Chapter 1: Triage and Transport in the Field for the Critically Ill Patient

The word “triage” originates from the French “trier” (to choose from among several) and was originally applied around 1792 by Baron Dominique Jean Larrey, surgeon-in-chief to Napoleon's Imperial Guard, in reference to the process of sorting wounded soldiers. Its aim was to optimize the use of available medical resources to maximize efficacy; patients with the greatest chance of survival and the least resource use are treated first.¹ Currently, the combination of an increasing patient population and diminished funding for hospital services is creating a need for optimized distribution of medical resources. Efficient management of major incidents involves triage, treatment, and transport. Useful triage tools would predict which patients have the greatest chance of survival, which patients are likely to die, and which will benefit most from advanced medical care such as mechanical ventilation. These are important issues not only for initial allocation of resources but also for future allocation of resources over time to support the ongoing needs of survivors of critical illness.

The challenges associated with the triaging process have caused health systems to initiate a number of adaptational strategies, including regionalization of care, specialization of critical care facilities, and better allocation of available personnel and equipment; the triaging process impacts multiple practices such as pre-hospital care, emergency department services, intensive care, surgical intervention, and the process of determining the order of rank for patients to receive advanced therapeutic treatments (including renal replacement therapy and organ transplantation). In the field, emergency medical services (EMS) providers must ensure that patients receive prompt and appropriate emergency care and are transported in a timely manner to a health care facility for further evaluation and treatment. Identifying the severity of the injury or illness, prioritizing medical management, and determining the appropriate facility to which a patient should be transported can have a profound impact on subsequent morbidity and mortality.²

It is well described that overtriage might overburden the local health care systems, have a negative impact on patient outcomes, and decrease cost-effectiveness. Frykberg and Tepas³ in their published experience with terrorist bombings found a mean over triage rate of 59% and identified a linear relationship between overtriage rate and critical mortality. However, being too selective might lead to unacceptably high rates of undertriage and also increased morbidity and mortality.⁴ Because poor triage quality may lead to adverse consequences and bring multiple ethical and legal questions, the process should be based on recommended (research-based) protocols and guidelines, and be clear, transparent, and consistent. Unfortunately, an extensive literature review published in 2013⁵ reported that even though there are some scoring systems available to evaluate the severity of injury, algorithms to guide the initial clinical management, and recommendations about where to transport injured patients, there is little documentation about the effectiveness of these strategies on clinical outcomes.

In this chapter, we review the most common triage protocols used for illness scoring as methods to identify the severity of the injury, and the most often recommended guidelines for field triage of injured patients, along with accompanying recommendations regarding transport of critically ill patients in the field.⁶

It is important to emphasize that these guidelines are based on anatomic, physiologic, and/or situational factors intended to be applicable to patients with major risk of injury and/or significant negative outcomes; however, in light of a relative dearth of evidence-based medicine support, such scores must be used with full appreciation of their limitations. Though the guidelines are useful for comparing institutional performances and outcomes in studies of certain groups of patients, great caution must be exercised when applying these protocols to individual patients.

In general, evidence-based guidelines focused on pre-hospital care are lacking. Beate Lidal et al⁵ conducted a systematic review of 120 publications to identify available research on the effects on health outcomes of validated triage systems used in the pre-hospital EMS, and found that none of the identified articles fulfilled their inclusion criteria or answered their scientific questions. They concluded that there is a lack of scientific documentation evaluating whether pre-hospital triage systems are effective, whether one triage system is more effective than others, and whether it is effective to use the same triage system in 2 or more settings of an EMS. This lack of validated efficacy was related to a gamut of important aspects of care: health outcomes, patient safety, patient satisfaction, user friendliness, resource use, goal achievement, and the quality of the information flow between the different settings of the EMS.

