Article 1
Paramedic Judgment as a Basis for Trauma Triage: Is it an Effective Strategy? Schaefer MP, Lamy C, Mederos-Rodriguez D, Berne JD. Am Surg. 2025 May;91(5):795-806.
The authors present a retrospective registry study that attempts to assess the effectiveness of “Paramedic Judgement” (PJ) as it relates to both over and under triage rates, comparing it to their standard objective criteria (SC) for activation. They define over and under triage using the standard Cribari Matrix. The study was conducted a large urban trauma center, with a multi-tiered activation system and the authors include 1835 patients in their final analysis. When looking at PJ compared to SC for full trauma team activation, they find that PJ alone leads to an over triage rate of roughly 69% compared to 55% in the SC group. Under triage was 1.2% in the PJ group and .13% in the SC group. Therefore, the percentage of correctly triaged patients was 30% in the PJ group compared to 45% in the SC group. On multivariate analysis, PJ was 2.05 times as likely to result in over triage of a patient compared to the SC group (p<.01). Older age patients (>55 years old) were less likely to be over triaged in both groups, whereas black patients were 1.93 times more likely to over triaged compared to whites. Finally, they present data related to the Need for Emergent Interventions in both the SC and PJ groups and find that patients triaged by PJ are less likely to require blood transfusion, a central line or an angiogram in the first six hours after admission. In their discussion, they note a paucity of data looking specifically at PJ as an effective criterion for correct pre-hospital triage, with certain studies supporting it and others questioning its accuracy. They conclude that, based on their results, objective criteria are more effective and accurate that paramedic judgement for pre-hospital triage.
Accurate triage of trauma patients is a difficult challenge for a busy trauma center and a busy pre-hospital system. The verification process’ emphasis on avoiding under triage inevitably leads to a (sometimes significant) rate of over triage, and this has long been accepted as the cost of preventing patients requiring emergent intervention from being delivered to treatment teams who are incapable of providing these interventions in an expeditious fashion. This study suggests that using paramedic judgement alone is inferior to triaging based on objective criteria. This is not a surprising finding, and the study design is unable to account for variability in paramedic training, various environmental factors and a large number of other, often difficult to measure, pre-hospital variables. As such, the conclusions a reader can take away from this study are somewhat limited, but it again highlights the complexity of pre-hospital triage and should encourage the trauma community to continue the elusive search for a set of clear, objective criteria that will lead to more accurate pre-hospital triage of critically injured patients.
Article 2
Prehospital to emergency department handoff: can team-based reporting improve markers of clinical efficiency in an adult emergency department? Gross CL, Cowgill CD, Selph BA, Cowgill JM, Saqr Z, Allen BR, Southwick FS, Hwang CW. BMJ Open Qual. 2025 May 7;14(2):e002948.
This prospective, single-center quality improvement study evaluated the impact of a synchronous, team-based reporting (TBR) model for EMS-to-ED handoffs on markers of clinical efficiency. The control group utilized the pre-existing opportunity-based reporting (OBR) model, whereas the TBR intervention required the simultaneous presence of the primary ED nurse, physician, and ancillary staff at the bedside during EMS handoff. Patients arriving as trauma activations or other “alert” categories (e.g., stroke, STEMI, sepsis) were excluded. Across six intervention cycles, 248 patients were included in the OBR group and 59 in the TBR group. Implementation of TBR was associated with reductions in key early care metrics, including time to CBC order (-67%), collection (-38%), and result (-22%), as well as time to patient disposition (-16%, corresponding to a 55-minute reduction). However, there was no significant improvement in total ED length of stay (-4%, 16 minutes), indicating that downstream system constraints such as hospital throughput and boarding remain the dominant drivers of overall patient flow.
This study demonstrates that a structured, synchronous TBR model for EMS-to-ED handoff is associated with improved front-end ED throughput and care coordination, likely through enhanced communication, early team alignment, and parallel task execution facilitated by a shared mental model. As a pragmatic, low-cost intervention, TBR is attractive from an operational standpoint; however, several important limitations warrant consideration. The non-randomized, single-center design and marked imbalance between control and intervention groups introduces potential selection bias and may limit generalizability. Additionally, the absence of adjustment for patient acuity, comorbidities, or ED crowding confounds interpretation of the observed effects. The lack of measurement of patient-centered outcomes further restricts its clinical applicability. Lastly, variability in implementation fidelity highlights potential challenges in scalability, as successful adoption likely requires sustained culture change and workflow enforcement. Overall, this QI study supports the use of a synchronous, team-based reporting model for EMS handoffs to improve front-end throughput and care coordination.
