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Triaging the right patient to the right place in the shortest timeP. A. Cameron1,2,3,4*, B. J. Gabbe1,5, K. Smith1,6,7 and B. Mitra1,2,31 Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia2 Emergency & Trauma Centre and 3 National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia4 Hamad Medical Corporation, Doha, Qatar5 College of Medicine, Swansea University, Swansea, UK6 Ambulance Victoria, Doncaster, Australia7 University of Western Australia, Perth, Australia

* Corresponding author. E-mail: [email protected]

Editors key points

Themajorityof traumadeaths occurwithin4 h of injury.

Transporting trauma patients directly totrauma centres (trauma bypass) reducesthe time to definitive treatment.

Optimal triage minimizes over triage andthe unnecessary activation of traumateams whilst avoiding under triage.

Effective development and monitoring oftrauma systems requires the collection ofdata frommultiple sources.

Trauma systems have been successful in saving lives and preventing disability.Making sure that the right patient gets the right treatment in the shortestpossible time is integral to this success. Most trauma systems have not fullydeveloped trauma triage to optimize outcomes. For trauma triage to beeffective, there must be a well-developed pre-hospital system with an efficientdispatch system and adequately resourced ambulance system. Hospitals musthave clear designations of the level of service provided and agreed protocols forreception of patients. The response within the hospital must be targeted toensure the sickest patients get an immediate response. To enable the mostappropriate response to trauma patients across the system, a well-developedmonitoring programme must be in place to ensure constant refinement of theclinical response. This article gives a brief overview of the current approach totriaging trauma from time of dispatch to definitive treatment.

Keywords: triage; wounds and injuries

It is nearly half a century since it dawned on the Westernworld that more people were being killed through civilian injurythan in wars. The biggest single killers were motor vehicles andit was clear that primary injury prevention, particularly targetedat reducing vehicle collisions, could save lives. The doctorsinvolved in managing the thousands of injury victims realizedthat early accurate assessment and treatment of victims wouldalso save lives. Importantly, experience from the Vietnam War,and previous wars, suggested that field stabilization and earlytransfer to an appropriate facility were critical factors in improv-ing survival.1 The concept that many deaths were preventablethrough better organization of care was established.2 TheAnglo-Americanmodel of traumacare involved trainedparame-dics, quickly assessing and stabilizing patients, then transferringto a facility capable of receiving a critically ill traumapatient. Thefacility itself neededtohavesystems inplace toensureanappro-priate response24/7 (24hperday,7daysperweek). Themodelofintegrated traumacare, learnt from the context ofwar,was slowto translate into civilian practice.

The elements of an integrated trauma system include:

(i) A pre-hospital system that has well-trained parame-dics, coordinated dispatch, appropriate transportplatforms and agreed protocols for hospital designa-tion, trauma bypass (the transfer of seriously injuredpatients to a trauma centre even if this means that

hospitals closer to the scene of injury are bypassed)and inter-hospital transfer.

(ii) Hospitals thathaveadequate facilities, staffing, andor-ganization 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 withlimited availability of sophisticated services.3

(iii) Post-acute hospital discharge rehabilitation and con-valescence.

(iv) A system-widemonitoring capability to ensure that theright patients go to the right hospitals and get the righttreatment.4

There is now growing evidence that providing trauma carewithin a well-organized system saves many lives5 6 and pre-vents long-term disability.7 The fundamental basis of a well-organized trauma system is an agreed trauma triage processat each step along the patient journey. The correct level ofparamedic response is based on specified dispatch criteria.This is then followed by transfer to an appropriate facilitybased on agreed patient, mechanistic, and geographic data.The hospital response on patient arrival is based on this pre-hospital data with additional information about paramedictreatment and response to early treatment.

The importance of accurate initial triage was recognizedmany years ago but with increasing sophistication of boththe treatments available and our ability to provide real time

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monitoring and feedback, there is now a greater ability andnecessity to ensure that regional systems provide optimalcare for individual patients. There is also the possibility to pro-gress from simple historical trauma scores to more accuraterisk predictions based on all available patient characteristics.

Very few trauma systems internationally are activelyresearchingoptimalparameters for identifyinghigh-riskpatientswho will benefit from trauma bypass or inter-hospital transferbecause of the necessity of highly complex treatments. Mosttrauma care is still delivered and assessed at an institutional,rather than regional, level, without carefulmonitoring and refer-ence to international benchmarks for optimization.

This article aims to describe the principles of best practicefor triaging of trauma patients at each point along thepatient journey to ensure optimal outcomes. Monitoring ofprocesses and outcomes at a jurisdictional level is intrinsic tothe optimization of trauma systems.

