- Email: [email protected]
Do we follow triage protocols?
Letters to the Editor / Injury, Int. J. Care Injured 41 (2010) 974–979
interest. Although, there have been significant controversy over the use of protocols, we greatly agree with the idea of the author to follow protocol in caring of trauma patients. It is obvious that ‘‘Time’’ is very important in taking care of trauma patients, especially for emergent and unstable cases, and prompt diagnosis and intervention is necessary to decrease rate of mortality and morbidity. Additionally, signs and symptoms of injury in trauma patients are non-specific, so without having a protocol for care of trauma patients, number of faults committed by trainees will increase.1 Therefore, providing accurate protocols is necessary to manage trauma patients more effectively. Undoubtedly, the role of training of health care providers is of great importance to reduce errors occurred during care of trauma patients,1 but if they follow these protocols, they will manage patients more effectively. Therefore, having a protocol for taking care of trauma patients is necessary to provide optimal trauma care. Most of the trauma protocols are designed by developed trauma centres where a large number of equipments like modern CT-scan and angiography apparatus and trained medical personnels are available. However, it should be considered that these protocols used in developed trauma centres are not practicable in developing centres because trauma centres in developing countries do not have enough equipments and trained medical personnels who are enable to take care of trauma patients. Additionally, some of modern facilities used in developed countries do not exist in most of developing and under developed trauma centres. In addition to what precedes, the load of trauma patients admitted in developing centres is much more than developed centres. In a developing trauma centre like our centre – Nemazi Hospital – approximately 30,000 trauma cases are admitted annually and these heavy load of patients cannot be managed according to those protocols planned in developed centres because few accessible equipments and trained medical personnels. If developing centres manage trauma patients according to those protocols used in developed centres, they will miss many of emergent cases definitely, which result in increasing in morbidity and mortality rate of developing centres. Therefore, developing centres should define priorities over the use of limited facilities in their centres. To reach to this purpose developing trauma centres should prepare modified protocol for trauma care based on quality and number of their equipments, number of trained personals and load of trauma patients, considering advanced protocols used in developed centres. These modified protocols should reassessed repeatedly to reduce faults and improve trauma care in these centres.1 The aim of writing this article is to say that although it is essential to have and follow protocol for trauma care, due to disequilibrium between demand and supply in developing trauma centres, these centres should design modified protocol adjusted to their circumstances to provide good trauma care. Conflict of interest None. Reference 1. Civil I. Guidelines, protocols and checklists: do we need them to provide good trauma care? Injury 2010;41:8–9.
Shahram Paydar, Roohollah Salahi*, Shahram Bolandparvaz, Hamid Reza Abbasi, Heshmatollah Salahi Shiraz University of Medical Sciences, Trauma Research Center, Iran
977
*Corresponding author at: Department of Surgery, Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Tel.: +98 9173147009; fax: +98 7116269136 E-mail address: [email protected] (Roohollah Salahi) doi:10.1016/j.injury.2010.01.106
Letter to the Editor Do we follow triage protocols? We would like to congratulate Davis et al. for their study of a two-tiered triage tool, aiming to distinguish patients with major trauma from those with minor trauma.1 Triage of trauma is complex, and no clear concensus has been reached regarding the best criteria for identifying seriously injured patients. The purpose of triage criteria in a trauma system is to properly identify and distribute seriously injured patients and to ensure an appropriate response in personnel, equipment, services and facilities. Because resources are limited, practicians must learn to use them optimally by admitting those patients most likely to benefit the best care efficiency. For example, in daily practice, the need for level-I trauma center care can exceeds its availability in many countries. We would like to go further into the debate, and highlight that compliance with triage protocol, not evaluated by Davis et al., is the corner-stone of triage efficiency. In real life experience strict adherence of care-givers to triage protocol is rare. Regarding the compliance of medical staff with the triage protocols, previous studies have demonstrated poor compliance with trauma guidelines by emergency medical services personnel. Wacher et al. (evaluating the implementation of a set of standardized pediatric triage protocols) have found that 58% of nurses felt confined by the protocols, and 42% admitted intentional deviation, when they believed that optimal patient care mandated that they do so.5 Correlation among dispositions determined by triage providers was poor, despite instructions to follow protocols as closely as possible. Although it is a basic assumption that protocols operate by standardization, these results indicate that nurses did not reliably choose the same protocol in a given case and did not reach the same triage endpoint even when they followed the same protocol. Nurses may decide under some circumstances to follow their intuition rather than the protocol’s recommendation. Moreover, it was found that physicians can too easily break from protocols to achieve disposition of patients, especially the more experienced one.4 We can notice that in the study of Lerner et al., after using SALT triage in a simulated exercise, only a third of physicians felt very confident using it.3 And it appeared a real disaster that practicians involved, using SALT as triage tool, were reluctant to leave their fellow to death and disposed to assume that trauma patients needed help, and that until the medical system collapsed, they would keep pushing victims into it as fast as possible.2 It remains a characteristic of human beings that we try to adapt triage rules. And even a well-designed triage tool may be inadvertently misapplied by physicians involved. Therefore, it is decisive to develop triage algorithms, but more investigations on imple-
§ All authors concur with the submission; the material submitted for publication has not been previously published and is not under consideration for publication elsewhere.
