Section 3. System Support and Development

Clinical Framework

3.0 Triage and Transfer

Introduction

For a trauma system to function effectively, major trauma patients must be identified in the field and then transported to specialist trauma facilities able to manage them. Trauma triage refers to the process of sorting patients according to the kind of injury, severity of the injury and facilities available. The ideal triage method would be applied quickly and easily under field conditions, give consistent results among different observers, and have a high rate of accuracy (Eastman, 1987).

The goal of a triage system is to consistently get the right patient to the right hospital in the right amount of time. In Victoria, this effectively means getting as many major trauma patients as possible into hospitals with specialist trauma skills in the least amount of time.

The level of care available at the destination has a significant impact on outcome (Sampalis et al., 1997; Cooper et al., 1998). It is therefore optimal to access the highest level trauma service possible within logistic and safety parameters. The Taskforce and Working Party considered at length the balance to be struck between destination and transport time.

The Taskforce endorses the triage and transfer guidelines (Appendices 7.1 - 7.4) developed by the Working Party. For each guideline, more detailed accompanying explanatory notes will be developed during industry consultation in the implementation phase. Triage and transfer guidelines aim to achieve definitional and interpretive consistency. These recommended triage guidelines will be subject to substantial and continuing audit by the STC and MECCC.

Triage Model

The Working Party selected the ACEP (1993) model trauma triage guidelines for local adaptation. This model has been applied to large populations nationally and is based on the identification of major trauma according to physiological, anatomical and mechanistic criteria. As these guidelines are similar to those already in use by ASV for identifying time-critical trauma patients, there is local support for their continued use.

Expertise in trauma management is difficult to develop and maintain, in part related to its relatively low incidence. Improved clinical outcomes are associated with some degree of concentration of experience. Major trauma management is, therefore, considered a specialised activity, much like burns or spinal care. This is the basis for proposing a triage model that mandates primary triage or secondary transfer to MTS for most major trauma patients.

Triage Destination and Transport Times

Transport time is determined with consideration of the 'golden hour' in trauma care (Petri, 1995). Given average activation and scene times, the Working Party considered that initially the 30-minute transport time would deliver most patients to an appropriate hospital within an hour of injury. This recognises that some flexibility in the 30-minute transport time is permissible if this means delivering a major trauma patient directly to a MTS, as definitive treatment in a MTS is one of the goals of the VSTS. Paediatric patients currently experience longer prehospital transport times, often up to 60 minutes. Physiological response to injury in children often permits this and so allows transport direct to the RCH.

There is evidence from some studies that the 'safe' prehospital transport time in adults may be up to 60 minutes. This is in the context of a system which delivers a high level of paramedic skill, and in which hospital designation has been achieved, and patients are delivered to appropriate hospitals for their level of injury (Petri et al., 1995; Feero et al. 1995). The Working Party determined it would be best to work with 30 minutes transport time cut-off in the initial phase and to closely monitor the triage process. Any future changes to lengthen or shorten transport cut-off time would be on the basis of audit data and on the advice of the STC. The Working Party has, therefore, recommended the following approach for prehospital triage of major trauma patients (see Figure 3.1).

Where a major trauma patient is less than 30 minutes transport time from a MTS, the patient should be transported to that service bypassing other hospitals. The aim is to minimise the time from injury to definitive treatment (Eastman, 1987). This is best achieved by primary triage of major trauma patients from the scene of injury to a MTS and by avoiding subsequent need for acute interhospital transfer whenever possible (Trunkey, 1983; Cales, 1985; Sampalis, 1993).

Where a major trauma patient is more than 30 minutes transport time from a MTS, the patient should be transported to the highest designated trauma service accessible within 30 minutes.

Where, in the ambulance paramedic's judgement, a major trauma patient's condition deteriorates to being an 'immediately life-threatening situation', the patient should be transported to the nearest designated trauma service for stabilisation, with subsequent transport to a MTS at the earliest appropriate time. Continued high standards of ambulance and MICA paramedic training is, therefore, essential to support informed and prudent decision making.

Transport time by road will vary according to time of day, traffic conditions and distance. The 30 minutes that determines triage destination refers to the estimated time from patient loading to arrival at the receiving trauma service. The 30 minutes should be flexible where a small increment added to the transport time means that the patient is delivered to a site that can provide definitive care. Small additional increments in transport time invariably result in less delay to definitive care than organising the process of secondary transfer (Sampalis et al., 1997).

