advanced automotive collision notification

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RECOMMENDATIONS FROM THE EXPERT PANEL:

ADVANCED AUTOMATICCOLLISION NOTIFICATION AND

TRIAGE OF THE INJURED PATIENT

P R E P A R E D B Y T H E

CENTERS FOR DISEASE CONTROL AND PREVENTION,

NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL, DIVISION OF INJURY RESPONSE

W I T H S U P P O R T F R O M

ONSTAR, THE GENERAL MOTORS FOUNDATION, AND THE CDC FOUNDATION

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention


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Centers fr Disease Cntrl and PreennNanal Center fr Injr Preenn and Cntrl

Diisin f Injr Respnse

Atlanta, Georgia

2008

RECOMMENDATIONS FROM THE EXPERT PANEL:

ADVANCED AUTOMATICCOLLISION NOTIFICATION AND

TRIAGE OF THE INJURED PATIENT


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II | ADVANCED AUTOMATIC COLLISION NOTIFICATION AND TRIAGE OF THE INJURED PATIENT

RECOMMENDATIONS FROM THE ExPERT PANEL: ADVANCED AUTOMATIC

COLLISION NOTIFICATION AND TRIAGE OF THE INJURED PATIENT,

is a plican f the

Nanal Center fr Injr Preenn and Cntrl,Centers fr Disease Cntrl and Preenn.

CENTERS FOR DISEASE CONTROL AND PREVENTION

Jlie L. Gererding, MD, MPHDirectr

COORDINATING CENTER FOR ENVIRONMENTAL HEALTH AND INJURY PREVENTION

Henr Falk, MD, MPHDirectr

NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL

Ileana Arias, PhDDirectr

DIVISION OF INJURY RESPONSE

Richard C. Hnt, MD, FACEPDirectr

SUGGESTED CITATION: Nanal Center fr Injr Preenn and Cntrl.RECOMMENDATIONS FROM THE ExPERT PANEL: Adanced Atmac

Cllisin Ncan and Triage f the Injred Paent. Atlanta (GA):Centers fr Disease Cntrl and Preenn; 2008.


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NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL, DIVIS ION OF INJURY RESPONSE | III

CONTENTS

BACkGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

DEVELOPMENT OF THE FIELD TRIAGE DECISION SCHEME:

THE NATIONAL TRAUMA TRIAGE PROTOCOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

VEHICLE TELEMATICS AND ADVANCED AUTOMATIC COLLISION NOTIFICATION . . . . . . . . . . . . . . . . . . . . . . 2

INCORPORATION OF VEHICLE TELEMATICS CONSISTENT WITH HIGH RISk FOR INJURY

INTO THE DECISION SCHEME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

ExPERT PANEL ON ADVANCED AUTOMATIC COLLISION NOTIFICATION

AND TRIAGE OF THE INJURED PATIENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

RECOMMENDATIONS FROM THE ExPERT PANEL ON ADVANCED AUTOMATIC

COLLISION NOTIFICATION AND TRIAGE OF THE INJURED PATIENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-6

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

APPENDIx A: FIELD TRIAGE DECISION SCHEME: THE NATIONAL TRAUMA TRIAGE PROTOCOL . . . . . . . . . . . . 8

APPENDIx B: ADVANCED AUTOMATIC COLLIS ION NOTIFICATION AND TRIAGE ExPERT PANEL . . . . . . . 9-11

APPENDIx C: ADVANCED AUTOMATIC COLLISION NOTIFICATION PROTOCOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12


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NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL, DIVIS ION OF INJURY RESPONSE | 1

BACkGROUND

Te optimal way to reduce the morbidity, mortality, and socioeconomic consequences o injuries is to prevent

their occurrence.1,2 When an injury does occur, however, emergency medical service (EMS) providers mustensure that patients receive prompt emergency care at the scene and are transported to an appropriate healthcare acility or urther evaluation and treatment. Determining the acility to which an injured patient shouldbe transported can have a proound impact on subsequent morbidity and mortality. Although basic emergencyservices are generally consistent across emergency departments, certain hospitals known as trauma centershave additional expertise and equipment or treating severely injured patients. rauma centers are classiedby state or local authorities depending on the scope o resources and services available, ranging rom Level I,

which provides the highest level o care, to Level IV.