Pre-hospitalThe majority of trauma deaths occur in the pre-hospital envir-onment or within 4 h of the trauma event.8 Mortality andmor-bidity can be reduced by effective identification, field triage,and transport of severely injured patients to specializedtrauma centres. This starts with recognition of the severity ofinjuries at the time of the call to Emergency Medical Services(EMS). In Australia and many other countries, the majority ofEMS systems use a commercial medical call-taking system,suchastheMedical PriorityDispatchSystem(MPDS) tocategor-ize EMS calls by problem type and urgency.9

The dispatch rules determined by individual EMS specify thedesignated level of ambulance response to send to each cat-egory (determinant code). An ideal system will mobilize EMSresources in a manner that is timely and appropriate topatient acuity and has the ability to positively influence thepatient outcome. This needs to be balanced by rational use ofresources and limiting potentially dangerous aeromedicaland lights and sirens responses.10

Inmostdevelopedcountries,HelicopterEmergencyMedicalServices (HEMS) complement ground ambulances in provid-ing pre-hospital care for severely injured patients. Althoughdebate continues, this combination is believed to improvethe patient outcome.11 12 Benefits include the possibility ofincreased level of care (superior interventions and trainingof HEMS paramedics or physicians) and the enhanced speedof the response.13 In many parts of the world helicopters arestaffed by physicians or anaesthetists. In Victoria, Australia,HEMS are staffed by highly trained Intensive Care flight para-medics who are authorized to perform interventions such asrapid sequence intubation of comatose patients, administra-tion of ketamine for traumatic pain, and red cell concentratein indicated patients.

HEMSdispatch shouldbeefficientasovertriage representsasignificant cost and is not without safety risks. HEMS dispatchcriteria validity has been questioned. A recent systematicreview on HEMS dispatch criteria for trauma patients demon-strated low accuracy in discrimination of appropriate patients

across criteria based on mechanism of injury, anatomy ofinjury, age and comorbidities.14 Themost promising single cri-terion appears to be loss of consciousness.14 15 When activat-ing anHEMS response, consideration is also given to a patientsgiven situation, regional and logistical factors.

Accurate pre-hospital trauma triage criteria are critical forensuring that patients with severe injuries are transported totrauma centres within appropriate timeframes. The goldenhour is often referred to in the trauma literature, as theoptimal timeframe for pre-hospital care and delivery to defini-tive treatment.16 This dogma does not take into accountadvanced life support interventions by paramedics to reducepreventable deaths and the fact that a longer transport timemay reduce overall time to definitive treatment by avoidingdelays at secondary hospitals before transfer. In the traumasystem implemented in the state of Victoria, Australia, thisdelay to definitive treatment caused by transport to a non-major trauma centre averaged greater than 6 h.17 The criteriaand coordination for onward transfer of time critical majortrauma patients to Level 1 centres must be clear and requiresstandard operating procedures agreed in advance.

Pre-hospital trauma triage criteria typically adopt a com-bination of physiological, anatomic, and mechanism of injurycomponents 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 theRevised Trauma Score19 and the CRAMS (Circulation, Respir-ation, Abdomen, Motor and Speech) scale,20 21 which werecumbersome to calculate and had inadequate sensitivity todetect serious injury. Other scoring systems, such as theInjury Severity Score (ISS), require knowledge of all injuries,22

some of which are not identified or confirmed in the pre-hospital setting.

Paramedic judgement is an important adjunct tofield triageguidelines but has not beendemonstrated to beanaccurate orreliable alternative triage method.23 In an Australian studycomparing experienced HEMS paramedic rating of the severityof injurywithhospital patientoutcomes, thesensitivityofpara-medic predictions for severe injury ranged from57.6% (95%CI:45.4, 68.9) for the head to 38.5% (95% CI: 22.1, 57.9) for theabdomen.24

Epidemiological surveillance where field triage guidelinesare assessed for over- and undertriage of severely injuredpatients is critical to driving improvements in triage criteriaand identifying local issues includingparamedic compliance.25

This has been facilitated by the advent of electronic patientcare records in the pre-hospital setting.26 Access to electronicdevices by EMS also raises the possibility of tailored decisionsupport tools including validated scoring systems.27 However,the feasibility of data entry by paramedics at the point ofcare is yet to be demonstrated.

