OPERATIONS: Facilities December 5, 2012 EMERGENCY RE-TRIAGE TO TRAUMA CENTERS

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1 I. PURPOSE To outline the criteria and process for re-triage of patients needing trauma care from non-trauma facilities to appropriate trauma centers. II. POLICY Under field trauma triage protocols, most critical trauma patients will be triaged directly to a Trauma Center from the field. Trauma patients, who present at other facilities via EMS or other arrival mode, should be considered for re-triage to trauma centers for definitive care when medically appropriate. III. DEFINITIONS A. Emergency Level Trauma Re-triage: The movement of patients meeting specific high-acuity criteria to trauma center for trauma care. Timeliness of evaluation and intervention at the trauma center likely to be more critical and the utilization of 911 is preferred. B. Urgent Level Trauma Re-triage: The movement of other patients with traumatic injuries to the trauma center whose needs may be addressed in a prompt fashion but are less likely to require immediate intervention. Mode of transportation may include CCT, Air Ambulance, BLS or 911. IV. EMERGENCY TRAUMA RE-TRIAGE PATIENT SELECTION A. Adult Patients (Age 15 and Over) appropriate for Emergency Trauma Re-Triage to the trauma center** include: 1. Patients with abnormal blood pressure/perfusion as evidenced by: a. Systolic blood pressure under 90 b. Need for high-volume fluid resuscitation (> 2 L NS) or immediate blood replacement 2. Patients with significant neurological findings or injuries, including a. GCS less than 9 or deteriorating by 2 or more during observation b. Blown pupil c. Obvious open skull fracture 3. Patients meeting anatomic criteria: a. Penetrating injury to head, neck, chest, or abdomen b. Extremity injury with ischemia evident or loss of pulses 4. Patients, who in the judgment of the evaluating emergency physician, are anticipated to have a high likelihood for emergent life- or limb-saving surgery or other intervention within two (2) hours. ** Note: Highland & Sutter Eden Medical Center utilize these re-triage criteria; other centers may vary. B. Pediatric Patients (below age 15) appropriate for Emergency Trauma Re-Triage to the Pediatric Trauma Center (Children s Hospital and Research Center, Oakland) include: 1. Hemodynamic Criteria a. Patients with abnormal blood pressure or poor perfusion (see age-appropriate vital signs chart below). Pediatric clinical signs of poor perfusion include: Cool, mottled, pale or cyanotic skin or prolonged capillary refill, low urine output, or lethargy

2 b. Requirement of more than two crystalloid boluses (20 ml/kg each) or requirement of blood transfusion (10 ml/kg) 2. Neurologic criteria a. GCS < 12 (pediatric scale see verbal for young children below) or decrease in GCS by 2 b. Blown Pupil c. Obvious open skull fracture d. Cervical spine injury with neurologic deficit 3. Respiratory Criteria a. Respiratory Failure b. Intubation Required 4. Anatomic Criteria a. Penetrating wound to the head, neck, chest, or abdomen 5. Patients, who in the judgment of the evaluating emergency physician, are anticipated to have a high likelihood for emergent life- or limb-saving surgery or other intervention within two (2) hours. Age-Appropriate Vital Signs Age Weight (kg) HR Systolic BP 0-12 months 0-10 <160 < years <150 < years <140 < years <120 <80 > or = 13 years >36 <100 <90 Pediatric GCS Verbal Scale for young children 5 Appropriate words for age, social smile, gaze fixes and follows 4 Cries but consolable 3 Persistently irritable 2 Restless and agitated 1 None

