For Doctors in a Hurry
- Improving air medical transport triage for trauma patients is currently limited by the lack of a standardized, evidence-based definition of medical need.
- Researchers used a four-round Delphi method with 32 multidisciplinary experts to vote on criteria requiring air transport.
- The panel reached greater than 70 percent agreement on 18 patient factors, six interventions, three system factors, and seven criteria combinations.
- The authors successfully developed a consensus-based algorithm and decision flow diagram to define when trauma patients require air medical transport.
- Future validation against patient outcomes will help deploy this triage tool to guide emergency medical services clinicians in the field.
Optimizing Prehospital Triage for Severe Trauma
Rapid prehospital intervention is critical for severely injured trauma patients, particularly those requiring time-sensitive treatments like red blood cells [1] or plasma, which increased the rate of unexpected 30-day survival among patients with a predicted mortality greater than 50 percent (67 percent versus 46 percent for standard care, p=0.031) [2]. While air medical transport can provide specialized care and expedite transfer to trauma centers, determining exactly which patients benefit most remains a persistent clinical challenge. Recent meta-analyses demonstrate that helicopter transport improves survival for specific cohorts, such as patients with severe traumatic brain injury presenting with a Glasgow Coma Scale score below 9, yielding a survival odds ratio of 1.37 (95 percent confidence interval 1.23 to 1.53) and a number needed to treat of 19 to save one life [3], even though a score of 3 has only a 60 percent positive predictive value for actual brain injury [4]. Furthermore, the critical care burden following severe injury is high, with 27.4 percent of these patients developing multiorgan failure that increases 30-day mortality risk by 65 percent (odds ratio 1.65, p=0.03), and prehospital resources are inherently limited [5]. To prevent both the overutilization of expensive flight assets and the dangerous under-triage of critical patients, a newly developed consensus algorithm now offers a standardized framework to help emergency medical services make these high-stakes triage decisions.
Assembling a Multidisciplinary Expert Panel
Although air medical transport improves survival for selected trauma patients, optimizing triage protocols has historically been limited by a lack of high-quality evidence and the absence of a standardized definition for which clinical circumstances truly warrant flight. To address this gap and provide clear guidance for first responders, researchers sought to develop a consensus-based definition of air medical transport need. The investigative team recruited a multidisciplinary, nationally representative panel with deep expertise in prehospital and hospital-based trauma care, including specialists from trauma surgery, anesthesiology, critical care, emergency medicine, and emergency medical services. A total of 32 of 45 invited panelists (71.1 percent) agreed to participate, ensuring a broad range of clinical perspectives.
To distill existing literature and clinical experience into actionable guidelines, the researchers utilized a web-based Delphi methodology (a systematic research framework that relies on iterative, anonymous surveys to gather expert opinions and forge a reliable consensus without the dominance of a single vocal participant). Panelists voted over 4 rounds to refine the guidelines. To ensure rigorous standards and clinical applicability, the threshold for selecting a final set of criteria was set at greater than or equal to 70 percent agreement among panelists.
Distilling the Triage Criteria
To build a practical triage algorithm, the researchers first presented the expert panel with criteria drawn from existing literature that represented a potential need for air medical transport. These initial variables encompassed a broad spectrum of clinical and logistical challenges, specifically including specific patient injuries, time-sensitive interventions, and broader system factors. In total, the panel evaluated 66 initial criteria during the iterative survey process.
Through successive voting rounds, the experts systematically narrowed down the list to isolate the most critical triage triggers that physicians and paramedics encounter in the field. Ultimately, the panelists reached a formal consensus on 18 patient factors that justify helicopter transport. They also agreed on 6 time-sensitive interventions that require the specialized capabilities of flight crews, alongside 3 system factors related to prehospital logistics. Recognizing that real-world clinical decisions often depend on complex, overlapping scenarios rather than isolated variables, the panelists additionally reached consensus on 7 combinations of criteria that collectively warrant air medical transport.
Core Themes and the Final Algorithm
During the consensus process, two key themes emerged that ultimately drove the panel's final recommendations. First, the experts emphasized the need for specialized care from air medical crews that may not be available from ground ambulance clinicians, such as the administration of blood products or advanced airway management. Second, they highlighted the need for overall prehospital time-savings to expedite definitive trauma care at specialized centers. To streamline these priorities into a practical clinical tool, the researchers used narrative feedback to eliminate redundant and overlapping criteria.
Following this refinement process, the team developed a finalized algorithm for air medical transport need, alongside a decision flow diagram suitable for educational dissemination. For practicing clinicians and emergency medical services directors, this consensus-based definition provides a standardized, operational framework to guide high-stakes triage decisions. Moving forward, the researchers note that further validation of this concept using actual patient outcomes, along with the identification of local implementation barriers, will be essential for deploying this triage tool effectively in the field.
References
1. Turenhout ECV, Bossers SM, Loer SA, Giannakópoulos GF, Schwarte LA, Schober P. Pre‐hospital transfusion of red blood cells. Part 2: A systematic review of treatment effects on outcomes. Transfusion Medicine. 2020. doi:10.1111/tme.12659
2. Gruen D, Guyette F, Brown JB, et al. Characterization of unexpected survivors following a prehospital plasma randomized trial. Journal of Trauma and Acute Care Surgery. 2020. doi:10.1097/TA.0000000000002816
3. Fritz CL, Rosen CL, Thomas CE, et al. Helicopter EMS for scene response to head-injured patients: systematic review & meta-analysis. BMC Emergency Medicine. 2025. doi:10.1186/s12873-025-01392-9
4. Iyanna N, Donohue JK, Lorence JM, et al. Early Glasgow Coma Scale Score and Prediction of Traumatic Brain Injury: A Secondary Analysis of Three Harmonized Prehospital Randomized Clinical Trials. Prehospital Emergency Care. 2024. doi:10.1080/10903127.2024.2381048
5. Campwala I, Guyette F, Brown JB, et al. Evaluation of critical care burden following traumatic injury from two randomized controlled trials. Scientific Reports. 2023. doi:10.1038/s41598-023-28422-5
