Ask not what your documentation can do for you, but what your documentation can do for the Greater Good.

(1)

Ask not what your documentation can do for you, but what your documentation

can do for the Greater Good.

Johnathan Jones, RN, BSN Trauma Coordinator

Providence Medford Medical Center

(2)

Johnathan Jones, RN, BSN

Current Positions:

• Trauma Program Coordinator - PMMC (Level 3 Trauma Center)

• Developed and implemented new quality process for trauma program

• Completed state site verification and designation with no deficiencies

• Trauma and EMS Consultant/Surveyor - State of Oregon

• Trauma and EMS Consultant/Surveyor - State of Idaho

• PACE Auditor – Centers for Medicare and Medicaid Services

(3)

Johnathan Jones, RN, BSN

Former Positions:

• Trauma Director UCSD - Hillcrest (Level 1 Trauma Center)

• Opened state-of-the-art, stand-alone trauma suites

• Maintained high level TQIP results

• Trauma Director - Kaiser Permanente (Level 3 Trauma Center)

• Developed 16-hour trauma academy course

• Implemented on-sight TNCC and ATLS

• Designated Level III TC in 5 months

• Trauma & Specialty Care Coord. - State of California, EMSA

• Authored CEMSIS Trauma Data Dictionary

• Designed and implemented CEMSIS Trauma Registry

• Implemented California State Trauma System

• Developed and implemented California Trauma Regionalization

• Trauma Program Coordinator – ATRMC (Level 3-4 Trauma Center)

• Developed unique documentation improvement program

(4)

Disclosures:

• None.

(5)

Objectives

• Emphasize the importance of accuracy in nursing documentation.

• Reveal how nursing documentation is transitioned into performance indicators.

• Discuss performance improvement project as it relates improved nursing documentation utilizing performance indicators.

• Underscore the importance of a quality indicator (Cribari Grid) for trauma activation emphasizing under and over triage.

(6)

Literature Search: Nursing Documentation Quality

Article: Quality criteria, instruments, and requirements for nursing

documentation: A systematic review of systematic reviews. (De Groot et al, 2019) Conclusion: ”Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be

important for high-quality nursing documentation. The lack of evidence-based quality indicators presents a challenge in the pursuit of high-quality nursing documentation.”

• Review more article on trauma performance/quality indicators.

(7)

Literature Search: Trauma Quality Indicators

Article: Evidence for quality indicators to evaluate adult trauma care: a systematic review. (Stelfox et al, 2011)

Conclusions: ”Many QIs for evaluating the quality of trauma care have been proposed, but the evidence to support these indicators is not strong. Practical recommendations to select QIs to measure the quality of trauma care will require systematic reviews of identified candidate indicators and empirical studies to fill the knowledge gaps for post-acute QIs.”

• This review could not find support that quality indicators are effective.

• At the time this article was published, many trauma centers and the ACS disagreed.

• This article referenced newer articles.

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Article: Indicators of the quality of trauma care and the performance of trauma systems. (Gruen et al, 2012)

Conclusion: ”A global endeavor is now under way to agree on a set of standardized performance indicators that are meaningful to patients, caregivers, clinicians,

managers and service funders, are likely to contribute to desired outcomes, and are valid, reliable and have a strong evidence base.”

• Some of the same authors wrote this article.

• Already known and implemented by level I and II trauma centers.

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Guide to Quality Indicators in Adult Care

(Quality of Trauma for Adult Care Committee, 2013)

Define Quality Indicators:

Article: Quality indicators are performance measures designed to compare actual care against ideal criteria for the purposes of quality measurement, benchmarking and

identifying potential opportunities for improvement.

“At present there are many different quality indicators for trauma care available, significant variation in the utilization of indicators by trauma centers and limited evidence to support the use of specific indicators over others.”

• All trauma centers are required to utilize performance or quality indicators.

• ACS Resources for Optimal Care of the Injured Patient 2014 “Orange Book” and/or State require the use of indicators.

• ACS TOPIC course established by 2013 and actively taught.

• TOPIC creates standard nomenclature for performance and quality indicators.

• Not much new information on indicators until 2021.

(10)

Article: Trauma quality indicators: internationally approved core factors for trauma management quality evaluation. (Coccolini, et al. 2021)

Conclusion: “Present trauma quality indicator core set represents the result of an international effort aiming to provide a useful tool in quality evaluation and

improvement. Further improvement may only be possible through international trauma registry development. This will allow for huge international data accrual permitting to evaluate results and compare outcomes.”

