British Journal of Anaesthesia 113 (2): 226–33 (2014)
Advance Access publication 24 June 2014 . doi:10.1093/bja/aeu231
Triaging the right patient to the right place in the shortest time
P. A. Cameron1,2,3,4*, B. J. Gabbe1,5, K. Smith 1,6,7 and B. Mitra 1,2,3
1
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
Emergency & Trauma Centre and 3 National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
4
Hamad Medical Corporation, Doha, Qatar
5
College of Medicine, Swansea University, Swansea, UK
6
Ambulance Victoria, Doncaster, Australia
7
University of Western Australia, Perth, Australia
2
* Corresponding author. E-mail: [email protected]
Editor’s key points
† The majority of trauma deaths occur within
4 h of injury.
† Transporting trauma patients directly to
trauma centres (trauma bypass) reduces
the time to definitive treatment.
† Optimal triage minimizes over triage and
the unnecessary activation of trauma
teams whilst avoiding under triage.
† Effective development and monitoring of
trauma systems requires the collection of
data from multiple sources.
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.
Keywords: triage; wounds and injuries
It is nearly half a century since it dawned on the Western
world that more people were being killed through civilian injury
than in wars. The biggest single killers were motor vehicles and
it was clear that primary injury prevention, particularly targeted
at reducing vehicle collisions, could save lives. The doctors
involved in managing the thousands of injury victims realized
that early accurate assessment and treatment of victims would
also save lives. Importantly, experience from the Vietnam War,
and previous wars, suggested that field stabilization and early
transfer to an appropriate facility were critical factors in improving survival.1 The concept that many deaths were preventable
through better organization of care was established.2 The
Anglo-American model of trauma care involved trained paramedics, quickly assessing and stabilizing patients, then transferring
to a facility capable of receiving a critically ill trauma patient. The
facility itself needed to have systems in place to ensure an appropriate response 24/7 (24 h per day, 7 days per week). The model of
integrated trauma care, learnt from the context of war, was slow
to translate into civilian practice.
The elements of an integrated trauma system include:
(i) A pre-hospital system that has well-trained paramedics, coordinated dispatch, appropriate transport
platforms and agreed protocols for hospital designation, trauma bypass (the transfer of seriously injured
patients to a trauma centre even if this means that
hospitals closer to the scene of injury are bypassed)
and inter-hospital transfer.
(ii) Hospitals that have adequate facilities, staffing, and organization to receive and manage trauma patients.
This includes a hierarchical designation from Level 1
(with all services available 24/7) to Level 3 or 4 with
limited availability of sophisticated services.3
(iii) Post-acute hospital discharge rehabilitation and convalescence.
(iv) A system-wide monitoring capability to ensure that the
right patients go to the right hospitals and get the right
treatment.4
There is now growing evidence that providing trauma care
within a well-organized system saves many lives5 6 and prevents long-term disability.7 The fundamental basis of a wellorganized trauma system is an agreed trauma triage process
at each step along the patient journey. The correct level of
paramedic response is based on specified dispatch criteria.
This is then followed by transfer to an appropriate facility
based on agreed patient, mechanistic, and geographic data.
The hospital response on patient arrival is based on this prehospital data with additional information about paramedic
treatment and response to early treatment.
The importance of accurate initial triage was recognized
many years ago but with increasing sophistication of both
the treatments available and our ability to provide real time
& The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: [email protected]
BJA
Triaging the right patient to the right place in the shortest time
monitoring and feedback, there is now a greater ability and
necessity to ensure that regional systems provide optimal
care for individual patients. There is also the possibility to progress from simple historical trauma scores to more accurate
risk predictions based on all available patient characteristics.
Very few trauma systems internationally are actively
researching optimal parameters for identifying high-risk patients
who will benefit from trauma bypass or inter-hospital transfer
because of the necessity of highly complex treatments. Most
trauma care is still delivered and assessed at an institutional,
rather than regional, level, without careful monitoring and reference to international benchmarks for optimization.
