The Role of Paramedic Discretion as Trauma Activation Criteria in a Rural Appalachian Trauma Center

Undertriage remains a significant challenge in rural trauma systems, where over 42 million Americans live more than an hour from a Level I or II trauma center. Paramedic discretion (PD) may serve as a practical adjunct to formal activation criteria by identifying patients who fall outside standard triggers yet require trauma system resources. The goal of this study was to evaluate the systems-level role of PD as a second-tier trauma activation (STA) criterion at a rural Level I Trauma Center. This was a retrospective study including adult patients evaluated as STA at a Level I Trauma Center over the course of 4.5 years using two comparison groups: STAs meeting criteria (2283 patients) and STAs activated by PD (1115 patients). PD-activated patients demonstrated equivalent outcomes to criteria-activated patients across all primary endpoints, including hospital length of stay (LOS) ≤ 48 hours ( P = 0.116), mortality( P = 0.578), discharge home ( P = 0.069), and Intensive Care Unit (ICU) admission ( P = 0.156). PD preferentially identified geriatric patients, those with blunt trauma mechanisms, and those with open wounds; populations recognized as being at elevated risk of undertriage. These findings suggest PD functions as an effective triage adjunct that reduces undertriage in rural trauma systems where standardized criteria alone may be insufficient.