Guidelines for Field Triage of Injured Patients

full-text:
Guidelines for Field Triage of Injured Patients

Guidelines for Field Triage of Injured PatientsRecommendations of the National Expert Panel on Field Triage, 2011
Recommendations and Reports
January 13, 2012 / 61(RR01);1-20

Prepared by
Scott M. Sasser, MD1,2
Richard C. Hunt, MD1
Mark Faul, PhD1
David Sugerman, MD1,2
William S. Pearson, PhD1
Theresa Dulski, MPH1
Marlena M. Wald, MLS, MPH1
Gregory J. Jurkovich, MD3
Craig D. Newgard, MD4
E. Brooke Lerner, PhD5
Arthur Cooper, MD6
Stewart C. Wang, MD, PhD7
Mark C. Henry, MD8
Jeffrey P. Salomone, MD2
Robert L. Galli, MD9


1Division of Injury Response, National Center for Injury Prevention and Control, CDC, Atlanta, Georgia
2Emory University School of Medicine, Atlanta, Georgia
3University of Washington, Seattle, Washington
4Oregon Health and Science University, Portland, Oregon
5Medical College of Wisconsin, Milwaukee, Wisconsin
6Columbia University Medical Center affiliation at Harlem Hospital, New York, New York
7University of Michigan Health System, Ann Arbor, Michigan
8Stony Brook University, Stony Brook, New York
9University of Mississippi, Jackson, Mississippi


The material in this report originated in the National Center for Injury Prevention and Control, Linda Degutis, DrPH, Director, and the Division of Injury Response, Richard C. Hunt, MD, Director, in collaboration with the National Highway Traffic Safety Administration, Office of Emergency Medical Services, and in association with the American College of Surgeons, John Fildes, MD, Trauma Medical Director, Division of Research and Optimal Patient Care, and Michael F. Rotondo, MD, Chair, Committee on Trauma.

Corresponding preparer: David Sugerman, MD, Division of Injury Response, National Center for Injury Prevention and Control, CDC, 4770 Buford Highway, MS F-62, Atlanta, GA 30341-3717. Telephone: 770-488-4646; Fax: 770-488-3551; E-mail: ggi4@cdc.gov.

Summary
In the United States, injury is the leading cause of death for persons aged 1–44 years. In 2008, approximately 30 million injuries were serious enough to require the injured person to visit a hospital emergency department (ED); 5.4 million (18%) of these injured patients were transported by Emergency Medical Services (EMS). On arrival at the scene of an injury, the EMS provider must determine the severity of injury, initiate management of the patient's injuries, and decide the most appropriate destination hospital for the individual patient. These destination decisions are made through a process known as "field triage," which involves an assessment not only of the physiology and anatomy of injury but also of the mechanism of the injury and special patient and system considerations. Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process through its "Field Triage Decision Scheme." This guidance was updated with each version of the decision scheme (published in 1986, 1990, 1993, and 1999). In 2005, CDC, with financial support from the National Highway Traffic Safety Administration, collaborated with ACS-COT to convene the initial meetings of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme; the revised version was published in 2006 by ACS-COT (American College of Surgeons. Resources for the optimal care of the injured patient: 2006. Chicago, IL: American College of Surgeons; 2006). In 2009, CDC published a detailed description of the scientific rationale for revising the field triage criteria (CDC. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage. MMWR 2009;58[No. RR-1]).

In 2011, CDC reconvened the Panel to review the 2006 Guidelines in the context of recently published literature, assess the experiences of states and local communities working to implement the Guidelines, and recommend any needed changes or modifications to the Guidelines. This report describes the dissemination and impact of the 2006 Guidelines; outlines the methodology used by the Panel for its 2011 review; explains the revisions and modifications to the physiologic, anatomic, mechanism-of-injury, and special considerations criteria; updates the schematic of the 2006 Guidelines; and provides the rationale used by the Panel for these changes. This report is intended to help prehospital-care providers in their daily duties recognize individual injured patients who are most likely to benefit from specialized trauma center resources and is not intended as a mass casualty or disaster triage tool. The Panel anticipates a review of these Guidelines approximately every 5 years.


Introduction
Purpose of This Report
Emergency Medical Services (EMS) providers in the United States make decisions about the most
appropriate destination hospital for injured patients daily. These decisions are made through a decision process known as "field triage," which involves an assessment not only of the physiology and anatomy of the injury but also of the mechanism of the injury and special patient considerations. The goal of the field triage process is to ensure that injured patients are transported to a trauma center* or hospital that is best equipped to manage their specific injuries, in an appropriate and timely manner, as the circumstances of injury might warrant.

Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has published a resource manual that provided guidance for the field triage process through a field triage decision scheme (1). This guidance was updated and published with each version of the resources manual during 1986–1999 (2–5). In 2009, CDC published guidelines on the field triage process (the Guidelines) (6). This guidance provided background material on trauma systems, EMS systems and providers, and the field triage process. In addition, it incorporated the 2005–2006 deliberations and recommendations of the National Expert Panel on Field Triage (the Panel), provided an accompanying rationale for each criterion in the Guidelines, and ensured that existing guidance for field triage reflected the current evidence. In April 2011, CDC reconvened the Panel to evaluate any new evidence published since the 2005–2006 revision and examine the criteria for field triage in light of any new findings. The Panel then modified the Guidelines on the basis of its evaluation. This report describes the Panel's revisions to the Guidelines and provides the rationale for the changes, including a description of the methodology for the Panel's review.

This report is intended to help prehospital-care providers in their daily duties recognize individual injured patients who are most likely to benefit from specialized trauma center resources and is not intended as a triage tool to be used in a situation involving mass casualties or disaster (i.e., an extraordinary event with multiple casualties that might stress or overwhelm local prehospital and hospital resources).