Compliance with Centers for Disease Control and Prevention Field Triage Guidelines in an Established Trauma System Alexis M Gage, MD, MPH, Neal Traven, PhD, Frederick P Rivara, MD, MPH, Gregory J Jurkovich, MD, FACS, Saman Arbabi, MD, MPH, FACS Regionalization of trauma care reduces mortality and has clear guidelines for transport to the highest level of trauma care. Whether prehospital providers follow the CDC triage algorithm remains to be determined. STUDY DESIGN: We performed a 5-year retrospective cohort analysis of linked data from Washington State’s Central Region Trauma Registry (CRTR) and King County Emergency Medical Services (KCEMS). Patients were analyzed based on transport to their designated hospital, as determined by geocode mapping, or directly to the level I center (no level II center is available in this region). RESULTS: Of the 12,106 patients in the study, 5,976 (49.4%) were transported directly to a level I center from the scene. Of the remaining 6,130 patients initially transported to level III to V centers, 5,024 (41.5%) remained in the respective level III to V centers and 1,106 (9.1%) were transferred to the level I center. Patients transported directly to a level I center were more likely to be male, younger, have a penetrating injury, lower scene Glasgow Coma Scale (GCS), lower scene blood pressure, and be more severely injured. Level I direct scene transport was significantly less likely for older patients. Compared with patients ages 18 to 45, the adjusted odds ratio for direct transport to the level I center was 0.7 (95% CI 0.59 to 0.83) for patients aged 46 to 55 years; 0.47 (95% CI 0.39 to 0.57) for those 56 to 65 years; 0.28 (95% CI 0.23 to 0.34) for patients 66 to 80 years; and 0.11 (95% CI 0.09 to 0.14) for those older than 81 years. CONCLUSIONS: Prehospital providers follow physiologic, anatomic, and mechanistic parameters in steps 1 to 3 of the CDC field triage guidelines. However, contrary to the special considerations guideline in step 4, older age was associated with transport to the lower level of trauma care in our region. (J Am Coll Surg 2012;215:148–156. © 2012 by the American College of Surgeons) BACKGROUND:
In 2008, there were approximately 181,000 deaths and 1.8 million people hospitalized in the United States due to injury.1 To combat this epidemic, trauma systems have been created to provide an organized approach to acutely injured patients.2 Studies have shown that well-organized systems of trauma care have decreased mortality among all treated trauma patients by 10% to 20%.3,4
One of the major components of a trauma system is triage and transport by emergency medical services (EMS). At any injury scene, prehospital providers determine which patients are at greatest risk for severe injury, begin medical management, and through a process of field triage, identify the most appropriate facility to which to transport the patient. The decision to transport an injured patient to the most appropriate facility can have a substantial impact on subsequent morbidity and mortality. Receiving care at a level I trauma center vs a nontrauma center can reduce the risk of death of a severely injured person by 25%.5 In 2006, to assist with destination transport decisions, the National Expert Panel on Field Triage, convened by the Centers for Disease Control and Prevention (CDC) and the National Highway Traffic Safety Administration, revised an algorithm first published by the American College of Surgeons-Committee on Trauma (ACS-COT) in 1986.6 The ACS-COT Decision Scheme was revised 3 times
Disclosure Information: Nothing to disclose. Presented at the Western Surgical Association 119th Scientific Session, Tucson, AZ, November 2011. Received December 22, 2011; Revised February 19, 2012; Accepted February 20, 2012. From the Department of Surgery, Harborview Medical Center (Gage, Jurkovich, Arbabi) and Harborview Injury Prevention and Research Center, University of Washington (Traven, Rivara), Seattle, WA. Correspondence address: Saman Arbabi, MD, MPH, FACS, Harborview Medical Center, 325 9th Avenue, Box 359796, Seattle, WA 98104. email:
[email protected]
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Abbreviations and Acronyms
AIS CR EMS GCS ISS KCEMS
⫽ ⫽ ⫽ ⫽ ⫽ ⫽
Abbreviated Injury Score central region emergency medical services Glasgow Coma Scale Injury Severity Score King County Emergency Medical Services
(1990, 1993, 1999).7-9 The most current 2009 Field Decision Scheme (Fig. 1) includes 4 decision steps (physiologic, anatomic, mechanism of injury, and special considerations) to help prehospital providers determine the most appropriate facility to care for the injured patient.10 Washington State has had an inclusive trauma system for more than 20 years based on the Statewide Emergency Services Act of 1990 (RCW 70.168). The Central Region, 1 of 8 trauma regions in the state, has jurisdiction over King County, the state’s most populated county, with more than 1.9 million residents and covering 2,134 square miles (890 persons/square mile).11 Recognizing that geographic and prehospital contextual factors may contribute to which facility an injured patient is ultimately triaged to, geocoding was used to investigate compliance with the 2009 CDC Field Triage guidelines in an established trauma system and to identify what prehospital patient characteristics dictate which trauma patients are transported directly to a level I trauma center, bypassing lower level facilities that may be closer. We hypothesized that prehospital providers in a well-established trauma system would comply with all 4 triage criteria.
