Objectives. Central MA EMS Corp. Field Triage Decision Scheme: The National Trauma Triage Protocol 5/27/2011

Transcription

1 Course GOAL Central MA EMS Corp. Region II Trauma Point-of-Entry Plan Region II Trauma Point-of-Entry Plan This presentation is designed to help you do your job as EMS providers more effectively by helping you improve your response to severely injured patients OEMS Approval # (2 hrs) Page 1 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 2 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Objectives Objectives Review the importance of accurate field triage Review the history of the American College of Surgeons Field Triage Decision Scheme Discuss changes in the 2006 Field Triage Decision i Scheme Field Triage Decision Scheme: The National Trauma Triage Protocol Review the criteria adopted by Massachusetts Discuss the Region II Trauma Point-of-Entry Plan details U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Injury Response Page 3 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 4 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 The Science behind the new guidelines Guidelines for Field Triage of Injured Patients: Recommendations of the National Expert Panel on Field Triage Published in CDC s Morbidity and Mortality Weekly Report (MMWR) January 2009 Available at the CDC website Published: January 2009 Available for FREE at: Page 5 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 6 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31,

2 Answer: Saving lives and reducing disability: Evidence-based Approach What was the number one cause of death for people ages 1-44 in the United States during 2006? Unintentional ti Injury Page 7 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 8 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 The STATS In 2004 alone, approximately 167,000 Americans died from injuries. An additional 41 million Americans sustained injuries serious enough to require an emergency department. t About 1 million EMS providers in the U.S. respond to 16.6 million transport calls per year and nearly half of these calls are related to injury. CDC-supported research shows... If you are severely injured, care at a Level I Trauma Center lowers your risk of death by 25%. Page 9 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Source: MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of traumacenter 10 Source: care American on mortality. Customer Satisfaction N Engl Index, J Oct. Med. 4, Jan. Jan 31, ; Page 354(4): What s It All About? Getting the right patient to the right place at the right time! Not all injuries require Level I Trauma Center care. Transporting less severely injured patients to a lower level TC or non-trauma center can help ensure that resources at Level I Trauma Centers are available for those patients who need them most. History of the Decision Scheme The American College of Surgeons (ACS) Committee on Trauma developed guidelines to designate trauma centers in 1976: - Set standards for personnel, facilities, and processes necessary for the best care of injured persons Follow-up studies showed mortality reduction in regions with trauma centers. Page 11 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 12 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31,

3 History of the Decision Scheme National consensus conference in 1987 resulted in first ACS field triage protocol, the Triage Decision Scheme The Decision Scheme serves as the basis for field triage of trauma patients in most EMS systems in the U.S. History of the Decision Scheme The Decision Scheme has been revised four times (1990, 1993, 1999, 2006) In the Centers for Disease Control and Prevention (CDC), with support from the National Highway Traffic Safety Administration (NHTSA), convened the National Expert Panel on Field Triage Page 13 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 14 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 National Expert Panel on Field Triage Membership National leadership, expertise, and contributions in the realm of injury prevention and control Members EMS Providers and Medical Directors Emergency Medicine Physicians and Nurses Trauma Surgeons Public Health Federal Agencies Automotive Industry National Expert Panel on Field Triage The role of the Expert Panel is to: Periodically review the Decision Scheme Ensure criteria are consistent with existing evidence Ensure criteria are compatible with advances in technology Make necessary recommendations for revision Page 15 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 16 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Field Triage Decision Scheme: The National Trauma Triage Protocol Step 1. Physiologic criteria, Step 2. Anatomic criteria, Step 3. Mechanism of injury criteria, and Step 4. Special patient or system considerations. This is the foundation for state trauma criteria and regional Trauma Point-of-Entry Plans. Steps of the decision scheme At each step, the decision scheme includes two transition boxes. One box indicates if the patient s condition is serious enough to require transport to a certain level of trauma care. The other box reveals that the patient s condition is not severe enough for trauma center attention but that transporting him or her to a hospital for observation and/or treatment should be according to protocol. In essence, the decision scheme helps you determine the gravity of the injury and the most appropriate destination facility for your patient or it helps you move further through the decision scheme criteria. Page 17 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 18 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31,

4 Why this Decision Scheme is Unique Takes into account recent changes in trauma assessment and care in the U.S., building on earlier versions. Adds views of a broader range of disciplines and expertise into the process Purpose The Decision Scheme was revised to: facilitate more effective triage better match trauma patients conditions with the medical resources best equipped to treat them. Page 19 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 20 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Step 1: 2006 Changes Added: Threshold for resp. rate (<20 breaths per minute) in infants Step 1: Physiologic Criteria EMS providers are taught the importance of respiratory rate assessment in infants. Practical triage criterion Respiratory rate can be easily measured. Page 21 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 22 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Step 1: 2006 Changes Removed: Revised Trauma Score Not a useful triage criterion Difficult and time-consuming to calculate EMS providers rarely calculate and use RTS as a decision-making tool; more useful for quality improvement and outcome measures Redundant; each of the RTS components (Glasgow coma scale, systolic BP, and respiratory rate) are already included in Step 1. Step 2: Anatomic Criteria Page 23 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 24 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31,

