Prehospital Emergency Care
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Accuracy of EMS Trauma Transport Destination Plans in North Carolina Chailee Moss MD, Christopher S. Cowden MPH, Laurie Meyer Atterton MD, Meredith H. Arasaratnam ScD, Antonio R. Fernandez PhD, NREMT-P, Jeff S. Evarts AAS, Brian Barrier BA, E. Brooke Lerner PhD, N. Clay Mann PhD, MS, Chad Lohmeier MBA, Frances S. Shofer PhD & Jane H. Brice MD, MPH To cite this article: Chailee Moss MD, Christopher S. Cowden MPH, Laurie Meyer Atterton MD, Meredith H. Arasaratnam ScD, Antonio R. Fernandez PhD, NREMT-P, Jeff S. Evarts AAS, Brian Barrier BA, E. Brooke Lerner PhD, N. Clay Mann PhD, MS, Chad Lohmeier MBA, Frances S. Shofer PhD & Jane H. Brice MD, MPH (2015) Accuracy of EMS Trauma Transport Destination Plans in North Carolina, Prehospital Emergency Care, 19:1, 53-60 To link to this article: http://dx.doi.org/10.3109/10903127.2014.916021
Published online: 30 May 2014.
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Date: 06 November 2015, At: 06:54
FOCUS ON EMS TRANSPORT ACCURACY OF EMS TRAUMA TRANSPORT DESTINATION PLANS IN NORTH CAROLINA Chailee Moss, MD, Christopher S. Cowden, MPH, Laurie Meyer Atterton, MD, Meredith H. Arasaratnam, ScD, Antonio R. Fernandez, PhD, NREMT-P, Jeff S. Evarts, AAS, Brian Barrier, BA, E. Brooke Lerner, PhD, N. Clay Mann, PhD, MS, Chad Lohmeier, MBA, Frances S. Shofer, PhD, Jane H. Brice, MD, MPH
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ABSTRACT Objective. Planning for time-sensitive injury may allow emergency medical services (EMS) systems to more accurately triage patients meeting accepted criteria to facilities most capable of providing life-saving treatment. In 2010, North Carolina (NC) implemented statewide Trauma Triage and Destination Plans (TTDPs) in all 100 of North Carolina’s county-defined EMS systems. Each system was responsible for identifying the specific destination hospitals with appropriate resources to treat trauma patients. We sought to characterize the accuracy of their hospital designations. Methods. In this cross-sectional study, we collected TTDPs for each county-defined EMS system, including their assigned hospital capabilities (i.e., trauma center or community hospital). We conducted a survey with each EMS system to determine how their TTDP was constructed and maintained, as well as with each TTDP-designated hospital to verify their capabilities. We determined the accuracy of the EMS assigned hospital designations by comparing them to the hospital’s reported capabilities. Results. The 100 NC EMS systems provided 380 designations for 112 hospitals. TTDPs were created by EMS administrators and medical directors, with only 55% of EMS systems engaging a hospital representative in the plan creation. Compared to the actual hospital capabilities, 97% of the EMS TTDP designations were correct. Twelve hospital designations were incorrect and the majority (10) overestimated hospital capabilities. Of the 100 EMS systems, 7 misclassified hospitals in their TTDP. EMS systems that did not verify their local hospitals’ capabilities during TTDP development were more likely to incorrectly categorize a hospital’s capabilities (p = 0.001). Conclusions. A small number of EMS systems misclassified hospitals in their TTDP, but most plans accurately reflected hospital capabilities. Misclassification occurred more often in systems that did not consult local hospitals prior to developing their TTDP. The potential of the TTDP to improve communication between EMS agencies and the facilities with which they work has not been fully realized. EMS agencies or systems should verify local hospital capabilities when engaging in destination planning efforts. Key words:
Received January 16, 2014 from the School of Medicine, University of North Carolina, Chapel Hill, North Carolina (CM, CSC, LMA), Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina (MHA, FSS, JHB), EMS Performance Improvement Center, Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina (JSE, BB, CL), Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (EBL), and Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, Utah (NCM). Revision received April 10, 2014; accepted for publication April 10, 2014. This paper was presented at the National Association of EMS Physicians annual meeting, January 2012. Support for the survey phase of the study was provided by the UNC Department of Emergency Medicine. Support for the data analysis phase was sponsored by National Highway Safety Administration grant DTNH22-07D-00049. This publication was developed in part with funding from the National Highway Traffic Safety Administration (NHTSA) of the U.S. Department of Transportation (DOT). The opinions, findings and conclusions expressed in this publication are those of the authors and not necessarily those of NHTSA or DOT. The United States Government assumes no liability for its content or use thereof. If trade or manufacturer’s names or products are mentioned, it is because they are considered essential to the object of the publication and should not be construed as an endorsement. The United States Government does not endorse products or manufacturers. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Current author affiliations: Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, Ohio (CM), Wilmington, North Carolina (LMA), Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina (JSS), and Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (FSS). Address correspondence to Jane H. Brice MD, MPH, Department of Emergency Medicine, CB #7594, University of North Carolina, Chapel Hill, NC 27599-7594, USA. E-mail: [email protected] doi: 10.3109/10903127.2014.916021
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triage; transportation of patients; emergency medical services PREHOSPITAL EMERGENCY CARE 2015;19:53–60
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INTRODUCTION The burden of trauma in the United States is tremendous; over 180,000 deaths were attributed to injury in the United States in 2010, and over 2.8 million hospitalizations were attributed to nonfatal injuries.1,2 It has been recognized that appropriate triage of injured patients can reduce cost and improve injury outcomes.3,4 The roots of modern trauma triage destination schemes may be found in military models of trauma care from the First World War.5 From these early models, trauma systems across the United States have been improved and standardized over time.6 When seriously injured patients are treated at an appropriately equipped trauma center, their outcomes are dramatically improved.3 However, when patients who are less seriously injured are transported to trauma center, the efficiency of the emergency medical services (EMS) and trauma systems may be compromised by increasing transport times and the number of patients taken to a trauma center. Transport to a trauma center may also unnecessarily subject lessinjured patients to the hazards associated with helicopter or expedited lights-and-sirens transport. Therefore, an important role of EMS is to identify seriously injured patients who should be transported to a trauma center. Given the risks associated with both over- and underestimating the severity of a patient’s injuries, the accuracy and the execution of EMS systems’ triage protocols significantly affects both the outcome of the injured patient and the EMS and trauma systems’ capacity to treat the next patient.7,8 Recognizing the importance of appropriate triage, the Centers for Disease Control and Prevention sponsored a National Expert Panel on Field Triage to update the guidelines used by EMS personnel for onscene trauma patient triage and transport decisions.9,10 The guidelines put forth specific anatomic, physiologic, and mechanism criteria for EMS personnel to utilize in quickly determining the appropriate type of facility for a given patient at the scene of an injury.10 These guidelines can be used by EMS providers as a tool for selecting the most appropriate destination facility for their patients, but to be truly useful they must be customized to reflect local facilities and transport times. That is, local EMS systems must incorporate the guidelines into their system-specific guidelines, designating which hospitals are appropriate destinations under a given circumstance. The manner in which EMS systems actually develop and revise their system-specific guidelines is not well understood. The present study aims to characterize
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how EMS systems within a single state develop and maintain their guidelines. Additionally, we sought to determine the accuracy of the guidelines.