Hospital designationsTrauma designation is essential in a trauma system and basic-ally describes theminimumresources necessary for the care ofpatients with serious injury. A systems approach to trauma

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careentailsdelineationof thevaryingfunctional rolesthathos-pitals within the systemwill play. Delineation is required as it isneither appropriate nor feasible for every hospital receivingseriously injured patients to be resourced to the highestlevel (i.e. major trauma service or Level I Trauma Centre).3

Pre-hospital triage guidelines stipulate that patients aretransported to the highest level of designation within definedtransport times (e.g. 45 min), bypassing other hospitals withlower designation (Fig. 1).

The American College of Surgeons Resources for OptimalCare of the Injured Patient outlines the resources necessaryfor optimal care and is used as a guide for the developmentof trauma centres throughout the USA.3 Trauma centresvary in their specific capabilities and are identified by Leveldesignationgenerally three to five levels with Level I beingthe highest. Requirements include trauma team availability,admission volumes, activation protocols (including surgical,neurosurgical, orthopaedic, anaesthesiology, radiology, andspecialized nursing), sophisticated medical diagnostic equip-ment, helipad, involvement in jurisdictional trauma planningcommittees, and continued education.

Trauma reception and resuscitationOn arrival to hospital, injured patients should bemanaged in adesignated resuscitation area and received by a trauma team.The original aim of the trauma teamwas to reduce the secondpeakof the tri-modal distribution of death after trauma, byap-propriately managing correctable disturbances to the airway,breathing and circulation, and was predicted to reduce pre-ventable deaths by 42%.28 The predictions have been largelyaccurate with patients treated by trauma teams shown to

have shorter Emergency Department (ED) time, ED to com-puted tomographic imaging time, ED to operating room time,and improved survival.29 30 Despite such obvious benefits,trauma teams are not universal, even within advancedtrauma systems. In 2007, in the UK, trauma teams were onlyavailable in 20% of hospitals, and a trauma team responsewasdocumented foronly 60%ofpatientswith an ISSof16.31

The trauma team usually comprises a multidisciplinarygroup of individuals drawn from the specialties of emergencymedicine, surgery, nursing and support staff, anaesthesia,and intensive care medicine, each of whom contributes sim-ultaneously to the assessment and management of thepatient, overseen by a team leader. The primary aims of theteam are to rapidly resuscitate and stabilize the patient, pri-oritize and determine the nature and extent of injuries, andprepare for transport to the site of definitive care, within oroutside the receiving hospital. This horizontal approach totrauma care aims to provide rapid input to a criticallyinjured patient without the need to contact and request thepresence of individual team members, thereby reducingtime to critical interventions.32

A trauma call activation system congregates differentmembers of personnel from specialty units at the time of noti-fication and permits effective use of hospital resources. At-tendance of such members may strain resources in hospitalswhere trauma presentations are common. Multiple activationprotocols have been developed incorporating a number ofvariablesphysiological, mechanistic, and patient character-istic featuresin an attempt to predict injury severity andthe need for interventions (Fig. 2). Optimal triage within atrauma system implies low overtriage without compromisingthe goal of minimizing undertriage.33 Overtriage is more

Major traumaservices

Regional traumaservices

Urgent careservices

Primary careservices

Primary careservices

Ambulance assessmentand patient transfer

Patient transfersCoordination, education,quality improvement

Metropolitantrauma services

Trauma incident

Fig 1 Trauma system.

BJA Cameron et al.

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likely among centres that receive low volumes of trauma andare not designated Level I trauma centres. In response to pro-blems with overtriage, some centres have developed two- orthree-tiered activation criteria that incorporate field physio-logic parameters, mechanism of injury, anatomic factors,and age to stratify patients. While tiered criteria have beenreported to be safe and effective, these should be tailored tothe characteristics of individual trauma systems. With appro-priate pre-hospital triage, higher acuity centres can effectivelyutilize a single-tiered trauma activation. In this setting wheremost presenting patients are severely injured, full traumateam activation is necessary and an element of overtriage isessential to ensure sufficient sensitivity.34

A trauma team approaches trauma resuscitation along theprinciples set out by the Advanced Trauma Life Support Course(ATLS) fromtheAmericanCollegeof Surgeons, but ina parallelapproachwithmultiple simultaneous pre-defined tasks. Thesetasks are usually determined by virtue of the specialization ofthe individual member. Video-assisted trauma resuscitationgoes beyond traditional clinical decision support, which tendsto target individuals in more static patient care scenarios.This has been shown to be successful in error reduction atmajor trauma centres.35 The effectmay be greater for resusci-tation teamsthatare lessexperiencedorwork in lower-volumecentres. It is expected that technological developments,along with computer-aided decision support, will improve theperformance of trauma resuscitation.35

