Triage & TransportNur Rachmat LubisDivisi Orthopaedi, Departemen Bedah FK UNSRI/ RS dr M. HoesinPalembang

Triage

[French, from trier, to sort, from Old French.]A method of quickly identifying victims who have immediately life-threatening injuries AND who have the best chance of surviving.

What is Trauma Triage?A method of matching the needs of the trauma patient to the resources of the hospital.

Trauma patients are assessed and transported to the most appropriate hospital for that patients injuries.

Clinical practiceNormal clinical practiceMultiple-casualty incidentMass casualties

Triage = Processby which priorities are set for the management of mass casualties.

Trauma TriageAppropriate: Right Patient to the Right Hospital at the Right TimeOVER Triage:Minimally injured pts are transported to Trauma CentersResult: Overburdens the system, no ill effect on pt careUNDER Triage:Severely injured pts are transported to Non-Trauma Centers Result: Hospitals may not be equipped to treat the pt and pt care may suffer

How do we perform Trauma Triage?Triage & Transport Pathways CardStandardized Injury Severity IndicatorsGCS RTSProvider experience/judgment

Steps to Increase Likelihood of Appropriate Trauma Triage Know the Trauma Triage and Transport Pathways Be familiar with severity indicators (GCS & RTS)Know your local resourcesOn Scene: Mutual Aid, ALS Intercept, Air TransportHospital: Local Hospital capabilities & distance to Regional Trauma Center

TaggingComplements TriageRapid Identification of patientColor Coded / Bar Coded systemPlastic bands can substitute tags

Noji et al, NEJM

SpeedAccuracyOrganization

3 AssessmentsVentilationPerfusionCognition2 TreatmentsAirway MaintenanceHemorrhage Control

START SYSTEMCreated in the 1980s by Hoag Hospital and the Newport Beach CA Fire DeptAllows rapid assessment of victimsIt should not take more than 15 sec/ PtOnce victim is in treatment area more detailed assessment should be made

START SYSTEMClasification is based on three items

RespiratoryPerfusionMental status evaluation

START First StepCan the Patient Walk?YESNOGreen (Minor)Evaluate Ventilation(Step-2)

START Step-2Ventilation Present?YESNO> 30/Min< 30/minEvaluate Circulation(Step-3)Open AirwayVentilation Present?NOYESBlackRed/ ImmediateRed/ Immediate

START Step-3CirculationAbsent Radial PulseControl HemorrhagePresent Radial PulseEvaluate Level of ConsciousnessRed/ Immediate

START Step-4Cant Follow Simple CommandsLevel of ConsciousnessCan Follow Simple CommandsYellow/ DelayedRed/ Immediate

Transport DecisionInjury SeverityHospital capability, location, driving timeArea Level III Trauma Hospital is 10 minutesRegional Level I Hospital is 20 minutesALS intercept is unavailable

The referring physician should contact physicians at the receiving hospital directly and provide the following information:1. Brief history of the injury.2. Current status of the patient including vital signs, physical exam and pertinenthistory, and any treatment rendered.3. Mode of transport, destination, and estimated time of arrival.Transport/Transfer Guidelines

Summary of triage theory & philosophy: sorting by priority A simple emergency plan: personnel, space, infrastructure, equipment, supplies = system

"Best for most" policy

Priority patients are those with a good chance of good survival.

JUST DO ITThank you

**The goal of prehospital care of trauma patients is to minimize injury through safe and rapid transport of the patient to the facility most appropriately equipped and staffed to treat the patients injuries. This is where trauma triage plays a crucial role. What exactly is trauma triage? It is a process by which trauma patients are assessed and transported to the most appropriate trauma facility for that patients injuries. This goes back to the Trauma System goal of getting the right patient to the right hospital in the right time.

