Deciphering the use and predictive value of "emergency medical services provider judgment" in out-of-hospital trauma triage: a multisite, mixed methods assessment

Abstract

Background: "Emergency medical services (EMS) provider judgment" was recently added as a field triage criterion to the national guidelines, yet its predictive value and real world application remain unclear. We examine the use and independent predictive value of EMS provider judgment in identifying seriously injured persons.

Methods: We analyzed a population-based retrospective cohort, supplemented by qualitative analysis, of injured children and adults evaluated and transported by 47 EMS agencies to 94 hospitals in five regions across the Western United States from 2006 to 2008. We used logistic regression models to evaluate the independent predictive value of EMS provider judgment for Injury Severity Score ≥ 16. EMS narratives were analyzed using qualitative methods to assess and compare common themes for each step in the triage algorithm, plus EMS provider judgment.

Results: 213,869 injured patients were evaluated and transported by EMS over the 3-year period, of whom 41,191 (19.3%) met at least one of the field triage criteria. EMS provider judgment was the most commonly used triage criterion (40.0% of all triage-positive patients; sole criterion in 21.4%). After accounting for other triage criteria and confounders, the adjusted odds ratio of Injury Severity Score ≥ 16 for EMS provider judgment was 1.23 (95% confidence interval, 1.03-1.47), although there was variability in predictive value across sites. Patients meeting EMS provider judgment had concerning clinical presentations qualitatively similar to those meeting mechanistic and other special considerations criteria.

Conclusions: Among this multisite cohort of trauma patients, EMS provider judgment was the most commonly used field trauma triage criterion, independently associated with serious injury, and useful in identifying high-risk patients missed by other criteria. However, there was variability in predictive value between sites.

Figure 1

Frequency of using the “EMS Provider Judgment” criterion among triage-positive patients, by site (n = 41,191).

Figure 2

Unadjusted and adjusted odds ratios for serious injury and specialized trauma resource use among each of the triage steps and EMS provider judgment (n = 80,918). *Unadjusted odds ratios were generated using bivariable logistic regression, including triage step and the outcome, without adjustment for other triage criteria or confounders. †Adjusted odds ratios were generated from multivariable logistic regression models including: triage criteria categories (physiologic, anatomic, mechanism, special considerations), EMS provider judgment, age, gender, field intravenous line placement, hospital type and site.