5 Step 2: 2006 Changes Added under Specific Injuries : Crushed, degloved, or mangled extremity Modified Open and depressed changed to open or depressed skull fracture Removed Burns moved to Step Four Step 3: Mechanism of Injury Criteria Page 25 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 26 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Added (for future use) Vehicle telemetry data consistent with high risk of injury (e.g., change in velocity, principle direction of force). Time Out What is vehicle telemetry? Combination of telematics and computing Integration of vehicle s electrical architecture, cellular communication, GPS systems, and voice recognition Can notify of exact location of crash Can enable communication with occupants Can provide key injury information to providers regarding force, mechanics, and energy of a crash that may help predict severity of injury For more information, visit: Page 27 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 28 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 High-risk auto collision? Modified Falls: Adults: >20 feet (one story = 10 feet) Children: >10 feet, or 2 3 times the child s height High speed auto crash was changed to high-risk auto crash Q: (Why do you think this change was made?) Page 29 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 30 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31,

6 Modified Intrusion modified to >12 inches at occupant site (passenger cabin) or >18 inches at any site (Intrusion refers to interior compartment intrusion, not exterior deformation of the vehicle.) Modified, continued Auto-pedestrian/struck/auto-bicycle injury changed to Auto v. pedestrian/bicyclist thrown, run over, or with significant (>20mph) impact Motorcycle crash details shortened to: Motorcycle crash >20mph Page 31 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 32 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Motorcycle crash >20mph? Removed: Rollover crash Increased injury severity associated with rollover crashes due to ejection, either partially or completely (usually when unrestrained) Ejection already a criterion for transport to TC under Mechanism-of-Injury Page 33 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 34 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Removed: Extrication time >20 minutes Modifications made to the triage protocol for cabin intrusion adequately address issues relevant to extrication time New auto technology is increasing the number of non-seriously injured patients who may require more than 20 minutes for extrication Removed: Crush depth & Vehicle deformity >20 inches and vehicle speed >40 mph Intrusion is already a criterion for transport to a trauma center associated with a high- risk MVC. Page 35 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 36 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31,

7 Step 4: Special Considerations Added Burns (moved from Anatomic Criteria to Special Considerations) Burn patients without other trauma should be transported to a burn center rather than a trauma center Not applicable for Region II (patient is transported to TC unless otherwise directed by Medical Control) Page 37 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 38 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Added Time-sensitive extremity injuries Not all hospitals able to evaluate whether additional intervention is required to preserve limb Substantial risk for morbidity even if they do not meet Anatomic Criteria Contact Medical Control and consider transport to the closest Level 1 or 2 Trauma Center Added End stage renal disease requiring hemodialysis Often coagulopathic Increases risk for and severity of hemorrhage EMS Provider judgment Impossible to predict all possible trauma circumstances Expertise/experience to make judgments in atypical situations Routinely make triage decisions Page 39 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 40 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Modified Age Older adults (55+): Increased risk of injury/death after age 55 Children (<15 years): Should be triaged to pediatric trauma centers -- Pregnancy Changed to read Pregnancy greater than 20 weeks (closer to fetal gestational age for potential viability) Removed: Cardiac and respiratory disease underlying medical conditions that can make consequences of injuries more difficult to manage but the presence of the disease itself should not mandate transfer to a trauma center Page 41 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 42 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31,

8 Removed Diabetes Mellitus No data indicate that the presence of diabetes or hyperglycemia outside of other trauma criteria requires transport to a high-level trauma center Morbid obesity Injuries that do not meet trauma center criteria may be adequately managed at non-trauma hospitals Removed Immunosuppression By itself does not increase risk or severity of injury Cirrhosis Without coagulopathy, and outside of other trauma criteria, does not increase the risk for severe injury Contact Medical Control and consider transport to closest Level 1 or 2 Trauma Center if injured cirrhotic patients have or are suspected of having coagulopathy Page 43 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 44 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Massachusetts Trauma Triage Criteria Incorporates new and/or revised CDC recommended criteria Removes time limit for transport to Trauma Center, consistent with CDC recommendations Requires MA Trauma Centers to be ACS verified (minimum standard) or MDPH designated (exceeds ACS standard) Region II Trauma POE Plan Includes statewide trauma field triage criteria based on CDC recommendations Recognizes Level I and II Trauma Centers with ACS (American College of Surgeons) verification Specifies which Trauma Centers are acceptable destinations for patients originating from within Region II. Page 45 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 46 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Frequently Asked Questions Region II Trauma Point-of-Entry Plan Q: What if I work in a different Region as well? A: You will need to be familiar with that Region s Trauma POE Plan (main difference will be TC destinations). Q: What if I m closer to an out-of-state hospital that is called a trauma center? A: Not all states require hospitals to be ACS verified before they can use the title trauma center. Only those Trauma Centers listed on the Region II Plan meet the criteria. All other hospitals, even if they call themselves a trauma center, should be treated as any other hospital. List format rather than algorithm format due to complexity of information Every EMT working in Region II should receive a copy of and become familiar with the Region II Trauma POE Plan. CMED can facilitate ALS Intercept for you when traveling the extra distance to a Level 1 Trauma Center (UMass). Page 47 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 48 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31,

9 Endorsing Organizations Endorsing Organizations With concurrence from the National Highway Traffic Safety Administration Page 49 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 50 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 References For more information visit: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System. Ten Leading Causes of Death, MacKenzie EJ, Rivara FP, Jurkovich GJ, Nahens AB, Frey KP, Egleston BL, Salkever DS, Scharfstein DO. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med Jan 26; 354(4): Centers for Disease Control and Prevention. Guidelines for Field Triage of Injured Patients, Recommendations of the National Expert Panel on Field Triage. MMWR 2009; 58 (1): Page 51 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31, 2009 Page 52 Source: American Customer Satisfaction Index, Oct. 4, 2008 Jan. 31,