Clearly, in some outer metropolitan and most rural areas, patients will be more than 30 minutes from a MTS, or possibly any trauma designated hospital. In such situations, the patient is transported to the highest designated trauma service available in the least amount of time. Early liaison with the MTS is required. If appropriate, medical retrieval or interhospital transfer to a MTS needs to be activated early after initial assessment and resuscitation.

Figure 3.1 Triage Destination Guidelines (Appendix 7.3)

Overtriage

Overtriage is the transport of patients with minimal injuries to a high level trauma service or MTS on a presumption that the patient is seriously injured (Esposito et al., 1995). At present, all prehospital triage criteria have limitations in identifying and predicting trauma severity. Overtriage, however, may stress the economic resources of the MTS and create frustration and resistance amongst other hospital providers.

A degree of overtriage is unavoidable and necessary to consistently detect serious injuries (Eastman, 1987). The ACS (1993) suggests the need for a 50 per cent overtriage rate to maintain a 10 per cent undertriage rate and avoid delivery of patients with occult serious injury to other than MTS. Triaging physiologically stable trauma patients where only mechanistic criteria are present has a high potential for overtriage, although of the mechanistic criteria, prolonged extrication and a fatality in the same vehicle yield the greatest predictive value.

The presence of any one of the physiologic or anatomic abnormalities included in the Prehospital Major Trauma Criteria (Appendix 7.2) constitutes major trauma for the purpose of primary triage. The presence of only high-risk mechanism of injury or co-morbid factor places the patient at risk of major trauma. This group of patients should be triaged to a designated trauma service for assessment but whether this needs to be a MTS or other trauma service will remain at the discretion of the attending ambulance officer. This needs to be so because:

• Excessive, and ultimately unnecessary, overtriage may result if physiologically stable patients with only mechanism of injury or co-morbid factors are automatically triaged as major trauma and delivered to a MTS from the scene.
• Prehospital consultation with an inhospital trauma consultant is currently not technically reliable and would probably not add significant benefit in triaging this subgroup of patients.

Triaging the Patient in an 'Immediately Life-Threatening Situation'

The Taskforce and Working Party gave close consideration to the most appropriate triage strategy for patients who severely deteriorate at the scene or during transport. There is some evidence to suggest that this group of patients have greatest need for the rapid response and skilled trauma resuscitation provided at MTS (Sampalis et al., 1997) and transport should, therefore, continue to the MTS. The Taskforce and Working Party, however, endorse that where a major trauma patient is in an immediately life-threatening situation, the patient should be taken to the nearest designated trauma service for stabilisation with subsequent transfer to a MTS at the earliest appropriate time. The Taskforce and Working Party agree that ambulance and MICA paramedics must be allowed to default from hospital bypass in circumstances of an immediately life-threatening situation during transport.

Instances of an immediately life-threatening situation might involve failed airway control, tension pneumothorax, exsanguination, cardiac arrest or other circumstances in which the patient appears to be 'dying'. It was the Working Party's view that the provision of solely objective criteria for ambulance diversion in such circumstances was unworkable because:

• Decisions about imminent and life-threateningdeterioration necessarily involve both a subjective component and objective criteria.
• Both paramedic levels provide trauma care during a critical phase post-injury. Decisions to divert before arriving at a MTS entail consideration of the differing skill levels of MICA and ambulance paramedics. Most, but not necessarily all, major trauma will be attended by a MICA paramedic. This is so at least in the short term and more so in metropolitan areas.
• There needed to be some allowance for avoiding clearly preventable prehospital morbidity, such as resulting from failed airway control. The Taskforce accept this despite recognising that improved outcomes have been demonstrated in transporting patients directly to a MTS with the staff, expertise and equipment to rapidly manage life-threatening conditions in trauma patients (Sampalis, 1997).

Audit of this patient group should be a priority for the STC to enable future change in triage guidelines, if appropriate, and to support educational strategies and foster compliance with recommended triage guidelines, especially for ASV.

Early Hospital Notification

The Taskforce and Working Party advise that early notification from the field to the receiving hospital regarding numbers, time of arrival, patient condition and any deterioration, maximises preparation time in the receiving hospital and streamlines resuscitation and stabilisation following patient reception.

