Last data update: May 06, 2024. (Total: 46732 publications since 2009)
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Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage
Sasser SM , Hunt RC , Sullivent EE , Wald MM , Mitchko J , Jurkovich GJ , Henry MC , Salomone JP , Wang SC , Galli RL , Cooper A , Brown LH , Sattin RW . MMWR Recomm Rep 2009 58 1-35 In the United States, injury is the leading cause of death for persons aged 1--44 years, and the approximately 800,000 emergency medical services (EMS) providers have a substantial impact on the care of injured persons and on public health. At an injury scene, EMS providers determine the severity of injury, initiate medical management, and identify the most appropriate facility to which to transport the patient through a process called "field triage." Although basic emergency services generally are consistent across hospital emergency departments (EDs), certain hospitals have additional expertise, resources, and equipment for treating severely injured patients. Such facilities, called "trauma centers," are classified from Level I (centers providing the highest level of trauma care) to Level IV (centers providing initial trauma care and transfer to a higher level of trauma care if necessary) depending on the scope of resources and services available. The risk for death of a severely injured person is 25% lower if the patient receives care at a Level I trauma center. However, not all patients require the services of a Level I trauma center; patients who are injured less severely might be served better by being transported to a closer ED capable of managing milder injuries. Transferring all injured patients to Level I trauma centers might overburden the centers, have a negative impact on patient outcomes, and decrease cost effectiveness. In 1986, the American College of Surgeons developed the Field Triage Decision Scheme (Decision Scheme), which serves as the basis for triage protocols for state and local EMS systems across the United States. The Decision Scheme is an algorithm that guides EMS providers through four decision steps (physiologic, anatomic, mechanism of injury, and special considerations) to determine the most appropriate destination facility within the local trauma care system. Since its initial publication in 1986, the Decision Scheme has been revised four times. In 2005, with support from the National Highway Traffic Safety Administration, CDC began facilitating revision of the Decision Scheme by hosting a series of meetings of the National Expert Panel on Field Triage, which includes injury-care providers, public health professionals, automotive industry representatives, and officials from federal agencies. The Panel reviewed relevant literature, presented its findings, and reached consensus on necessary revisions. The revised Decision Scheme was published in 2006. This report describes the process and rationale used by the Expert Panel to revise the Decision Scheme. |
Large cost savings realized from the 2006 Field Triage Guideline: reduction in overtriage in U.S. trauma centers
Faul M , Wald MM , Sullivent EE , Sasser SM , Kapil V , Lerner EB , Hunt RC . Prehosp Emerg Care 2011 16 (2) 222-9 BACKGROUND: Ambulance transport of injured patients to the most appropriate medical care facility is an important decision. Trauma centers are designed and staffed to treat severely injured patients and are increasingly burdened by cases involving less-serious injury. Yet, a cost evaluation of the Field Triage national guideline has never been performed. OBJECTIVES: To examine the potential cost savings associated with overtriage for the 1999 and 2006 versions of the Field Triage Guideline. METHODS: Data from the National Hospital Ambulatory Medical Care Survey and the National Trauma Databank (NTDB) produced estimates of injury-related ambulatory transports and exposure to the Field Triage guideline. Case costs were approximated using a cost distribution curve of all cases found in the NTDB. A two-way sensitivity analysis was also used to determine the impact of data uncertainty on medical costs and the reduction in trauma center visits (12%) after implementation of the 2006 Field Triage guideline compared with the 1999 Field Triage guideline. RESULTS: At a 40% overtriage rate, the average case cost was $16,434. The cost average of 44.2% reduction in case costs if patients were treated in a non-trauma center compared with a trauma center was found in the literature. Implementation of the 2006 Field Triage guideline produced a $7,264 cost savings per case, or an estimated annual national savings of $568,000,000. CONCLUSION: Application of the 2006 Field Triage guideline helps emergency medical services personnel manage overtriage in trauma centers, which could result in a significant national cost savings. |
Reduced mortality in injured adults transported by helicopter emergency medical services
Sullivent EE , Faul M , Wald MM . Prehosp Emerg Care 2011 15 (3) 295-302 BACKGROUND: Some studies have shown improved outcomes with helicopter emergency medical services (HEMS) transport, while others have not. Safety concerns and cost have prompted reevaluation of the widespread use of HEMS. OBJECTIVE: To determine whether the mode of transport of trauma patients affects mortality. METHODS: Data for 56,744 injured adults aged ≥18 years transported to 62 U.S. trauma centers by helicopter or ground ambulance were obtained from the National Sample Program of the 2007 National Trauma Data Bank. In-hospital mortality was calculated for different demographic and injury severity groups. Adjusted odds ratios (AOR) were produced by utilizing a logistic regression model measuring the association of mortality and type of transport, controlling for age, gender, and injury severity (Injury Severity Score [ISS] and Revised Trauma Score [RTS]). RESULTS: The odds of death were 39% lower in those transported by HEMS compared with those transported by ground ambulance (AOR = 0.61, 95% confidence interval [CI] = 0.54-0.69). Among those aged ≥55 years, the odds of death were not significantly different (AOR = 0.92, 95% CI = 0.74-1.13). Among all transports, male patients had a higher odds of death (AOR = 1.23, 95% CI = 1.10-1.38) than female patients. The odds of death increased with each year of age (AOR = 1.040, 95% CI = 1.037-1.043) and each unit of ISS (AOR = 1.080, 95% CI = 1.075-1.084), and decreased with each unit of RTS (AOR = 0.46, 95% CI = 0.45-0.48). CONCLUSION: The use of HEMS for the transport of adult trauma patients was associated with reduced mortality for patients aged 18-54 years. In this study, HEMS did not improve mortality in adults aged ≥55 years. Identification of additional variables in the selection of those patients who will benefit from HEMS transport is expected to enhance this reduction in mortality. |
Blast injuries from bombings: what craniofacial and maxillofacial surgeons need to know
Armstrong JH , Sullivent EE , Sasser SM . J Craniofac Surg 2010 21 (4) 954-9 Why should specialists in craniofacial and maxillofacial surgery care about blast injury from bombings, and what is important to know about blast injuries? The recently revised bombings curriculum Bombings: Injury Patterns and Care, Version 2.0, released through the Centers for Disease Control and Prevention National Center for Injury Prevention and Control, provides answers by addressing the global context of bombings, reviewing the 4 mechanisms of blast injury, and describing the management and care of blast casualties. |
Managing traumatic brain injury secondary to explosions
Burgess P , Sullivent EE , Sasser SM , Wald MM , Ossmann E , Kapil V . J Emerg Trauma Shock 2010 3 (2) 164-172 Explosions and bombings are the most common deliberate cause of disasters with large numbers of casualties. Despite this fact, disaster medical response training has traditionally focused on the management of injuries following natural disasters and terrorist attacks with biological, chemical, and nuclear agents. The following article is a clinical primer for physicians regarding traumatic brain injury (TBI) caused by explosions and bombings. The history, physics, and treatment of TBI are outlined. |
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