For medical transportation studies, the HEMS Manuscript⁷ is a draft in progress, developed by a multidisciplinary panel of experts on trauma funded by the National Highway Traffic Safety Administration, which attempts to develop guidelines recommending an evidence-based strategy for the triage and transportation of all pre-hospital trauma patients who use 911 services. After an extensive literature review considering mortality, morbidity, and undertriage of critically ill patients as critical outcomes, the panel concluded 2 strong and 3 weak recommendations for (1) the mode of transport (Helicopter Emergency Medical Services [HEMS] vs Ground Emergency Medical Services [GEMS]), (2) the use of online medical control, and (3) considerations for local adaptation. All recommendations were supported only by low- or very-low-quality evidence. In their manuscript they recommend:

1. Triage criteria for all trauma patients should include anatomic, physiologic, and situational components to risk-stratify injury severity and guide decisions as to destination and transport modality. (Strong recommendation, low-quality evidence.)

2. EMS providers should not be required to consult with online medical direction (OLMD) before activating HEMS for trauma patients meeting appropriate physiologic and anatomic criteria for serious injury (Strong recommendation, low-quality evidence); for all other trauma patients, OLMD may be used to determine transportation method as long as it does not result in a significant delay. (Weak recommendation, very-low-quality evidence.)

3. HEMS should be used to transport patients meeting appropriate physiologic and anatomic criteria for serious injury to an appropriate trauma center if there will be a significant time savings over GEMS. (Weak recommendation, very-low-quality evidence.)

4. GEMS should be used to transport all other patients to an appropriate hospital, so long as system factors do not preclude safe and timely transportation. (Weak recommendation, very low-quality evidence.)

In general, these recommendations consider the most seriously injured patients and their families to serve them with the most expedient transport possible to the hospital. Although none of the HEMS activation variables has been prospectively validated in multicenter trials, and while the time and cost-effectiveness of HEMS remain disputable, the panel recommends that the most seriously injured patients should be transported by HEMS over GEMS.

Triage protocols should only be initiated when it is apparent that resource deficits will occur across a broad geographical area despite efforts to expand or acquire additional capacity. Different triaging scorings have been developed to help providers in making the critical decisions necessary to increase the likelihood of favorable outcomes for patients. However, there is insufficient scientific documentation to decide whether triage scales are reproducible, and also whether the current triage scales differ concerning safety, reliability, and reproducibility, especially in the pre-hospital setting.⁸ Some of the most used triage scales are discussed as follows.

Field Triage Decision Scheme

In 1986, the American College of Surgeons developed the Field Triage Decision Scheme (called “Decision Scheme”),⁶ which serves as the basis for triage protocols for state and local EMS systems across the United States. The Decision Scheme is the most often recommended algorithm that guides EMS providers through a 4-step decision-making process to determine the most appropriate destination facility within the local trauma care system. Since its initial publication, the Decision Scheme has been revised multiple times, updated last in 2011.

The recommendations are based on physiologic, anatomic, mechanism of injury, or situational factors, where each of these categories includes at least some variables that are associated with risk of major injury and more severe outcomes. The algorithm is divided into a step-by-step approach as described in Table 1–1.

Although decisions might be dictated by standing protocols, for patients meeting the criteria in step 4, OLMD should be consulted to determine the most appropriate facility to treat patients requiring special consideration. If patients do not meet criteria for triage to a trauma center in steps 1 through 4 of the Decision Scheme, EMS providers should use local protocols for transport without the need to contact medical control. Owing to the complexity of traumatic injury and its evaluation, the last line of the Decision Scheme, essentially unchanged from previous versions, is “When in doubt, transport to a trauma center.”

The Sequential Organ Failure Assessment and Modified SOFA

The Sequential Organ Failure Assessment (SOFA) score is a validated measure of organ failure over time and a predictor of mortality in critically ill patients⁹ that has been incorporated into triage protocols for critical care in the event of an influenza pandemic or a mass influx of patients during a disaster.¹⁰ The SOFA score combines a clinical assessment of 2 organ systems (cardiovascular and central nervous) with laboratory measurements for evaluation of 4 other organ systems: respiratory, hematologic, liver, and renal. The SOFA score has been shown to reliably evaluate and quantify the degree of organ dysfunction present on admission to the intensive care unit (ICU) (initial score) or developing during ICU stay. The maximum SOFA score reflects cumulative organ dysfunction that develops and correlates with mortality, whereas the mean score is a good prognostic indicator-predicting outcome throughout an ICU stay.⁹

