examines the efficacy of current trauma triage rules to determine the exigency of field care and transport of severely injured patients from a variety of medical populations.

Field trauma triage systems currently used by emergency responders at mass casualty incidents and disasters do not adequately account for the possibility of contamination of patients with chemical, biological, radiological, or nuclear material. Following a discussion of background issues regarding m

Background. Careful adherence to standard precautions can protect both health care workers (HCWs) and patients from infections. The present study identified the perceptions and compliance with the use of standard precautions and assessed the determinants of noncompliance among the HCWs in an emergency and trauma triage centre. Methods. A cross-sectional study using a semistructured questionnaire was carried out to collect the relevant information from the study participants. Results. A total of 162 HCWs were recruited into the study, who reported varying degrees of compliance with standard precautions. While most of them declared the use of hand rub (95%) and gloves (77%), reported use of protective eye gear and outer protective clothing was very low (22 and 28%, resp.). Despite a perceived risk of exposure to blood-borne infections, 8% of the HCWs had not completed the hepatitis B vaccination schedule. About 17% reported at least one needle stick injury in the past year but only 5.6% received medical attention. Conclusion. Inadequate adherence to standard precautions among health care providers warrants new training and monitoring strategies. Establishment of an effective occupational health cell incorporating these elements including periodic surveillance could be the way forward.

近年,救命救急医療の発展に伴い,救急隊には的確な観察と適正な搬送が要求されている。欧米では外傷に関し種々のプレホスピタル・スコアが検討されているが,本邦ではほとんど検討されておらず,またシステムの異なる欧米のものを一概に適用するわけにもいかない。われわれは1994年,本邦で1972年に報告された外傷指数(Japan Trauma Index; JTI)をもとに新たな外傷トリアージスコア(Trauma Triage Score; TTS)を考案した。今回,外傷患者の重症度評価に対するTTSの有用性を検討するため,客観的重症度としてInjury Severity Score (ISS)を用い,それらの相関を検証した。対象と方法:当地域3市における全外傷患者に対し,1997年3, 6, 9, 12月(計1466件)の期間,現場で救急隊にTTSをつけてもらった。3週間後に全搬送先に郵送調査で確定診断名を記入してもらい,ISSを算出した。TTSに関しては,緊急手術・集中治療を要する患者,多発外傷や瀕死の患者を重症とし,ISSに関しては16点以上を重症としたうえで,TTSの重症予測正診率を感受性・特異性などを用いて検討した。またTTSとISSとの関係を単回帰分析により検証した。さらに全体の相関だけではなく,市ごとにも検証した。結果:TTSの重症予測正診率はsensitivity 93%, specificity 96%であった。また決定係数(r2)は0.59であった。しかし市ごとにみると相関は異なっていた(0.64, 0.62, 0.45)。考察:われわれが考案したTTSは救急隊が実際に現場で使用でき,かつ個々の外傷患者の重症度を的確に表すものであった。

The goal of trauma triage is to get the right patient to the right place at the right time. In an attempt to achieve this objective numerous authors have developed a variety of prehospital triage tools. Comparative evaluation to determine which of the currently developed triage tools has the greatest predictive power has been prevented mainly because of the varying definitions of major trauma. The use of small data sets and the absence of model validation techniques have also prevented the true worth of these triage tools from being accurately determined. The aim of this article is to critically appraise the major prehospital triage tools.

Trauma systems have been successful in saving lives and preventing disability. Making sure that the right patient gets the right treatment in the shortest possible time is integral to this success. Most trauma systems have not fully developed trauma triage to optimize outcomes. For trauma triage to be effective, there must be a well-developed pre-hospital system with an efficient dispatch system and adequately resourced ambulance system. Hospitals must have clear designations of the level of service provided and agreed protocols for reception of patients. The response within the hospital must be targeted to ensure the sickest patients get an immediate response. To enable the most appropriate response to trauma patients across the system, a well-developed monitoring programme must be in place to ensure constant refinement of the clinical response. This article gives a brief overview of the current approach to triaging trauma from time of dispatch to definitive treatment.

The CRAMS scale and the Triage Revised Trauma Score (TRTS) were compared to assess their potential use as a prehospital method of activating hospital trauma teams. We studied patients from the resuscitation room of Leeds General Infirmary who had enough data recorded to allow calculation of the admission TRTS and CRAMS scale. Patients were defined as having major injury if they died in hospital, were admitted to the ICU or had an Injury Severity Score (ISS) of15. Each triage scale was compared by calculating multiple sensitivity/specificity pairs and plotting the results on a receiver operator (ROC) curve. The optimal cut-offs on each scale were compared directly. Ninety-seven (46 per cent) of a total of 213 patients fulfilled the study criteria for major injury. The best cut-off points were a CRAMS of9 and a TRTS of12. The TRTS was significantly more specific (0.9 versus 0.75) but at a cost of poor sensitivity (0.6 versus 0.69, not significant). The performance of both scales was similar when compared on the ROC curve. CRAMS and the TRTS were unable to identify major injuries in our sample with sensitivity and specificity adequate to support their use as a tool to activate trauma teams in the UK.

