Are Prehospital Trauma Triage Criteria Effective?

Posted by Patrick Lickiss on Feb 8, 2012 in Assessment, General, Research, Treatment | 0 comments

Chances are, the system you work in has a list of trauma criteria. Patients meeting such criteria are transported to specific trauma hospitals where advanced services are available. Some systems present their trauma criteria as guidelines while others are set in stone. Some systems mandate that certain criteria be activated while others are left to the discretion of the paramedics. The real question is: do these criteria even work?

Before answering that question, we need to decide what makes up an effective trauma triage system. In my opinion, an effective trauma system doesn’t miss severe life-threatening injuries and exhibits a minimum level of over-triage.
Why not just activate every trauma patient regardless of severity? A more thorough assessment is better right?

Yes and no. Well, actually no. Thorough assessment is good, unnecessary assessment isn’t.  Think about what happens when you bring in a trauma patient. Depending on the hospital there are up to 15 or so people in the room or immediately on stand-by. This includes physicians, nurses, lab technicians, radiology technicians, respiratory therapists, social workers (my favorite!) and many more. When dedicated to your patient, at least initially, they are unavailable to respond to another patient.

Now think about what happens to your patient: labs, x-rays, CT scans and countless other diagnostics. Each time a vein is punctured, there is a risk of infection. Every x-ray and CT scan involves exposing your patient to radiation which has additive effects over time.  In the end, a trauma system should be judged both on catching serious injuries and not activating patients unnecessarily.

Imagine my pleasure at reading the following excerpt from an Australian study published last year in Injury:

Injury. 2011 Sep;42(9):889-95. Epub 2010 Apr 28.

Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria.

Cox S, Smith K, Currell A, Harriss L, Barger B, Cameron P.

Strategy & Planning Department, Ambulance Victoria, Australia. Shelley.Cox@ambulance.vic.gov.au

BACKGROUND: There is a paucity of literature comparing trauma patients who meet pre-hospital trauma triage guidelines (‘potential major trauma’) with trauma patients who are identified as ‘confirmed major trauma patients’ at hospital discharge. This type of epidemiological surveillance is critical to continuous performance monitoring of mature trauma care systems. The current study aimed to determine if the current trauma triage criteria resulted in under/over-triage and whether the triage criteria were being adhered to.

METHODS: For a 12-month time period there were 45,332 adult (≥16 years of age) trauma patients transported by ambulance to hospitals in metropolitan Melbourne. This retrospective study analysed data from 1166 patients identified at hospital discharge as ‘confirmed major trauma patients’ and 16,479 patients captured by the current pre-hospital trauma triage criteria, who did not go on to meet the definition of confirmed major trauma. These patients comprise the ‘potential major trauma’ group. Non-major trauma patients (N=27,687) were excluded from the study. Pre-hospital data was sourced from the Victorian Ambulance Clinical Information System (VACIS) and hospital data was sourced from the Victorian State Trauma Registry (VSTR). Statistical analyses compared the characteristics of confirmed major trauma and potential major trauma patients according to the current trauma triage criteria.

RESULTS: The leading causes of confirmed major trauma and potential major trauma were motor vehicle collisions (30.1% vs. 19.2%) and falls (30.0% vs. 48.7%). More than 80% of confirmed major trauma and 24.4% of potential major trauma patients were directly transported to a major trauma service. Overall, similar numbers of confirmed major trauma patients and potential major trauma patients had one or more aberrant vital signs (67.0% vs. 66.4%). Specific injuries meeting triage criteria were sustained by 69.2% of confirmed major trauma patients and 51.4% of potential major trauma patients, while 11.7% of confirmed major trauma patients and 4.6% of potential major trauma patients met the combined mechanism of injury criteria.

CONCLUSIONS: While the sensitivity of the current pre-hospital trauma triage criteria is high, if paramedics strictly followed the criteria there would be significant over-triage. Triage models using different mechanistic and physiologic criteria should be evaluated.

There are a few reasons I like this study, not the least of which is that the following ad campaign came out of Australia:

But I digress.  Basically, I think this study takes a pretty realistic look at what works and what doesn’t in their system.  According to the study authors, their triage criteria (and associated paramedic discretion) catch about 80% of confirmed traumas.  This is respectable sensitivity (ability to identify positive results).  The authors admit, however, that strict adherence to triage criteria would result in unacceptably high over-triage.

With no evidence to back this up, my gut reaction is that most trauma systems suffer from similar over triage, or at least the potential for over triage.