This article aims to describe the principles of best practice
for triaging of trauma patients at each point along the
patient journey to ensure optimal outcomes. Monitoring of
processes and outcomes at a jurisdictional level is intrinsic to
the optimization of trauma systems.
Pre-hospital
The majority of trauma deaths occur in the pre-hospital environment or within 4 h of the trauma event.8 Mortality and morbidity can be reduced by effective identification, field triage,
and transport of severely injured patients to specialized
trauma centres. This starts with recognition of the severity of
injuries at the time of the call to Emergency Medical Services
(EMS). In Australia and many other countries, the majority of
EMS systems use a commercial medical call-taking system,
such as the Medical Priority Dispatch System (MPDS) to categorize EMS calls by problem type and urgency.9
The dispatch rules determined by individual EMS specify the
designated level of ambulance response to send to each category (determinant code). An ideal system will mobilize EMS
resources in a manner that is timely and appropriate to
patient acuity and has the ability to positively influence the
patient outcome. This needs to be balanced by rational use of
resources and limiting potentially dangerous aeromedical
and ‘lights and sirens’ responses.10
In most developed countries, Helicopter Emergency Medical
Services (HEMS) complement ground ambulances in providing pre-hospital care for severely injured patients. Although
debate continues, this combination is believed to improve
the patient outcome.11 12 Benefits include the possibility of
increased level of care (superior interventions and training
of HEMS paramedics or physicians) and the enhanced speed
of the response.13 In many parts of the world helicopters are
staffed by physicians or anaesthetists. In Victoria, Australia,
HEMS are staffed by highly trained Intensive Care flight paramedics who are authorized to perform interventions such as
rapid sequence intubation of comatose patients, administration of ketamine for traumatic pain, and red cell concentrate
in indicated patients.
HEMS dispatch should be efficient as overtriage represents a
significant cost and is not without safety risks. HEMS dispatch
criteria validity has been questioned. A recent systematic
review on HEMS dispatch criteria for trauma patients demonstrated low accuracy in discrimination of appropriate patients
across criteria based on mechanism of injury, anatomy of
injury, age and comorbidities.14 The most promising single criterion appears to be loss of consciousness.14 15 When activating an HEMS response, consideration is also given to a patient’s
given situation, regional and logistical factors.
Accurate pre-hospital trauma triage criteria are critical for
ensuring that patients with severe injuries are transported to
trauma centres within appropriate timeframes. The ‘golden
hour’ is often referred to in the trauma literature, as the
optimal timeframe for pre-hospital care and delivery to definitive treatment.16 This dogma does not take into account
advanced life support interventions by paramedics to reduce
preventable deaths and the fact that a longer transport time
may reduce overall time to definitive treatment by avoiding
delays at secondary hospitals before transfer. In the trauma
system implemented in the state of Victoria, Australia, this
delay to definitive treatment caused by transport to a nonmajor trauma centre averaged greater than 6 h.17 The criteria
and coordination for onward transfer of time critical major
trauma patients to Level 1 centres must be clear and requires
standard operating procedures agreed in advance.
Pre-hospital trauma triage criteria typically adopt a combination of physiological, anatomic, and mechanism of injury
components tailored to meet individual trauma system needs,
generally adapted from early criteria developed in the USA.18
These have generally replaced scoring systems such as the
Revised Trauma Score19 and the ‘CRAMS’ (Circulation, Respiration, Abdomen, Motor and Speech) scale,20 21 which were
cumbersome to calculate and had inadequate sensitivity to
detect serious injury. Other scoring systems, such as the
Injury Severity Score (ISS), require knowledge of all injuries,22
some of which are not identified or confirmed in the prehospital setting.
