Critical Path Network: Assessing trauma patients boosts efficiency

When a 3-year-old boy was transferred to Eastern Maine Medical Center (EMMC) in Bangor, emergency department (ED) staff were told he was stable.

However, when the boy was given a score according to the hospital’s "trauma tier" pre-hospital triage system, it became clear the injuries were much more severe than anticipated.

Originally, the plan was to admit the child directly to the medical floor, but instead he went straight to the operating room for emergency surgery to remove a ruptured spleen, says Erik N. Steele, DO, ABFP, the facility’s administrator for emergency and trauma services.

Steele explains that the ED uses a unique prehospital assessment process to gauge the severity of trauma patients’ injuries before they get to the ED and to predict what level of response is needed.

"This helps us identify patients who are actually sicker than they are described to us, either because there were injuries that were not recognized, or because the patient’s condition deteriorated on the way here," he says.

Patients are given a score of Tier One, Two, or Three, so that the hospital’s trauma response is in place before the patient arrives, he explains. A hospital committee developed the tier system based on Maine’s existing pre-hospital triage system.

"We can score the patient in a matter of seconds using our triage form," Steele says. (See the EMMC Emergency Services Trauma Triage Worksheet and chart on staff called in for each tier.)

Here are benefits of the trauma tier scoring system:

Resources are used more efficiently.

Steele notes that previously, the hospital’s trauma team was mobilized for trauma cases, although they were not needed for the vast majority.

"This tool will help you determine what kind of patient you are getting, so you can match up the response to the patient," he says. For example, the scoring system reliably predicts which patients will require a bed in the intensive care unit (ICU), an operating room, or surgeon, he says.

He says this system would allow smaller EDs without in-house residents and other surgeons to avoid overcommitting limited resources.

"For a rural ED, calling up a trauma response means calling nurses, surgeons, and anesthesiologists in from home," Steele notes. "If you can do that only when a reliable system suggests you should, you can use those precious resources appropriately."

For instance, data have shown that 82% of the Tier One (most severe) trauma patients will go to the ICU or die in the ED. Based on that statistic, an accurate prediction can be made as to what resources, such as an ICU bed or respiratory therapy, will be needed, Steele says.

A smaller ED might use this to predict who is going to be transferred, he suggests, so that that process can be started.

Previously, Steele says, the team was not called in until the patient arrived. "That means that with severely injured patients, there is a chance that you won’t have the team there when you need them. Or you will overcorrect and call in the team every single time, in which case they will come in lots of times and be sitting around." That process is costly and hard on the call teams, he adds.

A trauma team is a significant dedication of resources, notes Pret Bjorn, the facility’s trauma coordinator.

"If you call in the trauma team every time you hear the screech of tires on the road, you are not going to create a system that endorses itself to surgeons or administration," Bjorn says.

Relationships with on-call physicians are improved.

Before the tier system was implemented, Steele reports that there were problems with on-call physicians who thought the ED called them needlessly. The system allows the ED to predict which patients need a general surgeon immediately, and which of those need the general surgeon within 30 minutes, he says.

"In exchange for calling only when we need them, they always come in, and there is no argument," he says. "The surgeons are pretty much guaranteed to get sick patients if they respond to a trauma page."

Only for a very small group of patients is the on-call physician required to drop everything and come to the ED, Steele says.

"For a slightly larger group, they will need to come within 30 minutes. And for about 80% of the population, we don’t call until we’ve assessed the patient, which means they may not even hear from us," he explains.

The goal is to avoid a knee-jerk response based on unscientific information, Bjorn says. "The goal is to cooperate with general surgeons and make life reasonable for them," he underscores.

Frequently, victims of motor vehicle crashes arrive largely uninjured and won’t require the general surgeon immediately, at least, Bjorn notes.

"It only takes three or four times of calling in the surgeon when the patient is fine before they are reluctant to come in next time you call," he says.

[For more information about the preassessment system for trauma patients, contact:

  • Pret Bjorn, Trauma Coordinator, EMMC Trauma Program, 489 State St., Bangor, ME 04401. Telephone: (207) 973-7260. Fax: (207) 973-7673. E-mail:
  • Erik N. Steele, DO, ABFP, Eastern Maine Medical Center, 489 State St., Bangor, ME 04401. Telephone: (207) 973-8270. Fax: (207) 973-8267. E-mail:]