Letters to the Editor / Injury, Int. J. Care Injured 41 (2010) 974–979
978
mentation of triage tools should have significantly fine design to discriminate between failure of the triage tool itself and human faults by applying the algorithms. Conflict of interest No conflict of interests. References 1. Davis T, Dinh M, Roncal S, et al. Prospective evaluation of a two-tiered trauma activation protocol in an Australian major trauma referral hospital. Injury 2010. doi: 10.1016/j.injury.2010.01.003. 2. Kahn C, Schultz C, Miller KT, et al. Doest START triage work? An outcomes assessment after disaster. Ann Emerg Med 2009;54:424–30. 3. Lerner EB, Schwartz RB, Coule PL, Pirrallo RG. Use of SALT triage in a simulated mass-casualty incident. Prehosp Emerg Care 2010;14:21–5. 4. Pearson SD, Goldman L, Garcia TB, et al. Physician response to a prediction rule for the triage of emergency department patients with chest pain. J Gen Intern Med 1994;9:241–7. 5. Wacher DA, Brillman JC, Lewis J, Sapien RE. Pediatric Telephone triage protocols: standardized decisionmaking or false sense of security? Ann Emerg Med 1999;33:388–94.
Jean-P. Tourtier* Department of Intensive Care, Military Hospital Val de Graˆce, 74 Boulevard Port Royal, 75005 Paris, France Karim Tazarourte SAMU 77, Hospital Marc-Jacquet, 77000 Melun, France Delphine Lemoullec Psychiatric Department, Hospital Clermont de l’Oise, 2 rue des Finets, 60607 Clermont Cedex, France Yves Auroy Department of Intensive Care, Military Hospital Val de Graˆce, 74 Boulevard Port Royal, 75005 Paris, France *Corresponding author. Tel.: +33 664442525; fax: +33 140514608 E-mail address: [email protected] (J-P. Tourtier) doi:10.1016/j.injury.2010.03.011
the role in triage of the focused assessment with sonography in trauma (FAST), which can be easily performed by surgeons. FAST offers a reliable tool not only for trauma treatment but also during triage that can be used successfully as a screening tool. FAST has now become an extension of the physical examination and helps to detect life-threatening injuries, and allows appropriate triage of the patients. In 1997, an international consensus conference committee defined the acronym FAST to describe the application of ultrasound in the initial evaluation of trauma patients.3 The development of hand-held ultrasound devices caused significant changes in the triage of multiply injured patients. The use of ultrasound has focused on the FAST exam, as a major adjunct to triage and management of illness as well as patient assessment. Sonography for victims of blunt abdominal trauma was one of the first applications for FAST in emergency medicine. Walcher et al. showed that the average FAST exam was complete in less than 3 min when the results were negative, whereas positive findings were detected within seconds.4 Melniker et al. published the First Sonography Outcomes Assessment Program Trial, a randomized, controlled clinical investigation.1 The authors proved that ultrasound reduced the time from emergency department presentation to operative care (57 min versus 166 min). In addition, in the multitrauma patients, FAST help to prioritize operative management (in conjunction with clinical history and physical examination). With growing evidence regarding its benefit, the FAST examination remains the most commonly used and widely accepted triage tool. Ultrasound examination has been useful in the diagnosis of shock, to assess cardiac function, for detecting increased intracranial pressure by measuring the optic nerve sheath diameter, for identification of abscess (or foreign body) and safe incision and drainage. It is quickly performed, noninvasive and inexpensive. Many surgeons now consider it as a standard part of the trauma evaluation during disaster. And many modern evidence-based trauma protocols have included FAST examination as a pivotal axis in the triage decisions. The challenge for the future is to develop effective triage systems, integrating both modern ultrasound imagery and physical examination, in order to identify patients who require the best available response for trauma problems, and focus the limited resources using a sensitive and specific system. Based on their exceptional experience, we would like to know the authors thoughts concerning the implementation of FAST to reduce undertriage. Conflict of interest No conflict of interests.