METHODS Study Design We conducted a cross-sectional survey of all 100 North Carolina EMS systems and 131 North Carolina hospitals to determine the accuracy and process for development of each system’s TTDP.
Setting and Population North Carolina has 100 EMS systems, largely defined by county boundaries, with the exception of two systems: one comprises the Cherokee Indian Nation and one comprises two small counties. There are 540 EMS agencies in North Carolina and each is required to affiliate with an EMS system. EMS systems oversee all of the EMS response agencies within their boundaries, (e.g., air medical services, ground transport services, and first responder agencies), and create system-wide treatment and transport protocols. Every EMS system is required to have a medical director who has overall medical authority for every EMS agency affiliated with the EMS system. The EMS systems are regulated by the North Carolina Office of EMS (NCOEMS).11 The NCOEMS surveys North Carolina hospitals requesting trauma center designation utilizing a standardized set of criteria.12 Hospitals may be designated by the NCOEMS at level I, II, or III, depending on the available specialists and resources. At the time of the study, 12 hospitals were designated as trauma centers (6 level I, 3 level II, and 3 level III). Of the 6 level I statedesignated hospitals, 5 were also American College of Surgeons-verified level I trauma centers. One of the level I trauma centers was additionally an American College of Surgeons-verified pediatric level I trauma center and 2 were American Burn Association-verified burn centers. One of the 3 level II state designated hospitals was also an American College of Surgeonsverified level II trauma centers and none of the level III state-designated hospitals were American College of Surgeons verified. In order to improve EMS readiness, NCOEMS used the National Expert Panel’s Field Triage Guidelines to create a planning tool known as the EMS trauma triage and destination plan (TTDP) (Figure 1). The plan is an algorithm merging the Trauma Guidelines with system resources to suggest ideal transport destinations for injured patients, depending on their location, type of injury, and symptoms. To create a TTDP, the EMS system must determine the capabilities of local health-care facilities and integrate them with the field triage guidelines. Although the NCOEMS has provided a standard
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FIGURE 1. Model process for trauma destination planning.
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56 template to all EMS systems, it also requires EMS systems to modify their specific TTDP so that their transport destinations reflect both the variable proximity and medical capabilities of their closest health-care facilities as well as the system resources.
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Survey Instrument The 14-item EMS system survey was designed to assess how EMS systems develop, disseminate, and maintain their TTDP. The intended respondent was the EMS system director or assistant director; when these personnel were not available, a training officer or any administrator with knowledge of the system’s TDP development process was asked to respond. Plan development questions included which EMS and community personnel were involved in TTDP development and whether plan creators verified area hospitals’ capabilities during plan development. We then asked what methods were used to educate personnel in use of their plans, how plan use is monitored, and how feedback is received from hospital personnel, including case review, for various types of patients. Finally, we asked how often the plan is reviewed and revised. To assess the accuracy of the EMS system’s TTDP, each North Carolina Hospital completed a 21-item survey to assess their capabilities. The survey’s intended respondents were emergency department administrative personnel, such as a charge nurse, resource nurse, or nurse manager. The hospital survey reflected the specific capabilities outlined in the TTDP. Measured variables included facility hours and capabilities, staff qualifications and availability, equipment capabilities, and mechanisms by which hospital staff provide feedback to EMS personnel on trauma patients.
Data Collection TTDPs for each system were obtained electronically from the North Carolina Office of EMS. The TTDPs were reviewed by a single reviewer (CM) who identified each hospital that was listed and determined if it was designated as a community hospital or a trauma center. We also determined the TTDP designation for air and ground transport time. The state TTDP template suggested a drive time (driving time outside of which air transport should be considered) of 50 minutes and a flight time (air time to trauma center outside of which a patient should be transported to the closest community hospital) of 30 minutes, but systems could alter these times. Hospitals were included if they were on any EMS system’s TTDP, or if they were on the list of licensed hospitals by the North Carolina Department of Health and Human Services with emergency departments as of January 3, 2011. Each hospital was contacted by phone by one of three trained interviewers (CM,
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CC, LA), and verbal consent was obtained from the respondent.
Statistical Analysis Determination of the counties that were “out of reach,” i.e., had any area more than an hour from a trauma center by drive time, was done by mapping 60-minute drive times from each state trauma center in Microsoft MapPoint (Redmond, WA). NCOEMS determination of the trauma capability level (community facility or trauma center) was obtained for each surveyed hospital. The responses for each EMS system and hospital, NCOEMS triage destination plan data and determinations of hospital capabilities, and mapping data were compiled using Microsoft Excel software (Redmond, WA). Summary statistics such as frequencies and percentages were used to describe the EMS systems’ TTDPs. To compare differences in plan construction method and accuracy of plans, Fisher’s exact test was used. A probability of p < 0.05 was considered statistically significant. All analyses were performed using SAS statistical software (version 9.3, SAS Institute, Cary, NC). Institutional review board approval for this study was obtained from the University of North Carolina Office of Human Research Ethics.
RESULTS Survey Respondents Each of North Carolina’s 100 EMS systems and 131 hospitals responded to the survey. Among EMS systems, the survey was most commonly answered by the EMS director of the system (68%). Among hospitals, the most common respondents were charge nurses, nurse managers, or other nurses (69%). Most EMS systems (90%) reported that their highest level of training was paramedic; 8% reported intermediate and 2% reported basic as their highest training levels. Call volume for the EMS systems ranged from 420 to 90,000 calls per year. There was an average of 3.3 agencies per EMS system TTDP, with a median of 2 and a range from 1 to 17.
