Compliance with prehospital triage protocols for major trauma patients.

BACKGROUND The extent to which severely injured patients receive definitive care at trauma centers is determined by the accuracy of prehospital major trauma criteria in predicting severe injuries and by the level of compliance with these triage instructions by prehospital providers. This study was conducted to evaluate the level of compliance with triage criteria in an established trauma system. METHODS The study involved a retrospective analysis of the 1995 Maryland statewide prehospital ambulance data. Prehospital providers in Maryland are instructed to consider transporting patients meeting any of the three nonexclusive major trauma criteria-physiology, injury, and mechanism-to designated trauma centers. Compliance with these criteria was defined as the proportion of patients transported to designated trauma centers among those meeting prehospital triage criteria as documented on the ambulance trip report. Special emphasis was placed on differences in the levels of compliance by age of the trauma patients. RESULTS A total of 32,950 transports were analyzed. Patients meeting injury criteria were most likely to be transported to trauma centers (86%), followed by those meeting mechanism criteria (46%), and physiology criteria (34%). When the level of compliance was stratified by age, there was no age difference in the level of compliance for patients meeting injury criteria (90.5% for patients aged 0-54 years vs. 88.7% for patients aged 55+ years; p = 0.197). For older patients meeting physiology criteria only or for those meeting mechanism criteria only, however, compliance was differentially low. For patients meeting physiology criteria only, the compliance was 40.3% for patients aged 0 to 54 years and 23.9% for patients aged 55 years and older (p = 0.0001); for patients meeting mechanism criteria only, compliance was 47.0% for patients aged 0 to 54 years and 39.7% for patients aged 55+ years (p = 0.002). CONCLUSION The majority of patients meeting prehospital major trauma criteria were transported to designated trauma centers. Patients meeting only physiology criteria, however, were much less likely to be transported to trauma centers, and there was a differentially low compliance for elderly trauma patients meeting physiology criteria alone. The causes and consequences of lower compliance with triage instructions for the elderly population deserve further investigation.

[1]  K. E. Rumsey.  Are Optometric Faculty Guilty of Ageism? , 1993, Optometry and vision science : official publication of the American Academy of Optometry.

[2]  C. Emerman,et al.  A comparison of EMT judgment and prehospital trauma triage instruments. , 1991, The Journal of trauma.

[3]  D. Diamond,et al.  The utility of physiological status, injury site, and injury mechanism in identifying patients with major trauma. , 1988, The Journal of trauma.

[4]  P. Ganz.  Does (or should) chronologic age influence the choice of cancer treatment? , 1992, Oncology.

[5]  D. Gann,et al.  Survival after trauma in geriatric patients. , 1987, Annals of surgery.

[6]  S. Kelly,et al.  The failure of triage criteria to identify geriatric patients with trauma: results from the Florida Trauma Triage Study. , 1996, The Journal of trauma.

[7]  T. Esposito,et al.  Do prehospital trauma center triage criteria identify major trauma victims? , 1995, Archives of surgery.

[8]  E. Mackenzie,et al.  Progress in the development of trauma systems in the United States. Results of a national survey. , 1995, JAMA.

[9]  M. Helfand,et al.  Oregon trauma system: change in initial admission site and post- admission transfer of injured patients. , 2008, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[10]  M. Levitt,et al.  A prospective comparison of paramedic judgment and the trauma triage rule in the prehospital setting. , 1994, Annals of emergency medicine.

[11]  L. Zone-Smith,et al.  Application of field triage guidelines by pre-hospital personnel: is mechanism of injury a valid guideline for patient triage? , 1995, The American surgeon.

[12]  G S Smith,et al.  Acute hospital costs of trauma in the United States: implications for regionalized systems of care. , 1990, The Journal of trauma.

[13]  S P Gormican,et al.  CRAMS scale: field triage of trauma victims. , 1982, Annals of emergency medicine.

[14]  D. Trunkey,et al.  Trauma Systems: Current Status—Future Challenges , 1988 .

[15]  W. W. Young,et al.  Do trauma centers improve outcome over non-trauma centers: the evaluation of regional trauma care using discharge abstract data and patient management categories. , 1990, The Journal of trauma.

[16]  E. DeMaria.  Evaluation and treatment of the elderly trauma victim. , 1993, Clinics in geriatric medicine.

[17]  B. Shaver,et al.  Age bias: physical therapists and older patients. , 1986, Journal of gerontology.

[18]  R E Burney,et al.  Geographic variation in preventable deaths from motor vehicle crashes. , 1995, The Journal of trauma.

[19]  E. Mackenzie,et al.  Trauma centers in the United States: identification and examination of key characteristics. , 1995, The Journal of trauma.

[20]  J. Koehler,et al.  A multicenter validation of the prehospital index. , 1987, Annals of emergency medicine.

[21]  L. D. Grant.  Effects of ageism on individual and health care providers' responses to healthy aging. , 1996, Health & social work.

[22]  J. Ornato,et al.  Ineffectiveness of the trauma score and the CRAMS scale for accurately triaging patients to trauma centers. , 1985, Annals of emergency medicine.

[23]  H. Thode,et al.  Evaluation of American College of Surgeons trauma triage criteria in a suburban and rural setting. , 1996, The American journal of emergency medicine.

[24]  R. Elashoff,et al.  Patterns of care related to age of breast cancer patients. , 1987, JAMA.

[25]  J. V. Stone,et al.  Triage in an established trauma system. , 1995, The Journal of trauma.

[26]  A. M. Maslanka.  Scoring systems and triage from the field. , 1993, Emergency medicine clinics of North America.

[27]  W G Baxt,et al.  The trauma triage rule: a new, resource-based approach to the prehospital identification of major trauma victims. , 1990, Annals of emergency medicine.

[28]  C. Slovis,et al.  Monitoring EMS protocol deviations: a useful quality assurance tool. , 1991, Annals of emergency medicine.

[29]  H C Thode,et al.  Evidence for and impact of selective reporting of trauma triage mechanism criteria. , 1996, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[30]  H. Meislin,et al.  A Prospective Evaluation of Prehospital Patient Assessment by Direct In-field Observation: Failure of ALS Personnel to Measure Vital Signs , 1990, Prehospital and Disaster Medicine.

[31]  Thrombolytic therapy for eligible elderly patients with acute myocardial infarction. , 1997, JAMA.

[32]  H. Thode,et al.  Incremental benefit of individual American College of Surgeons trauma triage criteria. , 1996, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[33]  G. A. Marshall,et al.  The Trauma Score as a triage tool in the prehospital setting. , 1986, JAMA.

[34]  H. Champion,et al.  A case control study for major trauma in geriatric patients. , 1989, The Journal of trauma.

[35]  D M Steinwachs,et al.  Evaluating performance of statewide regionalized systems of trauma care. , 1990, The Journal of trauma.

[36]  C. Currie.  Doctors and ageism. , 1987, British medical journal.