Article 3
Emergency Medical Individual Clinician Volume and Mortality in Trauma Patients. Beiriger J, Martin-Gill C, Silver DS, Sperry JL, Lu L, Guyette FX, Wisniewski S, Moore EE, Schreiber M, Joseph B, Wilson CT, Cotton B, Ostermayer D, Fox EE, Harbrecht BG, Patel M, Brown JB. JAMA Surg. 2026 Apr 1;161(4):389-396.
This landmark prospective cohort study by Beiriger et al, published in JAMA Surgery in February 2026, represents the first known investigation of individual EMS clinician trauma patient volume and patient outcomes in the United States. Using data from the LITES Task Order 1 database (2017–2021), the study included 6,769 patient-clinician interactions involving 359 clinicians and 3,649 patients transported by one air and one ground agency to a single quaternary trauma center. The authors found that for each additional 5 trauma patients transported annually, there was a 10% reduction in 6-hour mortality (aOR 0.899, 95%CI, 0.811-0.996) and a 2.6% reduction in in-hospital mortality (aOR 0.974, 95%CI, 949-0.999). Higher intubation volume was also associated with improved first-attempt airway success, and higher clinician volume correlated with shorter scene times. Notably, non-trauma volume and years of employment were not significant, suggesting trauma-specific exposure is the critical variable.
As a foundational study opening an important new line of inquiry, these findings provide compelling rationale for rethinking EMS staffing and training. The authors’ findings are consistent with multiple previous studies across many areas of medicine that describe an association between increased volume provider or hospital volume and improved patient outcomes. Despite the clear importance of the extension of these findings to EMS provider trauma volumes, some methodologic limitations must be noted. First, the authors perform numerous statistical comparisons across multiple exposures, outcomes, subgroups, and quality metrics without any adjustment for multiple testing. As the primary findings driving the paper's conclusions all sit close to the uncorrected α=.05 threshold, and even modest correction would likely render them nonsignificant. The effect sizes are also modest in absolute terms. The underlying mechanism of this volume/outcomes relationship remains unclear, as none of the measured prehospital factors explained the volume-mortality association. These limitations do not diminish the importance of these findings, but replication in larger, broader cohorts with appropriate correction for multiple comparisons will be essential before findings should inform policy.
Article 4
Rethinking trauma transport: Mortality and length of stay in non-EMS transported patients. Ferguson R, El Nouiri A, Dobesh K, Hamdan H, Gardner C, Johnson JL. Injury. 2026 Feb 16:113105.
This is a retrospective cohort study of the Michigan TQIP database (2014-2024) that compares outcomes for patients transported to a Level I or Level II trauma center by EMS, police, or private transport. EMS has been a longstanding valuable resource in providing specialized stabilization and rapid transport of patients to the hospital, especially when time to definitive management is a proven predictor of outcomes. However, it remains unclear if the benefit of EMS outweighs the cost of delayed hospital arrival in all circumstances. Historically, studies have compared EMS to police transport, but private transport had often been excluded. In this study, the most common method of transport was EMS (87.6%), followed by private transport (11.9%), and the majority suffered blunt trauma (87.3%). Risk-adjusted comparisons show a mortality and LOS benefit in private transport patients (OR 0.35, LOS ratio 0.69, p<0.001). Additionally, when stratified for mechanism of injury, non-EMS transport continued to show a mortality and LOS benefit in both penetrating and blunt injuries (p<0.001). Police transport was a smaller subgroup that did not demonstrate statistically significant benefit compared to EMS transport.
These findings suggest that private pre-hospital transport may confer a mortality and LOS benefit compared to EMS. Despite not having a trained team and medical resources en route to the hospital, patients with the same injury severity had better outcomes via private transport. This is an important consideration for high-density urban populations where the arrival of EMS or any en route intervention may cause more delay in definitive care. In rural populations, EMS transport may be more beneficial in initiating stabilizing interventions over longer transport times. Of note, this study did not account for pre-hospital transport times, interventions, and patient comorbidities, which can impact outcomes. While injury severity was captured in the analysis, there are other non-clinical factors that contribute to the accessibility of private transport - such as available bystanders and the ability to move a patient into a car. Frequently, EMS is called when these options are unavailable. Further investigation is needed to identify specific trauma scenarios where private transport is the more beneficial route to definitive care, challenging the longstanding assumption that EMS is the universally superior prehospital transport option.
