Hi everyone,
Today's Trauma Tuesday POTD is inspired by the upcoming rollout of new trauma activation aka "level" criteria in the MMC ED. Woohoo! Exciting! Change is fun!
In light of this, our main question today is, when EMS brings in a patient with a traumatic injury, how are we determining level 1 vs. level 2 vs. level 3?
As we all know, MMC is an adult level 1 and pediatric level 2 trauma center, and thus we get the whole host of traumatic injuries that roll into our ED, from sprained ankle to traumatic arrest to being on the South Side on a Monday afternoon (just kidding). But how does EMS determine if they are coming to a trauma center at all? How do hospitals determine what level those incoming traumas should be? And, with all that in mind, how is the MMC level criteria changing with our new rollout?
EMS Trauma Criteria
The goal of EMS trauma criteria is to determine the appropriate destination for the patient: trauma center vs. general ED. The criteria is determined by the Regional Emergency Medical Advisory Committee (REMAC - yes, that REMAC!) of New York City. The two main buckets to determine required transport to a trauma center are physical findings and mechanism of injury. The other bucket to determine possible transport to a trauma center is high risk patient. The options for a high risk patient are either transporting or contacting OLMC. The criteria they use is below.
It isn't the job of EMS to determine the level of the trauma or whether or not they are coming to North Side or South Side. Oftentimes they will call for a trauma notification to the North Side if the patient is giving bad vibes, but really their only job is determining transport to a trauma center or not.
Hospital Trauma Activation Criteria
Once a trauma notification is called in, or once the patient arrives to the ED, it is the job of the ED hospital staff to determine what level of trauma activation is indicated. Trauma activation criteria is determined by the hospital itself. This means that, though two hospitals may both be level 1 trauma centers, they may have different criteria that qualifies someone as a level 1 trauma patient. Trauma activation criteria revisions occur every so often after interdepartmental discussions and research-based committee decision-making, with MMC having just completed its own.
But why are revisions even necessary? Well, both under-triage and over-triage of traumas come with their own risk, so we want to get our triage levels right.
Under-triage means that the patient had more severe injuries than the original level indicated (e.g. the trauma was called as a level 2, but, after assessing injuries, actually met criteria for a level 1). There are obviously serious dangers to under-triage, as the patient may not have the necessary resources, specialties, or expedited care to care for their injuries. Be aware that there are higher rates of under-triage in pediatric and elderly patients. The MMC goal is to have less than 5% under-triage given the morbidity and mortality associated with these cases.
Over-triage, on the other hand, means that the patient had less severe injuries than the original level indicated (e.g. initially called as a level 1 but later determined to be a level 2). The risk of over-triage may seem less disastrous, but it does come with a cost, mostly with regards to inefficient resource mobilization. The MMC goal is to have 25-50% over-triage. Trauma surgery keeps track of these numbers closely, and the American College of Surgeons reviews our numbers as part of the verification process to remain a trauma center. The goal should really be to triage everyone into the correct trauma level to activate the correct resources immediately, but obviously there is a bit more leeway skewing us to over-triage rather than under-triage.
New MMC Trauma Activation Criteria
So EMS has transported a trauma patient to the MMC ED based on their trauma criteria, and the patient has arrived in the North Side in room 51. What level are we calling it?
Old Criteria
Our old trauma activation criteria is still hung up on the back wall of room 51. I know I still look to these boards as reminder for the detailed criteria. For adult patients, one very generalized way to think of it is that level 1 includes physiologic criteria, level 2 incorporates mechanism criteria, and level 3 is everyone else who likely needs admission for traumatic injury. For pediatric patients, it's quite similar, but blast explosion mechanism earns you a level 1 right off the bat. But what about our new criteria?
New Criteria
Here's the new trauma activation criteria that is being rolled out in the MMC ED, and it will soon physically replace the old criteria on the back wall of room 51. See if you can spot the main differences between the two...
New Criteria Differences from Old Criteria
Ok, I'll tell you.
Adult Level 1
HR > SBP
No longer HR >120
Respiration rate <10 or >29
No longer includes compromised airway
Adult Level 2
Patients transferred in from outside hospitals should only be activated if they meet the above criteria
No longer transfer patients from other hospitals automatically level 2
**Systolic blood pressure >110 over the age of 65 is a typo and should have always been systolic blood pressure <110 over the age of 65**
Adult Level 3/Consult
No changes
Pediatric Level 1
Traumatic arrest
Significant neurologic deficit
No longer suspected spinal cord injury or paralysis
Pediatric Level 2
No longer major peripheral neurologic deficit (sensory or motor), as was changed to level 1
No longer drowning associated with trauma, as was changed to level 3
Pediatric Level 3/Consult
Injured patients with GCS >13
Hangings and drownings with injury
Injured patients with bleeding disorders
Multi-system trauma involving more than one surgical specialty
Patients with complications of recent injuries
TLDR
As you can see, the old and new criteria are actually quite similar, but it's good to keep in mind the changes in HR and respiratory status criteria for adult level 1, transfer patients no longer automatically being an adult level 2, significant neurologic deficits qualifying as a pediatric level 1, and drowning with trauma qualifying as a pediatric level 3.
Look out for the new trauma activation criteria in room 51 coming soon, and happy leveling,
Kelsey
Resources:
- Dr. Nate Zapolsky's brain
- Dr. Dave Eng's brain, too
- https://www.maimonidesem.org/blog/ems-protocol-of-the-week-general-trauma-care-adult-and-pediatric
- https://www.aast.org/disaster-detail/acs-highlight-trauma-team-activation-optimizing-pr