What about your system?  Have you done anything to reduce the amount of over triage for trauma patients?  Are the study authors totally off base?  Let me know in the comments.

Pediatric Assessment Tips

Posted by Patrick Lickiss on Jan 18, 2012 in Assessment, General | 2 comments

Having a one year old at home has done more for my pediatric assessment skills than any class I could have ever taken. Pediatric patients have some very subtle changes and behaviors that can be easily over-looked. Given that kids can maintain for quite some time before deteriorating very quickly, it is important to learn to read the cues they give off. Over at Everyday EMS Tips, Greg has a great guide for comparing pediatric findings to what is “normal’ for the patient. Go take a look!

Upcoming Randomized Trial of Assessment and Referral by Paramedics

Posted by Patrick Lickiss on Aug 17, 2011 in Assessment, EMS 2.0, General, Research, Treatment | 2 comments

By far, one of the possibilities for the future of EMS which excites me the most is generally characterized as “community paramedicine”.  The idea that paramedics will be placed in a position to treat and release and treat and refer in the field, diverting patients from the local emergency rooms is an exciting one to be sure.  The first step in rolling out a system like that, however, is determining whether or not paramedics can safely determine which patients don’t actually need an ambulance transport.  Published recently in BMC Emergency Medicine (PDF link) was the study protocol for just such an experiment in Perth, Western Australia ^[1].

INCLUSION/EXCLUSION CRITERIA
Patients will be considered for the trial if they are suffering from the following conditions:

• Isolated minor injury
• Simple infection
• Hardware problem (like issues with a urinary catheter)

The exclusion criteria are:

• Younger than 16
• Third trimester pregnancy
• Not in the patient’s residence
• Residence is unsafe
• GCS < 15
• SpO2 < 95% on room air
• Heart rate > 100
• Systolic BP < 100
• Pain requiring narcotics
• Patient unable to wait four hours for further treatment

STUDY DESIGN
For patients meeting the eligibility criteria, the paramedics will call in, provide enrollment information and be told if the patient is randomized into the control arm (transport by ambulance to the ED) or the intervention arm (referral to the in-home hospital service).  Within four hours, a home hospital service nurse or nurse practitioner will respond to the patient’s residence for evaluation and treatment.  The patient might be treated and then released from the service, enrolled into ongoing care or referred to the ED.  As a side note for US readers, check out the website for Silver Chain, the home hospital service.  This is an amazing concept.

OUTCOMES
The primary outcome focus of the researchers is the proportion of patients needing unplanned medical care within 48 hours of enrollment.  The secondary outcome focuses include a variety of clinical, operational and investigatory measures.  Additionally, cost benefit and patient satisfaction data will be collected and analyzed.

ESTIMATED OUTCOMES
With an annual transport volume of approximately 100,000, researchers estimate that they can enroll roughly 10% of their total patient base in the study.  With a goal of 940 patients in both the control and intervention arms, it is estimated that patient enrollment will be completed within a year.

DISCUSSION
As I mentioned earlier, this is a truly exciting possibility.  If paramedics can be shown to safely determine whether or not a patient can be treated at home, it opens the door to diverting at least a portion of patients from overwhelmed Emergency Departments.  As the researchers note, there have been mixed messages in the literature about the ability of paramedics to safely evaluate patients for non-transport.  This study seems well designed and isn’t biting off too much at once.  By focusing on one piece at a time, the researchers appear to be approaching this type of program the right way.  I’ll keep an eye out for the completed study and will let you know the results when it is published, likely next year.

CITED ARTICLES
[1]- Arendts G, et al.: “ParaMED Home: A protocol for a randomised controlled trial of paramedic assessment and referral to access medical care at home”. BMC Emergency Medicine 2011; 11:7.

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Why Should You Care About Your Patients?

Posted by Patrick Lickiss on Aug 3, 2011 in Assessment, General, Research | 0 comments

Do you care about your patients or do you approach them like an auto mechanic would a malfunctioning car?  It’s an important distinction that sometimes gets lost in the shuffle of what we do day in and day out.  A call which is routine for a skilled practitioner may be anything but routine for a frightened patient.  About a year ago, I wrote about the importance of actually listening to your patients when you ask a question.  This idea of caring falls along the same lines.

I recently came across an abstract which looked at the benefits of a “caring” assessment in an ambulance service in Sweden ^[1].  According to the researchers, one of the major findings was that understanding of the patient’s “lifeworld” was vital for a complete evaluation of the patient’s condition.  What the heck is a lifeworld?  It sounds pretty new age if you ask me.