Not all injured patients can or should be transported to a Level I trauma center. Patients with less severeinjuries might be served better by transport to the nearest emergency department. ransporting all injuredpatients to Level I trauma centers, when many do not require that high a level o resources and expertise,unnecessarily burdens those acilities and makes them less available or the most severely injured patients.

Research has shown that the level o care an injured patient receives can also have a signicant impact onhealth outcome. Te National Study on the Costs and Outcomes o rauma (NSCO) evaluated the eecto trauma center care on mortality in moderately to severely injured patients and identied a 25% reductionin mortality or severely injured patients who received care at a Level I trauma center ratherthan at a nontrauma center.3

DEVELOPMENT OF THE FIELD TRIAGE DECISION SCHEME:THE NATIONAL TRAUMA TRIAGE PROTOCOL

Te Centers or Disease Control and Prevention (CDC) has taken an increasingly active role in theintersection between public health and acute injury care, including the publication o theAcute InjuryCare Research Agenda: Guiding Research for the Future.4 Building on these activities, CDC and the AmericanCollege o Surgeons-Committee on rauma (ACS-CO), with additional nancial support rom the NationalHighway rac Saety Administration (NHSA), convened a series o meetings o the National Expert Panelon Field riage to guide the 2006 revision o the riage Decision Scheme. Te expert panel was assembled tobring additional expertise to the revision process (e.g., EMS, emergency medicine, public health, the automo-tive industry, other ederal agencies) in order to provide:

a vigorous review o the available evidence;assist with the dissemination o the revised scheme, and the rationale behind it,to a larger public health and acute injury care community;emphasize the need or additional research in eld triage; and

establish the oundation or uture revisions.

Te major outcome o these meetings was the creation o the Field riage Decision Scheme: Te Nationalrauma riage Protocol (Decision Scheme)(see Appendix A).5


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2 | ADVANCED AUTOMATIC COLLISION NOTIFICATION AND TRIAGE OF THE INJURED PATIENT

VEHICLE TELEMATICS AND ADVANCED AUTOMATIC COLLISION NOTIFICATION

During the National Expert Panel on Field riage meetings, members discussed the potential or vehicle telem-

atics to more accurately guide trauma triage decisions. elematics is dened as the combination o telecommu-nications and computing.6 Vehicle telematics systems combine and integrate directly into the vehicles electricalarchitecture, cellular communications technology, Global Positioning System (GPS) satellite location capability,and sophisticated voice recognition.7

While vehicle telematics provide a wide array o services, Advanced Automatic Collision Notication (AACN)was the telematics service that was o particular interest to the National Expert Panel members. AACN is thesuccessor to Automatic Crash Notication (ACN) and is ound on a number o motor vehicles. (AACN isnow installed in approximately 5 million vehicles in the United States and Canada.) AACN alerts emergencyservices that a vehicle crash has occurred and automatically summons assistance.7

When a crash has occurred (as determined by various sensors, airbag deployment, or seatbelt pretensioners),the AACN system initiates an emergency wireless call to a telematics service provider (OnStar, AX, etc.) to

deliver the vehicles GPS location and crash-related data, and opens a voice communications channel to theemergency call center. AACN improves the data sent rom the ACN version by including crash severity datacollected by in-vehicle sensors.