METHODS We performed a retrospective cohort analysis of 12,106 injured patients in the Central Region (CR) of Washington State. Currently, the CR is served by 17 hospitals, 9 of which have been designated as trauma centers. There is a single level I trauma center, 3 level III trauma centers, 3 level IV trauma centers, and 1 level V trauma center, which provide a limited range of trauma services. There is no level II center in the region. The King County Emergency Medical Services (KCEMS) consists of 30 fire departments providing basic life support service and 6 paramedic agencies that provide advanced life support service in a tieredresponse system. Our outcomes of interest were to determine which prehospital characteristics dictate transport to a level I center and whether CDC guidelines for field triage were being followed in an established trauma system. The Washington State Central Region Trauma Registry is a comprehensive record of the inpatient care an injured patient receives in one of the state’s trauma hospitals. It con-
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tains detailed information about the injuries sustained, therapies delivered, and patient outcomes. However, the CR Trauma Registry does not contain accurate information on the geographic scene of injury location. KCEMS provides a large majority of the prehospital care of the severely injured in the county, and their database contains the incident location in addition to other prehospital information. Unfortunately, patient-identifying information is often not accurate for severely injured patients transported by EMS, and a unique consistent number or identifier does not exist to directly link a patient’s EMS records with trauma registry records. To overcome this problem, the Washington State CR Trauma Registry was first used to identify all patients aged 18 or older, who were injured in King County, were assessed in the field by prehospital providers, and were transported by ambulance to a CR trauma hospital between January 1, 2004 and December 31, 2008 (Fig. 2). The patients identified in the CR registry were matched to patients in the King County EMS database using probabilistic linkage and the key identifiers of incident date, time, age, birth date, name, destination, and mechanism. Probabilistic linkage has been used successfully in similar scenarios linking trauma registries with other datasets.12,13 Missing, incomplete, and duplicate records were identified from the database and excluded. The incident location of matched records were then geocoded (ArcGIS v9.3) to longitudinal and latitudinal coordinates.14 A series of geocoded maps were then produced to geographically illustrate the distribution of injury locations and transport destinations across the study region. Based on proximity, specific catchment areas were defined for each trauma center. Patients were geocoded into 2 distinct cohorts: patients transported directly to a level I center (represented by black dots) and those transported to a level III to V center (centers represented each by a different colored dot) who then may have gone on to receive care at the lower level center or may have been ultimately transferred to the level I center. Because the decision to triage to a level I center might depend on several patient characteristics that could confound the relationship between trauma center level and transport destination, stepwise multiple logistic regression analyses using the backwards method were performed to examine predictors of transport decisions. Data were analyzed using Stata version 11.0. Variables were selected for inclusion in the models based on clinical relevance and availability. As a preliminary step, we conducted univariate logistic regressions of the dependent variables on each individual predictor variable. Factors included in the regression model were age, sex, mechanism of injury, intubation at the scene, distance from the level I center, scene Glasgow
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Figure 1. Field triage decision scheme, United States, 2009. (From: Morbidity and Mortality Weekly Report, Jan 23, 2009;58,10 with permission.)
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41,751 Central Region Trauma Registry records
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16,272 by other transport
39,083 From scene 22,811 By ambulance
2,668 transferred in
4,919 outside King County
12,106 patient matches
17,892 in King County
5,786 no match identified
Figure 2. Selection criteria for analysis. CRTR, Central Region Trauma Registry; KCEMS, King County Emergency Medical Services.
