Consensus-driven trauma criteria key to region's success

Trauma Service Area - P, in southwest Texas, is a 26,000-square-mile region serving 2.5 million people in 22 counties. It has 35 general hospitals — 20 in the hub city of San Antonio and 15 rural facilities. All are designated trauma centers.

San Antonio's two Level I centers, University Hospital and the San Antonio Military Medical Center, the only ACS-verified Level I trauma center in the Department of Defense, receive almost all trauma patients who meet trauma alert criteria. Thirteen helicopters from three air medical programs and 70 EMS agencies provide transport.

"Without uniform trauma criteria, our regional system would be fractured," says Eric Epley, NREMT-P, executive director of the Southwest Texas Regional Advisory Council for Trauma (STRAC). "Our region is the size of West Virginia. And in the state of Texas, there are 21 other West Virginias, which are geographically, economically and socially diverse."

When the Texas trauma system was established 20 years ago, each of the 22 trauma service areas was required to develop a regional trauma system and form a regional advisory council (RAC) to provide the infrastructure and leadership to maintain it. Membership in a region's RAC is offered to all providers who care for patients. Theoretically, participation is voluntary, but in practice, state health grant funding goes to active members, Epley says, adding, "They whittled a carrot into the shape of a stick."

The metaphor doesn't apply to trauma triage guidelines, which are developed regionally rather than by the state. This approach allows for geographic differences and ensures that the people who are actually providing trauma care have control over how it is delivered. "The state required us to develop trauma alert criteria, but did not mandate what they should be," Epley explains. "In each region, the surgeons, emergency physicians, paramedics and nurses who care for patients, who know their constituents, are responsible for building their own system within the larger state structure."

Red Blue Criteria

Initially, the STRAC adopted Florida's Red and Blue Trauma Triage Criteria. The original protocol has since been integrated with Centers for Disease Control and Prevention and American College of Surgeons (ACS)-aligned guidelines, but the basic methodology remains the same: Patients meeting one of the Red criteria or any two of the Blue criteria are trauma alerts.

Injuries are stratified based on physiology, anatomy and mechanism of injury, along with comorbidities and age. For example, children younger than 5 and adults older than 55 are Blue criteria, so combining them with another Blue criterion, such as long-bone fracture, triggers a trauma alert. Vital signs-driven clinical findings and clinically based assessments of injuries provide the most accurate triage; mechanism of injury is not as reliable and is emphasized less.

"A rollover accident doesn't necessarily trigger a trauma alert," Epley says. "There should be a high degree of suspicion, but if there are no clinical findings and the person is walking around, a rollover in and of itself is not an exclusive determining factor."

In line with ACS recommendations, Epley says the goal is to have an undertriage rate of 5 percent or less. "We would rather be safe than sorry. I would rather have people come to a designated Level I trauma center and not need service, so we tolerate an overtriage rate of 50 percent or more because that's what's best for patients."

To achieve these goals, criteria are continually re-evaluated — both in a formal annual review and in monthly performance improvement meetings that include about 40 trauma system stakeholders. "We meet for two hours over lunch every month and review specific cases that have been brought to our attention and look at systems reports, and in evaluating cases and reports, we may find gaps in the criteria," Epley explains. "If that happens, any changes in the criteria are accomplished entirely by consensus."

He adds, "We've never had a nonunanimous vote. Consensus is absolutely crucial. It's really the only way a mature system can function, the only functional model. Our system members are routinely reminded that consensus really means 'they may not get exactly what they want, but they will get what they need.' And that takes maturity on the part of attendees and a strong commitment, from all involved, to what is best for patients, not what is best for a particular hospital or surgeon or EMS agency. If we take that approach — what is best for the patient — then consensus works, and we don't accidentally lose our way."

Beyond that, Epley stresses the importance of keeping regional trauma systems in the hands of providers. "People tend to respond positively if they are actually responsible for things," he explains. "If some committee in Austin is dictating our trauma criteria, then people feel disempowered. But if you empower them, then they respond well. We are on the bleeding edge of things here; we have learned many lessons over the years, and to see the improvements has been extremely rewarding."

For more information

Download a .pdf of the STRAC Red Blue Criteria.