• Quality indicators are working and should be nationally and internationally adopted.

• Need to define performance and quality indicators.

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Indicators Defined

• Performance Indicator:

• Yes/No/single value

• Single variable

• Line in the sand

• Quality Indicator:

• Utilizes performance

indicator(s) in a formula to determine a percentage.

*** This differentiation is not agreed upon by all the literature. ***

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Performance Indicators

Yes/No/Value with a Total

• Trauma team activation (TTA)

• Tracheal intubation in field

• Time to first CT Scan

• Time to antibiotic administration for open fracture

• Time to evacuate acute subdural hematoma

• Non-trauma/surgical service admissions

• Deep vein thrombosis prophylaxis initiated

• Tertiary survey completion in 24 hours

(13)

Quality Indicators

Requires Formula

• Nursing documentation completeness

• Set of variables to express percentage

• Cribari Grid - Over/Under Triage Rates

• Formula to determine under and over triage by utilizing the severity of injuries.

(14)

Elements Needed to Achieve Quality Indicators

• Accurate and complete documentation

• Process to collect data (trauma registry)

• Define performance indicators

• Determine what data will be included in a quality indicators

• Create Benchmark indicators

• Let’s look at types of trauma documentation

(15)

Trauma Flow Sheet

• Pros:

• Clearly outlines documentation required

• Provides communication in the room for review

• Trauma surveyors love this option

• Cons:

• Not integrated into medical record

• Can be difficult to read

• Not readily available if patient leaves

• Can be misplaced or lostED

Modified Team Response:

Trauma Team Activated By:

□ Field □ ED □ Transfer In

Team Response:

□ Full □ Modified

Last Meal: LMP: Tetanus:

Called Arrived

Physician Times:

Trauma Surgeon Neurosurgeon Orthopedic Surgeon

ED Physician Other

Names:

Suspected Injuries:

Current Medications:

Medical History:

Allergies:

Weight:

TRIAGE CRITERIA PREHOSPITAL DATA

Full Team Response: (TS arrival tracked)

□ Systolic BP <90 mmHg

□ Resp. Rate: Adult (<10 or >29) Infant (<20)

□ Glascow Coma Score (GCS) of 8 or Less

□ Airway compromise / Need for vent. support

□ Penetrating injury to head, neck, or torso, or proximal to elbow or knees

□ Flail chest / Severe chest wall instability

□ Two or more proximal long bone fractures

□ Spinal cord injury with motor sensory deficit

□ Transfers requiring blood transfusions

□ ED Provider Discretion [Note Reason]

□ Oral Airway ________ □ Nasal Airway _________

□ Oxygen ______ Liters/Hr Via:________________

□ Endo Tracheal Intubation Attempts:___________

□ Supraglottic Airway (i.e. King Air)

□ Sedation or Paralytics Used PTA

□ Assisted Ventilation

□ Pre-hospital Fluid Total ________________ mL

□ Control Bleeding

□ Monitor

□ C-Collar ONLY

□ Full Spinal Immobilization / Restriction

□ Splints __________________________________

□ Traction _________________________________

□ Restraints _______________________________

□ Other ___________________________________

Method of Arrival ^{EMS Agency}

□ Ambulance □ Police

□ Helicopter □ Other

□ Private Vehicle Mechanism of Injury

□ Auto

□ Seatbelt □ Airbag □ Driver □ Passenger □ Front □ Back □ Helmet

□ Motorcycle / ATV

□ Bicycle

□ Horse (Large Animal)

□ Pedestrian

□ Fall _____ Feet

□ Crush

□ GSW ________ Type

□ Blunt Assault

□ Stabbing

□ Other ____________

Site of Incident:

Time of Incident:

Brief Description of Incident:

2 3 4 5 6 7

R

L Pre-hospital Meds Given:

TRAUMA BAND #: _____________

TRAUMA TEAM DATA ADMITTING DATA

ARRIVAL DATE/TIME_____________/________ ACTIVATION TIME: __________

TRIAGE CRITERIA PREHOSPITAL TREATMENTS PREHOSPITAL DATA

□ Glascow Coma Score (GCS) of 9 - 14

□ Pulseless, crushed, degloved, or mangled extremity

□ Amputation above wrist or ankle

□ Open or depressed skull fracture

□ Suspected pelvic fracture

□ Significant passenger space Intrusion

□ Ejection □ Death in same compartment

□ Auto vs Ped/Bike (>20 mph impact)