Features of Plan Construction EMS directors and medical directors were involved in the construction of most plans, but 55% reported that local hospital representatives were directly involved in system TTDP construction (Table 1). Of all the counties, 91% reported verifying local hospital capabilities during the construction of their TTDP. Seven percent reported neither having a hospital representative nor verifying hospital capability during the construction of their TTDP.
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TABLE 1. EMS and hospital survey responses N = 100
EMS survey
What is the highest level of EMS certification provided by your system?
What is the current annual call volume of your EMS System?
How many agencies providing 9-1-1 response with transport capability are within your system?
When the triage destination plans were being completed, who was involved in the decision making?
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Did you verify hospital capabilities with your area hospitals? Did you have a meeting with hospital personnel to discuss your plans and your decisions? What methods did you use to disseminate your plans to your personnel?
How do you know that your personnel are following the triage destination plans?
How do you maintain or revise your triage destination plans?
Hospital survey Is your hospital currently designated as a trauma center by the North Carolina Office of Emergency Medical Services? At what level of trauma center is your hospital designated?
Does your hospital have an American Burn Association verified burn center?
TTDP Template Alteration Nine percent of systems altered the standard 60minute drive time to hospitals contained in their TTDP, with 5% decreasing the time allowed in their algorithm (range of 30–50 minutes), 3% increasing it (70–90 minutes), and one system omitting drive time from its TTDP. Air time was changed or absent in 10% of TTDPs, with 4% changing the limits to increase them, and 4% decreasing their time limits (2% omitted air transport from their system’s algorithm altogether).
Plan Distribution and Maintenance Seventy-seven percent of systems reported meeting with hospital representatives to discuss the decisions that had been made after the TTDP was finalized.
EMT Intermediate Paramedic 420–4,000 (first quartile) 4,001–7,499 (second quartile) 7,500–14,999 (third quartile) >15,000 (fourth quartile) Mean (SD) Minimum Maximum EMS director EMS training officer Medical director Hospital representative Other Yes Yes Distributed paper copies Face-to-face training session Online education Other (Email, CD) Nothing Ongoing QA EMS toolkits We do not monitor compliance Other Yearly review With hospital capability changes When there is a complaint When we revise our protocols No revision planned Yes No Level I Level II Level III Yes No
2 8 90 28 20 25 27 3.33 (3.07) 1 17 94 82 98 55 37 91 77 83 98 19 2 1 100 64 0 9 60 92 71 52 0 N = 131 13 118 6 3 3 2 129
Face-to-face training was the most popular method by which plans were distributed to EMS personnel (98% of systems), but many systems used various electronic media to communicate the TTDP (Table 1). All NC EMS systems reported the use of ongoing quality assurance to verify TTDP use by EMS personnel in the field; computer-generated performance improvement reports were also frequently used to monitor the plans’ usage (64%). Nine percent of systems reported other methods of monitoring, including peer reviews or other auditing systems. EMS systems reported a variety of TTDP maintenance practices, but most involved routine scheduled reviews, with some revision of plans because of an instigating event (e.g., a complaint or hospital change) (Table 1). For those systems that reported plan changes in which any time protocols were revised (53%),
58 we then asked how often they revised their system protocols; these schedules also varied despite the statemandated 2-year revision schedule.
Accuracy of the Plans EMS systems identified a total of 112 hospitals in their TTDP. In total, 380 categorizations of those hospitals were made by the EMS systems, with an average of 3.8 hospitals categorized per system (range 0–12, median 3). Of the 380 categorizations, 97% were correct. Of the 3% (n = 12) that were incorrect, 10 designated a hospital that was a community facility as a traumacapable facility (“overestimation”), and 2 designated a trauma-capable hospital as a community facility (“underestimation”).
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Relationships between Construction and Accuracy The 12 errors in categorization were contributed by 7% of North Carolina EMS Systems; 93% of systems did not make errors in categorization. No statistically significant differences could be identified between the 7% of systems that made errors and the 93% that did not. However, 2 of the 7 systems that made errors did not verify hospital capabilities with local hospitals, and only 29% of these systems involved a hospital representative in the creation of their TTDP, in contrast to 57% of those systems that did not make errors in their TTDP. Systems making incorrect categorizations also had a slightly smaller average number of agencies (2.9 in incorrect systems, 3.4 in correct systems). The involvement of specific personnel was not found to significantly change the accuracy of a system’s TTDP. The 9 systems that failed to verify area hospital capabilities during the creation of their TTDP contributed 30 of the 380 total categorizations. There was a statistically significant difference between the accuracy of hospital categorizations in counties that verified the hospitals’ capabilities and those that did not (p = 0.001). The 9 counties that did not verify the hospital capabilities had a higher proportion of incorrect categorization (16.7% overestimation, 0% underestimation) than those counties that did verify hospital capabilities (1.5% overestimation, 0.6% underestimation).
Rural Counties Mapping was used to identify EMS systems with areas that had drive times longer than 60 minutes to the nearest trauma center. Using this map, we determined that portions of 46% of systems were “out of reach,” meaning that any part of the system was outside the 60-minute drive time to any trauma center. Out-of-reach systems contributed 152 of the 380 TTDP categorizations, and had higher rates of incorrect cat-
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egorizations, with 3.3% overestimation and 1.3% underestimation, than counties that were in reach (2.19% overestimation and no underestimation). However, the overall difference in correct and incorrect categorization between “out-of-reach” systems and the remaining systems was not statistically significant (p = 0.2).