The purpose of the study was to evaluate real-time heart rate complexity as a trauma triage tool. Objectives achieved include 1. Real-time complexity determination has been demonstrated in trauma activation patients. 2. The real-time measures have been miniaturized into a hand-held device that is portable and user friendly 3. Triage algorithms have been proposed based upon prospectively collected data on trauma patients presenting to our institution. 4. The algorithm has been tested prospectively and retrospectively Key findings include: Heart rate complexity can be miniaturized and conducted in real time. Real-time analysis with a hand-held device is possible and results in improved trauma patient triage over standard existing triage guidelines. Adding electrical cardiometry to HRC-based triage does not improve triage HRC-based triage is valid after a variety of mechanisms of injury, including bunt, penetrating, and blast trauma.

Background: National benchmarks for trauma triage sensitivity (≥95%) and specificity (≥50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices. Methods: This was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity. Results: A total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4%) had ISS of 16 or greater. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4%). Conclusion: Reaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in overtriage). A 90% sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm. Level Of Evidence: Diagnostic test, level II. © 2013 Lippincott Williams and Wilkins.

Background United States trauma system guidelines specify when to triage patients to specialty centers. Nonetheless, many eligible patients are not transferred as per guidelines. One possible reason is emergency physician decision-making. The objective of the study was to characterize sensory and decisional determinants of emergency physician trauma triage decision-making. Methods We conducted a decision science study using a signal detection theory-informed approach to analyze physician responses to a web-based survey of 30 clinical vignettes of trauma cases. We recruited a national convenience sample of emergency medicine physicians who worked at hospitals without level I/II trauma center certification. Using trauma triage guidelines as our reference standard, we estimated physicians’ perceptual sensitivity (ability to discriminate between patients who did and did not meet guidelines for transfer) and decisional threshold (tolerance for false positive or false negative decisions). Results We recruited 280 physicians: 210 logged in to the website (response rate 74%) and 168 (80%) completed the survey. The regression coefficient on American College of Surgeons – Committee on Trauma (ACS-COT) guidelines for transfer (perceptual sensitivity) was 0.77 (p Conclusions On a case vignette-based questionnaire, both sensory and decisional elements in emergency physicians’ cognitive processes contributed to the under-triage of trauma patients.

No single system exists that will guarantee triage success. Familiarity with anatomic and physiologic indicators along with an awareness of the significance of injury mechanism and existing comorbid factors is mandatory for all who participate in trauma care. Moreover, there are unique demands of the prehospital environment. Until further refinements are made, a prehospital trauma triage system should minimize undertriage and its unnecessary morbidity and mortality.

The Integrated Trauma Program (ITP) is the cooperative trauma triage service of the University of Toronto trauma and burn hospitals and the Ontario Ministry of Health. It provides physicians in referring hospitals direct access to a trauma team leader (TTL) in one of several trauma centers through a single phone number. Three adult trauma centers, one pediatric trauma center, and one burn center, all affiliated with the University of Toronto, participate in this program. This article describes the system during the first two years of operation. From July 1989 to June 1991, 1530 requests for patient transfers from a total of 97 hospitals were processed. Of these transfer requests, 77% were accepted by the TTL to a trauma service as multiple trauma cases, 16% were accepted directly to a surgical service without involving the trauma team, 4% were refused by the TTL as inappropriate referrals, and 3% of requests were cancelled by the referring physician. The transfer requests are distributed to a specific trauma center by request of the referring physician (10%), according to a rotation (70%), or as selected by the ITP (20%) when the scheduled hospital is not readily available. Closure of all adult trauma centers occurred on 43 occasions. During these closures, 48 patients bypassed the Toronto trauma centers and were transferred to other cities. The ITP office also keeps an ongoing data base of patients transferred. The mechanism of injury in the majority of cases is vehicular crashes. The mean Injury Severity Score is 24 for adults and 17 for children.(ABSTRACT TRUNCATED AT 250 WORDS)

Accuracy in a pre-hospital trauma triage plays a critical role in reducing trauma mortality in a way that appropriately chooses a patient with severe injuries. Although various triage criteria have been devised and tested, there is no computer-based system developed that helps ambulance teams can make a decision in an appropriate manner. This research proposes to develop Expert Helper, an Expert System which provides a user-friendly environment for the paramedics to decide whether patient to be posted to Critical Care Medical Centers (CCMC).