3 V. EMERGENCY LEVEL RE-TRIAGE PROCEDURE A. Once the patient has been identified as qualifying for Emergency Trauma Re-triage, the trauma center should be contacted (see contact list and phone numbers below) as soon as possible and the patient should be specifically identified as an Emergency Trauma Re-Triage. Based on that notification (and that the center is not on trauma divert), the patient will be accepted. B. Simultaneous or as soon as possible following notification to the trauma center 911should be contacted and a Code 3 ambulance requested. C. Patient records and diagnostic imaging disks (if available) should be readied for transport unit. Records that are not ready at time of transport departure can be faxed. VI. URGENT LEVEL RE-TRIAGE PROCEDURE A. Once the patient has been identified for Urgent Trauma Re-triage, the trauma center should be contacted (see contact list and phone numbers below) and the patient should be specifically identified as an Urgent Trauma Re-Triage. B. If the patient is accepted, arrange for transport, appropriate to patient condition or potential need. C. Patient records and diagnostic imaging disks (if available) should be readied for transport unit. Records that are not ready at time of transport departure can be faxed. VII. TRAUMA CENTERS A. Alameda County Medical Center (Highland) and Sutter Eden Medical Center are the designated trauma centers for adult trauma patients (patients 15 years of age and older) in Alameda County. B. Children s Hospital in Oakland is the designated trauma center for pediatric trauma patients (patients under 15 years). C. When Highland or Sutter Eden are on trauma divert status, they are unable to accept patients who are identified as trauma patients because critical hospital resources (surgeons, operating rooms) are not available. Location and helipad availability are items to consider in choice of other trauma center destinations. Other local adult trauma centers include: 1. * Walnut Creek- John Muir Medical Center (JMH-WC) (helipad on site); 2. San Jose Regional Medical Center (helipad on site); 3. San Jose Santa Clara Valley Medical Center (helipad on site); 4. San Francisco General Hospital (no helipad on site). 5. San Mateo- Stanford Hospital (helipad on site); 6. Sacramento UC Davis Medical Center (helipad on site); * Emergency Re-Triage Criteria is the same at JMH-WC. D. Alternate pediatric trauma centers include Stanford Hospital, UC Davis Medical Center and Santa Clara Valley Medical Center in San Jose. Emergency Re-Triage Criteria are not shared at these facilities.

4 LOCAL TRAUMA CENTER CONTACT PERSONS/PHONE NUMBERS Adult Trauma Centers Contact Person Phone Number Alameda County Med Center Oakland (Highland) Attending Physician (510) *Sutter Eden Medical Center Castro Valley On-Call Trauma Surgeon (510) San Francisco General Hospital Attending Physician (415) *John Muir Health Walnut Creek Transfer Center (925) *Santa Clara Valley Medical Center San Jose ED Physician (408) *Regional Medical Center San Jose ED Physician *UC Davis Medical Center Sacramento ED Physician (916) * Stanford University ED Physician (650) * Indicates helipad on site Pediatric Trauma Centers Contact Person Phone Number *Children s Hospital Oakland Transfer Center (877) CHO-KIDS *Stanford University ED Physician (650) *UC Davis Medical Center Sacramento ED Physician (916) *Santa Clara Valley Medical Center San Jose ED Physician (408) Note: This list is subject to change

5 ALAMEDA COUNTY TRAUMA RE-TRIAGE PROCEDURE / CRITERIA (ADULT) TRAUMA RE-TRIAGE PROCEDURE Determine level of severity Contact Trauma Center & Transport Provider Determine appropriate level of transport if Emergency Level Re-triage steps 2 and 3 should be initiated simultaneously. Prepare patient and paperwork for immediate transport. Emergency re-triage vs. Urgent re-triage (see below) EMERGENCY LEVEL Re-triage Simultaneously contact 911 for emergent transport. Contact trauma center for patient acceptance stating Emergency trauma re-triage URGENT re-triage Contact trauma center below as noted for acceptance. Contact appropriate transport agency (911, CCT-P, CCT-RN, Air ambulance) If within Paramedic Scope of Practice and timely transport needed Contact 911 to request Code 3 ambulance (911)). If exceeds paramedic scope of practice, contact appropriate transport agencies (CCT-RN or Air Ambulance) or arrange for nursing staff to accompany paramedic ambulance. Urgent re-triage- Consider options for transport based on patient acuity CCT, ALS (911) or EMT (BLS) transfer. Fax additional paperwork that is not ready at time of transport departure. Do not delay transport. (SEE FAX LIST BELOW) TRAUMA LEVEL CRITERIA LEVEL OF SEVERITY EMERGENCY LEVEL RE-TRIAGE: These are patients whose needs are generally known immediately or soon after initial arrival, based on clinical findings. Avoid any unnecessary studies (e.g. CT scans or angiograms). Request 911 ambulance for transport while simultaneously contacting the trauma center for patient acceptance stating Emergency trauma re-triage. EMERGENCY LEVEL CRITERIA: Blood pressure / perfusion: Systolic pressure < 90 or Need for high volume fluid resuscitation (> 2 L NS) or immediate blood replacement GCS / Neuro GCS Less than 9 GCS Deteriorating by 2 or more during observation Blown pupil Obvious open skull fracture Anatomic criteria Penetrating injuries to head, neck, chest, or abdomen Extremity injury with ischemia evident or loss of pulses Provider judgment Patients who have a high likelihood of need for emergent life- or limb-saving surgery or other intervention within 2 hours.

