Evaluation of the Prehospital Index, presence of high-velocity impact and judgment of emergency medical technicians as criteria for trauma triage

Abstract

Objective:We sought to evaluate the performance of the Prehospital Index (PHI), the high-velocity impact (HVI) criterion and emergency medical technician (EMT) judgment for the prehospital triage of injured patients.Methods:The study population included all prehospital trauma patients transported by an emergency medical service to 2 level-I trauma centres for adults. All prehospital run sheets were linked to trauma registry data. The main outcome was severe trauma, defined as death within 72 hours, admission to the intensive care unit within 24 hours or an Injury Severity Score greater than 15. We assessed sensitivity, specificity and rates of overtriage.Results:Of 16 805 patients in the study population, 1113 (6.62%) had severe trauma. The combination of all 3 triage criteria (PHI score ≥ 4, HVI presence and EMT judgment) performed best for identifying patients with severe trauma, with a sensitivity of 74.2% but with an overtriage rate of 85.1%. Alone, EMT judgment had the highest sensitivity and a PHI score of 4 or greater had the lowest rate of overtriage.Conclusion:Although the combination of PHI score, HVI presence and EMT judgment offers the highest sensitivity for the identification of patients that could benefit from direct transport to a level-I trauma centre, overall sensitivity remains low and overtriage is high. More research is required to improve prehospital triage.

Deciphering the use and predictive value of “emergency medical services provider judgment” in out-of-hospital trauma triage

“…Our qualitative results suggest that patients meeting only the provider judgment criterion have similar clinical and situational presentations to patients meeting mechanistic (step 3) and other special considerations (step 4) criteria. While previous studies have had mixed results regarding the utility of EMS provider judgment in trauma triage, 4-12 we show that the cognitive reasoning processes encapsulated in this criterion can help identify seriously injured patients potentially missed by other triage criteria. However, our data also illustrate that the predictive value of this criterion varies between EMS systems, with strong predictive value in some systems and no apparent value in others.…”

“…One of the criteria added to the 2006 revised guidelines was “EMS provider judgment,” 3 though literature demonstrating the utility of provider judgment has been mixed. 4-12 Previous studies have suggested that EMS provider judgment can improve the sensitivity of field triage, 5-7,9,10,12 enhance the accuracy of other triage criteria, 11 or have no effect on triage accuracy. 4,8 A recent review of the literature found “no clear evidence supporting paramedic judgment as an accurate triage method,” but noted that variability in outcome measures and research methodology limited definitive conclusions.…”

A simplified trauma triage system safely reduces overtriage and improves provider satisfaction: a prospective study

“…Another study of prehospital triage demonstrated that adding variables such as ''high velocity impact'' and '' emergency medical technician (EMT) judgment'' significantly increased overtriage without improving triage sensitivity for detecting severe injury. 17 Multiple additional studies have demonstrated that overtriage can be significantly and safely reduced by excluding select variables from both prehospital and in-hospital triage guidelines. 18-20 A common finding among these studies has been the poor predictive value of mechanistic variables, which appears to have no additional value when used in conjunction with anatomic and physiologic variables.…”

Value of prehospital assessment of spine fracture by paramedics

“…Although previous research has shown that paramedics can accurately predict injury severity [ 22 – 24 ], the accuracy of spine fracture prediction has not yet been investigated. The purpose of this study was to answer the following question: how accurate can paramedics predict the presence of a spinal fracture?…”