Assuring that the right patient gets to the right hospital is the first, and some would say the most important, of the many decisions that medical professionals must make when caring for a severely injured patient. Patients with multiple, complex, or severe injuries need the resources and expertise offered by trauma centers with their complement of specially trained and experienced medical and ancillary staffs. The CDC reports that the overall risk of death for a severely injured patient is 25% lower when care is provided in a level I trauma center compared to a hospital that does not serve as a trauma center. But, trauma centers can save lives only if patients needing a trauma center are transported to a trauma center. Even if the nearest trauma center is further away than a non trauma center hospital closer to the scene of an accident, the immediate availability of the expertise and resources necessary to care for the severely injured  justify bypassing that closer, non designated hospital in favor of the more distant trauma center. In areas with functioning trauma systems, emergency medical personnel must decide, using the limited information available at the scene of injury, whether or not a trauma victim can receive the care they need at the nearest hospital or whether they are likely to need the resources of a trauma center. In the latter case, a decision must then be made as to the most appropriate mode of transportation to that center. These decisions are made based on field triage algorithms used by emergency medical personnel providing initial care to injured patients.

The word triage comes from the French verb “trier” meaning to sort. It was originally used to describe the process of sorting wool by its quality. Dominique Jean Larrey, Napoleon’s surgeon general, is credited with being the first to apply the term to the sorting of battlefield casualties. Triage is now used to describe the process by which groups of patients are prioritized for treatment and transport. In the case of an injured patient at the scene of their injury, a triage decision must be made to decide whether that patient can be treated at the nearest hospital, or if that patient should be transported, instead, to a trauma center that may be further away. How those decisions are made vary from one location to another based on the availability of trauma centers in the region, the distance to those trauma centers, and the transportation resources available to move the patient to those specialized facilities.

The goal of field triage is to assure that every patient needing the resources of the trauma center are transported to the nearest trauma center. At the same time, it is important to minimize the number of less severely injured patients transported to the trauma center to assure that the center’s resources are not overwhelmed with the care of less severe injuries making them less available to those more in need of them. Because the ability to make diagnoses is limited at the scene of injury, emergency medical personnel can’t make this determination with complete accuracy. Priority is given to assuring that all of those with severe injuries are transported to the trauma center even if that means that some patients with lesser injury may bypass a closer hospital. It is estimated that only approximately 5% of people sustaining an injury require a trauma center’s expertise. To assure that these patients reach the trauma center, it is generally accepted that at least 10% of injured patients need to be taken to the trauma center for evaluation. This also implies that 90% of injuries can, and should, be treated locally.

This important triage decision can be based only on things that Emergency Medical Personnel can measure or observe at an injury scene. Easily measured physiologic parameters such as vital signs have been used to assist medics in making this vital decision. Certain anatomic markers of injury can also be used. It is known that some mechanisms of injury are associated with a high likelihood of severe injury. So, these, too, are used to assist in decision making. It is also known that patients with certain chronic medical conditions which can complicate injury care are best treated in trauma centers. So, when that information is available, this, too, may influence a decision regarding patient destination.  Finally, pediatric patients and the elderly often require additional resources and expertise and may benefit from trauma center care.

The American College of Surgeons published a field triage decision scheme as a guideline for development of local emergency medical service triage protocols in 1986. That decision scheme was revised in 1990, 1993, and 1999. In 2005 the Center for Disease Control and Injury Prevention, along with the National Highway Traffic Safety Administration assembled an expert panel including, not just trauma surgeons, but also representatives from other entities such as the automotive industry, various government agencies, and public health officials to review and update this decision scheme. The resulting product was published by the American College of Surgeons in 2006 in its “Resources for Optimal Care of the Injured Patient” publication. Subsequently, the CDC published the findings of the expert panel that explained the rationale for the developed triage decision scheme. The developed scheme as published by the CDC is attached as an appendix at the end of this report.

While this decision scheme serves as a model for use in trauma systems throughout the nation, individual jurisdictions must adapt this guideline to the circumstances in their region. Factors such as the number of available trauma centers and the level of care provided at those centers, the distance to the region’s trauma centers, the modes of transportation available in the region, and the expertise of those doing those transports must all be considered in developing local triage decision schemes. Regardless of the local circumstances, however, the overall goal remains the same. Those suffering serious injury should be transported to the hospital best able to provide them with the resources and expertise necessary to give them the best chance of recovery.

Additional Resources

http://historical.hsl.virginia.edu/treasures/larrey.html

http://www.cdc.gov/FieldTriage/

http://www.cdc.gov/mmwr/PDF/rr/rr5801.pdf

American College of Surgeons. Resources for the optimal care of the injured patient: 2006. Chicago, IL: American College of Surgeons; 2006.

Author: Doug Norcross (2011)