Effective and reliable direct field to hospital consultation is technically possible at present, although the resources to facilitate this are limited and there is an issue of timing implementation with other communication initiatives, such as mobile data terminals. Consistent reliability of mobile systems also cannot be guaranteed at present. Earlier notification through sequencing priority at ASV's Communication Centre is possible.

Early Liaison and Interhospital Transfer to Major Trauma Services

To minimise time to definitive care and reduce current delays in activating interhospital transfer, the Taskforce endorses early liaison. A target time for the receiving trauma service to contact MTS is recommended at 15 - 30 minutes. Although monitoring compliance with this performance indicator will be problematic, this demonstrates the expectation of early contact and forms a baseline for subsequent review and adjustment.

After patient reception in a trauma designated emergency department, the presence of one of the stated physiological or anatomical criteria mandates early liaison with a MTS (Appendix 7.4). Improved communications technology at the MTS will ensure the immediate availability of a consultant with trauma expertise for advice regarding clinical management or need for transfer.

The success of timely referral of major trauma and liaison with the MTS will depend on reliable, one call, consultant level access at the MTS. Traditional referral patterns from some rural to metropolitan hospitals may not conform with proposed referral to a MTS, nor with the principles upon which the trauma system is based.

Specialist Trauma Transfer Guidelines (Appendix 8) have been developed for specialist trauma conditions to guide transfer to a MTS, where the MTS has a concentration of relevant expertise within the context of trauma management and/or is the state provider of that specialty. These guidelines incorporate specific aspects of management in the prehospital and emergency department setting and indications for transfer to the appropriate MTS for the following specialist conditions: neurotrauma, spinal trauma, paediatric trauma, obstetric trauma, burns, musculoskeletal trauma or barotrauma. These guidelines have been developed using published guidelines in consultation with specialists in each of the relevant fields. Timely transfer will be dependant, in part, on clinicians at receiving hospitals limiting diagnostic testing and interventions to those necessary for stabilisation prior to transport.

Although the probable need for interhospital transfer is indicated within developed guidelines, the Working Party and Taskforce opted to avoid an exhaustive list of injuries requiring transfer, instead relying on consultation to clarify transfer need. Consultation will occur after a detailed medical assessment and may allow for the non-transfer of major trauma in the following circumstances:

• The patient's injuries are assessed as not severe enough to warrant transfer
  and
• The referring hospital has the capacity to provide appropriate definitive treatment
  and
• The MTS is in agreement with non-transfer in a particular case.

Specialist Trauma Care

The Taskforce considered several issues relating to the management of neurotrauma because the acute nature of these injuries requires definitive care with minimal delay, and because few of the proposed designated trauma services are currently able to provide a full-time neurosurgical presence within the hospital.

The Taskforce has recommended minimum staffing standards for specialist neurosurgical support at MTS and MeTS. A 24-hour in-house neurosurgical registrar at MTS was considered appropriate because formulating the 'hierarchy of care' at patient reception would be more efficient and integrated by having a neurosurgical presence to assess the nuances of the patient's neurological condition on arrival. Also, patient groups other than major trauma, such as cerebral haemorrhage, require immediate intervention upon arrival in the emergency department.

Neurotrauma patients requiring critical care support should be managed only in hospitals with a neurosurgical unit and neurosurgical support. There was agreement that interhospital transfer under conditions of neurosurgical deterioration was to be avoided whenever possible by timely and proactive transfer of such patients to a MTS.

Interhospital referral links already in existence with The Alfred, RMH and RCH should be strengthened, and the process and timeliness of neurosurgical referral needs to be reviewed and streamlined.

The application of telemedicine has significant potential benefit in the management of neurotrauma, enabling prompt diagnosis and intervention in patients referred from metropolitan and rural hospitals and for patients already under the care of a neurosurgeon at a MTS.

The Taskforce considers that coordination between facilities in the introduction and application of this technology is essential and currently lacking. Telemedicine is discussed in more detail in the section 'Research, Service and Technology Developments'.

The Taskforce and Working Party have given consideration to the crucial role that the Victorian Spinal Cord Service at Austin and Repatriation Medical Centre has in the management of spinal trauma in Victoria. The Taskforce and Working Party recommends that the following applies to the triage and transfer of spinal trauma (Appendix 8.2):

In the prehospital setting:

• All major trauma (including isolated spinal trauma) should be triaged to the MTS, within safety and logistic constraints.

