How do we evaluate Arizona’s trauma system, you ask? Good question. Over the next few weeks I’ll blog about “Trauma System Evaluation 101” as well as some of the evaluation tools we use to assess Arizona’s trauma system.
The goal of any trauma system is to get the right patient to the right place in the right amount of time. Level I and II Trauma Centers have the equipment, staff and training for caring for the most severely injured patients (about 14% of all injuries). Level III Trauma Centers can care for the moderately injured patients (about 22% of all injuries) and stabilize and transfer the more seriously injured. Level IV Centers have the fewest resources and able to care for minor injuries (about 64% of all injuries) and stabilize and transfer the more seriously injured.
Remember, our goal is to get folks to the right place at the right time- which means severely injured patients arrive at a level I or II center (or are to be transferred there as quickly as possible)… and that mild or moderately injured patients aren’t over-triaged into an expensive level I or II facility. Over-triage means that patients whose injuries are not serious are never-the-less transferred to a level I or II trauma center instead of being transported to the closer level III or IV trauma center.
Why is this a problem? First off, it’s always better to keep a patient close to their home when possible. It’s easier on the patient and family for a lot of different reasons. Second, trauma care at a level I is an expensive proposition but considerably less expensive at the level III and IV trauma center. Third, if all of our trauma patients get sent to the level I trauma centers, not only will they be inundated with non-critical patients, but they won’t be able to respond when the patients that really need their help arrive.
Just like any other evaluation process, you have to look at a variety of different measures in order to perform a meaningful assessment. Looking for over-triage is one tool in the trauma system assessment tool box… but it needs to be looked at hand in hand with its partner measure – under triage. Measuring over-triage is done retrospectively. Hindsight is always more clear, particularly during a stressful situation. It’s human nature to be cautious, therefore it is awfully hard to fault the paramedic who, in an abundance of caution, decides to transport a kid to a level I trauma center, even though they do not appear seriously injured.
A few years ago, the CDC brought together experts from across the country to review the peer reviewed literature on trauma triage. The outcome of that process was the development of the Guidelines for the Field Triage on Injured Patients – a proscriptive, evidence-based tool that takes into account variation within states and regions, while providing some good directions to our EMS folks on how to make decisions in the field. Our own State Trauma Advisory Body adopted these guidelines a couple of years back. If you want to learn more about over-triage, here is a link to a good article recently by the Robert Wood Johnson Foundation on this topic. More next week.