Paramedic judgement is an important adjunct to field triage
guidelines but has not been demonstrated to be an accurate or
reliable alternative triage method.23 In an Australian study
comparing experienced HEMS paramedic rating of the severity
of injury with hospital patient outcomes, the sensitivity of paramedic predictions for severe injury ranged from 57.6% (95% CI:
45.4, 68.9) for the head to 38.5% (95% CI: 22.1, 57.9) for the
abdomen.24
Epidemiological surveillance where field triage guidelines
are assessed for over- and undertriage of severely injured
patients is critical to driving improvements in triage criteria
and identifying local issues including paramedic compliance.25
This has been facilitated by the advent of electronic patient
care records in the pre-hospital setting.26 Access to electronic
devices by EMS also raises the possibility of tailored decision
support tools including validated scoring systems.27 However,
the feasibility of data entry by paramedics at the point of
care is yet to be demonstrated.
Hospital designations
Trauma designation is essential in a trauma system and basically describes the minimum resources necessary for the care of
patients with serious injury. A systems approach to trauma
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Cameron et al.
care entails delineation of the varying functional roles that hospitals within the system will play. Delineation is required as it is
neither appropriate nor feasible for every hospital receiving
seriously injured patients to be resourced to the highest
level (i.e. ‘major trauma service’ or ‘Level I Trauma Centre’).3
Pre-hospital triage guidelines stipulate that patients are
transported to the highest level of designation within defined
transport times (e.g. 45 min), bypassing other hospitals with
lower designation (Fig. 1).
The American College of Surgeons Resources for Optimal
Care of the Injured Patient outlines the resources necessary
for optimal care and is used as a guide for the development
of trauma centres throughout the USA.3 Trauma centres
vary in their specific capabilities and are identified by ‘Level’
designation—generally three to five levels with Level I being
the highest. Requirements include trauma team availability,
admission volumes, activation protocols (including surgical,
neurosurgical, orthopaedic, anaesthesiology, radiology, and
specialized nursing), sophisticated medical diagnostic equipment, helipad, involvement in jurisdictional trauma planning
committees, and continued education.
Trauma reception and resuscitation
On arrival to hospital, injured patients should be managed in a
designated resuscitation area and received by a trauma team.
The original aim of the trauma team was to reduce the second
peak of the tri-modal distribution of death after trauma, by appropriately managing correctable disturbances to the airway,
breathing and circulation, and was predicted to reduce preventable deaths by 42%.28 The predictions have been largely
accurate with patients treated by trauma teams shown to
have shorter Emergency Department (ED) time, ED to computed tomographic imaging time, ED to operating room time,
and improved survival.29 30 Despite such obvious benefits,
trauma teams are not universal, even within advanced
trauma systems. In 2007, in the UK, trauma teams were only
available in 20% of hospitals, and a trauma team response
was documented for only 60% of patients with an ISS of ≥16.31
The trauma team usually comprises a multidisciplinary
group of individuals drawn from the specialties of emergency
medicine, surgery, nursing and support staff, anaesthesia,
and intensive care medicine, each of whom contributes simultaneously to the assessment and management of the
patient, overseen by a team leader. The primary aims of the
team are to rapidly resuscitate and stabilize the patient, prioritize and determine the nature and extent of injuries, and
prepare for transport to the site of definitive care, within or
outside the receiving hospital. This ‘horizontal’ approach to
trauma care aims to provide rapid input to a critically
injured patient without the need to contact and request the
presence of individual team members, thereby reducing
time to critical interventions.32
A trauma call activation system congregates different
members of personnel from specialty units at the time of notification and permits effective use of hospital resources. Attendance of such members may strain resources in hospitals
where trauma presentations are common. Multiple activation
protocols have been developed incorporating a number of
variables—physiological, mechanistic, and patient characteristic features—in an attempt to predict injury severity and
the need for interventions (Fig. 2). Optimal triage within a
trauma system implies low overtriage without compromising
the goal of minimizing undertriage.33 Overtriage is more
Major trauma
services
Metropolitan
trauma services
Regional trauma
services
Urgent care
services
Coordination, education,
quality improvement
Primary care
services
Primary care
services
Ambulance assessment
and patient transfer
Trauma incident
Fig 1 Trauma system.