Coma Scale (GCS), scene systolic blood pressure, Injury Severity Score (ISS), head Abbreviated Injury Score (AIS), and respiratory status. Significance was set at p ⬍ 0.05.
RESULTS A total of 12,106 patients were included in the study, and 11,749 (97%) were able to be accurately geocoded. Geocoded maps, based on destination of initial transport, aided in defining specific catchment areas for each trauma center in the region (Fig. 3). Black dots on the maps represent patients transported directly to the level I center from the scene. Transports directly to level III to V hospitals are represented by colored dots. Of the 12,106 patients, 5,976 Figure 4. Geocoded incident location of all matched patients, 2004 to 2008, transported directly to the level I trauma center. Red H represents the location of the level I trauma center; blue H represents the location of level III–V hospitals; black dots represent patients who went directly to the level I trauma center.
Figure 3. Geocoded incident location of all matched patients, 2004 to 2008, identified by initial destination. Blue Hs represent location of trauma centers in the region. Black dots represent patients transported directly to the level I trauma center. Patients transported directly to level III–V centers represented by dark green, orange, purple, light blue, orange, yellow, light green, and red dots.
were transported directly to a level I center (Fig. 4). When focusing on patients transported to the level I center only, best seen on the periphery of the map, there were a number of patients who were injured closer to level III to V hospitals but bypassed these centers and went directly to the level I center in our region. Excluding the patients who were injured in proximity to the level I center (the level I center was the closest trauma hospital), 3,240 patients bypassed the level III to V trauma centers and were directly transported to the level I center. Of the remaining 6,130 who were initially transported to level III to V centers, 5,024 remained in the respective level III to V centers, and 1,106 were transferred to the level I center (Table 1). Patients transported directly to a level I trauma center were more likely to be male, younger, had
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Table 1. Demographic, Scene, and Discharge Characteristics
Table 3. Adjusted Odds Ratio of Transport from Scene to Level I Trauma Center Based on CDC Step 3, Injury Severity Considerations
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Characteristic
n* Female, % Age, y Scene GCS Scene mean SBP, mmHg ISS Discharge status, % To home To homecare To SNF To rehabilitation Died
Scene transport to level III–V Remained at Transferred level III-V to level I
Direct scene transport to level I Direct to level I
5,024 53.5 57.3 14.6
1,106 34.3 44.4 14.4
3,240 27.8 36.5 13.1
137.4 7.4
135 12.8
128.7 17
46.3 9.8 28.9 3.0 1.8
67.2 3.5 15.0 2.4 1.8
70.0 3.7 11.1 6.5 6.9
*Excluding patients injured in proximity to the level I center. GCS, Glasgow Coma Scale; ISS, Injury Severity Score; SBP, systolic blood pressure; SNF, skilled nursing facility.
lower scene GCS scores, had lower scene systolic blood pressures, and were more severely injured (Table 1). Patients directly transported from the scene to the level I trauma center had higher in-hospital mortality rates, but survivors were more likely to be discharged to home after their hospitalization as compared with patients who were transported to a level III to V hospital first. Adjusted mortality rates for patients over the age of 55 were 10.7% at the level I trauma center and 3.2% at the level III to V centers. Step 1 in the CDC criteria assesses physiologic derangements. We found that the patients’ odds of being directly Table 2. Adjusted Odds Ratios of Transport from Scene to Level I Trauma Center Based on CDC Step 1, Physiologic Considerations Variable
GCS ⬎ 14 GCS 11–13 GCS 8–10 GCS 3–7 SBP ⬎ 120 mmHg SBP 90– 119 mmHg SBP ⬍ 90 mmHg Not intubated Intubated at scene
Odds ratio*
95% CI
Reference 1.96 2.17 2.88 Reference 1.19 2.2 Reference 2.67
— 1.33–2.91 1.25–3.76 1.85–4.48 — 1.01–1.39 1.52–3.19 — 1.46–4.87
*Adjusted for sex, age, mechanism, distance from level I trauma center, Injury Severity Score, head AIS, and respiratory rate; excluding patients injured in proximity to the level I center. AIS, Abbreviated Injury Score; GCS, Glasgow Coma Scale; SBP, systolic blood pressure.