□ Motorcycle/ATV crash ( >20 mph)

□ Fall >20 feet (Adult) or >10 Feet (Child)

□ Rollover MVC

□ EMS/ED Provider Discretion [Note Reason]

□ Rollover MVC □ Anticoagulants

□ Presence of intoxicants □ Burns

□ Heavy extrication □ Hanging

Co-morbid Factors

Pupil Reaction: B = Brisk S = Sluggish PP = Pin Point I = Irregular N = Nonreactive

TIME:

LAB IMAGING

Pupil Gauge (mm):

□ Trauma Panel

Time Ordered:_________________________ Time Ordered:_________________________

Plain Films:

□ C Spine X ray □ CXR □ Pelvis X Ray

□ See Epic for documentation

TRAUMA FLOW SHEET

□ Front □ Side

Controlled Unless Printed

□ See Epic for doc. of pupil size and reaction (min x 3)

□ Mercy Flights

□ Other: __________

□ See Epic for documentation

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Electronic Medical Record (EMR) Documentation

• Pros:

• When completed, very easy to abstract

• Can be very accurate

• Can be designed for electronic abstraction to trauma registry

• Cons:

• Takes a dedicated nurse to keep in real time

• Completeness is often dependent on design of the Trauma Narrator

• Trauma surveyors notoriously hate the Trauma Narrator because the information may be

scattered through electronic medical record

(17)

How Can Documentation Compliance Be Improved?

• Develop a TFS or EMR that captures all data points

• Review all trauma charts for quality

• Utilize quality indicators to determine a numerator and denominator of completeness

• Provide positive and/or negative feedback

(18)

ED Trauma Documentation Completeness Study 2002-2007

• Utilized 20 data points on trauma flow sheet as deemed important by trauma coordinator.

• Example: Document all physician arrival times, document trauma activation time, if in c-spine document all c-spine notes correctly, document 1^st full set of vitals, document 2^nd full set of vitals within 1 hours, etc…

• Deduct 5 points for each missing data point to reveal a percentage of completeness.

• Total quarterly. Must have at least 3 points to be considered for the reward (1 point modified and 2 points full activation).

• Provide positive reinforcement by rewarding top score with $50 restaurant gift card and rewarding runner-up with $25 movie gift certificate.

(19)

Documentation Improvement

• Each data point is the numerator

• Total nurses eligible is the denominator

• The performance indicators are:

• Documentation 100%

• Documentation 61-99%

• Documentation 60% or below

• Each performance indicator is a “line in the sand” to determine quality of the documentation in an objective manner.

• The benchmark in this case was not determined.

 100%

 61-99%

 60% & ↓

(20)

Improving Documentation

2005

Q2 2005

Q3 2005

Q4 2006

Q1 2006

Q2 2006

Total full trauma activations 8 9 11 13 7 Q315

Total modified trauma activations 34 35 29 30 29 37

Total trauma activations 42 44 40 43 36 52

Nurses eligible for rewards 36 31 27 26 33 36

Total nurses in ED 61 59 57 60 60 59

Documentation 100% 11 19 18 22 24 31

Documentation 100% (Pct) 31% 61% 67% 85% 73% 86%

Documentation 61-99% 17 9 8 4 9 5

Documentation 61-99% Pct) 47% 29% 30% 15% 27% 14%

Documentation 60% or below 8 3 1 0 0 0

Documentation 60% or below (Pct) 22% 10% 4% 0% 0% 0%

(21)

31%

61% 67%

85% 73% 86%

47%

29% 30%

15%

27%

22% 10% 14%

4% 0% 0% 0%

0%

20%

40%

60%

80%

100%

2005 Q2 2005 Q3 2005 Q4 2006 Q1 2006 Q2 2006 Q3

Results

Documentation 100% (Pct) Documentation 61-99% Pct) Documentation 60% or below (Pct)

(22)

ED Trauma Documentation Completeness Study 2005-2006 (18-months)

How is engagement and success achieved:

• Negative reinforcement:

• All scores between 61-80% received direct feedback from trauma coordinator.