228
Patient transfers
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Triaging the right patient to the right place in the shortest time
likely among centres that receive low volumes of trauma and
are not designated Level I trauma centres. In response to problems with overtriage, some centres have developed two- or
three-tiered activation criteria that incorporate field physiologic parameters, mechanism of injury, anatomic factors,
and age to stratify patients. While tiered criteria have been
reported to be safe and effective, these should be tailored to
the characteristics of individual trauma systems. With appropriate pre-hospital triage, higher acuity centres can effectively
utilize a single-tiered trauma activation. In this setting where
most presenting patients are severely injured, full trauma
team activation is necessary and an element of overtriage is
essential to ensure sufficient sensitivity.34
A trauma team approaches trauma resuscitation along the
principles set out by the Advanced Trauma Life Support Course
(ATLS) from the American College of Surgeons, but in a ‘parallel’
approach with multiple simultaneous pre-defined tasks. These
tasks are usually determined by virtue of the specialization of
the individual member. Video-assisted trauma resuscitation
goes beyond traditional clinical decision support, which tends
to target individuals in more static patient care scenarios.
This has been shown to be successful in error reduction at
major trauma centres.35 The effect may be greater for resuscitation teams that are less experienced or work in lower-volume
centres. It is expected that technological developments,
along with computer-aided decision support, will improve the
performance of trauma resuscitation.35
The massively haemorrhaging trauma patient poses additional challenges to the trauma team in requiring coordinated
and timely delivery of blood and blood products to restore
circulation and to treat and prevent impaired coagulation. Multiple scoring systems have been developed to identify patients
at risk of massive transfusion or coagulopathy, but most lack
clinical utility in that their sensitivity is too low to effectively
rule-out the condition.36 37 On arrival to hospital, accurate
and timely delivery of massive transfusion protocols may substantially improve outcomes.38 The addition of a transfusion
specialist to oversee the delivery of blood or blood products
may be invaluable and has been recommended to be part of
massive transfusion protocol implementation.39 In addition,
patients who are coagulopathic or at risk of developing coagulopathy, with or without the need for massive transfusions,
should be targeted with pre-emptive, early pro-coagulant
agents. Rigorous evidence behind the ideal type or quantity
of such agents are currently lacking, but most local guidelines
suggest a combination of fresh frozen plasma, platelets,
fibrinogen concentrates, tranexamic acid, calcium, and activated
recombinant factor VIIa.
Patients with major burn injuries or those with concomitant
burn injuries in addition to physical trauma should be triaged to
major trauma centres with burns services.40 The benefits of
such triage are towards goal-directed resuscitation of burns
shock through accurate fluid resuscitation and also the capacity for early debridement of burns injury. Blast injuries may
further complicate resuscitation of such patients and clinical
features of such injuries should be sought early through
history and investigations.
Management of trauma patients has improved substantially and a large proportion survive with a normal neurological
state, even in the setting of pre-hospital traumatic cardiac
arrest. Overall survival in pre-hospital traumatic cardiac arrest
patients ranges from 5 to 10% and there should be no hesitancy
in instituting advanced life support.41 42 Therapeutic hypothermia and extra-corporeal membrane oxygenation, with or
without head injury, although unproven, may further improve
outcomes in this sub-group. Triage, both pre-hospital and on
arrival to hospital, is essential to direct these patients to such
specialized resources within appropriate timeframes.
Outcomes
Most trauma systems research has focused on in-hospital mortality as the outcome of interest but most trauma patients
survive their injuries. The organization of trauma care, and
the optimal triage of patients, is aimed at reducing mortality
and morbidity.2 43 Therefore, the need to extend the focus of
outcome measurement beyond mortality is paramount. The
burden of traumatic injury is multi-faceted and understanding
the impact of triage decisions and the quality of care provided
to trauma patients requires a comprehensive and coordinated
approach to measuring outcomes.44 This approach requires
not only targeted measurement of mortality and morbidity
outcomes, but also application of these outcomes to systemwide monitoring. Integrated trauma systems span the prehospital, hospital, post-discharge, and rehabilitation phases
of patient care.2 Monitoring should aim to track the outcomes
of patients through these phases of care to improve understanding of burden and the inter-relationship between
outcomes.