Variable
ISS 0–8 ISS 9–15 ISS 16–24 ISS 25⫹
Odds ratio*
95% CI
Reference 2.03 4.57 14.83
— 1.75–2.36 3.71–5.63 11.34–19.4
*Adjusted for sex, age, systolic blood pressure, intubation, GCS, distance from Level I trauma center, mechanism, head AIS, respiratory rate; excluding patients injured in proximity to the level I center. AIS, Abbreviated Injury Score; GCS, Glasgow Coma Scale; ISS, Injury Severity Score.
transported to the level I center significantly increased the lower their GCS score at the scene was, the lower their scene systolic blood pressure was, and if the patient required intubation at the scene (Table 2). Step 2 in the CDC criteria bases triage decisions on the anatomic location of injury. As compared with patients with blunt injury, we found that patients with a penetrating injury were significantly more likely to be transported to a level I trauma center (odds ratio [OR] 11.01, 95% CI 8.59 to 14.37). The CDC step 3 criterion addresses the likelihood of having a severe injury. Patients were significantly more likely to be transported to the level I trauma center the higher their injury severity scores were (Table 3). Step 4 in the decision scheme recommends transport decisions based on age. After adjusting for sex, mechanism of injury, distance from a level I trauma center, ISS, head AIS, and respiratory rate, compared with patients ages 18 to 45, direct scene transports to a level I center were progressively less likely with advancing age, with those in the oldest age group 89% less likely to be transported to the level I center (Table 4). Similar results were found even for those patients who were more severely injured (ISS ⱖ 16; Table 4). In our system, injured patients can reach a level I trauma center in 1 of 2 ways: they can be transported directly from Table 4. Adjusted Odds Ratio of Transport from Scene to Level I Trauma Center Based on CDC Step 4, Age Considerations Variable
All patients Odds ratio* (95% CI)
ISS > 16 Odds ratio* (95% CI)
Age, y 18–45 46–55 56–65 66–80 81⫹
Reference 0.7 (0.59–0.83) 0.47 (0.39–0.58) 0.28 (0.23–0.34) 0.11 (0.09–0.14)
— 0.71 (0.52–0.97) 0.74 (0.50–1.08) 0.38 (0.26–0.54) 0.13 (0.09–0.20)
*Adjusted for sex, systolic blood pressure, GCS, distance from level I trauma center, mechanism, ISS, intubation, head AIS, respiratory rate; excluding patients injured in proximity to the level I center. AIS, Abbreviated Injury Score; GCS, Glasgow Coma Scale; ISS, Injury Severity Score.
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the scene to the level I hospital or they can first be transported to a level III to V hospital and then be transferred to the level I hospital. We found that even in looking at transfer patterns, older age continued to be associated with less likely transfer from a level III to V trauma center to a level I trauma center (Table 5).
DISCUSSION In 2009, the CDC and a multidisciplinary expert panel revised the American College of Surgeons-Committee on Trauma’s Field Triage Decision Scheme to aid prehospital providers in “getting the right patient to the right place at the right time.”10 We found that young age, male sex, low scene systolic blood pressure, low scene GCS, and higher injury severity scores all predict transport to the highest level of trauma care in our region. Our study is the first using geocoding technology to identify compliance with specific CDC field triage criteria in an established trauma system. We found that prehospital providers are adhering to the physiologic, anatomic, and mechanistic parameters set forth in steps 1 to 3 of the CDC field triage guidelines. However, contrary to the special considerations guideline in step 4, older age was associated with transport to the lower level of trauma care in our region. Even among patients with ISS of 16 or greater, prehospital providers are not following criteria to transport older patients to appropriate levels of trauma care. Furthermore, older age was inexplicably associated with not being transferred to the highest level of trauma care in the region. Using linked prehospital and hospital data and accurate geocode maps, the findings of this study correlate with findings in previous studies15-18 of undertriage of elderly trauma patients to state-designated trauma centers. There are, however, several limitations to our study. Similar to other retrospective cohort studies, our results are based on already acquired data, and we could not separately assess EMS provider “judgment.” Additionally, our study could Table 5. Multiple Logistic Regression of Factors Associated with Transfer from a Level III–V Center to a Level I Center Variable
Odds ratio*
95% CI
Age, y 18–45 46–55 56–65 66–80 81⫹
Reference 0.76 0.54 0.41 0.24
— 0.6–0.96 0.41–0.72 0.31–0.55 0.17–0.32
*Adjusted for sex, systolic blood pressure, GCS, distance from level I trauma center, mechanism, ISS, intubation, head AIS, respiratory rate; excluding patients injured in proximity to the level I center. AIS, Abbreviated Injury Score; GCS, Glasgow Coma Scale; ISS, Injury Severity Score.