According to Webster’s dictionary, lifeworld is “the sum total of physical surroundings and everyday experiences that make up an individual’s world”. Well that makes a little more sense.  Basically, it’s the recognition that each patient has a series of experiences which alter their perception of the situation they find themselves in.  What are the chances that “lifeworld” could impact a patient’s disease process and the medical care best suited for them?  Probably pretty good.

In fact, the researchers found that a “medical only” assessment presented an “obstacle to a full understanding of the individual, and thereby the illness per se”. ^[1] The likelihood is that you perform this “caring assessment” on a regular basis.  Think about a patient complaining of chest pain and shortness of breath.  Is your top differential diagnosis cardiac?  At the very least it should be a “must not miss” diagnosis.  Now a good practitioner would start asking the patient about when the symptoms started.  If you find out that the patient just lost her husband to a long battle with cancer and that their wedding anniversary is today, does that change your differential diagnosis?  Probably.  My hope is that all of you actually take the patient’s “lifeworld” into account when building a differential and determining treatment.  Remember to actually listen to your patient’s narrative, you can learn a lot.

In the end, the abstract for this article doesn’t include any numerical results and doesn’t quantify why one assessment is better than another.  While that would have been nice, I don’t know that it’s really necessary.  A lot of this is just common sense.  If you ask the patient about their situation and listen to the answers in a caring manner, you’re more likely to get the whole story.  If you get the whole story, you’re more likely to make the right treatment decision and the patient is more likely to feel like their suffering was reduced.  They feel this way not because you treated their symptoms, but because you connected with them and took the time to listen and understand them.  It may take a little more effort, but I think it’s worthwhile.

CITED ARTICLES
[1] - Wireklint, SB & Dahlberg, K: “Caring assessment in the Swedish ambulance service relieves suffering and enables safe decisions”. International Emergency Nursing 2011 July; 19(3): 113-9.

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Evaluation of the Canadian C-Spine Rule Continues

Posted by Patrick Lickiss on Jul 27, 2011 in Assessment, General, Research, Treatment | 2 comments

In an article published in February in the BioMed Central of Emergency Medicine (an OPEN journal by the way, not charging $85/article!) a study protocol was laid out for the next phase in the evaluation of the safety of the Canadian C-Spine Rule (CCR).  The full text of the article may be found here (PDF link).

For those not familiar, the CCR is a spinal clearance tool which is basically a cross between the State of Maine and the NEXUS criteria you’ve likely seen physicians use in the ED.  There’s a nice flow chart in the article, but the basics are as follows:

• Does the patient have a high risk factor indicating immobilization?
  • Older than 64 years
  • Dangerous mechanism
  • Numbness/tingling
• Does the patient have one low risk factor?
  • Minor rear-end MVC
  • Ambulatory on scene
  • No neck pain when asked
  • No neck pain with palpation
• Can the patient rotate their own head, left and right, to 45 degrees, regardless of pain

I really like this technique because it just makes sense:  Do they have any big things to worry about?  No.  Do they have something which indicates they’re uninjured? Yes.  Can they move their head? Yes.  Fantastic, don’t c-spine!

A BRIEF HISTORY OF THE CCR
The researchers in Canada have clearly been doing their due diligence.   This project has been on going, in one form or another, for the past 10+ years.  The CCR was first written about in 2001 and was compared at the time to both the standard NEXUS exam and radiological results.  Since then, the procedure has been validated amongst physician, ED triage nurse and paramedic level practitioners.  During the phase I and II trials, the CCR demonstrated a 99.7% sensitivity ^[1].

The researchers have since implemented the protocol amongst physicians in  multiple hospitals and are studying implementation amongst ED triage nurses as well.  One line in the article really stuck in my head after reading it:  ”While we hope to demonstrate that ED triage nurses can safely remove patient’s cervical immobilization devices, it would be significantly more valuable if we could empower the paramedics to selectively forgo immobilization in the first place, and avoid great discomfort to patients.” ^[1] Simply put, I love this idea!  If we have access to a tool which can benefit our patients, why don’t we give it to everyone involved in patient care, so that we can significantly benefit our patients more often!

Additionally, I love the idea of standardizing something like ruling out spinal immobilization across all levels of care from pre-hospital to in-hospital.  The main thing holding this article/study back from being one of the most ground breaking in EMS is the actual statement that spinal immobilization is not, in fact, beneficial and actually harms our patients.  But that might be asking too much.