The massively haemorrhaging trauma patient poses add-itional challenges to the trauma team in requiring coordinatedand timely delivery of blood and blood products to restorecirculationand to treatandprevent impaired coagulation.Mul-tiple scoring systems have been developed to identify patientsat risk of massive transfusion or coagulopathy, but most lackclinical utility in that their sensitivity is too low to effectivelyrule-out the condition.36 37 On arrival to hospital, accurateand timely delivery of massive transfusion protocols may sub-stantially improve outcomes.38 The addition of a transfusionspecialist to oversee the delivery of blood or blood productsmay be invaluable and has been recommended to be part ofmassive transfusion protocol implementation.39 In addition,patients who are coagulopathic or at risk of developing coagu-lopathy, with or without the need for massive transfusions,should be targeted with pre-emptive, early pro-coagulantagents. Rigorous evidence behind the ideal type or quantityof such agents are currently lacking, but most local guidelinessuggest a combination of fresh frozen plasma, platelets,fibrinogen concentrates, tranexamic acid, calcium, and activatedrecombinant factor VIIa.

Patientswithmajor burn injuries or thosewith concomitantburn injuries inaddition tophysical traumashouldbe triaged tomajor trauma centres with burns services.40 The benefits ofsuch triage are towards goal-directed resuscitation of burnsshock through accurate fluid resuscitation and also the cap-acity for early debridement of burns injury. Blast injuries mayfurther complicate resuscitation of such patients and clinicalfeatures of such injuries should be sought early throughhistory and investigations.

Management of trauma patients has improved substantial-ly and a large proportion survive with a normal neurologicalstate, even in the setting of pre-hospital traumatic cardiacarrest. Overall survival in pre-hospital traumatic cardiac arrestpatients ranges from5 to10%and there should benohesitancyin instituting advanced life support.41 42 Therapeutic hypother-mia and extra-corporeal membrane oxygenation, with orwithout head injury, although unproven, may further improveoutcomes in this sub-group. Triage, both pre-hospital and onarrival to hospital, is essential to direct these patients to suchspecialized resources within appropriate timeframes.

OutcomesMost traumasystems researchhas focusedon in-hospitalmor-tality as the outcome of interest but most trauma patientssurvive their injuries. The organization of trauma care, andthe optimal triage of patients, is aimed at reducing mortalityand morbidity.2 43 Therefore, the need to extend the focus ofoutcome measurement beyond mortality is paramount. Theburden of traumatic injury ismulti-faceted and understandingthe impact of triage decisions and the quality of care providedto trauma patients requires a comprehensive and coordinatedapproach to measuring outcomes.44 This approach requiresnot only targeted measurement of mortality and morbidityoutcomes, but also application of these outcomes to system-wide monitoring. Integrated trauma systems span the pre-hospital, hospital, post-discharge, and rehabilitation phasesof patient care.2 Monitoring should aim to track the outcomesof patients through these phases of care to improve under-standing of burden and the inter-relationship betweenoutcomes.

Many studies focus on care in designated trauma centres, butthis approach fails to capture important information frompatientswho receive their trauma care in non-designated hospi-tals. The result is limited understanding of the factors predictiveof triage to traumacentres, and lost potential to benchmarkout-comesofpatientsmanagedattraumacentreswiththosewhodonot. Few studies have addressed this question, but the studiesthat have been published found improved mortality and func-tional outcome for seriously injured patients managed attraumacentrescomparedwithnon-traumacentres,highlightingthe importance of appropriate trauma triage.7 45

Additionally, limiting data collection to trauma centres oracute hospital care prevents a comprehensive evaluation ofthe impact of trauma triage decision making as interpretingchanges in outcome in one care setting may not reflectchanges inanother. Forexample, lower incidenceof in-hospitalmortality would generally be interpreted as evidence ofimproved care but in the context of worsening pre-hospitalmortality, overall systemperformancecouldbe interpreteddif-ferently. Similarly, improved survival of trauma patients in thecontextofworseningmorbidityoutcomes could suggest a shiftin burden from fatal to non-fatal injury. A recent study of roadtransport-relatedtraumaburdenusedpopulation-baseddata-sets of death and major trauma to evaluate the impact ofthe introduction of an inclusive trauma system in Victoria,


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Australia, and found a significant decline in the incidence ofmortality, reduced risk-adjusted in-hospital mortality, and anoverall reduction in burden asmeasured by Disability AdjustedLife Years.46