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not identify the ultimate reason for direct transport of the patients to the level I center. Other factors, such as patient preference, weather or traffic challenges, season, time of day, local medical control override, or patient DNR status may influence transport decisions and were not accounted for in the analysis. Triage of older adults will be of even more importance in the coming years, as this population grows to 72.1 million persons aged 65 and older in the United States by 2030.19 As the population ages and remains increasingly active, the proportion of older trauma patients is expected to increase.20 The key finding of this study is that prehospital providers are not following CDC step 4 recommendations to triage older patients to the highest level of trauma care in the region in an established trauma. The reason for this apparent undertriage is not clear. Are we less aggressive in treating the older trauma patients? When these data were presented in the Central Region quality assurance meeting, the EMS providers suggested that many other factors associated with age may be in play. Many older patients already have various medical providers practicing at lower level trauma centers who are intimately involved in their care, and patient preference plays a large factor. Also, recognition of what constitutes significant injuries in the elderly is difficult, and EMS providers believe that further training about elderly trauma is necessary. These discussions have led to the development of educational presentations to help prehospital and hospital providers recognize severely injured elderly trauma patients. Additionally, although not available during our study period, the Central Region Trauma Registry now records the use of anticoagulants in our patients. This study, however, does not address an important question: do older patients benefit from transport to the highest level of trauma care? Unadjusted mortality was less at the level III to V trauma centers as compared with the level I center in our region. The advantage of transporting older trauma patients to a level I trauma center has not been clearly shown in the literature either. The National Study on the Cost and Outcomes in Trauma (NSCOT) showed that neither mortality nor functional outcome was improved for elderly trauma patients who were treated at level I trauma centers as compared with treatment at nontrauma centers.5 Therefore, establishing appropriate and evidencebased guidelines for the care of older trauma patients may be one of the most important challenges facing the trauma community. Author Contributions
Study conception and design: Gage, Rivara, Jurkovich, Arbabi
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Discussion
Acquisition of data: Gage, Traven, Rivara, Jurkovich, Arbabi Analysis and interpretation of data: Gage, Traven, Rivara, Jurkovich, Arbabi Drafting of manuscript: Gage, Rivara, Jurkovich, Arbabi Critical revision: Gage, Rivara, Arbabi
REFERENCES 1. US Dept of Health and Human Services. Centers for Disease Control and Prevention. WISQARS: Web-Based Injury Statistics Query and Reporting System: injury mortality reports, 2008. Atlanta, GA: CDC; 2011. Available at: http://webappa. cdc.gov/cgi-bin/broker.exe Accessed August 24, 2011. 2. Hoyt D, Coimbra R, Potenza B. Trauma systems, triage, and transport. In: Feliciano D, Mattox K, Moore E. Trauma. 6th ed. New York: McGraw Hill; 2008:57–81. 3. Nathans A, Jurkovich G, Rivara F, et al. Effectiveness of state trauma systems in reducing injury-related mortality: a national evaluation. J Trauma 2000;48:25–30. 4. Nathens A, Jurkovich G, Cummings P, et al. The effect of organized trauma systems of trauma care on motor vehicle crash mortality. JAMA 2000;283:1990–1994. 5. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma center care on mortality. N Engl J Med 2006;354:366–378. 6. American College of Surgeons. Hospital and Prehospital Resources for the Optimal Care of the Injured Patient: Appendices A Through J. Chicago, IL: American College of Surgeons: 1986. 7. American College of Surgeons. Resources for the Optimal Care of the Injured Patient: 1990, Chicago, IL: American College of Surgeons; 1990. 8. American College of Surgeons. Resources for the Optimal Care of the Injured Patient: 1993, Chicago, IL: American College of Surgeons; 1993. 9. American College of Surgeons. Resources for the Optimal Care of the Injured Patient: 1999, Chicago, IL: American College of Surgeons; 1999. 