Letter to the Editor Quality of triage We would like to congratulate Nie et al. for their study describing a dynamically regulated triage strategy, adopted during the post-earthquake period with numerous casualties.2 The authors reported that surgeons were more likely to under-triage patients than emergency medicine physicians. This is a crucial topic, as far as adequate triage is the key for surviving. The rate of surgeons undertriage was said to be 3%. To decrease this rate must be a priority. We want to go further into the debate, and highlight §
All authors concur with the submission; the material submitted for publication has not been previously published and is not under consideration for publication elsewhere.
References 1. Melniker LA, Leibner E, McKennedy MG, et al. Ramdomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med 2006;48:227–35. 2. Nie H, Tang SY, Bond Lau W, et al. Triage during the week of the Sichuan earthquake: a review of utilized patient triage, care, and disposition procedures. Injury 2010. doi: 10.1016/j.injury.2010.01.113. 3. Scalea TM, Rodriguez A, Chiu WC, et al. Focused assessment with sonography for trauma (FAST): results from an international consensus conference. J Trauma 1999;46:466–72. 4. Walcher F, Weinlich M, Conrad G, et al. Prehospital ultrasound imaging improves management of abdominal trauma. Br J Surg 2006;93:238–42.
Jean-Pierre Tourtier* Department of Intensive Care, Military Hospital Val de Graˆce, Secre´tariat de Re´animation, 74 Boulevard Port Royal, 75005 Paris, France
interest. Although, there have been significant controversy over the use of protocols, we greatly agree with the idea of the author to follow protocol in caring of trauma patients. It is obvious that ‘‘Time’’ is very important in taking care of trauma patients, especially for emergent and unstable cases, and prompt diagnosis and intervention is necessary to decrease rate of mortality and morbidity. Additionally, signs and symptoms of injury in trauma patients are non-specific, so without having a protocol for care of trauma patients, number of faults committed by trainees will increase.1 Therefore, providing accurate protocols is necessary to manage trauma patients more effectively. Undoubtedly, the role of training of health care providers is of great importance to reduce errors occurred during care of trauma patients,1 but if they follow these protocols, they will manage patients more effectively. Therefore, having a protocol for taking care of trauma patients is necessary to provide optimal trauma care. Most of the trauma protocols are designed by developed trauma centres where a large number of equipments like modern CT-scan and angiography apparatus and trained medical personnels are available. However, it should be considered that these protocols used in developed trauma centres are not practicable in developing centres because trauma centres in developing countries do not have enough equipments and trained medical personnels who are enable to take care of trauma patients. Additionally, some of modern facilities used in developed countries do not exist in most of developing and under developed trauma centres. In addition to what precedes, the load of trauma patients admitted in developing centres is much more than developed centres. In a developing trauma centre like our centre – Nemazi Hospital – approximately 30,000 trauma cases are admitted annually and these heavy load of patients cannot be managed according to those protocols planned in developed centres because few accessible equipments and trained medical personnels. If developing centres manage trauma patients according to those protocols used in developed centres, they will miss many of emergent cases definitely, which result in increasing in morbidity and mortality rate of developing centres. Therefore, developing centres should define priorities over the use of limited facilities in their centres. To reach to this purpose developing trauma centres should prepare modified protocol for trauma care based on quality and number of their equipments, number of trained personals and load of trauma patients, considering advanced protocols used in developed centres. These modified protocols should reassessed repeatedly to reduce faults and improve trauma care in these centres.1 The aim of writing this article is to say that although it is essential to have and follow protocol for trauma care, due to disequilibrium between demand and supply in developing trauma centres, these centres should design modified protocol adjusted to their circumstances to provide good trauma care. Conflict of interest None. Reference 1. Civil I. Guidelines, protocols and checklists: do we need them to provide good trauma care? Injury 2010;41:8–9.