In interhospital transfer:

• Major trauma which includes a spinal cord injury should be transferred to the MTS. In the presence of spinal cord deficit, subsequent transfer to the Victorian Spinal Cord Service will occur once the patient is medically stable.
• Isolated spinal cord trauma, with a neurological deficit, should be transferred to the Victorian Spinal Cord Service at A&RMC at the earliest appropriate time, usually in less than 12 hours.
• Early consultation by all trauma services receiving spinal cord trauma patients with A&RMC should occur to optimise patient outcomes. Stronger links between MTS and the Victorian Spinal Cord Service, such as through dual appointments of consultant medical staff or establishment of liaison nursing or allied health positions based at the A&RMC, will enhance optimal reception and care of patients with acute spinal injury.
• All spinal cord trauma in children should be transferred to, and managed at, the RCH during the acute phase.

The relatively small number of paediatric presentations, the concentration of the necessary specialist skills, clinical supports and an already established paediatric intensive care retrieval service (Pearson et al., 1997; Hall et al., 1996) support a centralised model for a paediatric MTS. This should be located at the RCH.

Currently, air transport is frequently utilised for primary paediatric retrieval from the scene. Most paediatric major trauma in Melbourne is transported directly to the RCH, whether by road or air and sometimes with longer transport times than adults, as the physiological response to trauma in children frequently permits transport times up to 60 minutes.

The proposed model will see a continuation of all paediatric major trauma being triaged to the paediatric MTS for initial resuscitative care if possible and/or definitive treatment. Emergency departments in metropolitan Melbourne and rural Victoria will continue to provide initial stabilisation and resuscitation to paediatric major trauma patients where required, as well as support and treatment for non-major paediatric trauma. Specific hospitals have been designated as paediatric MeTS where there is a degree of concentration of paediatric expertise. Guidelines for transferring paediatric major trauma to RCH have been endorsed by the Taskforce (Appendix 8.4).

The RCH will also be responsible for coordinating paediatric trauma education, training and research, as well as quality management throughout Victoria in conjunction with the adult MTS.

Specialised burns units providing optimal care for severely burned patients are situated at The Alfred (adult) and RCH (paediatric). Trauma services at any level may receive patients with major burns plus traumatic injury for resuscitation and stabilisation and should be familiar with the burns trauma transfer guidelines. Early communication and transfer should be undertaken as appropriate (Appendix 8.6).

Barotrauma can only be definitively treated at a hyperbaric facility. Iatrogenic, diving related, and other barotrauma necessitates treatment in a hospital-based recompression facility. The Alfred provides hyperbaric services for Victoria.

Other hospitals receiving or managing barotrauma patients should consult early, initiate treatment and transfer according to recommended guidelines (Appendix 8.3).

The Taskforce and Working Party have given consideration to the crucial role that St Vincent's Hospital has in the management of injuries requiring microsurgery. In this respect, the Taskforce considers that St Vincent's Hospital should continue to have a leading role in the management of injuries requiring microsurgery.

With regard to prehospital transfer: All major trauma should be triaged to the MTS (according to Appendix 7).

With regard to interhospital transfer:

• Multiple trauma, incorporating the need for microsurgery, should be referred and transferred to the MTS.
• Isolated injuries requiring microsurgery should be referred and transferred according to established referral patterns; this would include St Vincent's Hospital in many cases.

The Taskforce considers that the colocation of Major Trauma Services with specialist facilities and services for trauma care is an issue that requires ongoing monitoring.

Triage and Transfer Guidelines

The following is a brief description of the triage and transport guidelines developed by the Working Party.

This guideline places the trauma triage and transfer guidelines within the context of the bigger picture of prehospital emergency transport and transfers. The guidelines concern themselves with major trauma. Non-trauma and non-major trauma admissions should be managed according to current guidelines.

This guideline uses physiological, anatomical and mechanistic criteria to identify major trauma patients in the prehospital setting. Proposed major trauma triage criteria conform closely with currently-used ASV criteria for time-critical trauma. This will aid integration and utilisation of these prehospital trauma triage guidelines.

This guideline describes the process used by prehospital personnel in deciding on the triage destination for major trauma patients.