6 URGENT LEVEL RE-TRIAGE: Contact Trauma Center stating Urgent trauma re-triage for acceptance and appropriate transport provider based on patient acuity. These patients may require limited diagnostic procedures to discover abnormalities upon findings of significant abnormalities, transport should be arranged in a timely manner and further extensive workup should not be necessary. URGENT LEVEL CRITERIA Any patient meeting criteria for field transport to a trauma center that arrives via private auto or EMS should be considered a potential urgent re-triage. Criteria includes but not limited to the following: CNS GCS < 14 with abnormal CT scan Depressed skull fracture Spinal cord or major vertebral injury Chest >3 rib fractures and/or pulmonary contusion Widened mediastinum or other signs of great vessel injury on CXR Cardiac injury Pelvis/Abdomen Unstable pelvic ring or pelvic ring disruption Solid organ injury confirmed by ultrasound exam or CT scan Extremity Two or more long bone fractures Suspected crush injury or compartment syndrome Multi-System Injury Major injury to more than 2 body regions Signs of hypoperfusion (e.g. elevated lactate level > 4 or base deficit more than X) TRAUMA CENTER CONTACT INFORMATION TRAUMA CENTER SUTTER EDEN MEDICAL CENTER HIGHLAND HOSPITAL CHILDREN S HOSPITAL TRAUMA CENTER ACCEPTANCE (510) ask for on call Trauma Surgeon (510) ask for Attending Physician (877) CHO-KIDS ask for Intensivist on duty FAX NUMBER FOR RECORDS (510) (510) (510)

7 ALAMEDA COUNTY PEDIATRIC EMERGENCY TRAUMA RE-TRIAGE PROCEDURE Determine if patient meets Emergency Trauma Re-Triage Criteria Contact Pediatric Trauma Center Determine appropriate level of transport and arrange transport (should be done simultaneously to Trauma Center contact) Prepare patient and paperwork for immediate transport. See Criteria Below Pediatric Patients are below age 15 Children s Hospital and Research Center Oakland If within Paramedic Scope of Practice and timely transport needed Contact 911 to request Code 3 ambulance (911)). If exceeds paramedic scope of practice, contact appropriate transport agencies (CCT-RN or Air Ambulance) or arrange for nursing staff to accompany paramedic or EMT ambulance. Fax additional paperwork that is not ready at time of transport departure. Do not delay transport. (SEE FAX LIST BELOW) EMERGENCY TRAUMA RE-TRIAGE CRITERIA - PEDIATRIC Blood pressure / perfusion: Hypotension or tachycardia (based on age-appropriate chart below) or clinical signs of poor perfusion (see below) Need for more than two crystalloid boluses (20 ml/kg each) or need for immediate blood replacement (10 ml/kg) GCS / Neurologic GCS Less than 12 (pediatric scale see verbal scale below) GCS Deteriorating by 2 or more during observation Blown pupil Obvious open skull fracture Cervical spine injury with neurologic deficit Anatomic criteria Penetrating injuries to head, neck, chest, or abdomen Respiratory Criteria Respiratory failure or intubation required Provider judgment Patients, who in the judgment of the evaluating emergency physician, are anticipated to have a high likelihood for emergent life- or limb-saving surgery or other intervention within 2 hours.

8 TRAUMA CENTER CONTACT INFORMATION Children s Hospital Oakland PEDIATRIC CLINICAL SIGNS OF POOR PERFUSION Cool, mottled, pale or cyanotic skin Low urine output Lethargic Prolonged capillary refill EMERGENCY RE- TRIAGE OTHER TRANSFERS FAX NUMBER FOR RECORDS (877) CHO KIDS (877) CHO - KIDS (510) PEDIATRIC GCS VERBAL SCALE (<2) 5 Coos and Babbles 4 Irritable 3 Only cries to pain. 2 Only moans to pain 1 None Normal Vitals (Broselow) AGE WEIGHT HEART RATE SYSTOLIC BP BROSELOW COLOR Newborn 3-5 Kg Grey -Pink 1 Year 10 Kg Purple 3 Years 15 Kg White 5 Years 20 Kg Blue 8 Years 25 Kg Orange 10 Years 30 Kg Green Important Pediatric Re- Triage Exceptions: 1. Pregnant patients of any age should be re-triaged to an adult trauma center. 2. Major Burns should be preferentially re-triaged to one of the burn centers. 3. Contact hospital first for major extremity injuries with vascular compromise.