title: Out-of-hospital decision making and factors influencing the regional distribution of injured patients in a trauma system.
abstract: BACKGROUND
  The decision-making processes used for out-of-hospital trauma triage and hospital selection in regionalized trauma systems remain poorly understood. The objective of this study was to assess the process of field triage decision making in an established trauma system.
  
  
  METHODS
  We used a mixed methods approach, including emergency medical services (EMS) records to quantify triage decisions and reasons for hospital selection in a population-based, injury cohort (2006-2008), plus a focused ethnography to understand EMS cognitive reasoning in making triage decisions. The study included 10 EMS agencies providing service to a four-county regional trauma system with three trauma centers and 13 nontrauma hospitals. For qualitative analyses, we conducted field observation and interviews with 35 EMS field providers and a round table discussion with 40 EMS management personnel to generate an empirical model of out-of-hospital decision making in trauma triage.
  
  
  RESULTS
  A total of 64,190 injured patients were evaluated by EMS, of whom 56,444 (88.0%) were transported to acute care hospitals and 9,637 (17.1% of transports) were field trauma activations. For nontrauma activations, patient/family preference and proximity accounted for 78% of destination decisions. EMS provider judgment was cited in 36% of field trauma activations and was the sole criterion in 23% of trauma patients. The empirical model demonstrated that trauma triage is driven primarily by EMS provider "gut feeling" (judgment) and relies heavily on provider experience, mechanism of injury, and early visual cues at the scene.
  
  
  CONCLUSIONS
  Provider cognitive reasoning for field trauma triage is more heuristic than algorithmic and driven primarily by provider judgment, rather than specific triage criteria.
authors.affiliation: Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon 97239-3098, USA. newgardc@ohsu.edu
authors.forename: Craig D
authors.initials: CD
authors.lastname: Newgard
authors.forename: Maria J
authors.initials: MJ
authors.lastname: Nelson
authors.forename: Michael
authors.initials: M
authors.lastname: Kampp
authors.forename: Somnath
authors.initials: S
authors.lastname: Saha
authors.forename: Dana
authors.initials: D
authors.lastname: Zive
authors.forename: Terri
authors.initials: T
authors.lastname: Schmidt
authors.forename: Mohamud
authors.initials: M
authors.lastname: Daya
authors.forename: Jonathan
authors.initials: J
authors.lastname: Jui
authors.forename: Lynn
authors.initials: L
authors.lastname: Wittwer
authors.forename: Craig
authors.initials: C
authors.lastname: Warden
authors.forename: Ritu
authors.initials: R
authors.lastname: Sahni
authors.forename: Mark
authors.initials: M
authors.lastname: Stevens
authors.forename: Kyle
authors.initials: K
authors.lastname: Gorman
authors.forename: Karl
authors.initials: K
authors.lastname: Koenig
authors.forename: Dean
authors.initials: D
authors.lastname: Gubler
authors.forename: Pontine
authors.initials: P
authors.lastname: Rosteck
authors.forename: Jan
authors.initials: J
authors.lastname: Lee
authors.forename: Jerris R
authors.initials: JR
authors.lastname: Hedges
mesh_terms: D000465:Algorithms; D003657:Decision Making; D004632:Emergency Medical Services / Q000458:organization & administration*; D005260:Female; D005843:Geography; D006801:Humans; D008297:Male; D009922:Oregon; D011156:Population Density; D012042:Registries; D014193:Trauma Centers; D015599:Trauma Severity Indices; D014218:Triage / Q000379:methods*; D014861:Washington; D014947:Wounds and Injuries / Q000628:therapy*