• All scores 60% and below receive direct feedback from the ED nurse manager.

• After 2005 Q1, 42% of nurses with scores at or below 80% came to trauma.

coordinator proactively wanting to know why they did not win.

• Some low performing nurses (less than 60%) felt the ED on their own volition.

(23)

Over/Under Triage Quality Indicator Dr. Chris Cribari – “Cribari Grid”

History:

• Previous chair of the Verification Review

Subcommittee of the ACS Committee on Trauma.

• Developed a table-format grid that provides a method for calculating these numbers.

• The standard for calculating over and undertriage is examining each admission to see if they met trauma activation triage criteria.

• The Cribari method is designed for a benchmarking approach.

• Allows identification of patients with higher ISS that might have benefited from a higher trauma

activation.

(24)

Quality Indicator: Over and Under Triage

• Does the trauma triage criteria used by the facility activate the most injured patients appropriately?

• Determine over triage (≤ 50%) and under triage (≤ 5%) rates utilizing:

• Trauma triage criteria

• Trauma activation level

• Documenting injuries

• Abbreviated Injury Scoring (AIS)

• Injury Severity Scoring (ISS)

• Cribari Grid

• Formula works best at trauma centers with 500+ trauma activations a year.

(25)

Trauma Triage Criteria

• Refer to Guidebook for Trauma Activation Criteria

• Gathered research or lack-there-of for many of the activation criteria

• Google - MMWR Triage Criteria and take a look at it some time

• Last printed in 2012 and currently under review

Sasser SM, Hunt RC, Sullivent EE, Wald MM, Mitchko J, Jurkovich GJ, Henry MC, Salomone JP, Wang SC, Galli RL, Cooper A, Brown LH, Sattin RW; National Expert Panel on Field Triage, Centers for Disease Control and Prevention (CDC). Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field

(26)

• Criteria from MMWR is put into algorithms by states and other groups to determine full and modified trauma

activations.

• In the case of Oregon, the

activation criteria is in the form of a rule.

• Question: Does it stratify the injuries correctly into full and modified trauma activations?

(27)

• Variation in trauma triage criteria

• Field triage criteria

• Hospital triage criteria

• Combined field and hospital triage criteria

• Literature does not clearly define the triage best option but almost all literature compares to the CDC option

• Oregon trauma centers act cohesively within the state using the state criteria

• In California, counties or groups of counties determine trauma triage criteria

• Other states and internationally a variety of trauma triage criteria is utilized

(28)

• Trauma triage criteria

• Trauma activation level

• Cribari Grid

(29)

EMS Report

• 45-year-old female passenger in single-car motor vehicle crash.

• Struck tree on driver’s side at 70 mph; 18+ inches intrusion into the vehicle.

• Driver dead on scene.

• 45 minutes of extrication time due to intrusion, position of car, and snow.

• Gave passenger Fentanyl 25 mcg IV.

• Vitals are BP 110/92, HR 90, RR 20, O₂ Sat 96%, and GCS 15.

• Full c-spine precautions with midline c-spine tenderness.

• Right arm splinted for deformed forearm.

• Reported LOC for at least 30 seconds and nausea.

• Seatbelt sign on left side of abdomen with pain on left side.

• Open alcohol container found in the vehicle.

Trauma Activation or not a Trauma Activation?

Full or Modified?

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EMS Report

• 45-year-old female passenger in single-car motor vehicle crash.

• Struck tree on driver’s side at 70 mph; 18+ inches of intrusion into vehicle.

• Driver dead on scene.

• 45 minutes of extrication time due to intrusion, position of car, and snow.

• Gave Fentanyl 25 mcg IV.

• Vitals are BP 110/92, HR 90, RR 20, O₂ Sat 96%, and GCS 15.

• Full c-spine precautions with midline c-spine tenderness.

• Right arm splinted for deformed forearm.

• Reported LOC for at least 30 seconds.

• Seatbelt sign on left side of abdomen with pain on left side.

• Open alcohol container found in the vehicle.

Trauma Activation /not a Trauma Activation Full/Modified

(31)

• Documenting injuries

• Cribari Grid

(32)

Documenting Injuries

Anything in nursing documentation, physician documentation, and/or studies is fair game for the abstraction of injuries.

Displaced closed right forearm fracture Grade 1 spleen injury

Abrasion to right zygomatic area

LOC for 30 seconds with concussion, evidenced by nausea

• Abstraction is a coding term for locating something in the chart and converting it to something else.

