Triage Questions
Lerner EB, Drendel AL, Cushman JT, et al. Ability of the physiologic criteria of the field triage guidelines to identify children who need the resources of a trauma center. Prehosp Emerg Care. Oct. 6, 2016. [Epub ahead of print.]
Trauma is the leading cause of death for children over the age of 1 year. Early recognition and appropriate transport to trauma systems improves patient outcomes.
Background: E. Brooke Lerner, PhD, and her team were curious about the validity of the Field Triage Guidelines developed by the American College of Surgeons and Centers for Disease Control and Prevention, and she and her colleagues set out to investigate their effectiveness.
Lerner, the principal investigator of this study, is an EMS provider with a PhD in epidemiology. She’s diligently used scientific methods to improve prehospital care for several decades. With hundreds of scientific EMS studies published in peer-reviewed journals, her accomplishments are a crown jewel in our profession.
Lerner’s advocacy of, and inquiry into, systematic improvements in the assessment and care of children is only one of her areas of specialty. Readers may also want to read her paper on the use of lactate to improve trauma triage that was published by the Journal of Trauma and Acute Care Surgery in September.
Methods: This was an observational study conducted over three years at three regional pediatric trauma centers. The authors used research assistants positioned at each of the study hospitals to interview arriving EMS crews who had just transported a traumatically injured patient under the age of 15 years directly from the scene of the injury.
The research assistants recorded the patient’s Glasgow coma scale (GCS), systolic blood pressure and respiratory rate–the physiologic criteria of the Field Triage Guidelines–as reported by EMS. Hospital medical records were used to compare the EMS-provided vital signs with the information documented by ED staff as well as the outcomes of the patients within the study. Patients who died, were admitted to an ICU, or received non-orthopedic surgery within 24 hours of arrival to the hospital met the case definition for requiring a trauma center.
Results: Of the 5,594 pediatric patients included within the study, 279 met the case definition for requiring a trauma center. Of the 279 patients who met the case definition, 137 (49%) also met the physiologic criteria of the Field Triage Guidelines. This means that 51% of the patients who needed a trauma center wouldn’t have been identified by these Field Triage Guidelines (i.e., under-triage). Of the 935 patients who met the physiologic criteria of the Field Trauma Guidelines, 18% didn’t need a trauma center (i.e., over-triage).
The researchers also found EMS vital signs, which would be used to determine if a patient met the physiologic criteria, were missing, not obtained, and differed from the vital signs obtained from the ED staff in more instances than would be expected.
Discussion: The methods and sample size used for this study are strong and the results tell a compelling story for us to re-examine our pediatric care. The fact that 28—53% of children didn’t have a documented blood pressure is concerning. The emphasis on observational assessments, such as work of breathing and appearance, in our EMS training programs may have also sent a signal de-emphasizing collecting a complete set of vital signs.
It’s also interesting that EMS vital signs were different than those obtained in the ED. One might be tempted to immediately indict the prehospital vitals as inaccurate, but we think more investigation is needed. How were these vital signs obtained? Was the variability due to expected alterations in pulse, blood pressure and respiration when stress on scene is high? Traumatically injured children compensate rapidly and it can be difficult to determine the acuity of their condition in the prehospital setting.
Conclusion: This research would indicate that GCS had the highest positive predictive value, but overall the current guidelines don’t apply well to pediatric patients. We hope that readers will follow in Lerner’s footsteps and get passionate about doing great research that improves prehospital care.
Bottom Line
What we already know: Early recognition and transport of children in need of trauma centers saves lives.
What this study adds: The current physiologic criteria of the Field Triage Guidelines are only moderately helpful for determining if a pediatric patient requires a trauma center. Alternative triage systems should be developed and properly investigated. This study also strongly suggests that prehospital pediatric vital sign assessment needs further study and improvement.
Learn more from David Page at the EMS Today Conference & Exposition, Feb. 23—25, in Salt Lake City. EMSToday.com
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