At any rate, check out the article and stay tuned, the idea of standardizing care across practitioner levels is an interesting one that bears more reflection.

ARTICLE CITED
[1] - Vaillancourt C, et. al: “Evaluation of the safety of C-spine clearance byparamedics: design and methodology”. BMC Emergency Medicine 2011 11:1.

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Pediatric Poisoning Refresher

Posted by Patrick Lickiss on Jul 13, 2011 in Assessment, General, Research, Treatment | 2 comments

While browsing through recent journal articles, I came across a retrospective study published by the University of California at San Diego Emergency Medicine Department ^[1]. Looking back at eight years worth of EMS documentation (this is one of the limitations of a retrospective study) the researchers attempted to quantity particular information about pediatric poisonings in that time period.  I say that this is a limitation of a retrospective study because the validity of the research relies on the quality of documentation performed before the study was designed.  This can prove to be time consuming and may not yield useful results.

THE FINDINGS

There were more than 40,000 paramedic transport calls for patients 5 years and younger over the study period; 996 (2.5%) of these calls had the chief complaint of poisoning. Of the calls classified as poisonings, 38% involved a 1-year-old and 35% involved a 2-year-old. Fifty-six percent of these poisonings involved either prescription or over-the-counter medications. An additional 16% were due to household cleaners. Eighty-eight percent of all calls were classified as mild in acuity, with 13% of poisoning calls for children under a year of age classified as moderate or acute; 50% of moderate or acute poisoning calls were to children 2 years of age. July and March were the months with the highest incidence of poisoning calls. The fewest calls were received on Saturdays and Sundays^[1].

There are a few items of interest in these findings.  First of all, the vast majority (over 70%) of poisonings take place with patients 2 years old and younger.  It seems like a lot of presentations in that population should including poisoning as a potential differential diagnosis, particularly if you are struggling to find a cause for the symptoms.  Next, the majority of poisoning calls for pediatrics involve medications.  Keep in mind that therapeutic effects in adults are potentially fatal in pediatrics.  This is especially true with regards to medications targeted at the cardiovascular system like digoxin and beta-blockers.  Finally, “moderate” or “acute” poisonings were more likely to occur with patients two years of age.  This is logical as these patients are becoming more active and mobile.  When responding to patients in this age group (for other calls, not for poisonings) take a quick look around on scene and see if there are medications or household cleaners in easy reach of children.  This is the perfect opportunity to provide some education to the family, particularly if you’re not the primary caregiver.

NATIONAL STATISTICS
According to the American Association of Poison Control Centers,  over 52% of poisonings in 2009 occurred in patients aged 0-5 years.  Since 2006, the pediatric ingestion of analgesics has seen a particularly marked increase ^[2].  According to the CDC, children are twice as likely to be seen in the Emergency Department for medication poisoning as they are for poisonings from household cleaners ^[3].

ACTIONS WE CAN TAKE
We discussed earlier about maintaining an elevated index of suspicion for poisoning in pediatric patients.  We also discussed gently providing education to caregivers when an unsafe situation is discovered on scene (though not necessarily during a response for poisoning).  What about treatment options?  Poison Control is a valuable resource and every EMS practitioner should have the number in his or her cell phone.  Poison Control is staffed by medical providers who are able to provide you with valuable information, even if you do not know the exact toxin which has been ingestion.  Often, the individual answering the phone will be able to determine the substance based on partial labels, color, uses, etc.  I have had excellent luck with identifying myself as a paramedic on scene of a 911 call after the line is answered.  I am often transferred to a pharmacist right away and have been able to get treatment suggestions as well as findings (including ECG changes) to watch out for.  After that, it’s as easy as contacting my base hospital, letting them know that I contacted poison control and getting an order to treat as suggested by the pharmacist.

I encourage everyone reading this to stop for a moment and put the following number in your phone:  (800)222-1222.  You can call that number from anywhere in the U.S. and you will be connected to your local poison control center.

So how about it?  Have you used Poison Control on duty?  What about off duty?  What was your experience like?  Are you taught about using Poison Control during annual training?  Let me know in the comments.

CITED ARTICLES
[1] - Vilke GM: “Pediatric Poisonings in Children Younger than Five Years Responded to by Paramedics”. J Emerg Med 2011 Jan 5, [Epub ahead of print].

[2] – American Association of Poison Control Centers – 2009 Detailed Statistics (PDF Link)

[3] – Centers for Disease Control and Prevention – Poisoning Factsheet

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