DISCUSSION The Field Triage Guidelines were designed to assist EMS providers in identifying severely injured patients. However, in real-world situations destination decisions are not so simple. Communities may have multiple trauma centers or long transport times to the nearest trauma center. A system-specific guideline such as the TTDP can provide a tool for EMS providers to use in the field to select the best destination once they have identified a severely injured patient. These system-specific guidelines are based on the community’s actual resources and transport times. These tools are important for both improving patient outcomes and efficiently using scarce EMS and trauma resources. We found that all EMS systems in North Carolina had developed system-specific guidelines, and the majority of these guidelines accurately identified area hospitals’ capabilities. The 46 EMS systems in this study with some areas more than 60 minutes from a trauma center are overwhelmingly rural and economically underserved. Rural trauma has been shown to lead to more fatalities than urban trauma, both due to higher speed vehicular collisions and increased transport time to hospitals.13,14 Thus, it may be necessary to support these rural EMS systems in their effort to alter their TTDP to best ensure effective triage of EMS system patients. Unfortunately, there is a sizeable research gap regarding how to best assist communities with long transport times. Those EMS systems that did not accurately identify hospital capabilities were a very small proportion of the state’s systems, but did have much lower rates of involvement of hospital representatives during the construction of their TTDP, although this was not statistically significant. We attribute a lack of statistically significant differences in the systems that made errors to small sample size. Additionally, those counties that did not verify hospital capabilities with their area hospitals after TTDP construction were more likely to make errors and, in particular, to attribute more resources to a hospital than it really possessed. Thus, these findings support continued close involvement of hospital representatives and hospital verification in the construction of system TTDPs. Creating system-specific guidelines creates an opportunity for collaboration between EMS systems and their hospital partners. It is concerning that nearly half (45%) of the EMS systems did not engage their
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hospital partners during the TTDP development process. This is a missed opportunity to strengthen relationships and the planning process. Involvement of hospital personnel in system-specific guideline development should be encouraged to facilitate communication and feedback between hospitals and EMS systems. It may seem intuitive that once a provider has identified a severely injured patient they should easily be able to select the nearest trauma center. However, there are a number of decisions that need to be made before patient contact; these decisions require understanding the designation of each hospital, the drive and fly times to those hospitals from each area of a community, and the EMS resources within a community. Triage destination planning is analogous to fire planning. Fire agencies meticulously plan fire responses well before they occur; buildings are inspected so that a building fire-fighting plan is in place well before a fire arises. Improvement in firefighter line-of-duty death rates, civilian fire-related deaths, and containment of fires in the last 30 years has been attributed in part to improvements in fire response planning techniques.15 Additionally, fire inspection programs improve community satisfaction by increasing communication between fire agencies and their constituents.16 Just as fire departments plan their response to fires based on types of building and location, so should EMS agencies plan their responses to patients with varying complaints and distances from trauma services well in advance of actual EMS calls. This type of planning has the potential to decrease costs and increase the communication between EMS agencies and the facilities to which they transport patients. A model process for trauma transport destination planning is suggested in Figure 2. There are many barriers to realizing the full potential of system-specific plans. First, the plans must evolve to reflect changes in community resources and advances in the science of treating injured patients. Thus, it is concerning that 16% of our communities had no plans to reevaluate the TTDP. Of course, a plan for communicating changes must be in place to relay each revision to street-level providers, and revisions could be costly depending on how changes are communicated. Another barrier to fully realizing the potential of system-specific plans is ensuring their regular use in clinical practice. Although 98% of North Carolina EMS systems relayed their TTDP to providers through faceto-face meetings, we do not know how well the TTDP was incorporated into clinical practice. Although the incorporation of TTDPs in clinical practice was beyond the scope of the current study, it is an area that must be evaluated in order to fully realize the benefit of systemspecific tools, and merits further study. Failure to effectively use TTDPs has broader implications for EMS system performance improvement.
Enga ge hospital a nd community partners i n plan development
Revi ew plan at least a nnually to assess for cha nges i n hospal ca pa bilies or community needs
Veri fy a rea hospital ca pa bilies
Provi de feedback to EMS pers onnel about performance
Di s tribute plan to EMS pers onnel with educaon
Audi t EMS provider a dherance to plan
FIGURE 2. Model process for plan development, dissemination, use, and review. Model process for trauma destination planning.
System-specific guidelines such as the TTDP are an important tool for ensuring standardization within a community, and form the basis for quality improvement reviews. Without a planning tool like the TTDP, it is difficult to evaluate the choices a specific provider makes. Without a performance review of the care of injured patients, EMS communities and providers cannot improve and standardization cannot occur. Thus, future studies evaluating the incorporation of systemspecific tools will have significant implications for performance evaluation and quality improvement efforts in EMS systems. We found that a wide range of strategies is employed by North Carolina counties in creating their Trauma Triage Destination Plan. Most counties involved their medical directors and key administrative personnel in the development of the plan, which indicates that an appropriate level of attention was accorded to plan development. We are encouraged that most systems modifying the TTDP algorithm made time limits more rigorous, increasing the likelihood that a patient would be transferred more quickly by air to a higher level facility. In the few systems that incorrectly categorized hospitals, the tendency to overestimate capabilities is concerning. This may mean that EMS systems send patients to unprepared facilities, rather than ensuring that trauma patients go to appropriate trauma facilities. Further, many systems did not involve a hospital representative directly in the construction of their plan, a missed opportunity for the planning process to
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improve collaboration between EMS agencies and their local facilities. Overall, the findings of this study are encouraging; the TTDP has been supported with careful planning in most of North Carolina’s EMS systems, and the rate of error was low but may be attributable to lack of communication between EMS systems and their local health-care facilities. Full realization of the potential of system-specific tools such as the TTDP requires study of the incorporation of TTDP into practice by clinical providers; in the future this may be instrumental in EMS quality improvement efforts.
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LIMITATIONS This triage destination survey took place in North Carolina, and, given the variation of state resources and EMS system structure, our results should be generalized cautiously to other states. Our sample size was limited to the 100 systems within our state, so rates of error were small enough that subtle effects due to community variation in approach to triage destination planning may have been undetectable. Additionally, this survey was done with EMS and hospital personnel, so there may have been some variation in results related to miscommunication or lack of knowledge among survey respondents.
CONCLUSIONS North Carolina EMS systems are able to construct accurate triage strategies for trauma using planning tools. We strongly urge collaboration between EMS agencies and hospitals to improve communication and improve the accuracy of EMS assessment of facility capabilities in the TTDPs in the small number of facilities that were improperly assessed. Counties that report verifying hospital capabilities are more likely to correctly plan for patient triage to appropriate trauma destinations. Caution should be exercised during TTDP creation, as overestimation of facility capability seems to be the more common error, and may be dangerous to patients. Data on the outcomes of patients in counties that more accurately constructed their plans would be useful in further characterizing the efficacy of EMS agency planning well before an event occurs.