As the SOFA score requires laboratory measurement of 4 parameters (creatinine, platelet count, partial pressure of arterial oxygen, and serum bilirubin), this scoring system may be impractical with constrained resources. Looking for an alternative, Grissom et al¹¹ proposed a modified SOFA (MSOFA) score that requires only 1 laboratory measurement (creatinine, which can be measured using a bedside point-of-care testing device), eliminates the platelet count, and replaces the other laboratory test results with clinical measurements: saturation of oxygen and jaundice. They evaluated the accuracy of both scores in 2 key areas: (1) ability to predict mortality and (2) ability to predict need for mechanical ventilation in critically ill patients after admission to the ICU. Findings were that for predicting mortality on days 1 and 3, the MSOFA and SOFA scores are equally accurate, but for predicting mortality at day 5 of ICU stay, the predictive accuracy for both was diminished.

Both scores are equivalent in predicting ongoing requirements for mechanical ventilation, but because both scores exclude the patients with more than 11 points, the system excluded about 94% of total patients in their cohort, but up to 40% of these excluded patients would survive in a setting where ample critical care resources were available. This illustrates that these scoring systems can only be 1 part of an overall system of triage.¹⁰ The overall triage process should be based on a consideration of scoring systems and the analysis of preexisting comorbidities; to successfully use limited resources to save lives, strategically excluding patients with high risk of mortality must be considered.

Simple Triage Scoring System

Initially during the influenza pandemic in 2009, the UK Department of Health recommended the SOFA score as part of a staged triage and treatment prioritization tool during the initial weeks of an overwhelming influenza pandemic and to prioritize admission to critical care beds.¹² Further data analysis suggests that SOFA score may not be a good predictor of outcome in this cohort of patients, and had surge capacity been overwhelmed, it may have led to inappropriate limitation of therapy. Before the pandemic, in 2007 Talmor et al¹³ proposed the Simple Triage Scoring System (STSS) as a potential alternative tool in predicting mortality and optimizing the utilization of critical care resources during epidemics. It uses only vital signs and patient characteristics that are readily available at initial presentation (age, shock index [heart rate > blood pressure], respiratory rate, oxygen saturation, and altered mental state). In 2011 Adeniji and Cusack¹² reviewed the performance of the admission STSS and SOFA scoring systems as indicators of optimal utilization of hospital resources, and of mortality during the H1N1 infection; they found that the STSS accurately risk-stratified patients with this viral illness with regard to the need for admission to the ICU and for mechanical ventilation, suggesting that the STSS performs better in this population and overall would be a more appropriate early assessment triage rule.

Abbreviated Injury Scale, Injury Severity Score, and the New Injury Severity Score

The Abbreviated Injury Scale (AIS) ranks different injuries with a numerical score from 1 for minor injury to 6 for probably lethal/maximum injury. In 1974, the Injury Severity Score (ISS) was derived from AIS scores and it uses an ordinal scale (range: 1-75) that summarizes and takes account of the effect of multiple injuries.¹⁴ The ISS is calculated by assigning AIS scores to injuries in each of 6 body regions (head/neck, face, thorax, abdomen/visceral pelvis, bony pelvis/extremities, and external structures) and then adds the squares of the highest AIS scores in each of the 3 most severely injured body regions. Only the most severe injury in each body region is used in the score. If an AIS score of 6 is assigned to any body region, the maximal ISS of 75 is assigned. The ISS is an accepted method of determining the overall severity of injury and correlates with mortality, morbidity, and length of hospital stay, and it has been used to predict mortality and risk for postinjury multiple organ failure.¹⁴

In a more recent study developed in a level 1 university trauma center, the New Injury Severity Score (NISS) showed that 7.5% patients with discrepant scores (NISS > ISS) had longer hospital and ICU stay and higher mortality rate (all P < .01), suggesting that the NISS has better predictive power related with these outcomes.¹⁵

Trauma Score and Revised Trauma Score

Because of the increasing number of trauma patients admitted to critical care facilities, familiarity with trauma scales is important. The Trauma Score (TS) is based on the Glasgow Coma Scale (GCS), and on the status of the cardiovascular and respiratory systems, it assigns values to each parameter and the scores are summed to obtain the total TS, which ranges from 1 to 16. Mortality risk varies inversely with the TS.¹⁶

After an evaluation of the TS by the same author, it was found that it underestimates the importance of head injuries, so the Revised Trauma Score (RTS)¹⁷ was proposed. The RTS demonstrated substantially improved reliability in outcome predictions compared to the TS and yielded more accurate outcome predictions for patients with serious head injuries than the TS. Currently, the RTS is the most widely used physiologic trauma scoring tool.