A number of instruments have been devised to aid in the triage of trauma patients. Little work, however, has been done to demonstrate that these triage instruments offer an advantage over the judgment of an emergency medical technician (EMT) in determining which patients require transportation to a trauma center. The purpose of this study was to compare EMT judgment against three scoring systems; the triage-revised Trauma Score, the Prehospital Index, and the CRAMS scale. Data were gathered on trauma victims transported by the City of Cleveland EMS system. The EMTs rated the patient's overall severity on a 4-point scale and estimated the probability of patient mortality. We found that the EMT prediction of mortality was as accurate as the various scores. In a subset of patients, we also found that the EMT assessment performed as well as the scoring systems in identifying patients who either died or required emergent operative intervention. We conclude that EMT judgment is as accurate as these three scoring systems in identifying patients at high risk for death or the need for immediate operative intervention.

We analysed the trauma triage system at a specific level I trauma centre to assess rates of over- and undertriage and to support recommendations for system improvements. The triage process is designed to estimate the severity of patient injury and allocate resources accordingly, with potential errors of overestimation (overtriage) consuming excess resources and underestimation (undertriage) potentially leading to medical errors. We first modelled the overall trauma system using risk analysis methods to understand interdependencies among the actions of the participants. We interviewed six experienced trauma surgeons to obtain their expert opinion of the over- and undertriage rates occurring in the trauma centre. We then assessed actual over- and undertriage rates in a random sample of 86 trauma cases collected over a six-week period at the same centre. We employed Bayesian analysis to quantitatively combine the data with the prior probabilities derived from expert opinion in order to obtain posterior distributions. The results were estimates of overtriage and undertriage in 16.1 and 4.9% of patients, respectively. This Bayesian approach, which provides a quantitative assessment of the error rates using both case data and expert opinion, provides a rational means of obtaining a best estimate of the system's performance. The overall approach that we describe in this paper can be employed more widely to analyse complex health care delivery systems, with the objective of reduced errors, patient risk and excess costs.

BACKGROUND: The study objective was to validate prehospital indicators mandated by the Ohio legislature. METHOD: The design was a retrospective case review using adult and pediatric tools developed to assess prehospital documentation of anatomic and physiologic indicators of significant trauma. RESULTS: There were 400 adult records with Glasgow Coma Score, the most frequently cited (23.5%). Fifty-four percent of the adult cases had at least 1 item checked. There were 104 pediatric cases reviewed, where 49% of the cases had at least 1 indicator checked. CONCLUSIONS: The mandated trauma indicators appear to be valid measures for use in trauma research. Language: en

The Emergency Medical Treatment and Active Labor Act (EMTALA) was conceived as a means to ensure that patients with emergent conditions would receive stabilizing care and to avert the potentially dangerous, economically driven, interhospital transfer of patients. This legislation and its subsequent application arrived near the time that regional and statewide trauma systems were established. Trauma systems were developed to guide optimal resource use for the injured patient regardless of the patient's ability to pay. Unfortunately, when coupled with current economic and litigation threats to community emergency and surgical practitioners, EMTALA represents a threat to the continuation of the trauma system concept. Trauma systems are dependent on a tiered hospital network where severely injured patients are taken to a hospital with resources aligned to manage the worst of injuries. When primary triage from the field cannot accomplish this task, secondary triage from a nondesignated or lower-level hospital to the higher-level trauma center is needed. EMTALA has served as a driver to change the priority for secondary triage from addressing the needs of the severely injured patient to filling community hospital surgical specialist emergency department on-call coverage gaps for less severely injured patients. Further, legal action associated with claims of EMTALA violations has needlessly extended medical examination and "stabilization" efforts at community emergency departments prior to needed secondary triage. Higher-level trauma centers will benefit from codifying system-wide emergency medical services practices related to primary and secondary triage, establishing trauma center capacity and divert practices, and initiating "transfer center" operations that control transfer of patients to these centers.

New York State developed a statewide trauma program in the early 1990s. Designation of trauma centers and prehospital triage of patients by emergency medical services are pillars of the system. Outcomes are evaluated as part of the quality improvement system. New York has a statewide trauma registry with population-based data for all of the state but New York City. Studies made possible because of the trauma registry provided evidence to guide revision of the emergency medical services trauma triage protocol for adult patients. For example, pulse50 or120 beats/min was retained as a physiologic criteria, while crumple zone and crash speed were eliminated as mechanism criteria. Patients with certain physiologic criteria treated in regional centers showed a considerably reduced mortality rate when compared with patients treated in area trauma centers and noncenters. Other "high-risk" populations were identified for special consideration by emergency medical technicians for trauma center transport because of their associated higher mortality. One "high-risk" group, patients older than 55 years or younger than 5 years, has associated 11% mortality (compare with a statewide average of 7.43%) and represents 41% of all registry patients. Population-based trauma registries and structured prehospital trauma records that accurately record the presence or absence of trauma criteria are essential to evaluate trauma triage criteria; improve quality, efficiency, and access; and guide care.