*Normal clinical practice: one doctor or nurse and one patient. = Do everything possible for every patient.Multiple-casualty incident: one doctor and many patients. = Triage, but still capable of dealing with all patients.Mass casualty: one doctor overwhelmed by casualties. = Triage, do what you can for the greatest number.Smallest surgery for biggest results.Triage = not dogmatic, not a series of rules, but a LOGICAL approach and a philosophy.*Inaccuracy in trauma triage results in either over-triage (minimally inured patients are transferred to trauma centers) or under-triage (severely inured patients are taken to non-trauma centers). In under-triage, critically injured patients are taken to hospitals that are not fully staffed or equipped to meet all of the patients life- and limb-saving needs. In over-triage, minimally injured patients are taken to trauma centers that may already be overburdened with critical trauma patients.

When triaging patients, a priority is generally given to reducing under-triage because under-triage may result in preventable disability and death from delays to definitive care. Although over-triage causes minimal to no adverse effects on the patient, it does result in excessive cost and burden to the trauma center. According to the American College of Surgeons Committee on Trauma (ACS COT), in most systems an under-triage rate of 5-10% is considered unavoidable and is associated with an over-triage rate 30-50%. The trauma systems performance improvement plan is designed to evaluate the triage criteria to afford the best balance between access to quality care for severely injured patients without overtaxing the receiving trauma facility with minimally injured patients or inappropriately transporting minimally injured patients long distances.

*OVERVIEW only more detail on the next slide

Triage Card: provided in your handout/folder. More are available through the NHBEMS and the EMS-C Program

RTS & GCS: We realize these scores might not be calculated by every provider in the field, BUT they are important tools to identify major trauma patients (those who need a Trauma Center)

Provider Experience & Judgment: That feeling in your gut that tells you sick v. not sick. ALSO know your local resources.*In order to perform Trauma Triage accurately, providers must be familiar with severity indicators, or scoring systems and scales. These are outlined below/later. In addition, providers must discuss in a proactive manner their local resources including their own abilities, ALS intercept, air medical resources, local hospital capabilities, and regional trauma center distance and capabilities. Algorithms on which types of patients to transport where must be developed in cooperation with local medical control.

Every person in New Hampshire who has sustained a significant or critical injury should be transported to a hospital which has the capability of providing definitive trauma care for that patients injuries. Every person who has sustained a minor or moderate injury should be transported to the nearest hospital. Potential exceptions to this may be applied if prehospital providers are: 1). unable to maintain an adequate airway or 2). if the expected transport time to a trauma center exceeds 30 minutes. In the first case, and possibly in the second case, it is appropriate to transport the patient to the nearest hospital. *Tagging is an activity that should occur simultaneously to the primary triage process, one a patient is classified it should be tagged so that rescue technicians identify those that need to be transported and treated.*Most disaster triage systems utilize a color category, in particular the START triage system uses the colors red, yellow, green and black, based on physical exam findings and how these correlate with a probability of survival.*Flow of Patients one triaged. Please note how both walking wounded (green) and non-salvageable (black) stay out side the treatment area. Also note that as patients status can change, triage should be dynamic in an effort to asses changes categories.***Triage scheme as recommended by the Simple Triage and Rapid Treatment protocol. Not how the first question is Is the Patient a Walking Wounded if so categorize as green.*****Acceptable Actions:Decision to assign this patient a Status II DeterminationDecision to provide a trauma communication to the hospital which includes your Status Determination, Incident Facts, and a description of patient informationDecision to provide this patient with a rapid assessment, care, and transportationDecision in coordination with Medical Control to transport this patient to a Regional Level II Trauma Hospital after providing them with the following information to assist in making this decision: calculation of Status II; calculation of GCS 12, RTS 10, chest wall injury, RR >29, MOI +Decision not to request air transport via Medical Control due to travel times by ground to a Regional Level II Trauma HospitalKey Points:Review the importance of pre-planning your service area resources, advanced life support, and air medical transportReview the importance of recognizing early which patients need to go to what Level Trauma Hospital and how to communicate to Medical ControlReview the significance of using Status Determinations and early trauma communication with the hospitalReview Trauma Triage criteria that providers should utilize when making transport decisions, including air medical transport

*Emergency plan does not cost money, organisation does not cost money. It costs time, effort and motivation.