CRAMS Scale

The Circulation, Respiration, Abdomen, Motor, Speech (CRAMS) scale is another trauma triage scale that is frequently used to decide which patients require triage to a trauma center. Patients with lower CRAMS scale scores would be expected to require critical care unit admission.¹⁸

Critical care regionalization is becoming more common and studies have supported that the transport of critically ill patients to a tertiary care center leads to better patient outcomes.¹⁹ As a result, there is increased interfacility transport of critically ill patients and the need to develop methods for transport of these patients using practices based on the best scientific and management evidence.

Composition of the Transport Team

There are no national data on overall transport volumes or team composition within transport systems. Published guidelines recommend that a minimum of 2 medically qualified people in addition to vehicle operators accompany a critically ill patient, but there are no standard recommendations regarding which patients may be transferred solely with paramedics, which patients require a nurse in attendance, and which patients require a physician in attendance.²⁰

While in urban areas ground transport is most common, in rural areas air transport is more often required because of the distances involved and the difficulties of road travel. In most settings, the emergency medical technician (EMT) is the highest-level care provider on the interfacility transport team, but for critical care transports, it is most often a physician, nurse, or paramedic; many critical care transport programs are using physicians who are still in training on board transport vehicles. However again, there is little information speaking to how the level of experience of the physicians affects outcome. Therefore, current standards for interfacility transport dictate that the decision on transport mode and team composition is based on individual patient requirements, considering minimization of transport time and anticipated treatment requirements during transport.

Medical Management during the Transport

After a literature review concerning medical management in the pre-hospital setting, Ryynänen et al²¹ concluded that cardiopulmonary resuscitation and early defibrillation are essential for survival, but providing these interventions in the pre-hospital setting has not shown improved survival, so the data regarding their effectiveness are contradictory. Better documentation is available supporting a reduction in mortality in patients with myocardial infarction when pre-hospital thrombolytic treatment is provided. Regarding the trauma patient, it is accepted to provide basic life support (BLS) in the case of penetrating trauma and in cases of short distance to a hospital, but in patients with severe head injuries, advance life support (ALS) provided by paramedics and intubation without anesthesia can even be harmful. There is also some evidence supporting use of ALS among patients with epileptic seizures as well as those with respiratory distress.

Managing Airway

Critical care transport often involves advanced airway management that includes establishment of an advanced airway with standard endotracheal tube or backup tools such as laryngeal mask, pharyngotracheal lumen tube, or needle cricothyrotomy with emergency transtracheal jet ventilation. In addition to advanced airway management, ALS transport crews should have equipment available for decompression of tension pneumothorax (ie, either needle or chest tube thoracostomy).²⁰

Mechanical ventilation of intubated patients during transport has been shown to be optimal in comparison with manual ventilation; therefore, several types of ventilators are available for the transport environment. Transport ventilators must be monitored continuously during transport as they are subject to problems such as power failure and disconnection. Pressure-controlled ventilators are used most commonly during transport, and in aircraft they must be adjusted for altitude changes. While providing mechanical ventilation, patients need continuous oximetry and end-tidal carbon dioxide monitoring, to identify clinically unrecognized hypoxia.²²

Hemodynamic Monitoring

Interfacility critical care transport requires continuous monitoring and clinical management of the patient throughout the transport environment.²² The transporting vehicle should have the necessary power converters for all equipment that could be needed, battery backup in case of electrical failure, and backup oxygen supply in case of vehicle breakdown. In cold climates, provision must be made for maintenance of a warm environment in case of vehicle failure. Transport monitor devices include devices for measuring electrocardiography (ECG), blood pressure, oxygen saturation, and, if necessary, end-tidal carbon dioxide level, pulmonary artery pressure, intra-arterial pressure, and intracranial pressure.²⁰