INCORPORATION OF VEHICLE TELEMATICS CONSISTENT WITHHIGH RISk FOR INJURY INTO THE DECISION SCHEME

In earlier versions o the Decision Scheme, a number o vehicle crash characteristics were incorporated into theprehospital triage decision evaluation. Tese included, among others, high vehicle speed, vehicle deormity >20inches, and intrusion >12 inches or unbelted occupants as mechanism o injury criteria. National Automotive

Sampling System Crashworthiness Data System (NASS-CDS) data indicate that risk or injury, impact direction,and increasing crash severity are linked.8 An analysis o 621 Australian motor vehicle crashes indicated thathigh-speed impacts (>60 km/hr [>35 mph]) were associated with major injury, dened as Injury Severity Score[ISS >15], ICU admission >24 hours requiring mechanical ventilation, urgent surgery, or death (OR = 1.5;CI: 1.12.2).9 Previously, the useulness o vehicle speed had been limited because o the challenges to EMSpersonnel in estimating impact speed accurately. New AACN technology installed in some automobiles can,however, identiy vehicle location, measure change in velocity (delta V), and detect the crashs principaldirection o orce, airbag deployment, rollover, and the occurrence o multiple collisions.8 As a result, and inrecognition that this inormation might become more available in the uture, vehicle telemetry data consis-tent with a high risk or injury (e.g., change in velocity and principal direction o orce) was added as a triagecriterion.


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EXPERT PANEL ON ADVANCED AUTOMATIC COLLISION NOTIFICATIONAND TRIAGE OF THE INJURED PATIENT

In ollow up to the need to explore urther how AACN could improve triage, CDC selected and convenedan expert panel (see Appendix B). Te purpose o the panel was to develop a medical protocol or utilizationo AACN data rom crashes to better predict severity o injury and use this inormation to improve theability to respond to crashes and appropriately triage crash victims. Tis panel included representation romthe ollowing disciplines: public saety answering points (911 call centers), EMS, emergency medicine, traumasurgery, engineering, public health, vehicle telematics providers, NHSA, and the Health Resources andServices Administrations EMS or Children program.

Te expert panel met three times rom 2007 to 2008, with the second meeting serving as a subset o the entirepanel to deliberate on available data. Key discussion points included:

Crash characteristics that predicted a 20% or greater likelihood o having a serious injury wereconsidered signicant and warranted special recognition and action.

Severe injury was dened as having an ISS o 15 or greater.I additional data was available rom direct verbal contact with vehicle occupants, this shouldbe used to rene or alter the prediction o vehicle crash telematic data. Specically, knowing thenumber o occupants, age, gender, and level o consciousness would be important additional dataelements in predicting severity o injury.More work needs to be done, but the available inormation strongly supports immediateutilization o vehicle telemetric data in eld triage decision guidelines.

Te ollowing section, Recommendations rom the Expert Panel on Advanced Automatic CollisionNotication and riage o the Injured Patient summarizes the expert panels conclusions.


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RECOMMENDATIONS FROM THE EXPERT PANEL ON ADVANCED AUTOMATICCOLLISION NOTIFICATION AND TRIAGE OF THE INJURED PATIENT

Advanced Automatic Collision Notication (AACN) shows promise in improving outcomesin severely injured crash patients by:

.Predicting the likelihood o serious injury in vehicle occupants. Decreasing response times by prehospital care providers. Assisting with eld triage destination and transportation decisions. Decreasing time to denitive trauma care. Decreasing death and disability rom motor vehicle crashes.

Current AACN data transmitted rom the vehicle to the telematics provider can improve accuracyin triage o the injured patient.

Seatbelt use by an occupant signicantly infuences injury severity. Inormation regarding belt useshould be included in AACN data transmission.

AACN providers should obtain specic occupant inormation that is known to alter or infuenceinjury severity and to signicantly infuence response to injury, including age and gender.

Further renement o the best data to obtain will require urther investigations and data analyses.

Because AACN data have not been previously used in clinical decision-making, pilot studiesshould be implemented as soon as possible using the ollowing protocol (See Appendix C):

In the event o a crash, the ollowing electronic inormation will be transmitted by the vehicle1.to the AACN providers:

- Delta V

- Principal direction o orce (PDOF)- Seatbelt usage/or without- Crash with multiple impacts- Vehicle type

Tis inormation is received by the AACN provider and analyzed to identiy those patientswho, based upon the data alone, have a > 20% risk o having a severe injury (dened as an[ISS] > 15). I the analysis indicates that the risk o severe injury is< 20%, then the AACN provider proceeds per standard protocol.