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ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20
Accuracy of EMS Trauma Transport Destination Plans in North Carolina Chailee Moss MD, Christopher S. Cowden MPH, Laurie Meyer Atterton MD, Meredith H. Arasaratnam ScD, Antonio R. Fernandez PhD, NREMT-P, Jeff S. Evarts AAS, Brian Barrier BA, E. Brooke Lerner PhD, N. Clay Mann PhD, MS, Chad Lohmeier MBA, Frances S. Shofer PhD & Jane H. Brice MD, MPH To cite this article: Chailee Moss MD, Christopher S. Cowden MPH, Laurie Meyer Atterton MD, Meredith H. Arasaratnam ScD, Antonio R. Fernandez PhD, NREMT-P, Jeff S. Evarts AAS, Brian Barrier BA, E. Brooke Lerner PhD, N. Clay Mann PhD, MS, Chad Lohmeier MBA, Frances S. Shofer PhD & Jane H. Brice MD, MPH (2015) Accuracy of EMS Trauma Transport Destination Plans in North Carolina, Prehospital Emergency Care, 19:1, 53-60 To link to this article: http://dx.doi.org/10.3109/10903127.2014.916021
Published online: 30 May 2014.
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Date: 06 November 2015, At: 06:54
FOCUS ON EMS TRANSPORT ACCURACY OF EMS TRAUMA TRANSPORT DESTINATION PLANS IN NORTH CAROLINA Chailee Moss, MD, Christopher S. Cowden, MPH, Laurie Meyer Atterton, MD, Meredith H. Arasaratnam, ScD, Antonio R. Fernandez, PhD, NREMT-P, Jeff S. Evarts, AAS, Brian Barrier, BA, E. Brooke Lerner, PhD, N. Clay Mann, PhD, MS, Chad Lohmeier, MBA, Frances S. Shofer, PhD, Jane H. Brice, MD, MPH
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ABSTRACT Objective. Planning for time-sensitive injury may allow emergency medical services (EMS) systems to more accurately triage patients meeting accepted criteria to facilities most capable of providing life-saving treatment. In 2010, North Carolina (NC) implemented statewide Trauma Triage and Destination Plans (TTDPs) in all 100 of North Carolina’s county-defined EMS systems. Each system was responsible for identifying the specific destination hospitals with appropriate resources to treat trauma patients. We sought to characterize the accuracy of their hospital designations. Methods. In this cross-sectional study, we collected TTDPs for each county-defined EMS system, including their assigned hospital capabilities (i.e., trauma center or community hospital). We conducted a survey with each EMS system to determine how their TTDP was constructed and maintained, as well as with each TTDP-designated hospital to verify their capabilities. We determined the accuracy of the EMS assigned hospital designations by comparing them to the hospital’s reported capabilities. Results. The 100 NC EMS systems provided 380 designations for 112 hospitals. TTDPs were created by EMS administrators and medical directors, with only 55% of EMS systems engaging a hospital representative in the plan creation. Compared to the actual hospital capabilities, 97% of the EMS TTDP designations were correct. Twelve hospital designations were incorrect and the majority (10) overestimated hospital capabilities. Of the 100 EMS systems, 7 misclassified hospitals in their TTDP. EMS systems that did not verify their local hospitals’ capabilities during TTDP development were more likely to incorrectly categorize a hospital’s capabilities (p = 0.001). Conclusions. A small number of EMS systems misclassified hospitals in their TTDP, but most plans accurately reflected hospital capabilities. Misclassification occurred more often in systems that did not consult local hospitals prior to developing their TTDP. The potential of the TTDP to improve communication between EMS agencies and the facilities with which they work has not been fully realized. EMS agencies or systems should verify local hospital capabilities when engaging in destination planning efforts. Key words:
Received January 16, 2014 from the School of Medicine, University of North Carolina, Chapel Hill, North Carolina (CM, CSC, LMA), Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina (MHA, FSS, JHB), EMS Performance Improvement Center, Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina (JSE, BB, CL), Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (EBL), and Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, Utah (NCM). Revision received April 10, 2014; accepted for publication April 10, 2014. This paper was presented at the National Association of EMS Physicians annual meeting, January 2012. Support for the survey phase of the study was provided by the UNC Department of Emergency Medicine. Support for the data analysis phase was sponsored by National Highway Safety Administration grant DTNH22-07D-00049. This publication was developed in part with funding from the National Highway Traffic Safety Administration (NHTSA) of the U.S. Department of Transportation (DOT). The opinions, findings and conclusions expressed in this publication are those of the authors and not necessarily those of NHTSA or DOT. The United States Government assumes no liability for its content or use thereof. If trade or manufacturer’s names or products are mentioned, it is because they are considered essential to the object of the publication and should not be construed as an endorsement. The United States Government does not endorse products or manufacturers. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Current author affiliations: Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, Ohio (CM), Wilmington, North Carolina (LMA), Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina (JSS), and Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (FSS). Address correspondence to Jane H. Brice MD, MPH, Department of Emergency Medicine, CB #7594, University of North Carolina, Chapel Hill, NC 27599-7594, USA. E-mail: [email protected] doi: 10.3109/10903127.2014.916021
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INTRODUCTION The burden of trauma in the United States is tremendous; over 180,000 deaths were attributed to injury in the United States in 2010, and over 2.8 million hospitalizations were attributed to nonfatal injuries.1,2 It has been recognized that appropriate triage of injured patients can reduce cost and improve injury outcomes.3,4 The roots of modern trauma triage destination schemes may be found in military models of trauma care from the First World War.5 From these early models, trauma systems across the United States have been improved and standardized over time.6 When seriously injured patients are treated at an appropriately equipped trauma center, their outcomes are dramatically improved.3 However, when patients who are less seriously injured are transported to trauma center, the efficiency of the emergency medical services (EMS) and trauma systems may be compromised by increasing transport times and the number of patients taken to a trauma center. Transport to a trauma center may also unnecessarily subject lessinjured patients to the hazards associated with helicopter or expedited lights-and-sirens transport. Therefore, an important role of EMS is to identify seriously injured patients who should be transported to a trauma center. Given the risks associated with both over- and underestimating the severity of a patient’s injuries, the accuracy and the execution of EMS systems’ triage protocols significantly affects both the outcome of the injured patient and the EMS and trauma systems’ capacity to treat the next patient.7,8 Recognizing the importance of appropriate triage, the Centers for Disease Control and Prevention sponsored a National Expert Panel on Field Triage to update the guidelines used by EMS personnel for onscene trauma patient triage and transport decisions.9,10 The guidelines put forth specific anatomic, physiologic, and mechanism criteria for EMS personnel to utilize in quickly determining the appropriate type of facility for a given patient at the scene of an injury.10 These guidelines can be used by EMS providers as a tool for selecting the most appropriate destination facility for their patients, but to be truly useful they must be customized to reflect local facilities and transport times. That is, local EMS systems must incorporate the guidelines into their system-specific guidelines, designating which hospitals are appropriate destinations under a given circumstance. The manner in which EMS systems actually develop and revise their system-specific guidelines is not well understood. The present study aims to characterize
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how EMS systems within a single state develop and maintain their guidelines. Additionally, we sought to determine the accuracy of the guidelines.