Defibrillation has been performed safely during flight, and its use does not interfere with other systems on helicopters and fixed-wing aircraft. Medications should be administered by an infusion pump throughout transport to ensure accurate dosing. Many small infusion pumps are available and can be reprogrammed rapidly to manage unstable patients. In addition, new portable intra-aortic balloon pumps and left-ventricular assist devices are available, and can be transported on most ambulances, helicopters, and airplanes.²²

Medication

Medication lists have been published for the management of the obstetric, neonatal, pediatric, and adult patients during transport.²⁰ Special medications may be required according to patient needs, and protocols should be prepared beforehand for the use of these medications on route. Some common pharmacologic practices include the use of paralytic agents to facilitate endotracheal intubation, and thrombolytic agents for acute cardiac and stroke patients, but in general their use is still controversial.

Intravascular Access

Intraosseous (IO) access is an accepted method for providing vascular access in the out-of-hospital critically ill patients when traditional intravenous access is difficult or impossible. Different IO techniques have been used showing overall success rates of 50% using the manual needle, 55% using the bone injection gun, and 96% using the EZ-IO.²³

Controversies in Management

Blood product transfusion during interfacility transport is controversial. It has been shown that in HEMS using flight nurses, the transfusion of blood can be performed safely and is feasible during transport,²⁴ but the use of blood product transfusions is still limited to the length of the transport during which crystalloid infusion alone will not stabilize a patient. Use of blood products during transport requires adherence to strict standard blood transfusion protocols, with blood administered by properly trained transport personnel.

Modes of Transport

Current options for mode of transport are the ground ambulance, either a helicopter or a fixed-wing aircraft, and watercraft.²⁰ In many urban centers, all options are available, and in more remote rural areas the airplane is essential. Factors that will influence the mode of transport include the distance and duration of transport, the diagnosis and complications that may arise during transport, the level of training and techniques the transporting personnel can provide, the urgency of access to tertiary care, and local weather conditions and geography. In the United States, helicopters are used frequently for the transportation of trauma patients; a 2007 overview estimated that 753 helicopters and 150 dedicated fixed-wing aircraft are in EMS.²⁵

Ground Ambulance

Ground ambulances have the advantage of rapid deployment, high mobility, and lower cost. However, patients and equipment are subject to significant deceleration and vibration forces.²⁰ Ground ambulance vehicles are usually most readily available and should be considered for transport distances of 30 miles or less. They are categorized as vehicles for BLS or ALS. BLS ambulances are most often staffed with 2 EMTs whereas ALS ambulances are staffed with a paramedic, nurse, or physician as the highest-level provider. Ground ambulances are limited by surface conditions or traffic congestion. All of them should have a backup equipment supply (ie, batteries or oxygen tanks), and ALS ambulances, particularly, must have the necessary outlets for managing ventilators or balloon pumps for interfacility critical transfers. The US Department of Transportation (DOT) has published standards that have been adopted by most states that relate to minimum ambulance configuration and equipment requirements.²⁶ Communication between the ground ambulance and the receiving facility or designated medical control center can be considered during transport.

Helicopter

Fixed-wing or rotary aeromedical transport may be necessary during disasters to extricate victims via air.²⁰ Helicopters should be considered for transports over distances of 30 to 150 miles. They travel at ground speeds of 120 to 180 miles/h and often are dispatched from the receiving tertiary facility or urban area emergency service providers. The physical location of the helicopter at the time of dispatch is important to consider because an inflight round trip to transport a patient may not offer advantages over a 1-way trip by an available ground vehicle. Helicopters usually require a warm-up time of 2 to 3 minutes before liftoff and, allowing for communication time, can be launched within 5 to 6 minutes of receipt of the flight request. Medical transport helicopters are usually staffed by critical care crews, and the number of patients who can be transported is determined by aircraft capacity. Under normal weather conditions, helicopters can fly point to point and land at accident scenes or sending facilities; the liftoff capability depends on the type of helicopter used. Helicopter transports are limited by adverse weather conditions and available landing sites (often a problem in densely populated areas).

Fixed-Wing Aircraft

Fixed-wing aircraft should be considered for transport over distances exceeding 100 to 150 miles. Being faster, they have the advantage of having a greater range and the ability to fly in difficult weather conditions, but they are limited by the need for ground transportation at both ends.²⁰ Though there is reduced noise, significant forces (fore/aft) are exerted on the patient and may affect critically ill patients who have a decreased physiologic reserve. Aircraft cabins are normally pressurized at altitudes between 6000 and 8000 ft, and this may have effects not only on the patient's clinical condition but also on medical devices.