I the AACN data analysis indicates a2. > 20% risk o severe injury, then the AACN providerdirectly contacts the vehicle occupant to obtain more inormation. During the communication

with the occupant, the AACN provider will inquire about:

- Age (> 55 years old have increased risk o severe injury)- Injuries to vehicle occupants- Number o patients- Number o vehicles involved in the crash


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Tis inormation may help rene the AACN data; in eect, moving the 20% value either upor down as the occupant inormation increases or decreases the likelihood that a severe injuryhas occurred. For example, i the occupant is able to communicate clearly that he or she is

uninjured and < 55 years o age, then the risk o severe injury is lessened. Similarly, i thereis no (or inappropriate) voice response rom the occupant, i the occupant is over or equal toage 55 years, or i he or she indicates an injury, then the risk o severe injury remains at least 20%(based upon the AACN data alone) and is potentially greater.

I the AACN provider determines that the occupant is at3. >20% risk o severe injury, thencommunication should be made with the relevant Public Saety Answering Point (PSAP)that AACN data obtained rom the vehicle indicates that the occupant is at risk or a severeinjury, and that the PSAP should dispatch resources as appropriate according to local protocoland consistent with the Field riage Decision Scheme: Te National rauma riage Protocol.

I the AACN data indicate that the risk o injury is


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REFERENCES

Sasser S, Varghese M, Kellermann A, Lormand JD, editors. Prehospital trauma care systems.1.

Geneva: World Health Organization; 2005.

Sasser S, Varghese M, Joshipura M, Kellermann A. Preventing death and disability through the timely2.provision o prehospital trauma care. WHO Bulletin [serial on the Internet]. 2006 Jul;84(7):

Available rom: http://www.who.int/bulletin/volumes/84/7/editorial20706html/en/print.html.[Accessed: September 19, 2008]

MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national3.evaluation o the eect o trauma-center care on mortality. New England Journal of Medicine2006;354(4):366-78.

Centers or Disease Control and Prevention; National Center or Injury Prevention and Control.4.CDC Acute Injury Care Research Agenda: Guiding Research or the Future [monograph on the

Internet]. Atlanta (GA): Centers or Disease Control and Prevention; 2005. Available rom:http://www.cdc.gov/ncipc/pub-res/research_agenda/agneda.htm. [Accessed: August 8, 2008]

American College o Surgeons. Resources or the Optimal Care o the Injured Patient. Chicago, IL:5.ACS; 2006.

elematics. Dictionary.com.6. Te Free On-line Dictionary of Computing. Denis Howe.http://dictionary.reerence.com/browse/telematics. [Accessed: May 13, 2008]

Ball W. elematics.7. Prehospital Emergency Care2006; 10(3):320-321.

Hunt RC. Emerging communication technologies in emergency medical services.8.

Prehospital Emergency Care2002;6(1):131-6.

Palanca S, aylor DM, Bailey M, Cameron PA. Mechanisms o motor vehicle accidents that predict9.major injury. Emergency Medicine(Fremantle) 2003;15(5-6):423-8.


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THIS FIELD TRIAGE DECISION SCHEME, ORIGINALLY DEVELOPED BY THE AMERICAN COLLEGE OF SURGEONS COMMITTEE ON TRAUMA, WAS REVISED BY ANEXPERT PANEL REPRESENTING EMERGENCY MEDICAL SERVICES, EMERGENCY MEDICINE, TRAUMA SURGERY, AND PUBLIC HEALTH. THE PANEL WAS CONVENEDby the centers for disease control and prevention (cdc), with support from the national highway traffic safety administration(nhtsa). its contents are those of the expert panel and do not necessarily represent the official views of cdc and nhtsa.

