Prehospital Trauma Triage Decision-making: A Model of What Happens between the 9-1-1 Call and the Hospital

Abstract

Objective We describe the decision-making process used by emergency medical services (EMS) providers in order to understand how: 1) injured patients are evaluated in the prehospital setting; 2) field triage criteria are applied in-practice; and 3) selection of a destination hospital is determined. Methods We conducted separate focus groups with advanced and basic life support providers from rural and urban/suburban regions. Four exploratory focus groups were conducted to identify overarching themes and five additional confirmatory focus groups were conducted to verify initial focus group findings and provide additional detail regarding trauma triage decision-making and application of field triage criteria. All focus groups were conducted by a public health researcher with formal training in qualitative research. A standardized question guide was used to facilitate discussion at all focus groups. All focus groups were audio-recorded and transcribed. Responses were coded and categorized into larger domains to describe how EMS providers approach trauma triage and apply the Field Triage Decision Scheme. Results We conducted 9 focus groups with 50 EMS providers. Participants highlighted that trauma triage is complex and there is often limited time to make destination decisions. Four overarching domains were identified within the context of trauma triage decision-making: 1) initial assessment; 2) importance of speed versus accuracy; 3) usability of current field triage criteria; and 4) consideration of patient and emergency care system-level factors. Conclusions Field triage is a complex decision-making process which involves consideration of many patient and system-level factors. The decision model presented in this study suggests that EMS providers place significant emphasis on speed of decisions, relying on initial impressions and immediately observable information, rather than precise measurement of vital signs or systematic application of field triage criteria.

Paramedic Judgement, Decision-Making and Cognitive Processing: A Review of the Literature

“…After removal of duplicates, a total of 362 abstracts and titles were reviewed and from that, the full text of 59 articles were further assessed resulting in six articles included in the final summary. One article (47) was quantitative using a Likert scale survey, while four articles utilised a qualitative approach (48)(49)(50)(51) with the remaining article mixed-methods (52). Of the qualitative articles a mixture of data collection was used including interviews (48)(49)(50)52), clinical scenarios (18,49), case study (51), questionnaire survey (47,52) and real-life observation (50).…”

“…This theme appeared across studies examining various types of settings seen in paramedic practice including mental illness (51), trauma triage and hospital destination choices (49), as well as during general paramedic practice (52). For example, Shaban (51) reported sub-conscious processes were a significant driving theme encompassing safety (patient and paramedic) in mental illness attendances, whereas Jones et al (48) reported its use where speed over accuracy was warranted in the setting of trauma amidst abundant time-sensitive pressures. Paramedics in Ryan and Halliwell (52) also reported making intuitive-driven decisions overall based on pattern recognition pulling from previous experience.…”

“…Wyatt's participants also responded to unfamiliar problems with problem solving heuristics (mental shortcuts) (50), and Ryan and Halliwell (52) emphasised the application of tools such as mnemonics and checklists to gather clinical data to aid in a systematic approach. Clinical guidelines (or protocols) were also implemented (algorithmic thinking), however, were not seen to be blindly followed in word-for-word fashion, but rather interpreted via the lens of prior experiences, particularly among more senior paramedics (48,50). Jones et al (48) argued that decision-making is not linear, patient assessments, interactions and their needs are not linear, and so guidelines, which are fashioned in a linear step-by-step fashion, were not often used in the setting of trauma triage.…”

Promotion of prehospital emergency care through clinical decision support systems: opportunities and challenges

“…25 Andersen 25 showed that this model provides a schematic overview of reasoning in dual-process theory. Decision making in emergency medical services emphasizes speed; therefore, Jones et al 28 proposed a medical decision making model in emergency medical services to describe how patients are evaluated in prehospital care, triage is applied, and the destination hospital is determined. Fig.…”

Multicenter Analysis of Transport Destinations for Pediatric Prehospital Patients

“…Little is known about the frequency with which children are transported to a hospital with higher‐level pediatric resources. Most prior research on destination decision‐making has focused on the identification of injured patients who need a trauma center . However, transport to hospitals with higher‐level pediatric resources can be just as important for patients with medical‐related complaints as it is for trauma‐related complaints.…”