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
AVs 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
Victorias 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
Victorias 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