Hospital Bypass Protocol

Updated June 2013
Reviewed Oct 2014; Oct 2105; Oct 2016; Oct 2017; Oct 2018; Oct 2019; Oct 2021

Triage Criteria for EMS facility bypass and transfer

Goal:

Transport protocols must ensure that patients who meet triage criteria for activation of a regional trauma system plan (trauma patients who are medically unstable, unconscious, or at high risk of multiple and/or severe injuries) will be quickly identified and transported directly to an appropriate trauma facility rather than to the nearest hospital EXCEPT under the following circumstances.

1. If an adequate airway cannot be established and/or maintained, or in cases of traumatic cardiac arrest, the patient should be taken to the NEAREST ACUTE CARE FACILITY for stabilization.
2. If transport time to the indicated trauma facility exceeds 20 minutes and EMS is unable to arrange air transport (where available) and/or hand off the patient to a higher level of pre-hospital care, the patient will be transported to the nearest facility.
3. Rural EMS systems with advanced life support (ALS) capabilities and the concurrence of their medical director and/or medical control may bypass local facilities if that facility lacks the resources to address the trauma patients specialty need.
4. If expected transport time is excessive (>20 minutes), or if expected extrication time is lengthy (>15 minutes) activation of air transport resources should be considered (where available).

PATIENT CRITERIA FOR ACTIVATION OF REGIONAL TRAUMA SYSTEM PROTOCOLS

The Regional Trauma System Plan and Bypass Protocol will be initiated for any trauma patient who is medically unstable, unconscious and/or at risk of multiple and/or severe injury as indicated by the following:

CRITICAL PATIENTS

Patients who are physiologically and hemodynamically unstable whose injuries may include:

PHYSIOLOGICAL CRITERIA

*CHEST

1.  major chest wall injury
2.  penetrating thoracic wound
3.  flail chest

*PELVIS

1.  pelvic ring disruption with shock (systolic <90)

*ABDOMEN

1.  blunt trauma with hypotension
2.  penetrating abdomen wound

*MULTIPLE SYSTEM TRAUMA

1.  chest injury with head injury
2.  abdominal or pelvic injury with head injury

*SPECIALIZED PROBLEMS

1.  second or third degree burns >10% BSA or involving airway
2.  barotrauma
3.  uncontrolled hemorrhage
4.  second/third trimester pregnancy
5.  respiratory rate below 10 or above 36
6.  Glascow Coma Scale score less than or equal to 10
7.  Systolic blood pressure less than 90 mmHg
8.  Heart rate above 130 or below 50
9.  Penetrating injuries to the head, neck and/or torso
10.  Two or more long-bone fractures
11.  Amputation proximal to wrist or ankle

URGENT PATIENTS

*CENTRAL NERVOUS SYSTEM

1.  prolonged loss of consciousness, posturing, paralysis, or lateralizing sign
2.  spinal injuries with or without deficit
3.  Glascow Coma Score (GCS) >10
4. open, penetrating, or depressed skull fracture
5. CSF leak
6. GCS deterioration >2 points

*THORACIC

1.  suspected cardiac/great vessel injury
2.  possible requirement for prolonged mechanical ventilation
3.  respiratory distress with rate >35 or <10

*ABDOMEN

1.  blunt trauma without hypotension

*MULTIPLE SYSTEM TRAUMA

1.  severe facial injury with head injury

*SPECIALIZED PROBLEMS

1.  carbon monoxide poisoning
2.  severe maxillofacial or neck injuries
3.  Revised Trauma Score (RTS) <11
4.  open fractures

*SECONDARY DETERIORATION

1.  Patient requiring mechanical ventilation
2.  sepsis
3.  organ system(s) failure

PATIENT CRITERIA FOR CONSIDERATION OF BYPASS PROTOCOL

Criteria should cause suspicion that the patient may have sustained a severe injury. Consultation with medical control (if available) is recommended to assist in the decision as to whether or not to activate the Regional Trauma System Plan for these patients.

GUIDELINES FOR TRAUMA TEAM ACTIVATION

HIGH INDEX OF SUSPICION DUE TO MECHANISM

1.  Falls >20 feet (>10 feet if <15)
2.  Motor vehicle accident (MVA) with crash speed >30 mph (>20 mph if age <15)
3.  MVA with >30 inches of vehicle deformity
4.  MVA with rearward displacement of front axle
5.  MVA with passenger compartment intrusion

* >18 inches on patients side of vehicle
* >24 inches on opposite side of vehicle

1.  Rollover MVA
2.  Ejection from Vehicle
3.  Death of same vehicle occupant
4.  Pedestrian struck at >20 mph
5.  Pedestrian rolled or rolled over by vehicle
6.  2 or more patients with urgent needs of interventions

ANATOMICAL SITE/MECHANISM OF INJURY

1.  penetrating trauma
2.  two or more long bone fractures
3.  impalement injuries (including handlebar injuries in children)
4.  possible smoke inhalation
5.  burns >20% BSA in patient between 6 & 55
6.  second and third degree burns >10% BSA in patient between <6 or >55

PATIENT AGE OR CONDITION

1.  age <5 or >55
2.  Known cardiac or respiratory disease
3.  Revised Trauma Score <11
4.  Compromised physiological status

* Unconsciousness
* Impaired respirations
* hypotension
* –<60 (birth – 1 year)
* –<70 (1 – 6 years)
* –<80 (7 – 13 years)
* –<90 (>13 years)