APPENDIx A:


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APPENDIx B:ADVANCED AUTOMATIC COLLISION NOTIFICATIONAND TRIAGE EXPERT PANEL

J. LEE ANNEST, PhD |Director, Oce o Statistics and Programming, National Center or InjuryPrevention and Control, Centers or Disease Control and Prevention; Atlanta, Georgia

JEFFREY S. AUGENSTEIN MD, PHD, FACS |Proessor o Surgery, Director, Ryder rauma Center andDirector, William Lehman Injury Research Center, Ryder rauma Center at the University o Miami/

Jackson Medical Center; Miami, Florida

GEORGE BAHOUTH, DSc|ransportation Saety Engineering, Senior Research Scientist, Pacic Institute orResearch and Evaluation; Calverton, Maryland

WILLIAM L. BALL |Vice President, Public Policy, General Motors OnStar; Detroit, Michigan

ROBERT R. BASS, MD, FACEP |Executive Director, Maryland Institute or Emergency Medical ServicesSystems; Baltimore, Maryland

PETER BAUR |Manager, Product Analysis, BMW o North America, LLC; Woodcli Lake, New Jersey

BOB BAILEY, MA |Principal Investigator, Field riage Medical Protocol, Committee or Vehicleelematics, and CDC Foundation Contractor or Division o Injury Response, National Center orInjury Prevention and Control, Centers or Disease Control and Prevention; Atlanta, Georgia

ALAN BLATT |Director,Center or ransportation Injury Research, CUBRC (Calspan-Universityat Bualo Research Center); Bualo, New York

ALASDAIR k.T. CONN, MD, FACS

|Chie o Emergency Services, Massachusetts General Hospitaland Associate Proessor o Surgery, Harvard Medical School; Boston, Massachusetts

ARTHuR CooPER, MD, FACS, FAAP, FCCM ACS |Proessor o Surgery at the Columbia UniversityCollege o Physicians and Surgeons, and Medical Director, Harlem Hospital Injury Prevention Program;New York, New York

PAUL R. G. CUNNINGHAM, MD, FACS |Proessor and Chair, Department o Surgery, State Universityo New York, Upstate Medical University; Syracuse, New York

THEODORE DELBRIDGE, MD, MPH, FACEP |Proessor and Chair, Department o Emergency Medicine,Brody School o Medicine, East Carolina University; Greenville, North Carolina

kENNERLY H. DIGGES, PhD, PE |Research Proessor o Engineering, Te George Washington University;Washington, DC

ROBERT M. DOMEIER, MD, FACEP |EMS Medical Director, St. Josephs Mercy Hospital;Ann Arbor, Michigan

LAURIE FLAHERTY, RN, MS |Program Analyst, Oce o Emergency Medical Services, National Highwayrac Saety Administration, U.S. Department o ransportation; Washington, DC


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ROBERT L. GALLI, MD, FACEP |Proessor and Chair, Emergency Medicine/Medical oxiology/elEmergency,University o Mississippi Healthcare; Jackson, Mississippi

DANIEL G. HANkINS, MD, FACEP |Consultant, Department o Emergency Medicine, Mayo Clinic andCo-Medical Director, Mayo Clinic Medical ransport; Rochester, Minnesota

MARk C. HENRY, MD |Proessor and Chair, Department o Emergency Medicine, School o Medicine,Stony Brook University; Stony Brook, New York

RICHARD C. HUNT, MD, FACEP |Director, Division o Injury Response, National Center or InjuryPrevention and Control, Centers or Disease Control and Prevention; Atlanta, Georgia

RAMON W. JOHNSON, MD, FACEP, FAAP |Board o Directors, American College o EmergencyPhysicians; Mission Viejo, Caliornia

GREGORY J. JURkOVICH, MD, FACS |Proessor o Surgery, University o Washington, and Chie o rauma,Harborview Medical Center; Seattle, Washington

