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April 1, 2011

Implementation of a field destination guideline

By Jim Sideras

Many EMS systems are blessed with multiple levels of hospital trauma centers, as well as other types of receiving facilities. EMS providers are often faced with the decision of which is the most appropriate emergency treatment facility to transport trauma patients. The CDC's Guideline for Field Triage of Injured Patients offers a clear protocol to follow to ensure the injuries of the patient are matched to the appropriate level of receiving facility.

Introduction

Injures are a significant portion of the incidents that are handled by EMS agencies. Without a clear set of guidelines or protocols, the EMS provider is often left on their own to determine where an injured patient should be transported. Often there may be a number of hospital trauma centers, or other patient care facilities that can treat patients. If patients are injured on the outskirts of a community, there may be closer but smaller health care facilities, or larger yet further away trauma centers. However, if there is not an implemented field destination guideline, the EMS provider will have to make decisions based on their own experience. This may not always provide a consistent level of care to patients within an EMS system.

Scope of injures

According to the Centers for Disease Control, in the United States, injury is the leading cause of death for persons aged 1–44 years(1). In 2005, injuries accounted for approximately 174,000 deaths in the United States(2), with an additional 41 million injuries serious enough to require the injured person to visit a hospital emergency department (ED)(3) . Injuries also have a substantial economic cost. The lifetime medical cost of injuries that occurred in 2000, the most recent year for which data were available, was estimated to be $80.2 billion(4).

Optimal care

In order to ensure trauma patients receive care that meets their needs, an EMS system protocol needs to be developed. This protocol ensures that the allocation of resources is properly used so that the entire system, including EMS and hospital providers, is tuned to run at its optimal levels. Additionally, having an established plan will be beneficial in systems with multiple EMS providers to ensure consistency within the system. Along with providers, some systems may have various levels of trauma centers. These trauma centers are designated level I, II, III, or IV.

Although all levels provide consistent, high quality care, the designation applies to the resources and personnel available to the center.

When discussing trauma centers, a Level I is the greatest amount of resources and personnel to provide care for every aspect of injury, from prevention through to rehabilitation. They are usually associated with a medical teaching facility.

A Level II often differs in that they cannot always provide continuous subspecialties or the same level of prevention and research.

A Level III center is capable of providing assessment, resuscitation, and emergency surgery. Injured patients can be stabilized before transported to a higher level trauma center.

A Level IV center is capable of providing 24-hour physician coverage, resuscitation, and stabilization before transported a higher level trauma center.

When taking into account the severity of a patient's injures, not all patients need to be transported to a Level I or II trauma center. In some systems, these facilities are already overburdened with patients. The addition of patients who could be treated at other locations can further exacerbate a busy trauma center's ability to handle those patients who should be receiving care.

In the event a system has more than one trauma center, or treatment facilities, a protocol to determine the prioritization of patients will need to be established. Even in smaller communities without a designated trauma center, the development of this protocol is important.

The protocol will allow providers to quickly and consistently determine patients that can be treated locally and those patients whose best interest would be treatment in a further trauma center.

Good news

The work to develop this protocol has been done. In 2009, the Centers for Disease Control reissued the Guidelines for Field Triage of Injured Patients. Although some may feel the name implies the typical triaging of patients, in actuality this guideline determines which patients should be seen by various level trauma centers or receiving hospitals. The guideline was first developed in 1986 and has been continually refined by a panel of experts from across the country and multiple disciplines.

The CDC has developed an easy four-step process — which can be found in more detail on their website — for the National Trauma Triage Protocol that guides the provider through a "decision scheme" or flow chart. Remember, this is for trauma patients, and helps determine when a patient should be transported to a level I or II trauma center, or other facilities.

These steps are:

Step one

Measure vital signs and level of consciousness, transport to the highest level of care within the trauma system when:

  • Glasgow Coma Scale <14 or
  • Systolic Blood Pressure <90 mmHg or
  • Respiratory rate <10 or >29 (<20 in infant < 1yr)

If patient does not have these conditions, then go to the next step.

Step two

Assess anatomy of injury. Transport to the highest level of care within the trauma system when:

  • All penetrating injuries to head, neck, torso, and extremities proximal to the elbow and knee
  • Flail chest
  • Two or more proximal long-bone fractures
  • Crushed, degloved, or mangled extremity
  • Amputation proximal to the wrist or ankle
  • Pelvic fractures
  • Open or depressed skull fractures
  • Paralysis

If patient does not have these conditions, then go to the next step.

Step Three

Assess mechanism of injury and evidence of high-energy impact. These patients can be transported to the appropriate trauma center which, depending on the trauma system, may not need to be the highest level of trauma care.

Falls

  • Adults: >20 ft (one story is equal to 10 feet)
  • Children: > 10 feet or 203 times the height of the child

High-risk auto crash

  • Intrusion: > 12 inches into occupant site; 18 inches into any site
  • Ejection (partial or complete) from automobile
  • Death in the same passenger compartment
  • Vehicle telemetry data consistent with a high risk of injury

Auto vs. pedestrian/bike thrown, run over, or with significant (>20 MPH) impact

Motorcycle crash > 20 MPH

If patient does not have these conditions, then go to the next step.

Step Four

For these patients, the EMS provider should contact medical control and consider transport to a trauma center or a specific resource hospital.

Age

  • Older adults: Risk of injury death increases after age 55
  • Children: Should be triaged preferentially to pediatric-capable trauma centers

Anticoagulation and Bleeding Disorders

Burns

  • Without other trauma mechanism: Triage to burn facility
  • With trauma mechanism: Triage to trauma center

Time sensitive extremity injury
End-stage renal disease requiring dialysis
Pregnancy > 20 weeks
EMS provider judgment

In the event the patient does not meet any of the criteria, the EMS provider should transport according to local protocol.

Conclusion

Systems often fail to give proper direction to EMS providers concerning whether trauma patients should be transported to the closed medical facility or to a further level I or II trauma center. The use of a protocol, especially one that is has been nationally accepted, is very important to ensure patients are receiving the optimal level of care for their injures. If you would like a copy of the Field Triage Decision Scheme: the National Trauma Triage Protocol, visit www.cdc.gov/fieldtriage

References
1. CDC. WISQARS: web-based injury statistics query and reporting system: leading causes of death reports, 1999–2005. Atlanta, GA: US Department of Health and Human Services, CDC; 2008.

2. CDC. WISQARS: web-based injury statistics query and reporting system: injury mortality reports, 1999–2005. Atlanta, GA: US Department of Health and Human Services, CDC; 2008.

3. McCaig LF, Nawar EW. National Hospital Ambulatory Medical Care Survey: 2004 emergency department summary. Advance Data from Vital Health Stat 2006;372.

4. Finkelstein EA, Corso PS, Miller TR. The incidence and economic burden of injuries in the United States. New York, NY: Oxford University Press; 2006.


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