Watercraft

Watercrafts are rarely used for interfacility critical care transport. However, in special environments, such as offshore islands and oil platforms, watercrafts play a role in medical transport.²⁰ Their use usually comes into play in situations where inclement weather does not allow for helicopter transport. Because of problems with water damage to electric equipment and dangers of staff electric shock from defibrillators, the monitoring and ALS activities that can be supported on watercraft are limited.

Critical care triage and transport are not uncommon practices; yet there is a relative lack of available comparative research studies that address (sometimes controversial) practices in this area of medicine because of the ethical implications of such studies, the nature of urgent and intensive care, and the large number of variables to consider.

Ethical Impact

When resource scarcities occur, ethical and international laws dictate that triage protocols should be used to guide resource allocation, and that they should equitably provide every person the “opportunity” to survive.²⁷ As this law does not guarantee either treatment or survival, performing triage of critical care services introduces several ethical challenges. To conscientiously meet these challenges, it is important to be familiar with the 4 principles of biomedical ethics developed by Beauchamp and Childress²⁸ and to understand their application to the critically ill patient.

• Autonomy: Respect for autonomy is a fundamental criterion for decision making in health care and provides that competent persons have the right to make choices regarding their own health care.²⁸ In the critical care setting, autonomy is very difficult to assess due to the urgency of the situations, lack of privacy, and lack of an established medical relationship. For the health care provider, it is important to focus on good and clear communication, even when the informed consent is not part of triage procedure.

• Beneficence: Beneficence is the moral obligation of contributing to the benefit or well-being of people, and thus is a positive action done for the benefit of others, rather than merely refraining from harmful acts.²⁸ By applying a system of triage, the health care provider strives to improve the quality of care by using the available resources as effectively and efficiently as possible. The ultimate goal of triage is to preserve and protect endangered human lives as much as possible by assigning priority to patients with an immediate need for life-sustaining treatment. In triage, the tendency of overtriage, particularly in patients with trauma, may be a tendency for beneficence, to “err on the side of caution.” However, overtriage not only increases the cost of medical care but also may result in worse outcome.²⁹

• Nonmaleficence: The principle of nonmaleficence can be described as “do no harm” and it is part of The Hippocratic Oath every health care provider commits to. Harm is not directly inflicted by triage except, perhaps when hopelessly injured patients are considered in the dead category.²⁸ Even during disasters, health care professionals are always obligated to reasonably provide the best care. So the aim of triage is to secure fair and equitable resources and protections for vulnerable groups. Triage guidelines aim to avoid harm to the patient by sorting the patients as quickly and efficiently as possible. However, in emergency care, especially in situations of overcrowding, treating one patient might indirectly threaten the welfare of another patient; any delay in treatment can potentially be harmful, but may be unavoidable if resources are limited. Our best efforts to use good communication skills and maximize allocation of resources can help us preserve principle of nonharming by reducing as much as possible any delay in treatment.

• Justice: Distributive justice requires that, given limited resources, allocation decisions must be made fairly, and that the benefits and burdens are distributed in a just and fair way.²⁸ Triage schemes are designed to allocate the benefits of receiving health care among the injured persons, but it does not mean than each person will receive equality if there are scarce resources; this aspect makes the triage of critically ill patients especially challenging. The triage equity perspective should be based on 3 principles: (1) Principle of equality: Based on the idea that each person's life is of equal worth and everyone should have an equal chance to receive necessary care. But this does not imply that the triage system can simply operate on a first-come first-service basis, because in an emergency care scenario this is a suboptimal strategy. (2) Principle of utility: It considers providing the greatest good for the greatest number. To respect this principle, the triage system should allocate scarce medical resources as efficiently as possible, seeking to achieve survival, restoration or preservation of function, and minimize suffering. To maximize benefit at the macro level, bad consequences for some (at micro level) may be justified if an action produces the greatest overall benefit. (3) The principle of worst-off: This principle depends on how worst-off is defined; most likely in critical care it means the severely ill or injured patient with greatest risk of death. To consider this principle, triage systems would give priority to treat this sickest group, but when resources are scattered, this approach can be inefficient if maximizing the benefits for the close-to-death group of patients who are not likely to survive consumed resources that could have saved lives of those not as sick, but more likely to survive. Triage systems should focus on minimizing the number of avoidable deaths, directing resources to salvageable patients.