METHODS Study Design We conducted a cross-sectional survey of all 100 North Carolina EMS systems and 131 North Carolina hospitals to determine the accuracy and process for development of each system’s TTDP.
Setting and Population North Carolina has 100 EMS systems, largely defined by county boundaries, with the exception of two systems: one comprises the Cherokee Indian Nation and one comprises two small counties. There are 540 EMS agencies in North Carolina and each is required to affiliate with an EMS system. EMS systems oversee all of the EMS response agencies within their boundaries, (e.g., air medical services, ground transport services, and first responder agencies), and create system-wide treatment and transport protocols. Every EMS system is required to have a medical director who has overall medical authority for every EMS agency affiliated with the EMS system. The EMS systems are regulated by the North Carolina Office of EMS (NCOEMS).11 The NCOEMS surveys North Carolina hospitals requesting trauma center designation utilizing a standardized set of criteria.12 Hospitals may be designated by the NCOEMS at level I, II, or III, depending on the available specialists and resources. At the time of the study, 12 hospitals were designated as trauma centers (6 level I, 3 level II, and 3 level III). Of the 6 level I statedesignated hospitals, 5 were also American College of Surgeons-verified level I trauma centers. One of the level I trauma centers was additionally an American College of Surgeons-verified pediatric level I trauma center and 2 were American Burn Association-verified burn centers. One of the 3 level II state designated hospitals was also an American College of Surgeonsverified level II trauma centers and none of the level III state-designated hospitals were American College of Surgeons verified. In order to improve EMS readiness, NCOEMS used the National Expert Panel’s Field Triage Guidelines to create a planning tool known as the EMS trauma triage and destination plan (TTDP) (Figure 1). The plan is an algorithm merging the Trauma Guidelines with system resources to suggest ideal transport destinations for injured patients, depending on their location, type of injury, and symptoms. To create a TTDP, the EMS system must determine the capabilities of local health-care facilities and integrate them with the field triage guidelines. Although the NCOEMS has provided a standard
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FIGURE 1. Model process for trauma destination planning.
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56 template to all EMS systems, it also requires EMS systems to modify their specific TTDP so that their transport destinations reflect both the variable proximity and medical capabilities of their closest health-care facilities as well as the system resources.
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Survey Instrument The 14-item EMS system survey was designed to assess how EMS systems develop, disseminate, and maintain their TTDP. The intended respondent was the EMS system director or assistant director; when these personnel were not available, a training officer or any administrator with knowledge of the system’s TDP development process was asked to respond. Plan development questions included which EMS and community personnel were involved in TTDP development and whether plan creators verified area hospitals’ capabilities during plan development. We then asked what methods were used to educate personnel in use of their plans, how plan use is monitored, and how feedback is received from hospital personnel, including case review, for various types of patients. Finally, we asked how often the plan is reviewed and revised. To assess the accuracy of the EMS system’s TTDP, each North Carolina Hospital completed a 21-item survey to assess their capabilities. The survey’s intended respondents were emergency department administrative personnel, such as a charge nurse, resource nurse, or nurse manager. The hospital survey reflected the specific capabilities outlined in the TTDP. Measured variables included facility hours and capabilities, staff qualifications and availability, equipment capabilities, and mechanisms by which hospital staff provide feedback to EMS personnel on trauma patients.
Data Collection TTDPs for each system were obtained electronically from the North Carolina Office of EMS. The TTDPs were reviewed by a single reviewer (CM) who identified each hospital that was listed and determined if it was designated as a community hospital or a trauma center. We also determined the TTDP designation for air and ground transport time. The state TTDP template suggested a drive time (driving time outside of which air transport should be considered) of 50 minutes and a flight time (air time to trauma center outside of which a patient should be transported to the closest community hospital) of 30 minutes, but systems could alter these times. Hospitals were included if they were on any EMS system’s TTDP, or if they were on the list of licensed hospitals by the North Carolina Department of Health and Human Services with emergency departments as of January 3, 2011. Each hospital was contacted by phone by one of three trained interviewers (CM,
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CC, LA), and verbal consent was obtained from the respondent.
Statistical Analysis Determination of the counties that were “out of reach,” i.e., had any area more than an hour from a trauma center by drive time, was done by mapping 60-minute drive times from each state trauma center in Microsoft MapPoint (Redmond, WA). NCOEMS determination of the trauma capability level (community facility or trauma center) was obtained for each surveyed hospital. The responses for each EMS system and hospital, NCOEMS triage destination plan data and determinations of hospital capabilities, and mapping data were compiled using Microsoft Excel software (Redmond, WA). Summary statistics such as frequencies and percentages were used to describe the EMS systems’ TTDPs. To compare differences in plan construction method and accuracy of plans, Fisher’s exact test was used. A probability of p < 0.05 was considered statistically significant. All analyses were performed using SAS statistical software (version 9.3, SAS Institute, Cary, NC). Institutional review board approval for this study was obtained from the University of North Carolina Office of Human Research Ethics.
RESULTS Survey Respondents Each of North Carolina’s 100 EMS systems and 131 hospitals responded to the survey. Among EMS systems, the survey was most commonly answered by the EMS director of the system (68%). Among hospitals, the most common respondents were charge nurses, nurse managers, or other nurses (69%). Most EMS systems (90%) reported that their highest level of training was paramedic; 8% reported intermediate and 2% reported basic as their highest training levels. Call volume for the EMS systems ranged from 420 to 90,000 calls per year. There was an average of 3.3 agencies per EMS system TTDP, with a median of 2 and a range from 1 to 17.
