Prospective Validation of the National Field Triage Guidelines for Identifying Seriously Injured Persons

Abstract

Background: The national field trauma triage guidelines have been widely implemented in US trauma systems, but never prospectively validated. We sought to prospectively validate the guidelines, as applied by out-of-hospital providers, for identifying high-risk trauma patients.

Study design: This was an out-of-hospital prospective cohort study from January 1, 2011 through December 31, 2011 with 44 Emergency Medical Services agencies in 7 counties in 2 states. We enrolled injured patients transported to 28 acute care hospitals, including 7 major trauma centers (Level I and II trauma hospitals) and 21 nontrauma hospitals. The primary exposure term was Emergency Medical Services' use of one or more field triage criteria in the national field triage guidelines. Outcomes included Injured Severity Score ≥16 (primary) and critical resource use within 24 hours of emergency department arrival (secondary).

Results: We enrolled 53,487 injured children and adults transported by Emergency Medical Services to an acute care hospital, 17,633 of which were sampled for the primary analysis; 13.9% met field triage guidelines, 3.1% had Injury Severity Score ≥16, and 1.7% required early critical resources. The sensitivity and specificity of the field triage guidelines were 66.2% (95% CI, 60.2-71.7%) and 87.8% (95% CI, 87.7-88.0%) for Injury Severity Score ≥16 and 80.1% (95% CI, 65.8-89.4%) and 87.3% (95% CI 87.1-87.4%) for early critical resource use. Triage guideline sensitivity decreased with age, from 87.4% in children to 51.8% in older adults.

Conclusions: The national field triage guidelines are relatively insensitive for identifying seriously injured patients and patients requiring early critical interventions, particularly among older adults.

Figure 1

Enrollment and sampling schematic. Numbers in bold represent patients sampled for the primary sample.

Figure 2

Frequency of individual field triage criteria applied by Emergency Medical Services personnel among patients with known triage criteria (n = 4,372); 60% of the 7,299 triage-positive patients had individual triage criteria known and formed the denominator for this figure.

Figure 3

Sensitivity and specificity of field triage practices in 7 counties using the national field trauma triage guidelines, initial hospital destination, and final hospital destination (n = 17,633). Critical resources within 24 hours included emergent intubation in the emergency department; major nonorthopaedic surgical intervention (ie, brain, spine, neck, thorax, abdominal-pelvic, or vascular surgery); interventional radiology procedures; packed RBC transfusion ≥6 U (or any transfusion in a child); or death. Estimates based on “field triage criteria” are calculated without respect to the type of hospital to which a patient was transported. Estimates using “initial hospital” are based on the type of hospital to which a patient was initially transported (ie, Level I or II trauma center vs other), regardless of field triage status. Results using “final hospital” are based on the final hospital destination (Level I or II vs other) after accounting for inter-hospital transfers, regardless of field triage status.

Figure 4

(A) Sensitivity and (B) specificity of the national field triage criteria in 7 counties, by age group (n = 17,633).