Most of the available literature related to triage focuses just on a medical perspective (clinically based guidelines recommendations) or an ethical perspective (with its conflicting principles). Aacharya et al²⁸ conducted a literature review, in an attempt to bring together these 2 strands of thought. They consolidated the results from the analysis, using the 4 principles of biomedical ethics, proposing a clinically integrated and ethically based framework of emergency department triage planning. After their review they concluded that emergency triage is a dynamic process that takes relevant ethical principles into account; as triage involves significant moral implications, public representatives and ethics scholars should participate in the development of ethically sound institutional policies on triage planning. As a dynamic process, triage planning is a process susceptible to change and should be reviewed by multidisciplinary task forces and hospital ethics committees.

Safety

Safety of patients and EMS providers as well as the benefits and cost-effectiveness of the mode of transport are key considerations when assessing whether to transport a critically ill patient by ground or air, but the support regarding this topic is still controversial: One study has found no difference in transport times for HEMS versus GEMS³⁰; one found a positive, but not statistically significant, point estimate for the association between HEMS transport and scene trauma mortality³¹; and another, focused only on patients with severe injury as defined by ISS, found that transport by helicopter was associated with improved hospital-to-discharge outcomes, compared to ground transport.³² Methodologically, it is very difficult to evaluate the different transport modalities due to the influence of multiple variables such as local weather, traffic congestion, and EMS crew training. In general, the data indicate that the risks of aeromedical transport are very low, and the risk of ground transportation cannot be ignored.

Medical Legal Issues

Interfacility transport of patients has received increased legal attention especially regarding topics such as transfers of unstable patients, transfers of uninsured patients, and “antidumping legislation.”²⁰ Legally the sending facility is responsible for initiating the transfer, selecting the mode of transportation and the equipment on the transporting vehicle (including the level of expertise of transferring personnel), and ensuring that the receiving facility has space and personnel available for care of the patient. The sending physician is responsible for the risks of transfer and for deciding that the benefits to the patient following successful transfer outweigh the risks. A receiving facility that has specialized units shall not refuse to accept an appropriate transfer if that hospital has the capability to treat the individual. This is a nondiscrimination clause and is designed to prevent receiving facilities from accepting only funded patients.

In addition, owing to the high degree of acuteness of these patients and potential for adverse outcomes, the resultant liability implications make it mandatory that transferring personnel have medical malpractice coverage.

Education and Training

A study has showed that training on triage skills using standardized simulated cases can decrease undertriage by 12%.³³ Training modules for all transporting personnel should be developed in such a way that it is consistent with the policies and practices of the local emergency medical services and critical care community. The facilities and the crew should be subjected to ongoing curriculum development and quality assurance by the medical director.

Triage, treatment, and transport of injured patients require careful attention to priorities, prevention of further injuries, and delivering reassurance and compassion to those who are injured. As mentioned by Pepe and Kvetan,³⁴ early treatment in the field should be focused on seriously injured persons who require immediate care but with a chance of survival. And most importantly, beyond the pre-hospital injury “management” or “treatment,” we should always provide the best possible pre-hospital care.

Critically ill patients generally require a high level of care during transport. Recommendations regarding transport of critically ill patients are supported by data that show that the critically ill patient has better outcomes in tertiary centers than in other facilities and that transport of the critically ill patient does not adversely affect the patient during transport and improves outcome when compared with national norms. Established systems of care (encompassing critical transport as a component) have societal outcomes better than those of comparable communities without such a system and better than those in the same community before the system was in place; regionalization of specialized care is cost-effective and improves utilization of community resources.

Even though conducting research in the pre-hospital environment and in EMS presents multiple challenges, there is a real need for more research specifically related to field triage recommendations, cost-effectiveness recommendations, how to improve trauma surveillance, and data systems able to analyze the impact of various policies and procedures affecting the care of acutely injured persons.