Features of Plan Construction EMS directors and medical directors were involved in the construction of most plans, but 55% reported that local hospital representatives were directly involved in system TTDP construction (Table 1). Of all the counties, 91% reported verifying local hospital capabilities during the construction of their TTDP. Seven percent reported neither having a hospital representative nor verifying hospital capability during the construction of their TTDP.
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TABLE 1. EMS and hospital survey responses N = 100
EMS survey
What is the highest level of EMS certification provided by your system?
What is the current annual call volume of your EMS System?
How many agencies providing 9-1-1 response with transport capability are within your system?
When the triage destination plans were being completed, who was involved in the decision making?
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Did you verify hospital capabilities with your area hospitals? Did you have a meeting with hospital personnel to discuss your plans and your decisions? What methods did you use to disseminate your plans to your personnel?
How do you know that your personnel are following the triage destination plans?
How do you maintain or revise your triage destination plans?
Hospital survey Is your hospital currently designated as a trauma center by the North Carolina Office of Emergency Medical Services? At what level of trauma center is your hospital designated?
Does your hospital have an American Burn Association verified burn center?
TTDP Template Alteration Nine percent of systems altered the standard 60minute drive time to hospitals contained in their TTDP, with 5% decreasing the time allowed in their algorithm (range of 30–50 minutes), 3% increasing it (70–90 minutes), and one system omitting drive time from its TTDP. Air time was changed or absent in 10% of TTDPs, with 4% changing the limits to increase them, and 4% decreasing their time limits (2% omitted air transport from their system’s algorithm altogether).
Plan Distribution and Maintenance Seventy-seven percent of systems reported meeting with hospital representatives to discuss the decisions that had been made after the TTDP was finalized.
EMT Intermediate Paramedic 420–4,000 (first quartile) 4,001–7,499 (second quartile) 7,500–14,999 (third quartile) >15,000 (fourth quartile) Mean (SD) Minimum Maximum EMS director EMS training officer Medical director Hospital representative Other Yes Yes Distributed paper copies Face-to-face training session Online education Other (Email, CD) Nothing Ongoing QA EMS toolkits We do not monitor compliance Other Yearly review With hospital capability changes When there is a complaint When we revise our protocols No revision planned Yes No Level I Level II Level III Yes No
2 8 90 28 20 25 27 3.33 (3.07) 1 17 94 82 98 55 37 91 77 83 98 19 2 1 100 64 0 9 60 92 71 52 0 N = 131 13 118 6 3 3 2 129
Face-to-face training was the most popular method by which plans were distributed to EMS personnel (98% of systems), but many systems used various electronic media to communicate the TTDP (Table 1). All NC EMS systems reported the use of ongoing quality assurance to verify TTDP use by EMS personnel in the field; computer-generated performance improvement reports were also frequently used to monitor the plans’ usage (64%). Nine percent of systems reported other methods of monitoring, including peer reviews or other auditing systems. EMS systems reported a variety of TTDP maintenance practices, but most involved routine scheduled reviews, with some revision of plans because of an instigating event (e.g., a complaint or hospital change) (Table 1). For those systems that reported plan changes in which any time protocols were revised (53%),
58 we then asked how often they revised their system protocols; these schedules also varied despite the statemandated 2-year revision schedule.
Accuracy of the Plans EMS systems identified a total of 112 hospitals in their TTDP. In total, 380 categorizations of those hospitals were made by the EMS systems, with an average of 3.8 hospitals categorized per system (range 0–12, median 3). Of the 380 categorizations, 97% were correct. Of the 3% (n = 12) that were incorrect, 10 designated a hospital that was a community facility as a traumacapable facility (“overestimation”), and 2 designated a trauma-capable hospital as a community facility (“underestimation”).
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Relationships between Construction and Accuracy The 12 errors in categorization were contributed by 7% of North Carolina EMS Systems; 93% of systems did not make errors in categorization. No statistically significant differences could be identified between the 7% of systems that made errors and the 93% that did not. However, 2 of the 7 systems that made errors did not verify hospital capabilities with local hospitals, and only 29% of these systems involved a hospital representative in the creation of their TTDP, in contrast to 57% of those systems that did not make errors in their TTDP. Systems making incorrect categorizations also had a slightly smaller average number of agencies (2.9 in incorrect systems, 3.4 in correct systems). The involvement of specific personnel was not found to significantly change the accuracy of a system’s TTDP. The 9 systems that failed to verify area hospital capabilities during the creation of their TTDP contributed 30 of the 380 total categorizations. There was a statistically significant difference between the accuracy of hospital categorizations in counties that verified the hospitals’ capabilities and those that did not (p = 0.001). The 9 counties that did not verify the hospital capabilities had a higher proportion of incorrect categorization (16.7% overestimation, 0% underestimation) than those counties that did verify hospital capabilities (1.5% overestimation, 0.6% underestimation).
Rural Counties Mapping was used to identify EMS systems with areas that had drive times longer than 60 minutes to the nearest trauma center. Using this map, we determined that portions of 46% of systems were “out of reach,” meaning that any part of the system was outside the 60-minute drive time to any trauma center. Out-of-reach systems contributed 152 of the 380 TTDP categorizations, and had higher rates of incorrect cat-
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egorizations, with 3.3% overestimation and 1.3% underestimation, than counties that were in reach (2.19% overestimation and no underestimation). However, the overall difference in correct and incorrect categorization between “out-of-reach” systems and the remaining systems was not statistically significant (p = 0.2).