Shahram Paydar, Roohollah Salahi*, Shahram Bolandparvaz, Hamid Reza Abbasi, Heshmatollah Salahi Shiraz University of Medical Sciences, Trauma Research Center, Iran
977
*Corresponding author at: Department of Surgery, Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Tel.: +98 9173147009; fax: +98 7116269136 E-mail address: [email protected] (Roohollah Salahi) doi:10.1016/j.injury.2010.01.106
Letter to the Editor Do we follow triage protocols? We would like to congratulate Davis et al. for their study of a two-tiered triage tool, aiming to distinguish patients with major trauma from those with minor trauma.1 Triage of trauma is complex, and no clear concensus has been reached regarding the best criteria for identifying seriously injured patients. The purpose of triage criteria in a trauma system is to properly identify and distribute seriously injured patients and to ensure an appropriate response in personnel, equipment, services and facilities. Because resources are limited, practicians must learn to use them optimally by admitting those patients most likely to benefit the best care efficiency. For example, in daily practice, the need for level-I trauma center care can exceeds its availability in many countries. We would like to go further into the debate, and highlight that compliance with triage protocol, not evaluated by Davis et al., is the corner-stone of triage efficiency. In real life experience strict adherence of care-givers to triage protocol is rare. Regarding the compliance of medical staff with the triage protocols, previous studies have demonstrated poor compliance with trauma guidelines by emergency medical services personnel. Wacher et al. (evaluating the implementation of a set of standardized pediatric triage protocols) have found that 58% of nurses felt confined by the protocols, and 42% admitted intentional deviation, when they believed that optimal patient care mandated that they do so.5 Correlation among dispositions determined by triage providers was poor, despite instructions to follow protocols as closely as possible. Although it is a basic assumption that protocols operate by standardization, these results indicate that nurses did not reliably choose the same protocol in a given case and did not reach the same triage endpoint even when they followed the same protocol. Nurses may decide under some circumstances to follow their intuition rather than the protocol’s recommendation. Moreover, it was found that physicians can too easily break from protocols to achieve disposition of patients, especially the more experienced one.4 We can notice that in the study of Lerner et al., after using SALT triage in a simulated exercise, only a third of physicians felt very confident using it.3 And it appeared a real disaster that practicians involved, using SALT as triage tool, were reluctant to leave their fellow to death and disposed to assume that trauma patients needed help, and that until the medical system collapsed, they would keep pushing victims into it as fast as possible.2 It remains a characteristic of human beings that we try to adapt triage rules. And even a well-designed triage tool may be inadvertently misapplied by physicians involved. Therefore, it is decisive to develop triage algorithms, but more investigations on imple-
§ All authors concur with the submission; the material submitted for publication has not been previously published and is not under consideration for publication elsewhere.
Letters to the Editor / Injury, Int. J. Care Injured 41 (2010) 974–979
978
mentation of triage tools should have significantly fine design to discriminate between failure of the triage tool itself and human faults by applying the algorithms. Conflict of interest No conflict of interests. References 1. Davis T, Dinh M, Roncal S, et al. Prospective evaluation of a two-tiered trauma activation protocol in an Australian major trauma referral hospital. Injury 2010. doi: 10.1016/j.injury.2010.01.003. 2. Kahn C, Schultz C, Miller KT, et al. Doest START triage work? An outcomes assessment after disaster. Ann Emerg Med 2009;54:424–30. 3. Lerner EB, Schwartz RB, Coule PL, Pirrallo RG. Use of SALT triage in a simulated mass-casualty incident. Prehosp Emerg Care 2010;14:21–5. 4. Pearson SD, Goldman L, Garcia TB, et al. Physician response to a prediction rule for the triage of emergency department patients with chest pain. J Gen Intern Med 1994;9:241–7. 5. Wacher DA, Brillman JC, Lewis J, Sapien RE. Pediatric Telephone triage protocols: standardized decisionmaking or false sense of security? Ann Emerg Med 1999;33:388–94.