This guideline describes the criteria and process for interhospital transfer of major trauma upon emergency department reception.

These guidelines describe specific aspects of management in the prehospital and emergency department settings and give indications for transfer to an appropriate MTS for the following specialist conditions:

• Neurotrauma
• Spinal trauma
• Barotrauma
• Paediatric trauma
• Obstetric trauma
• Burns
• Musculoskeletal trauma.

Consultation Process

The triage and transfer guidelines will undergo a wider consultation process with stakeholders and key providers in the implementation phase. Greater levels of detail in definition and application will be developed and included. After implementation, triage guidelines will be subject to performance measurement and continuous improvement.

Clinical Management

Trauma Teams: Recommendations

In relation to the trauma team approach to trauma care, the Taskforce recommends:

4.1 (p.62) All hospitals designated to receive major trauma patients have a formal trauma team response to the initial reception and management of trauma patients.

4.2 (p.62) The composition of the trauma team be sourced from clinicians throughout the hospital (such as surgery, intensive care, anaesthetics and emergency department) in order to provide optimal expertise in filling each role in the team.

The multidisciplinary trauma team approach to trauma resuscitation and stabilisation is one recommended by several bodies (ACS, 1993; NRTAC, 1993). All hospitals designated to receive trauma patients must have a formal organised response to the initial reception and management of trauma patients. The establishment of a trauma team is crucial to this. Clarifying the roles and responsibilities of each member of the team enables an optimally coordinated approach during resuscitation, when many tasks must be carried out simultaneously.

Trauma team members should comprise the most skilled clinicians available to fulfil each role within the team. Clinicians should, therefore, be sourced from throughout the hospital, such as from ICU, anaesthetics and the emergency department, to provide optimal expertise in trauma resuscitation.

The practice of allocating the various roles of the trauma team to particular 'craft groups' may restrict the development of skills and the subsequent adaptability of team members. Ambulance paramedics should play an active role in the trauma team within rural or regional hospitals where availability of experienced and skilled hospital staff may be limited. Ambulance paramedics should receive appropriate training, to participate competently in such a role where required.

Generic trauma team guidelines (Appendix 11) provide the minimum standards for major trauma reception. Trauma team guidelines will need to be modified to suit local circumstances, especially in smaller hospitals. At a MTS, members of the trauma team should be available for trauma team response within five minutes of the call. The team leader should be a consultant level medical officer and must be available within the hospital 24 hours a day. The team leader could be of a range of disciplines (general surgeon, emergency physician, anaesthetist, intensivist) but should be EMST qualified.

The rapid availability of key consultant surgeons must be guaranteed at MTS.
While the continual presence in the hospital is not practical, there is a need for the on-call surgeons participating in trauma team resuscitations to be available within 15 minutes ideally and within a maximum of 30 minutes. This may inhibit those surgeons undertaking private surgical sessions while on call at a MTS.

Efficient operation of a trauma team is contingent on early activation to ensure that the team is assembled on arrival of the patient. Early activation is, in turn, dependent on early notification by prehospital providers.

Role of Director of Trauma Services: Recommendations

In relation to the role of Director of Trauma Services, the Taskforce recommends:

The Taskforce recommends:

5.1 (p.63) All Major, Metropolitan, Regional Trauma Services and Urgent Care Services have a designated person/s to fulfil the role of Director of Trauma Services.

The Director of Trauma Services (Appendix 12) will be a pivotal position in the operational delivery of trauma services. This role will provide the link between the statewide coordinating bodies, such as the STC and the clinicians involved in trauma care delivery and will set expectations for those hospitals managing trauma. In general terms, those undertaking this role will be responsible for:

• Management and organisation of the multidisciplinary trauma staff (including the trauma team) and establishing clear lines of responsibility for patient and staff management, including:
  - Development and implementation of guidelines and procedures.
  - Ensuring appropriate numbers of adequately trained staff and maintenance
  of skills.
• Leading a multidisciplinary, representative hospital committee.
• Ensuring the collection of trauma registry data and the development and implementation of other quality improvement initiatives, including internal case review, and forwarding such data for STC review.

The role should be filled at each hospital that receives major trauma patients, with the exception of PIS. It may be appropriate for the role to be filled by more than one person. The extent to which the role is dedicated to one person will vary depending on the volume of trauma at each institution.