• The above injuries need to be coded into severity

• Abbreviated Injury Scoring (AIS) is the method of choice

(33)

• Abbreviated Injury Scoring (AIS)

• Cribari Grid

(34)

Literature Review

Article: Evolution of the Abbreviated Injury Scale: 1990-2015 (Loftis et al, 2018)

Conclusions: Each updated version of AIS reflects improving medical care and new advances in understanding, measuring, and documenting injury. AIS changes over time reflect its international and cross-domain utilization for describing injury

severity and set the standard for how the world now studies traumatic injury.

• AIS is far from perfect and some other scoring systems exist, but it is the accepted standard.

• The book and course is currently $750.

(35)

Abbreviated Injury Scoring (AIS)

• Abbreviated Injury Scale (AIS) was initially developed in the mid-1960s for tracking injury in any moving

object.

• Has grown to become an

internationally recognized scoring system for a variety of traumatic injuries.

• Codes injuries with an injury severity known as the pre-dot score.

• The pre-dot is the number after the decimal point or dot.

(36)

• Displaced closed right forearm fracture

• Right displaced distal radial shaft fracture transverse (752251.2)

• Right displaced distal ulna shaft fracture transverse (752253.2)

• The number after the decimal point or dot is the pre-dot severity score.

Documented on TFS, ED physician note, radiology read, and general surgeon history and physical

(37)

• Grade 1 spleen injury

• Spleen laceration simple capsular tear 1 cm with no trabecular vessel involvement, Grade 1 laceration (544222.2)

Documented on TFS, ED physician note, radiology read, and general surgeon history and physical

(38)

• Abrasion to right zygomatic area

• Face skin abrasion (210202.1)

5,13

3, 13 5,13

Documented on TFS, ED physician note, and general surgeon history and physical

(39)

• LOC for 30 seconds with concussion evidenced by nausea

• Cerebral concussion brief loss of consciousness <= 30 minutes (161004.2)

Documented on TFS, ED physician note, and general surgeon history and physical

(40)

• Injury Severity Scoring (ISS)

• Cribari Grid

• Lots of literature about issues with ISS.

(41)

Injury Severity Score (ISS)

• ISS utilizes the AIS severity code (pre-dot score) to determine severity of the injury.

• Anatomical regions of head or neck, face, chest, abdominal or pelvic contents, extremities or pelvic girdle, and external are used to separate the injuries.

• Calculating ISS is achieved by taking the highest AIS pre-dot score for each region (up to 3), squaring each score, and adding together.

• Maximum ISS is 75.

A² + B² + C² = ISS

• ISS is the most widely used scoring system to estimate mortality and morbidity.

(42)

Injury Severity Scoring (ISS)

Calculating ISS:

• Head or neck – Score 2 (A)

• Cerebral concussion brief loss of consciousness <= 30 minutes (161004.2)

• Face

• Chest

• Abdominal or pelvic contents – Score 2 (B)

• Spleen laceration simple capsular tear 1 cm with no trabecular vessel involvement, Grade 1 laceration. (544222.2)

• Extremities or pelvic girdle – Score 2 (C)

• Distal radial shaft fracture transverse. (752251.2)

• Distal ulna shaft fracture transverse. (752253.2)

• External – Score 1

• Face skin abrasion (210202.1)

ISS Score 2² + 2² + 2² = 12 4 + 4 + 4 = 12

(43)

Performance Indicator from a Formula:

Over and Under Triage

• Cribari Grid – Quality Indicator

(44)

Cribari Grid:

• Table-format grid that provides a simplified method to calculate under and over triage

• Utilizes trauma activation level and ISS range to determine over and under triage of trauma activation criteria

• This is a tool to focus quality priorities

• Controversial:

• You are at a trauma center without the dilution of another trauma center nearby

• Have over 500 trauma admissions

(45)

• Under triage calculated with

“limited or no-team activations with ISS 16-75” divided by “total patients limited or no-team

activations” A/B=C

• Over triage calculated with “full trauma activations with ISS 0-15”

divided by “full trauma activations ” D/E=F

ISS 0-15 ISS 16-75 Total Full Trauma Activation 4 (D) 24 28 (E)

Limited or No Trauma

Activation 92 (A) 68 160 (B)

Under Triage Rate 43% (C) Ideally ≤ 50%

Over Triage Rate 14% (F) Ideally ≤ 5%

(46)

Why is under/over triage as a quality indicator important:

• Over triage utilization activates the trauma when the team is not needed.