Jean-P. Tourtier* Department of Intensive Care, Military Hospital Val de Graˆce, 74 Boulevard Port Royal, 75005 Paris, France Karim Tazarourte SAMU 77, Hospital Marc-Jacquet, 77000 Melun, France Delphine Lemoullec Psychiatric Department, Hospital Clermont de l’Oise, 2 rue des Finets, 60607 Clermont Cedex, France Yves Auroy Department of Intensive Care, Military Hospital Val de Graˆce, 74 Boulevard Port Royal, 75005 Paris, France *Corresponding author. Tel.: +33 664442525; fax: +33 140514608 E-mail address: [email protected] (J-P. Tourtier) doi:10.1016/j.injury.2010.03.011
the role in triage of the focused assessment with sonography in trauma (FAST), which can be easily performed by surgeons. FAST offers a reliable tool not only for trauma treatment but also during triage that can be used successfully as a screening tool. FAST has now become an extension of the physical examination and helps to detect life-threatening injuries, and allows appropriate triage of the patients. In 1997, an international consensus conference committee defined the acronym FAST to describe the application of ultrasound in the initial evaluation of trauma patients.3 The development of hand-held ultrasound devices caused significant changes in the triage of multiply injured patients. The use of ultrasound has focused on the FAST exam, as a major adjunct to triage and management of illness as well as patient assessment. Sonography for victims of blunt abdominal trauma was one of the first applications for FAST in emergency medicine. Walcher et al. showed that the average FAST exam was complete in less than 3 min when the results were negative, whereas positive findings were detected within seconds.4 Melniker et al. published the First Sonography Outcomes Assessment Program Trial, a randomized, controlled clinical investigation.1 The authors proved that ultrasound reduced the time from emergency department presentation to operative care (57 min versus 166 min). In addition, in the multitrauma patients, FAST help to prioritize operative management (in conjunction with clinical history and physical examination). With growing evidence regarding its benefit, the FAST examination remains the most commonly used and widely accepted triage tool. Ultrasound examination has been useful in the diagnosis of shock, to assess cardiac function, for detecting increased intracranial pressure by measuring the optic nerve sheath diameter, for identification of abscess (or foreign body) and safe incision and drainage. It is quickly performed, noninvasive and inexpensive. Many surgeons now consider it as a standard part of the trauma evaluation during disaster. And many modern evidence-based trauma protocols have included FAST examination as a pivotal axis in the triage decisions. The challenge for the future is to develop effective triage systems, integrating both modern ultrasound imagery and physical examination, in order to identify patients who require the best available response for trauma problems, and focus the limited resources using a sensitive and specific system. Based on their exceptional experience, we would like to know the authors thoughts concerning the implementation of FAST to reduce undertriage. Conflict of interest No conflict of interests.
Letter to the Editor Quality of triage We would like to congratulate Nie et al. for their study describing a dynamically regulated triage strategy, adopted during the post-earthquake period with numerous casualties.2 The authors reported that surgeons were more likely to under-triage patients than emergency medicine physicians. This is a crucial topic, as far as adequate triage is the key for surviving. The rate of surgeons undertriage was said to be 3%. To decrease this rate must be a priority. We want to go further into the debate, and highlight §
All authors concur with the submission; the material submitted for publication has not been previously published and is not under consideration for publication elsewhere.
References 1. Melniker LA, Leibner E, McKennedy MG, et al. Ramdomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med 2006;48:227–35. 2. Nie H, Tang SY, Bond Lau W, et al. Triage during the week of the Sichuan earthquake: a review of utilized patient triage, care, and disposition procedures. Injury 2010. doi: 10.1016/j.injury.2010.01.113. 3. Scalea TM, Rodriguez A, Chiu WC, et al. Focused assessment with sonography for trauma (FAST): results from an international consensus conference. J Trauma 1999;46:466–72. 4. Walcher F, Weinlich M, Conrad G, et al. Prehospital ultrasound imaging improves management of abdominal trauma. Br J Surg 2006;93:238–42.
Jean-Pierre Tourtier* Department of Intensive Care, Military Hospital Val de Graˆce, Secre´tariat de Re´animation, 74 Boulevard Port Royal, 75005 Paris, France