Background: Rural communities rely heavily on EMS teams to provide high quality care during transport to often distant medical facilities. Compliance with standardized protocols has been shown to increase triage effectiveness on a global scale, and our providers use the EMS Prehospital Treatment Protocol Handbook to guide care. The purpose of this study is to evaluate if the clinical documentation of our EMS providers follows standard protocols. 

Methods: Tri-County regional trauma calls in the Maine Incident Reporting System database from July 1st, 2022 to July 31st, 2022 were reviewed. The logs were compared to the EMS Prehospital Treatment Protocol Handbook. Documentation was analyzed for inclusion of relevant details as outlined by the appropriate protocol. The author of each log was documented to establish trends among personnel.

Results: 121 cases were included in the final analysis. The most common chief concerns included falls (n = 76) and motor vehicle collisions (n = 24). The most commonly used protocol was the Trauma Triage protocol. 28 cases (23.1%) did not include a Glasgow Coma Scale (GCS). Two of the GCS scores were below 8, but neither patient was intubated. Of the 28 cases without GCS documentation, 20 cases involved the chief concern of “fall” (71.4%) and 7 were motor vehicle collisions (25%). Of the 38 unique authors, 13 providers were responsible for the cases without GCS documentation, with two providers being responsible for 11 of the 28 cases.

Conclusion: The Trauma Triage protocol was broadly used to cover injuries ranging from standing height falls to head on motor vehicle collisions. Although it is possible that clinical care was provided appropriately when a GCS was not recorded, it could also indicate that our patients were not triaged effectively in the field. Given that two providers accounted for 39% of documentation issues, targeted education could drastically increase the rate of GCS documentation in our group. GCS could also be programmed as a required field for all trauma calls in order to increase compliance throughout the entire group. Locating more validated trauma protocols based on the mechanism of injury could further define how patients need to be triaged as opposed to using one protocol for all trauma. The next step in this study would be to investigate how the rates of GCS documentation changed after implementation of these proposed strategies. 

References:
Van Rein, E.A.J. et al. “Compliance to prehospital trauma triage protocols worldwide: A systematic review.” Injury. 2018; 49(8): 1373-1380. https://pubmed.ncbi.nlm.nih.gov/30135040/

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