VIkAS kAPIL, DO, MPH, FACOEM |Associate Director or Science, Division o Injury Response, NationalCenter or Injury Prevention and Control, Centers or Disease Control and Prevention; Atlanta, Georgia

SCOTT kEBSCHULL |Principal Engineer, Dynamic Research Inc.; orrance, Caliornia

CARLA KoHoyDA-INGLIS, MPA |Program Manager, University o Michigan Program or Injury Researchand Education (UMPIRE); Ann Arbor, Michigan

RobERT bob C. LANGE, MSME |Executive Director, Structure & Saety Integration, General MotorsCorporation; Warren, Michigan

BROOkE LERNER, PhD |Associate Proessor, Departments o Emergency Medicine and Population Health,Medical College o Wisconsin; Milwaukee, Wisconsin

DAN MANz |Emergency Medical Services Division Director, Vermont Department o Health; Burlington,Vermont

DAvID "MARCo" MARCozzI, MD, MHS-CL, FACEP |Director, Emergency Care Coordination Center,OPEO, Oce o the Assistant Secretary or Preparedness and Response, Department o Health andHuman Services, MAJ, USAR-MC; Washington, DC

BRENT MYERS, MD, MPH, FACEP |Medical Director, Wake County EMS and Wake Medical Health andHospitals Emergency Services Institute; Raleigh, North Carolina

AVERY B. NATHENS, MD, PhD, FACS |Canada Research Chair in Systems o rauma Care, Division HeadGeneral Surgery and Director o rauma, St. Michael's Hospital, University o oronto; oronto, Canada

ROBERT OCONNOR, MD, MPH, FACEP |Proessor and Chair, Department o Emergency Medicine,University o Virginia Health System, and Immediate Past President, National Association o EMSPhysicians; Charlottesville, Virginia

NANCY POLLOCk |Public Saety proessional and ormer Executive Director o the Minneapolis-St. PaulMinnesota Metropolitan Emergency Services Board; Minneapolis-St. Paul, Minnesota



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STEPHEN A. RIDELLA |Chie, Human Injury Research Division, Oce o Applied Vehicle SaetyResearch, National Highway rac Saety Administration, U.S. Department o ransportation;

Washington, DC

JEFFREY P. SALOMONE, MD, FACS |Associate Proessor o Surgery, Division o rauma/Surgical CriticalCare, Department o Surgery, Emory University School o Medicine; Atlanta, GeorgiaSCOTT SASSER, MD, FACEP |Department o Emergency Medicine, Emory University School o Medicine,and also the Division o Injury Response, National Center or Injury Prevention and Control, Centers orDisease Control and Prevention; Atlanta, Georgia

RICHARD SATTIN, MD, FACP |Proessor and Research Director, Department o Emergency Medicineand Proessor, Department o Medicine, Medical College o Georgia; Augusta, Georgia

TASMEEN SINGH, MPH, NREMPT |Executive Director, Emergency Medical Services or ChildrenNational Resource Center, Childrens National Medical Center; Silver Spring, Maryland

GARY WALLACE |Vice President, Corporate Relations, AX Group; Irving, exas

STEWART WANG, MD, PhD, FACS |Proessor o Surgery, Director, University o Michigan Programor Injury Research and Education (UMPIRE); Ann Arbor, Michigan

SUPPORT STAFF

DEIDRE GISH-PANJADA, MbA |Senior Vice President, AMP Management Services; Olathe, Kansas

JOHN SEGGERSON

|McKing Management Consultant Contractor or Division o Injury Response,National Center or Injury Prevention and Control, Centers or Disease Control and Prevention;

Atlanta, Georgia


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APPENDIx C:ADVANCED AUTOMATIC COLLISION NOTIFICATION PROTOCOL


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Centers fr Disease Cntrl and Preenn

Nanal Center fr Injr Preenn and Cntrl

Diisin f Injr Respnse

www.cdc.g/injr

advanced automotive collision notification

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