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Out-of-Hospital Decision Making and Factors Influencing the Regional Distribution of Injured Patients in a Trauma System

Newgard, Craig D. MD, MPH; Nelson, Maria J. MD, MCR; Kampp, Michael BS; Saha, Somnath MD, MPH; Zive, Dana MPH; Schmidt, Terri MD, MS; Daya, Mohamud MD, MS; Jui, Jonathan MD, MPH; Wittwer, Lynn MD, MS; Warden, Craig MD, MPH, MS; Sahni, Ritu MD, MPH; Stevens, Mark EMT-P; Gorman, Kyle MBA; Koenig, Karl EMT-P; Gubler, Dean DO; Rosteck, Pontine EMT-P; Lee, Jan EMT-P; Hedges, Jerris R. MD, MS, MMM

Journal of Trauma and Acute Care Surgery: June 2011 - Volume 70 - Issue 6 - p 1345-1353
doi: 10.1097/TA.0b013e3182191a1b
Original Article

Background: The decision-making processes used for out-of-hospital trauma triage and hospital selection in regionalized trauma systems remain poorly understood. The objective of this study was to assess the process of field triage decision making in an established trauma system.

Methods: We used a mixed methods approach, including emergency medical services (EMS) records to quantify triage decisions and reasons for hospital selection in a population-based, injury cohort (2006–2008), plus a focused ethnography to understand EMS cognitive reasoning in making triage decisions. The study included 10 EMS agencies providing service to a four-county regional trauma system with three trauma centers and 13 nontrauma hospitals. For qualitative analyses, we conducted field observation and interviews with 35 EMS field providers and a round table discussion with 40 EMS management personnel to generate an empirical model of out-of-hospital decision making in trauma triage.

Results: A total of 64,190 injured patients were evaluated by EMS, of whom 56,444 (88.0%) were transported to acute care hospitals and 9,637 (17.1% of transports) were field trauma activations. For nontrauma activations, patient/family preference and proximity accounted for 78% of destination decisions. EMS provider judgment was cited in 36% of field trauma activations and was the sole criterion in 23% of trauma patients. The empirical model demonstrated that trauma triage is driven primarily by EMS provider “gut feeling” (judgment) and relies heavily on provider experience, mechanism of injury, and early visual cues at the scene.

Conclusions: Provider cognitive reasoning for field trauma triage is more heuristic than algorithmic and driven primarily by provider judgment, rather than specific triage criteria.

From the Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine (C.D.N., M.J.N., M.K., D.Z., T.S., M.D., J.J., C.W., R.S.), Oregon Health & Science University, Portland, Oregon; Portland Veteran Affairs Medical Center (S.S.), Portland, Oregon; Clackamas County American Medical Response (T.S.), Clackamas, Oregon; Tualatin Valley Fire and Rescue (M.D., M.S.), Aloha, Oregon; Multnomah County Emergency Medical Services, Multnomah County Health Department (J.J.), Portland, Oregon; Clark County Emergency Medical Services (L.W.), Vancouver, Washington; Clackamas County Fire District #1 (C.W., K.G., K.K.), Clackamas, Oregon; EMS and Trauma Systems, Public Health Division, Oregon Department of Human Services (R.S.), Portland, Oregon; Legacy Emanuel Trauma Program (D.G.), Portland, Oregon; Northwest American Medical Response (P.R.), Portland, Oregon; Metrowest Ambulance (J.L.), Hillsboro, Oregon; and Department of Medicine (J.R.H.), John A. Burns School of Medicine, University of Hawaii-Manoa, Honolulu, Hawaii.

Submitted for publication November 3, 2010.

Accepted for publication March 7, 2011.

Supported by a grant from the Robert Wood Johnson Foundation Physician Faculty Scholars Program and the Oregon Clinical and Translational Research Institute, grant number UL1 RR024140; from the National Center for Research Resources, a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research; and from the Department of Veterans Affairs (to S.S.).

Presented at the 2009 Society for Academic Emergency Medicine Annual Meeting, May 13, 2009, New Orleans, Louisiana.

Address for reprints: Craig D. Newgard, MD, MPH, Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, mail code CR-114, Portland, OR 97239-3098; email:

© 2011 Lippincott Williams & Wilkins, Inc.