• Tue. Sep 27th, 2022

Revised Field Triage Guidance Released – JEMS: EMS, Emergency Medical Services

ByMadeleine J. Pierce

May 3, 2022
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Via the American College of Surgeons Trauma Committee

In the United States, unintentional injuries are a leading cause of death, with injuries being the most common reason for calling 9-1-1 to activate emergency medical services (EMS).1, 2 To improve clinical outcomes, a field triage process is needed to identify critically injured patients and quickly transport them to the appropriate care facility. The first Field Triage Decision Scheme was developed in 1986 and has been updated periodically over the past three decades. The most recent version, updated in 2021, is published online in the Journal of Trauma Surgery and Acute Care.

An interdisciplinary expert panel led by the American College of Surgeons (ACS) undertook the 2021 review with support from the National Highway Traffic Safety Administration (NHTSA) Office of EMS, Office of Maternal Health and of the Health Resources and Services Administration (HRSA), and the EMS program for children. It was based on a series of scientific literature reviews conducted by Oregon Health and Science University as well as an extensive EMS Stakeholder Feedback Tool, which aimed to capture the perspective of EMS clinicians working in the field.

This update is designed to improve usability, performance, compliance, and enforcement of the directive. The guideline is based on the latest science and direct feedback from EMS clinicians to improve prehospital care for injured patients across the country. The new guideline will be most effective when fully implemented in trauma systems and adopted by EMS clinicians.

“The Field Triage Guidelines for Injured Patients help EMS clinicians identify patients most at risk for serious injury after a traumatic event and refer high-risk patients to the most appropriate trauma center available for care for them. Getting the right patient to the right place at the right time saves lives,” said Eileen M. Bulger, MD, FACS, Medical Director of ACS Trauma Programs.

The importance of a triage directive in the field

“Field triage is the process of identifying critically injured patients requiring care at specialized trauma centers from among the largest number of patients with minor to moderate injuries who can be treated at lower level trauma centers or non-trauma hospitals,” authors note in the recently published paper.

An effective field triage guideline has a dual purpose: it aims to eliminate under-triage, when a critically injured patient is taken to a hospital that lacks the resources for proper care; and it establishes a manageable level of over-triage, when a patient with minor to moderate injuries is taken unnecessarily to a trauma center, resulting in an overuse of the trauma system’s limited resources.

Proper triage and transport of severely injured patients to a trauma center can improve outcomes. Studies show that there is a 20% lower in-hospital mortality and a 25% lower 1-year mortality in patients treated in a Level I trauma center compared to non-trauma hospitals.3

“EMS clinicians play a vital role in our communities when responding to difficult and life-threatening emergencies. For more than 50 years, the U.S. Department of Transportation and NHTSA have supported EMS systems and first responders in their important mission,” said Steven Cliff, PhD, NHTSA Deputy Administrator. “The Field Trauma Triage Guidelines are an important resource for EMS clinicians, helping them save lives and provide critical care for traumatic injuries. We appreciate the leadership of the American College of Surgeons on this essential publication.

Guideline Updates

Among the updates included in the 2021 guideline are substantial changes to its format and structure. Previously, the guideline used a stepwise algorithmic format that was deemed too complex to be used in the field. The new guideline has been redesigned to reflect the flow of information to EMS clinicians and actual use of the guideline in the field.

The restructuring groups the triage criteria into two main categories based on the risk of serious injury: high risk criteria (red) and moderate risk criteria (yellow). Each category is accompanied by a recommendation indicating the destination of the patient’s transport.

Guidelines, resources and implementation tools are available at www.facs.org/fieldtriageguidelines.

Quote: National Guidelines for Field Triage of Injured Patients: Recommendations from the National Field Triage Expert Panel, 2021. Journal of Trauma Surgery and Acute Care. DOI: 10.1097/TA.0000000000003627


  1. Top 10 causes of death, USA 2019, both sexes, all ages, all races. Centers for Control and Prevention of Disasters; 2021. Available at: https://wisqars-viz.cdc.gov:8006/lcd/home. Accessed March 30, 2022.
  2. Wang HE, Mann NC, Jacobson KE, Ms MD, Mears G, Smyrski K, et al. National characteristics of emergency medical services responses in the United States. Prehospital emergency care. 2013;17(1):8-14.
  3. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national assessment of the effect of trauma center care on mortality. N English J med. 2006;354(4):366-78.