Despite its importance, comprehensive outcomesmonitor-ing of trauma systems across all phases of patient care is chal-lenging both within and between jurisdictions. Routine,population-based long-term follow-up of seriously injured

patients is rare with only the Victorian State Trauma Registryachieving this to date.47 Nevertheless, recent initiatives in theUK toestablishaconsensus foroutcomemeasures48 andpilot-ingofmeasurementof functional andquality-of-life outcomesin several countries are steps in the right direction.47 49 Sup-porting the capacity to monitor trauma patient outcomesover the continuum of care requires increased sophisticationin theelectronic captureof importantdatasuchaspre-hospital

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

Mechanism

Injuries

Signs

OtherCriteria

Trauma Call Out Criteria

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 (

care and enhanced data linkage capacity with administrativedatasets in the health and social sectors.50 51 Enhancedlinkage of trauma registry data with other key datasets willenable efficient and cost-effective monitoring of traumasystems into the future. Notwithstanding these benefits, inter-jurisdictional comparisons and benchmarking will rely on har-monization of data fields, approaches to risk-adjustment andconsensus on the handling of missing data. These challengesare not insurmountable as evidenced by previous studies andthe ongoing experiences in Australia of the Victorian StateTrauma Registry. Nevertheless, international collaborationand cooperation will be critical.

The futureEven though short-term mortality post major trauma is athistorical lows, endeavours to further improve outcomes con-tinue. Definitive care of haemorrhagic shock now involvesdamagecontrol resuscitation, comprisingpermissivehypoten-sion where appropriate, haemostasis, and damage controlsurgery. Triage to centralized trauma centres has resulted inlonger pre-hospital times, with the golden hour post injuryoften spent outside an ED. Combined with improved trainingand equipment, there is a real opportunity for delivery or atthe least to initiate definitive care in the pre-hospital phase.Telemedicinecan further increase thecapabilityofpre-hospitalstaff to deliver such care.52

Bed-side ultrasound is now routinely used in EDs and mayimprove the diagnostic capacity for pre-hospital cliniciansand improve triage of trauma patients further. Point-of-caredevices for pathology testing are now available for an arrayof testsandmaybemoreaccurate thanvital signs inpredictingin-hospital mortality.53 The ability for more accurate assess-ment may enable better pre-hospital definitive managementfor certain clinical scenarios such as ongoing bleeding andcoagulopathy.

Pre-hospital blood transfusions have been shown to be bothfeasible and safe, although effectiveness is still debated.54 Itmay be that the transfusion of red cells alone, with no agentsto combat coagulopathy, is the reason that there have beenminimal benefits thus far. After pre-hospital transfusions,patients appear to arrive in worse clinical states and can bemore coagulopathic because of further dilution of coagulationfactors.55 It is therefore vital to triage the most appropriatepatients to receive such therapy. Trials examining the pre-hospital use of pro-coagulant agents are currently in progressandmayprovideguidelines towardshaemostatic resuscitationbefore theED.56Where redcell transfusion is notavailable, pre-hospital transfusion of synthetic haemoglobin-based oxygencarriers is currently being trialled.57

Triage of the exsanguinating patient does not necessarilyhave tobe toanED, but couldbe toalternate facilities designedfor emergent interventions aimed at arresting haemorrhageand rapid assessment. Some EDs now initiate resuscitation inthe CT room to allow concurrent resuscitation and imaging.Minimally invasive endovascular techniques involve blockingbleeding blood vessels/organs via arterial embolization,

balloon catheters, or both and realigning blood vessels viastent graft. These emergent percutaneous therapies couldbe performed in the same physical location as resuscitation,surgery, and critical care. The RAPTOR suite (resuscitationwith angiography, percutaneous techniques and operativerepair) has become available in a small number of advancedcentres and demands timely and accurate pre-hospitaltriage to prevent death in the exsanguinating traumapatient.58

It is estimated that, by2030, traumawill be the third leadingcontributor to the worldwide burden of disease. It is the moredensely populated, developing regions of the world, withunder-developed trauma systems, that are currently worstaffected. While optimization of trauma triage in advancedtrauma systems has the potential to marginally improve out-comes, introduction of trauma systems and triage amongother populations can deliver inspiring results.59 It is neces-sary, and perhaps the duty, of practitioners in advancedtrauma systems to deliver trauma training programmes to re-source poor countries. It is likely that the basic components ofan integrated trauma system, including accurate triage of se-verely injured patients to appropriately resourced facilities, ateam-based approach with systematic assessment and man-agement of initial resuscitation will make a significant differ-ence in these countries.

Authors contributionsAll authors contributed to the research, design, and writing ofthis review.

Declaration of interestNone declared.

FundingB.J.G. and P.A.C. are supported by NHMRC Career Developmentand Practitioner Fellowships. B.M. is supported by an NHMRCEarly Career Fellowship.

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