Many studies focus on care in designated trauma centres, but
this approach fails to capture important information from
patients who receive their trauma care in non-designated hospitals. The result is limited understanding of the factors predictive
of triage to trauma centres, and lost potential to benchmark outcomes of patients managed at trauma centres with those who do
not. Few studies have addressed this question, but the studies
that have been published found improved mortality and functional outcome for seriously injured patients managed at
trauma centres compared with non-trauma centres, highlighting
the importance of appropriate trauma triage.7 45
Additionally, limiting data collection to trauma centres or
acute hospital care prevents a comprehensive evaluation of
the impact of trauma triage decision making as interpreting
changes in outcome in one care setting may not reflect
changes in another. For example, lower incidence of in-hospital
mortality would generally be interpreted as evidence of
improved care but in the context of worsening pre-hospital
mortality, overall system performance could be interpreted differently. Similarly, improved survival of trauma patients in the
context of worsening morbidity outcomes could suggest a shift
in burden from fatal to non-fatal injury. A recent study of road
transport-related trauma burden used population-based datasets of death and major trauma to evaluate the impact of
the introduction of an inclusive trauma system in Victoria,
229
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Cameron et al.
Trauma Call Out Criteria
Mechanism
Injuries
This is not an exclusive list
Signs
Treatment
All patients who have undergone the
following pre-hospital interventions
Other
Criteria
TheAlfred
• MBA / cyclist impact >30 kph
• Pedestrian impact >30 kph
• Extrication >30 minutes
• Vehicle rollover
• Fatality in same vehicle
• Ejection from vehicle
• Fall >3 M
• Explosion
• All significant blunt injuries accessed by ambulance
• All penetrating head, neck & truncal injuries
including groin & axilla
• All injuries involving:
• Suspected spinal cord injury
• Traumatic Amputation proximal to carpus/tarsus
• #Pelvis / pulseless limp / #dislocations
with vascular compromise
• Evisceration
• Blast injuries
• Severe crush injury
• Serious burns >20% TBSA (all face)
• SBP >100 mmHg (<75 mmHg, child)
• GCS <14
• SpO2 <90%
• RR <10 or >30
• Any airway manoeuvre including intubation
• Assisted ventilation
• Pleural decompression
• Haemostatic dressings / tourniquet application
• >1000 ml IV fluid or blood transfusion
• Neuromuscular blockade
• Mass Casualty Incident / >1 patient reception
simultaneously
• All inter-hospital trauma transfers
• Pregnancy
• Significant co-morbidity
• Anticoagulant therapy including warfarin
VOB#4072 update April 2009
Fig 2 Trauma call-out criteria from The Alfred Hospital, Melbourne, Australia. Reproduced with permission from The Alfred Trauma Service, Melbourne, Australia.
Australia, and found a significant decline in the incidence of
mortality, reduced risk-adjusted in-hospital mortality, and an
overall reduction in burden as measured by Disability Adjusted
Life Years.46
Despite its importance, comprehensive outcomes monitoring of trauma systems across all phases of patient care is challenging both within and between jurisdictions. Routine,
population-based long-term follow-up of seriously injured
230
patients is rare with only the Victorian State Trauma Registry
achieving this to date.47 Nevertheless, recent initiatives in the
UK to establish a consensus for outcome measures48 and piloting of measurement of functional and quality-of-life outcomes
in several countries are steps in the right direction.47 49 Supporting the capacity to monitor trauma patient outcomes
over the continuum of care requires increased sophistication
in the electronic capture of important data such as pre-hospital
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Triaging the right patient to the right place in the shortest time
care and enhanced data linkage capacity with administrative
datasets in the health and social sectors.50 51 Enhanced
linkage of trauma registry data with other key datasets will
enable efficient and cost-effective monitoring of trauma
systems into the future. Notwithstanding these benefits, interjurisdictional comparisons and benchmarking will rely on harmonization of data fields, approaches to risk-adjustment and
consensus on the handling of missing data. These challenges
are not insurmountable as evidenced by previous studies and
the ongoing experiences in Australia of the Victorian State
Trauma Registry. Nevertheless, international collaboration
and cooperation will be critical.