10. US Dept of Health and Human Services. Centers for Disease Control and Prevention. Guidelines for field triage of injured patients: Recommendations of the National Expert Panel on Filed Triage. MMWR 2009;58(RR-1):1–35. 11. US Census Bureau. State and county quick facts: King County Washington, 2009. Available at: http://quickfacts.census.gov/ qfd/states/53/53033.html. Accessed April 25, 2012. 12. Tromp M, Ravelli A, Bonsel G, et al. Results from simulated data sets: probabilistic record linkage outperforms deterministic record linkage. J Clin Epidemiol 2011;64:565–572. 13. Gonzalez R, Cummings G, Mulekar M, et al. Increased mortality in rural vehicular trauma: Identifying contributing factors through data linkage. J Trauma 2006;404–409. 14. Robinson J, Wyatt S, Hickson D, et al. Methods for retrospective geocoding in population studies: the Jackson Heart Study. J Urban Health 2010;87:136–150. 15. Chang D, Bass R, Cornwal E, et al. Undertriage of elderly trauma patients to state-designated trauma centers. Arch Surg 2008;143:776–781. 16. Lane P, Sorondo B, Kelly J. Geriatric trauma patients – are they receiving trauma center care? Acad Emer Med 2003;10:244– 250.
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17. Zimmer-Gembeck M, Southard P, Hedges J, et al. Triage in an established trauma system. J Trauma 1995;39:922–928. 18. Garwe T, Cowan L, Neas B, et al. A propensity score analysis of prehospital factors and directness of transport of major trauma patients to a Level I trauma center. J Trauma 2011;70:120–129. 19. US Dept of Health and Human Services – Administration on Aging. Aging statistics. Washington, DC. Available at: http:// www.aoa.gov/aoaroot/aging_statistics/index.aspx. Accessed September 1, 2011. 20. MacKenzie E, Morris J, Smith G, et al. Acute hospital costs of trauma in the United States: implications for regionalized systems of care. J Trauma 1990;30:1096–1101.
Discussion INVITED DISCUSSANT: DR JOHN WEIGELT (Milwaukee, WI): This article addresses a mature trauma system and finds that we do not follow our recommended triage guidelines 50% of the time. The data beg a number of questions and I have 3 for the authors. Because the premise for the triage guidelines is to improve care, should we assume that care was less than optimal in 50% of the injured patients in your system? Your system covers a fairly large geographic area and does not include a Level II hospital. Is the lack of Level II centers an explicit decision by your system or is this a system defect that produces the results of your study? Finally, you support a premise of regionalization of trauma care in your article. We are facing a number of changes in health care during the next few years packaged in the Patient Protection and Affordable Care Act or the Affordable Care Act. One is an increase in covered lives. Using care of the injured as a microcosm of health care, could you comment on whether your Level I trauma center could provide optimal care to all patients if suddenly your under triage problem was resolved by complete adherence to step 4 of the CDC triage guidelines. Is this a request you could honor or an example of “be careful for what you ask for?” DR GREGORY JURKOVICH (Seattle, WA): I will try to address the 3 questions that Dr Weigelt has asked. Would improvement of care happen if these patients were transferred to a Level I trauma center? I think we have pretty good and substantial data that care would be improved in patients younger the age of 55 years, with an Injury Severity Score (ISS) ⬎16, if they were cared for at a Level I trauma center. We also have, I think, pretty good information that if you are older than 55 years of age, care at a Level I trauma center also improves outcomes for those most severely injured, that is, an ISS ⬎25. There is not, however, good data that care is improved for the elderly with less severe ISS, for example, ⬍16, at trauma centers vs nontrauma centers. One of the big challenges in trauma system design and implementation, particularly as the population ages, is how to improve the care of elderly patients, and how to explain why the elderly with moderately severe injuries do not do better at a trauma center than a nontrauma center. Two hypotheses come to mind for that. One, it is a matter of physiology. It does not matter what kind of care you give, the die has been cast, so to speak, and the physiology precludes them
