Field Triage Guideline – A new look and important updates

Learn what’s changed in the 2021 ACS FTG and how to implement the trauma triage guidelines


Since 1976, EMS providers have had a trauma triage tool to help identify severely injured patients and get them to the right destination. The document, now referred to as the “National Guideline for the Field Triage of Injured Patients” or “Field Triage Guideline (FTG)” for short, is reviewed and updated every 5 to 10 years after advisory groups meet to consider recent research and changes in the industry. Until the recent news that a 2021 version had been published, the 2011 Guidelines for Field Triage of Injured Patients were used across the United States to direct triage and transport of trauma patients.

Since this Guideline fills such an important role in EMS systems of trauma care, let’s take a deeper dive into how it was updated, what is included, and what EMS agencies should be doing with the revised recommendations.

Expert panel

First responders stage a simulated triage outside Great American Ball Park during a mass casualty training exercise, Thursday, Sept. 19, 2019, in Cincinnati.
First responders stage a simulated triage outside Great American Ball Park during a mass casualty training exercise, Thursday, Sept. 19, 2019, in Cincinnati. (AP Photo/John Minchillo)

The American College of Surgeons led the most recent effort and seated an impressive 27-member expert panel representing a wide range of EMS and trauma care organizations including:

  • American College of Emergency Physicians (ACEP)
  • Emergency Medical Services for Children (EMSC)
  • Emergency Nurses Association (ENA)
  • National Association of EMS Educators (NAEMSE)
  • National Association of Emergency Medical Technicians (NAEMT)
  • National Association of State EMS Officials (NASEMSO)
  • National Highway Traffic Safety Administration (NHTSA)
  • Pediatric Trauma Society (PTS)
  • Society of Trauma Nurses (STN)
  • National Registry of EMTs (NREMT)
  • National Association of EMS Physicians (NAEMSP)

The Office of Emergency Medical Services at the National Highway Transportation Safety Administration is noted for providing support, guidance and involvement in the project as well.

The expert panel spent a few years sifting through trauma care and EMS research published since the 2011 edition and applying strict analytical rules (positive likelihood ratios) to grade the data and apply it to their new recommendations. In the end, the panel cited 98 references in the manuscript published in the Journal of Trauma and Acute Care Surgery.

A significant part of the revision involved gathering feedback from EMS providers directly using the previous version of the guidelines in the field. A 40-question feedback tool was distributed to EMS providers of all levels through 29 national organizations. A total of 3,958 responses were received and shared with the expert panel to give them direct feedback about how EMTs and paramedics used the tool and what they felt did and did not work.

New look for trauma triage guidelines

The first thing providers will notice is a completely new look for the Field Triage Guideline. Previous editions were based on a flow-chart or stepwise type algorithm, where the provider had to start at the top and potentially work their way to the bottom to determine if the patient required transport to a trauma center. The new document allows the provider to quickly scan across and down the page for criteria that their patient may meet. The format represents how EMS providers acquire information during a scene and primary survey (left to right) and the potential that specific findings represent risk of injury (higher risk at the top).

Criteria changes

I encourage you to read the original recommendations manuscript for a nice explanation of each addition, change and deletion. Even if you aren’t a big fan of reading this sort of scientific literature, this is one to check out. The body of the paper itself is only 22 pages and double-spaced. It really helps you understand the changes and why they are important.

A few significant modifications include:

  • Inclusion of patients that experienced major hemorrhage in the high-risk category
  • Use of the shock index (ratio of heart rate to SBP)
  • More age-adjusted vital sign indicators
  • Addition of pulse oximetry values
  • Use of only the motor assessment portion of the GCS
  • Consideration of unrestrained or improperly restrained children in MVCs
  • Differentiation between extrication and entrapment
  • Change of fall height criteria to 10 feet for all age groups
  • Addition of suspicion of child abuse and special/high resource healthcare needs

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After the explanation of the criteria changes, the document goes on to express how each state, region and EMS system must critically look their process to implement the Guideline. The panel recognizes the wide variety of trauma care facilities, transport resources, geography, call volume and providers across the country and leaves it up to each system to determine specific appropriate destinations and transport modes.

Trauma triage training materials

The American College of Surgeons then used its resources to develop turn-key educational material on the changes. The training begins with one presentation that covers the changes made to the Guideline and the basics of how the recommendations may be implemented in a trauma system. The presenter may include details about EMS and trauma center resources specific to the audience.

The second presentation has multiple versions aimed at either experienced providers or new EMTs and paramedics not familiar with the systematic approach to trauma care. Each presentation also has versions available based on whether local protocols use an ABCD approach to the primary survey or the MARCH ideology. Within each presentation are six patient case studies. Instructors can further personalize the presentation by selecting cases that reflect the characteristics of the system in which the audience practices. ACS recommends discussing three to five cases. The slide decks include thorough speaker notes to guide instructors through the didactic material and the case studies.

Performance measures

The next logical step in the implementation of any new protocol or guideline is to measure how well EMS providers can use the process and the difference it makes to patient outcomes. The ACS partnered with the National EMS Quality Alliance (NEMSQA) to develop performance measures using the National EMS Information System (NEMSIS) data standards. The measures include:

  • Percentage of trauma patients that meet any of the FTG criteria and are transported to any level of trauma care facility
  • Percentage of trauma patients that meet the RED FTG criteria and are transported to a Level I or II trauma care facility
  • Percentage of trauma patients that meet any of the FTG criteria and a pre-arrival alert or trauma team activation is initiated
  • Histogram of the distance to the nearest Level I or II trauma care facility from the scene of injury for patients that met the FTG red criteria but were NOT transported to a Level I or II facility

The supporting documents provide the details needed for use of these measures in any size agency.

The ACS trauma triage guideline is not …

It is important to point out that the FTG is not meant to be a multiple-patient or mass casualty triage assessment product. It does not take the place of protocols like SALT or START. It also does not override the trauma team activation (TTA) criteria that hospitals use to prepare their internal personnel for an incoming trauma patient. While the documents may be similar, it is expected that hospitals have slightly different criteria in their activation levels based on their internal capabilities and resources. Hospitals closely monitor and adjust their TTA protocols based on their over- and under-triage rates and performance improvement reviews.

Implementing the ACS Field Triage Guidelines

What’s next? How do EMS providers begin using the Field Triage Guideline? The ball is now in the courts of the EMS systems including state, regional and local leaders and medical directors. State and regional EMS and trauma systems should begin reviewing the documents and deciding the best way to implement them in their areas.

It is important and interesting to note that the ACS included a “terms of use” statement in the release. They specifically disallow the modification or revision of the Guideline or the supporting material, except where indicated (educational materials). While it is temping for states and regions to feel their needs and system processes are unique, the ACS reiterates that the “criteria are evidence-based and have undergone a rigorous expert panel review.” Use of the Guideline as written is also important to support future research and evaluation of the criteria.

Thanks to ACS, NHTSA, NASEMSO, NEMSQA and all the agencies and organizations that came together again to develop evidence-based guidelines to support trauma care systems and improve trauma patient outcomes.

Stay safe out there.

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