Barriers and enablers to the implementation of trauma triage tools in emergency and first responder services: A scoping review protocol using the Consolidated Framework for Implementation Research

Introduction

Trauma - defined as injury caused by an external force - is one of the top reasons for death and disability in the world (World Health Organization [WHO], 2024). Understanding the epidemiology of trauma and its causes, severity, and distribution among the population is critical to recognising vulnerable groups and providing evidence-based approaches to prevention and treatment (Alberdi et al., 2024). In Ireland, the recent National Office for Clinical Audit (NOCA) Major Trauma Audit data provide insight into national trauma patterns, showing that 62% of major trauma cases result from low falls and that over half of all patients are aged 65 years or older, highlighting the vulnerability of older adults within the Irish context (NOCA, 2023). These national findings reinforce the importance of understanding how trauma affects different population groups, particularly when planning targeted prevention strategies and allocating clinical resources. The key to emergency trauma management is appropriate triage. This ensures that patients are prioritised based on their level of injury and taken to facilities that can provide appropriate care. Inappropriate triage can have significant consequences: overtriage can overwhelm major trauma centres, while undertriage may delay definitive care and increase morbidity and mortality (Huabbangyang et al., 2023). Thus, it is crucial to introduce effective triage mechanisms to achieve equal access to timely treatment and effective use of healthcare facilities.

One of the key components of effective trauma systems are trauma triage tools (TTTs). TTTs allow ambulatory and emergency staff to quickly examine patients and make a decision on transfer to the most appropriate care centres. TTTs generally include variables on physiological measures (e.g., systolic blood pressure, respiratory rate, Glasgow Coma Scale) and mechanism-of-injury (e.g., falls, blunt impacts, high velocity of impacts, etc.) that are systematically applied to determine injury severity (Harthi et al., 2025; Donnelly et al., 2025). Their use decreases subjectivity by enhancing consistency in triage decisions across regions and providers by standardising assessment.

In Ireland, the Health Service Executive (HSE) has recently introduced a new Trauma Triage Tool (TTT) as part of a wider national trauma system reform. This reform also designates the Mater Misericordiae University Hospital as the Main Trauma Centre, representing a significant change in practice for prehospital providers, particularly for ambulance staff (Government of Ireland, Department of Health, 2021). The effectiveness of the new trauma system depends on the consistent and accurate implementation of the TTT. However, international evidence indicates that even when evidence-based TTTs are available, they are not always reliably used in routine practice. For example, tools such as START (Simple Triage and Rapid Treatment) and digital triage algorithms have demonstrated clinical utility, yet their implementation in real-world prehospital settings remains limited (Donnelly et al., 2025; Sehgal et al., 2024). Persistent non-adherence to triage protocols has been documented across emergency care contexts, reflecting a persistent gap between tool validation and the operational realities of prehospital decision-making (Donnelly et al., 2022).

The international literature identifies two closely linked challenges in trauma triage: achieving acceptable under- and over-triage, and ensuring the effective application of TTTs in routine practice. A considerable portion of TTT’s fail to meet recommended benchmarks, such as those suggested by ASCOT, and structural factors - including regional differences and lack of accessibility to large trauma facilities - undermine precision in triage (Newgard et al., 2022; Trauma System Implementation Programme, 2022). Furthermore, TTT performance also differs between population, clinical, and outcome measures, showing that an approach might not be appropriate (Donnelly et al., 2022). For instance, standard triage tools often classify older adults less accurately due to atypical physiological responses, while paediatric assessment is complicated by age-related physiological thresholds (Irish Children Triage System, 2016; Harthi et al., 2025).

Difficulties related to the implementation - such as insufficient training, unequal regional regulation, lack of leadership, and resource availability - have been widely reported (Paterson et al., 2024; Wiertsema et al., 2021). Dixon et al. (2021) highlight that as although structured triage tools have the potential to enhance consistency in decision-making, local leadership, staff training, and organizational culture influence uptake significantly. Comparable barriers and enablers have also been reported across broader emergency care innovations (Cicolo et al., 2020; Bhardwaj et al., 2024). However, much of this evidence focuses on general healthcare innovation rather than trauma-specific triage systems, demonstrating the need for a targeted synthesis to guide implementation of the HSE TTT within Ireland’s evolving trauma system (Health Service Executive, 2022). Emerging evidence also suggests that workforce readiness and inter-agency coordination influence TTT uptake, yet these factors remain insufficiently examined (Lee et al., 2025).

While previous studies on triage system? validity - such as those by Elbaih et al. (2022) and Marcussen et al. (2022), recognise the role of contextual factors, they pay little attention to the problems of adoption, implementation processes, and long-term sustainability. The application of implementation science frameworks, such as the Consolidated Framework of Implementation Research (CFIR 2.0), offers a structured means of systematically identifying of contextual barriers and enablers across five implementation domains, thereby guiding evidence-based analysis of factors influencing successful adoption of TTTs (Damschroder et al., 2022; Liao et al., 2024).

However, few studies have explicitly applied CFIR or similar frameworks too TTT implementation, resulting is a fragmented understanding of factors influencing tool adoption and maintenance. To address this gap, this scoping review will synthesise and organise the existing literature on implementation barriers and enablers, mapping these findings onto CFIR domains. The purpose of the review is to evaluate evidence-based interventions, including leadership involvement, specific training, and workflow modifications, designed to enhance the sustainability of TTT use in emergency and prehospital care. Ultimately, this synthesis seeks to inform policy and support clinical-decision making, to optimise trauma triage processes and patient outcomes.

Research aim and objectives

Methodology

The scoping review by the researcher will be performed in accordance with the methods described by Arksey and O’Malley (2005) and reported in line with the PRISMA-ScR guidelines (Mattos et al., 2023).

Outcomes

The review will provide: (1) CFIR-aligned barriers and enablers related to TTT implementation; (2) frequency tables on the extent to which each CFIR construct and domain is covered; (3) gaps—that is, CFIR constructs that exhibit low coverage in existing literature; (4) prioritised CFIR constructs mapped to ERIC-suggested implementation strategies, such as leadership, audit and feedback, adaptation of workflow, champions, and training, using the CFIR-ERIC matching tool. These deliverables will assist trauma system designers, policymakers, and scientists to formulate informed implementation approaches to fill the gap between tool validation and real-world use in trauma systems. Ultimately, the scoping review will offer a comprehensive and theoretically informed basis to guide further design of trauma systems to fill the gap between the availability of evidence-based triage instruments and their use in routine practice.