DISCUSSION The Field Triage Guidelines were designed to assist EMS providers in identifying severely injured patients. However, in real-world situations destination decisions are not so simple. Communities may have multiple trauma centers or long transport times to the nearest trauma center. A system-specific guideline such as the TTDP can provide a tool for EMS providers to use in the field to select the best destination once they have identified a severely injured patient. These system-specific guidelines are based on the community’s actual resources and transport times. These tools are important for both improving patient outcomes and efficiently using scarce EMS and trauma resources. We found that all EMS systems in North Carolina had developed system-specific guidelines, and the majority of these guidelines accurately identified area hospitals’ capabilities. The 46 EMS systems in this study with some areas more than 60 minutes from a trauma center are overwhelmingly rural and economically underserved. Rural trauma has been shown to lead to more fatalities than urban trauma, both due to higher speed vehicular collisions and increased transport time to hospitals.13,14 Thus, it may be necessary to support these rural EMS systems in their effort to alter their TTDP to best ensure effective triage of EMS system patients. Unfortunately, there is a sizeable research gap regarding how to best assist communities with long transport times. Those EMS systems that did not accurately identify hospital capabilities were a very small proportion of the state’s systems, but did have much lower rates of involvement of hospital representatives during the construction of their TTDP, although this was not statistically significant. We attribute a lack of statistically significant differences in the systems that made errors to small sample size. Additionally, those counties that did not verify hospital capabilities with their area hospitals after TTDP construction were more likely to make errors and, in particular, to attribute more resources to a hospital than it really possessed. Thus, these findings support continued close involvement of hospital representatives and hospital verification in the construction of system TTDPs. Creating system-specific guidelines creates an opportunity for collaboration between EMS systems and their hospital partners. It is concerning that nearly half (45%) of the EMS systems did not engage their
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hospital partners during the TTDP development process. This is a missed opportunity to strengthen relationships and the planning process. Involvement of hospital personnel in system-specific guideline development should be encouraged to facilitate communication and feedback between hospitals and EMS systems. It may seem intuitive that once a provider has identified a severely injured patient they should easily be able to select the nearest trauma center. However, there are a number of decisions that need to be made before patient contact; these decisions require understanding the designation of each hospital, the drive and fly times to those hospitals from each area of a community, and the EMS resources within a community. Triage destination planning is analogous to fire planning. Fire agencies meticulously plan fire responses well before they occur; buildings are inspected so that a building fire-fighting plan is in place well before a fire arises. Improvement in firefighter line-of-duty death rates, civilian fire-related deaths, and containment of fires in the last 30 years has been attributed in part to improvements in fire response planning techniques.15 Additionally, fire inspection programs improve community satisfaction by increasing communication between fire agencies and their constituents.16 Just as fire departments plan their response to fires based on types of building and location, so should EMS agencies plan their responses to patients with varying complaints and distances from trauma services well in advance of actual EMS calls. This type of planning has the potential to decrease costs and increase the communication between EMS agencies and the facilities to which they transport patients. A model process for trauma transport destination planning is suggested in Figure 2. There are many barriers to realizing the full potential of system-specific plans. First, the plans must evolve to reflect changes in community resources and advances in the science of treating injured patients. Thus, it is concerning that 16% of our communities had no plans to reevaluate the TTDP. Of course, a plan for communicating changes must be in place to relay each revision to street-level providers, and revisions could be costly depending on how changes are communicated. Another barrier to fully realizing the potential of system-specific plans is ensuring their regular use in clinical practice. Although 98% of North Carolina EMS systems relayed their TTDP to providers through faceto-face meetings, we do not know how well the TTDP was incorporated into clinical practice. Although the incorporation of TTDPs in clinical practice was beyond the scope of the current study, it is an area that must be evaluated in order to fully realize the benefit of systemspecific tools, and merits further study. Failure to effectively use TTDPs has broader implications for EMS system performance improvement.
Enga ge hospital a nd community partners i n plan development
Revi ew plan at least a nnually to assess for cha nges i n hospal ca pa bilies or community needs
Veri fy a rea hospital ca pa bilies
Provi de feedback to EMS pers onnel about performance
Di s tribute plan to EMS pers onnel with educaon
Audi t EMS provider a dherance to plan
FIGURE 2. Model process for plan development, dissemination, use, and review. Model process for trauma destination planning.
System-specific guidelines such as the TTDP are an important tool for ensuring standardization within a community, and form the basis for quality improvement reviews. Without a planning tool like the TTDP, it is difficult to evaluate the choices a specific provider makes. Without a performance review of the care of injured patients, EMS communities and providers cannot improve and standardization cannot occur. Thus, future studies evaluating the incorporation of systemspecific tools will have significant implications for performance evaluation and quality improvement efforts in EMS systems. We found that a wide range of strategies is employed by North Carolina counties in creating their Trauma Triage Destination Plan. Most counties involved their medical directors and key administrative personnel in the development of the plan, which indicates that an appropriate level of attention was accorded to plan development. We are encouraged that most systems modifying the TTDP algorithm made time limits more rigorous, increasing the likelihood that a patient would be transferred more quickly by air to a higher level facility. In the few systems that incorrectly categorized hospitals, the tendency to overestimate capabilities is concerning. This may mean that EMS systems send patients to unprepared facilities, rather than ensuring that trauma patients go to appropriate trauma facilities. Further, many systems did not involve a hospital representative directly in the construction of their plan, a missed opportunity for the planning process to
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improve collaboration between EMS agencies and their local facilities. Overall, the findings of this study are encouraging; the TTDP has been supported with careful planning in most of North Carolina’s EMS systems, and the rate of error was low but may be attributable to lack of communication between EMS systems and their local health-care facilities. Full realization of the potential of system-specific tools such as the TTDP requires study of the incorporation of TTDP into practice by clinical providers; in the future this may be instrumental in EMS quality improvement efforts.
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LIMITATIONS This triage destination survey took place in North Carolina, and, given the variation of state resources and EMS system structure, our results should be generalized cautiously to other states. Our sample size was limited to the 100 systems within our state, so rates of error were small enough that subtle effects due to community variation in approach to triage destination planning may have been undetectable. Additionally, this survey was done with EMS and hospital personnel, so there may have been some variation in results related to miscommunication or lack of knowledge among survey respondents.
CONCLUSIONS North Carolina EMS systems are able to construct accurate triage strategies for trauma using planning tools. We strongly urge collaboration between EMS agencies and hospitals to improve communication and improve the accuracy of EMS assessment of facility capabilities in the TTDPs in the small number of facilities that were improperly assessed. Counties that report verifying hospital capabilities are more likely to correctly plan for patient triage to appropriate trauma destinations. Caution should be exercised during TTDP creation, as overestimation of facility capability seems to be the more common error, and may be dangerous to patients. Data on the outcomes of patients in counties that more accurately constructed their plans would be useful in further characterizing the efficacy of EMS agency planning well before an event occurs.
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