Why is CDC Putting Out New Field Triage Guidelines?

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Comment by Dan on July 21, 2009 at 6:31pm

No matter how long the list of fine academics - it's exactly these type of simple but powerful issues that can get overlooked. I think perhaps a partial explanation why - might be that the EMS profession has learned a lot about MCI management in recent years. We know a lot more about Triage today then ever before. I tend to agree with the posters who think the word "triage" in this context is a bit misleading.

Comment by ems rn on July 16, 2009 at 8:24pm

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The guidelines were endorsed by the: (1) Air and Surface Transport Nurses Association, (2) Air Medical Physician Association, (3) American Academy of Pediatrics, (4) American College of Emergency Physicians, (5) American College of Surgeons, (6) American Medical Association, (7) American Pediatric Surgical Association, (8) American Public Health Association
Commission on Accreditation of Medical Transport Systems, (9) International Association of Flight Paramedics, (10) National Association of Emergency Medical Technicians, (11) National Association of EMS Educators, (12) National Association of EMS Physicians, (13) National Association of State EMS Officials, (14) National Native American EMS Association, (15) National Ski Patrol, (16) The Joint Commission, and the (17) National Highway Traffic Safety Administration.

If there was a "real" problem using the term "triage" it should have been brought up by one of those groups before publication of the guidelines. To change it now would only create further confusion. EMS providers, as medical professionals, should be educated enough to realize terms can mean different things, depending on the context.

We now field triage STEMI & stroke patients, to PCI & stroke centers.
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Comment by Joshua Todd on July 13, 2009 at 7:10pm

I agree that the nomenclature should more closely follow industry standards and federal terminology.

Comment by Ben Waller on July 13, 2009 at 12:38pm

Dr. Hunt, I understand the history, but is that what really matters right now?
I don't disagree with the concept of sending patients to the most appropriate facility, regardless of whether the incident generated one patient or two hundred patients. That is exactly what these documents do, regardless of what you call the documents.

When you say "triage" to a field provider, they're automatically going to think "sorting patients into ones that need immediate intervention, those that can recieve delayed care, those who have minor injuries, and the dead and those who have injuries incompatible with life."

That definition of "triage", in some form, permeates every field triage scheme that included tagging patients, and it permeates the NIMC system's Medical Group definitions.

Insisting upon staying with a traditional name that is out of synch with current field practice is going to have two immediate negative outcomes. The first is adding confusion, because the word "triage" will have two or more diffirent meanings. The second is that "triage" is defined as a different activity than "transportation" by NIMS. Transportation, not triage, is the step of transporting patients to the most appropriate destination.

If you change the terminology to reflect those realities while maintaining the core concepts, you'll likely have better compliance and better end results. You'll certainly inject less confusion into the system.

Is the point of the Guidelines to maintain traditional CDC terminology, or is it to create a system that's easy for field providers to use, standardizes terminology with other federally-mandated terminology, and that fits with commonly-used triage tagging systems?

Comment by Rick Hunt, MD, FACEP on July 9, 2009 at 12:02pm

Thank you for your comments. Since 1987, the Decision Scheme (developed by ACS) has served as the basis for the field triage for trauma patients in the majority of EMS systems. Since that time, the Decision Scheme has been revised four times: 1990, 1993, 1999, and most recently in 2006 by the National Expert Panel on Field Triage convened by CDC, in collaboration with ACS and NHTSA.

While I understand the technical argument for Destination Guidelines, given the history and overall purpose of guidelines, I believe that staying with “Field Triage Decision Scheme: The National Trauma Triage Protocol,” for now is important. I agree that when you apply the Decision Scheme to a single patient, it is being used to determine appropriate destination for an individual. However, because the Decision Scheme, for implementation at a regional or state-wide level—ultimately, helping to guide patient care by multiple EMS providers—it functions as a triage tool to direct the care of a many patients and conserve scarce resources (trauma centers).

While it says CDC on the Guidelines (with extraordinary support of NHTSA and ACS-Committee on Trauma), these Guidelines really are intended to be OUR national Guidelines, with national input. So keep the dialogue coming!

Comment by NinFin on July 3, 2009 at 10:54am

I agree with Ben that the wording is confusing and should be looked at. We are consistently told by NIMS that everyone from Police to Fire to EMS should be using the same verbiage to reduce confusion during an incident. This should be looked at and addressed before the "implementation" of this new plan

Comment by Ben Waller on July 2, 2009 at 9:59pm

If we're talking about "triage" for a single patient, then the term indeed is a misnomer. Triage literally means "to sort". It's difficult to sort a single patient.

Once again, if we're talking about a transport destination for a single patient - or several patients - let's call this document what it actually is, a "Destination Guideline". Calling it triage is going to add mass confusion to something that's confusing enough already.

Comment by ems rn on July 2, 2009 at 7:00pm

Ben - The American College of Surgeons, Committee on Trauma, has been calling this "Field Triage" back to at least 1990 (the earliest version of "Resources for the Optimal Care of the Injured Patient" that I have).

This "field triage" is designed, I believe, more so for non-mass casualty incidents.

Working in an area where almost every hospital is a level II trauma center, but with only one level I trauma center, these guidelines – and the CDC’s endorsement of them – is very helpful.

Thank you, Dr. Hunt for all your hard work.

Comment by Ben Waller on July 1, 2009 at 11:26pm

Wouldn't "Destination Guidelines" be a more appropriate term for what this program really is? There are many field triage systems, including START, the METTAG system, and simple things like color-coded surveyor's tape. None of them include destination guidelines.

Under the NIMS incident management model, the Medical Group Supervisor controls several distinct functional units - the Triage Unit, the Treatment Unit, and the Transport Unit. Both the national model for incident management and the most popular triage tagging systems clearly identify triage as being a seperate function from transportation.

Don't you think it would make sense to use similar terminology for the CDC system? To do other wise is likely going to create additional confusion in managing mass casualty incidents - something that's difficult enough as is. By definition, mass casualty incidents overwhelm the initial field resources. Anything we do to help the patients also needs to be simple for the responders and to use the same terminology and system as the existing incident management and triage tagging models. If not, implementation will be spotty, at best.