• Under triage potentially misses the sickest patient leaving a sick patient vulnerable.

• When you can track under/over triage, benchmarking with other trauma centers becomes possible.

• This quality indicator can demonstrate quality or opportunities for improvement.

(47)

Summary

Quality documentation is the essential first stop for

performance indicators, quality indicators,

benchmarks, and/or risk- adjusted mortality.

Without quality

documentation, quality care is difficult to achieve!

Quality Documentation

Performance Indicators Quality

Indicators Benchmarks

Risk-Adjusted Mortality

Quality Trauma Care

(48)

Questions

^?

Thank you

johnathan.jones@providence.org

(49)

References

American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient: 2014, 6th. ed. Chicago: American College of Surgeons; 2014.

Braken P, Amsler F, Gross T. Simple modification of trauma mechanism alarm criteria published for the

TraumaNetwork DGU^® may significantly improve overtriage - a cross sectional study. Scand J Trauma Resusc Emerg Med. 2018 Apr 24;26(1):32. doi: 10.1186/s13049-018-0498-x. PMID: 29690930; PMCID:

PMC5916718.

Brown JB, Stassen NA, Bankey PE, Sangosanya AT, Cheng JD, Gestring ML. Mechanism of injury and special consideration criteria still matter: an evaluation of the National Trauma Triage Protocol. J Trauma. 2011 Jan;70(1):38-44; discussion 44-5. doi: 10.1097/TA.0b013e3182077ea8. PMID: 21217479.

Calgary University. Quality of Trauma for Adult Care Committee: Guide to quality indicators in adult trauma care.

Carr BW, Hammer PM, Timsina L, Rozycki G, Feliciano DV, Coleman JJ. Increased trauma activation is not equally beneficial for all elderly trauma patients. J Trauma Acute Care Surg. 2018 Sep;85(3):598-602. doi:

10.1097/TA.0000000000001986. PMID: 29787528.

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References

Centers for Disease Control and Prevention (CDC). CDC - Injury Prevention and Control: Field Triage -

Guidelines for the Field Triage of Injured Patients. 2011. http://www.cdc.gov/fieldtriage/index.html. Accessed October 2, 2021.

Coccolini F, Kluger Y, Moore EE, Maier RV, Coimbra R, Ordoñez C, Ivatury R, Kirkpatrick AW, Biffl W, Sartelli M, Hecker A, Ansaloni L, Leppaniemi A, Reva V, Civil I, Vega F, Chiarugi M, Chichom-Mefire A, Sakakushev B,

Peitzman A, Chiara O, Abu-Zidan F, Maegele M, Miccoli M, Chirica M, Khokha V, Sugrue M, Fraga GP, Otomo Y, Baiocchi GL, Catena F; the WSES Trauma Quality Indicators Expert Panel. Trauma quality indicators:

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Davis JW, Dirks RC, Sue LP, Kaups KL. Attempting to validate the overtriage/undertriage matrix at a Level I trauma center. J Trauma Acute Care Surg. 2017 Dec;83(6):1173-1178. doi: 10.1097/TA.0000000000001623.

PMID: 29189678; PMCID: PMC5732627.

De Groot K, Triemstra M, Paans W, Francke AL. Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews. J Adv Nurs. 2019 Jul;75(7):1379-1393. doi:

10.1111/jan.13919. Epub 2019 Jan 15. PMID: 30507044.

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References

Sasser SM, Hunt RC, Sullivent EE, Wald MM, Mitchko J, Jurkovich GJ, Henry MC, Salomone JP, Wang SC, Galli RL, Cooper A, Brown LH, Sattin RW; National Expert Panel on Field Triage, Centers for Disease Control and Prevention (CDC). Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field

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PMCID: PMC7006360.

Voskens FJ, van Rein EAJ, van der Sluijs R, Houwert RM, Lichtveld RA, Verleisdonk EJ, Segers M, van Olden G, Dijkgraaf M, Leenen LPH, van Heijl M. Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients. JAMA Surg. 2018 Apr 1;153(4):322-327. doi: 10.1001/jamasurg.2017.4472. PMID: 29094144;

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