The future
Even though short-term mortality post major trauma is at
historical lows, endeavours to further improve outcomes continue. Definitive care of haemorrhagic shock now involves
damage control resuscitation, comprising permissive hypotension where appropriate, haemostasis, and damage control
surgery. Triage to centralized trauma centres has resulted in
longer pre-hospital times, with the ‘golden hour’ post injury
often spent outside an ED. Combined with improved training
and equipment, there is a real opportunity for delivery or at
the least to initiate definitive care in the pre-hospital phase.
Telemedicine can further increase the capability of pre-hospital
staff to deliver such care.52
Bed-side ultrasound is now routinely used in EDs and may
improve the diagnostic capacity for pre-hospital clinicians
and improve triage of trauma patients further. Point-of-care
devices for pathology testing are now available for an array
of tests and may be more accurate than vital signs in predicting
in-hospital mortality.53 The ability for more accurate assessment may enable better pre-hospital definitive management
for certain clinical scenarios such as ongoing bleeding and
coagulopathy.
Pre-hospital blood transfusions have been shown to be both
feasible and safe, although effectiveness is still debated.54 It
may be that the transfusion of red cells alone, with no agents
to combat coagulopathy, is the reason that there have been
minimal benefits thus far. After pre-hospital transfusions,
patients appear to arrive in worse clinical states and can be
more coagulopathic because of further dilution of coagulation
factors.55 It is therefore vital to triage the most appropriate
patients to receive such therapy. Trials examining the prehospital use of pro-coagulant agents are currently in progress
and may provide guidelines towards haemostatic resuscitation
before the ED.56 Where red cell transfusion is not available, prehospital transfusion of synthetic haemoglobin-based oxygen
carriers is currently being trialled.57
Triage of the exsanguinating patient does not necessarily
have to be to an ED, but could be to alternate facilities designed
for emergent interventions aimed at arresting haemorrhage
and rapid assessment. Some EDs now initiate resuscitation in
the CT room to allow concurrent resuscitation and imaging.
Minimally invasive endovascular techniques involve blocking
bleeding blood vessels/organs via arterial embolization,
balloon catheters, or both and realigning blood vessels via
stent graft. These emergent percutaneous therapies could
be performed in the same physical location as resuscitation,
surgery, and critical care. The RAPTOR suite (resuscitation
with angiography, percutaneous techniques and operative
repair) has become available in a small number of advanced
centres and demands timely and accurate pre-hospital
triage to prevent death in the exsanguinating trauma
patient. 58
It is estimated that, by 2030, trauma will be the third leading
contributor to the worldwide burden of disease. It is the more
densely populated, developing regions of the world, with
under-developed trauma systems, that are currently worst
affected. While optimization of trauma triage in advanced
trauma systems has the potential to marginally improve outcomes, introduction of trauma systems and triage among
other populations can deliver inspiring results.59 It is necessary, and perhaps the duty, of practitioners in advanced
trauma systems to deliver trauma training programmes to resource poor countries. It is likely that the basic components of
an integrated trauma system, including accurate triage of severely injured patients to appropriately resourced facilities, a
team-based approach with systematic assessment and management of initial resuscitation will make a significant difference in these countries.
Authors’ contributions
All authors contributed to the research, design, and writing of
this review.
Declaration of interest
None declared.
Funding
B.J.G. and P.A.C. are supported by NHMRC Career Development
and Practitioner Fellowships. B.M. is supported by an NHMRC
Early Career Fellowship.
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