Prehospital triage

In locations with well-organized EMS and with several alternative hospitals at varying levels of trauma capabilities, a refinement on the organization of systems for trauma management is to establish pre-hospital triage criteria. This implies that the more severely injured patients would be taken to the nearest suitable hospital and not necessarily the geographically nearest hospital. Hence, this involves bypassing nearby, but less well-equipped hospitals with the more severely injured patients, assuming that the transport time to the better equipped hospital is not inordinate. This is based on training EMS personnel in various triage criteria, including the use of scoring algorithms such as the trauma score and the pre-hospital index. This also implies detailed, pre-existing arrangements with the EMS and the hospitals in a given city or area.

GUIDELINES FOR ESSENTIAL TRAUMA CARE Designation of trauma centres

The above also implies that a given political jurisdiction has worked out such arrangements with the hospitals. This is usually accompanied by the process of trauma centre designation, which is slightly different from the concept of verification mentioned earlier. Designation implies that the political jurisdiction has made a selection among various alternative hospitals as to which ones should be expected to meet varying criteria of trauma capability (ranging from small rural hospitals up to large urban trauma centres).

Referrals and inter-hospital transfer

As another part of planning of systems for trauma management, the relationship between hospitals is often considered. This includes transfer criteria specifying which types of injuries or levels of severity of injury should be transferred from smaller hospitals to larger ones. It also includes inter-hospital transfer agreements and protocols to facilitate such transfer. The goals of such transfer agreements and protocols are to decrease the time needed to carry out the transfer of a critically injured patient; to assure that the transfer is carried out in such a way as to diminish the probability of problems during transport; and to optimize care at each end of the transfer by assuring the necessary communication between medical providers at each end. These types of formal arrangements have hitherto primarily pertained to high-income countries. However, in almost every environment an informal system has arisen to assess which types of problems cannot be handled at smaller hospitals and hence are referred to larger facilities. This also considers which larger facilities are willing and able to take these patients, as well as the manner in which transport of such patients is arranged and paid for. Some of the same principles apply as discussed above, though in different formats, depending on local political considerations. However, the basic principle of knowing the capacity of each institution remains. Some progress might be made, even in greatly varying contexts, through a clearer definition of which specific injuries or level of injury severity might particularly benefit from referral in a given environment (10).

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