Characterizing re-triage guidelines: A scoping review of states' rules and regulations.

BACKGROUND: State guidelines for re-triage, or emergency inter-facility transfer, have never been characterized across the United States. METHODS: All 50 states' Department of Health and/or Trauma System websites were reviewed for publicly available re-triage guidelines within their rules and regulations. Communication was made via phone or email to state agencies or trauma advisory committees to obtain or confirm the absence of guidelines where public data was unavailable. Guideline criteria were abstracted and grouped into domains of Center for Disease Control Field Triage Criteria: pattern/anatomy of injury, vital signs, special populations, and mechanisms of injury. Re-triage criteria were summarized across states using median and interquartile ranges for continuous data and frequencies for categorical data. Demographic data of states with and without re-triage guidelines were compared using the Wilcoxon rank sum test. RESULTS: Re-triage guidelines were identified for 22 of 50 states (44%). Common anatomy of injury criteria included head trauma (91% of states with guidelines), spinal cord injury (82%), chest injury (77%), and pelvic injury (73%). Common vital signs criteria included Glasgow Coma Score (91% of states) ranging from 8 to 14, systolic blood pressure (36%) ranging from 90 to 100 mm Hg, and respiratory rate (23%) with all using 10 respirations/minute. Common special populations criteria included mechanical ventilation (73% of states), age (68%) ranging from <2 or >60 years, cardiac disease (59%), and pregnancy (55%). No significant demographic differences were found between states with versus without re-triage guidelines. CONCLUSION: A minority of US states have re-triage guidelines. Characterizing existing criteria can inform future guideline development.

Not every trauma patient with a radiographic head injury requires transfer for neurosurgical evaluation: Application of the brain injury guidelines to patients transferred to a level 1 trauma center.

BACKGROUND: Patients with radiographically-identified traumatic brain injury are often transferred to our regional trauma center for neurosurgical evaluation, yet few injuries require neurosurgical intervention. Transfer is costly, inconvenient, and potentially risky in inclement weather. We propose that previously-published brain injury guidelines (BIG)1 can help to determine which patients could avoid mandatory transfer. METHODS: Retrospective chart review of patients transferred between January 2012 and December 2013 was performed. Patients were classified as having minor (BIG 1), moderate (BIG 2), or severe (BIG 3) head injuries based on previously-published guidelines. Patient characteristics and outcomes were compared. RESULTS: No BIG 1 patients deteriorated or required surgical intervention. One BIG 2 patient required a non-emergent operation and another was readmitted with a worsened injury. In the BIG 3 group, 11.9% required neurosurgical procedures and 20% died. CONCLUSIONS: The BIG classification can help stratify patients for whom transfer is considered.