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The role of ambulance and prehospital

triage in an integrated trauma system

Ian Patrick
General Manager Clinical & Community Services
Ambulance Victoria (Australia)
Ambulance Victoria – The context
• 237,629 square km
• 5.9 million population
• 4.8 million in Melbourne (capital city)
• 650K emergency cases a year and 300K non
emergency
AV’s Referral Service - 000 Demand Management
Primary Triage

Emergency
Department
Emergency transport

Specialist
Facility/
GP Clinic
Secondary NEPT transport
Triage
No transport
required
(Locum doctor/nurse
Telephone advice)
Right care, right place, right time….
Ambulance Victoria – The context
• 3,800 paramedics (3300 ALS, 500 Intensive Care)
• 1000 on call skilled volunteers (rural/remote)
• Retrieval Physicians (ARV- road and air)
• >230 road response locations
• 4 fixed wing aircraft
• 5 rotary wing aircraft
• Dedicated research department focused on clinical and
operational improvements
Victoria’s State Trauma System
•Pre 2000 – no coordination or triage, trauma transport to >22 hospitals
•Established in 2000 in response to the Review of trauma and emergency
services 1999 (RoTES) report
•Negative trend in rate of mortality improvements (5% in the 80s, 1% in the
90s)
Goals
•Integrated trauma system with prevention, coordinated prehospital and
hospital care and rehab/post discharge care
•Reduce prehospital and hospital death and long term complications and
disability
Victoria’s State Trauma System
•Designation of two adult hospitals and one paediatric hospital as major
trauma services (MTS) operating as the hub of an integrated system
•State Trauma Committee (commissioned by State Govt, independent
chair)
•Trauma triage and transfer protocols
•Enhanced retrieval and transfer services
•Coordinated education and training
•Ongoing research, service and technology developments
•Comprehensive data registry and reporting (VSTR) – link to AV data
•Quality management (multidisciplinary case review and continuous
improvement strategies)
Major Trauma Inclusion Criteria
Victorian State Trauma System – 10 year review
10 year Road Trauma Results (published 2014)
• 40% increase in those direct to mandated highest level of care (30 min
drive time)
• Incidence increased (30%) with population growth, HI severity reduced,
injuries the same.
• Reduced length of stay in hospitals for major trauma patients
• Reduced cost per case ($633K)
• Years of life lost decrease by 43%
• 28% reduction in disability adjusted life years
• Better mortality than international benchmarks
Trauma Mortality 10 year review
Ambulance Victoria – the trauma context
• ~50,000 trauma patients
• ~18,000 potential major trauma
• ~3000 meet major trauma criteria (hospital based criteria)
• 93% blunt, 4% penetrating, 2% burns
• 91% accidental, 6% assaults and 3% self harm
• 42/100,000 metropolitan population
• 64/100,000 rural population
• Major trauma ratio 2:1 metropolitan : rural
Ambulance Victoria – the trauma context
• 40% transport accidents
• 30% low falls (>65 yo increasing)
• Head injury rates fell over first 10 years now steady
• Median response times to major trauma = 13mins in
metropolitan region and 34mins in rural regions
• Median activation time retrieval = 4.6 hours metro and 2.8
hours rural
• Median retrieval time = 6.7 hours metro and 8.3 hours rural
• 11% in hospital mortality (steady but not the full picture)
Ambulance Victoria in the State Trauma System
• Membership of the State Trauma Committee
• Expert medical advisors (rural and metro trauma experts)
• Standardised civilian call taking and dispatch (AMPDS – under
review)
• Trauma guidelines (7) – Triage and transport guidelines,
RSI, chest decompression, fluid, blood (HEMS), #
management, FAST (HEMS)
• Integrated road and air response (including retrieval)
• Electronic patient care record – every episode of care since
2006 available (response and clinical data)
Ambulance Victoria in the State Trauma System

• 100% QA audit of MT cases - medical consultant oversight
• Trauma Victoria state-wide education initiative directed
towards clinical staff who provide early patient care for major
trauma outside a MTS.
• Trauma research – triage and 4RCTs (2 current)
• TxA in bleeding trauma (PATCH) and Hypothermia in STBI
(POLAR)
Ambulance Victoria in the State Trauma System
• 86% AV pts to MTS or highest level of care in 45mins (80%
agreed health department KPI)
• 66% meeting MT criteria are transported direct to a MTS
• Transport time predominant reason for non MTS transport
• 79% receive definitive care at a MTS (91% if transport related)
• 94% of inter hospital transfers receive definitive care at MTS
• >90% MT patients identified through AV triage guidelines
• Prehospital trauma deaths with AV ~350 treated
Ambulance Victoria in the State Trauma System
• 800 MICA RSIs in Trauma
• 160 chest decompression (thoracostomy) per year
• 50 blood transfusions per year
• 300-400 helicopter transports from scene direct to MTS
• 800-1000 inter hospital trauma retrievals per year (40% metro
and 60% rural)
Ambulance triage of Major Trauma
• Trauma triage guidelines - specific paediatric and adult –
cornerstone of an integrated trauma system
Triage criteria based on a hierarchy of
• physiological x 5
• anatomical x 11
• Mechanistic x 8 modified by other criteria; age, co
morbidities, pregnancy
• Travel time to trauma centre (previously 30 min drive time)
Ambulance triage of Major Trauma

• 2010 retrospective review (06-07) - 45,000 trauma patients,
16,479 potential major trauma
• 1800 total major trauma. 1160 direct from scene to MTS
• Significant over triage partially moderated by paramedic ability
to override guidelines (<10% specific)
Ambulance triage of Major Trauma
• HR and RR significant cause of over triage, anatomical and
mechanistic criteria to a lesser extent
• Major trauma triage guidelines subsequently revised
• Refined physiologic, mechanistic and pattern of injury criteria
for greater specificity
• Further reviewed and changes validated in 2014
VSTR review 2011 notes increasing cases between 30-45min
drive times vs maximum 30 min drive time limit
• No increase prehospital or early hospital death
Ambulance triage of Major Trauma
• Patients treated in MTS better outcomes
• Max road transfer time increased to 45 mins
2013 review
• Increased number of cases with drive time > 45mins
• No change in deaths in transit or first 30mins in
hospital
• Risk adjusted in hospital survival continues to trend
down (now consistent trend for last 5 years)
Ambulance and major trauma
Current improvements
• Better identification at time of call - Dispatch grid review
(AMPDS code/dispatch type vs actual paramedic findings) –
the right response to the right patient. Better identification of
sick patients, reduce demand and improve supply
• Data mining and analytics – better use of the available
data. Independent emergency services and logistics experts
engaged
• HEMS- improved aircraft (travel time and range) and
dispatch
Ambulance and Major Trauma
Future – marginal improvements?
• Longer drive time
• Improve triage specificity – repeat past reviews of MT
identification (2016 review)
• Improve retrieval times – internal and external processes
• Clinical guideline changes (eg finger vs needle
thoracostomy)
• Prehospital mortality improvements (prevention and
understanding of AV impact)
AV triage of Major Trauma
AV triage of Major Trauma
Major Trauma Inclusion Criteria
Ambulance Victoria

Thank you