Undertriage of older trauma patients: is this a national phenomenon?

The epidemiology of dying within 48 hours of presentation to emergency departments: a retrospective cohort study of older people across Australia and New Zealand

BACKGROUND

Emergency department (ED) clinicians are more frequently providing care, including end-of-life care, to older people.

OBJECTIVES

To estimate the need for ED end-of-life care for people aged ≥65 years, describe characteristics of those dying within 48 hours of ED presentation and compare those dying in ED with those dying elsewhere.

METHODS

We conducted a retrospective cohort study analysing data from 177 hospitals in Australia and New Zealand. Data on older people presenting to ED from January to December 2018, and those who died within 48 hours of ED presentation, were analysed using simple descriptive statistics and univariate logistic regression.

RESULTS

From participating hospitals in Australia or New Zealand, 10,921 deaths in older people occurred. The 48-hour mortality rate was 6.43 per 1,000 ED presentations (95% confidence interval: 6.31-6.56). Just over a quarter (n = 3,067, 28.1%) died in ED. About one-quarter of the cohort (n = 2,887, 26.4%) was triaged into less urgent triage categories. Factors with an increased risk of dying in ED included age 65-74 years, ambulance arrival, most urgent triage categories, principal diagnosis of circulatory system disorder, and not identifying as an Aboriginal or Torres Strait Islander person. Of the 7,677 older people admitted, half (n = 3,836, 50.0%) had an encounter for palliative care prior to, or during, this presentation.

CONCLUSIONS

Our findings provide insight into the challenges of recognising the dying older patient and differentiating those appropriate for end-of-life care. We support recommendations for national advanced care planning registers and suggest a review of triage systems with an older person-focused lens.

Management of the Geriatric Trauma Patient

With a rapidly aging worldwide population, the care of geriatric trauma patients will be at the forefront of every career in Trauma and Acute Care Surgery. The unique intersection of advanced age, comorbidities, frailty, and physiologic changes presents a challenge in the care of elderly injured patients. It is well established that increasing age is associated with higher mortality and worse outcomes after injury, but it is also clear that there is room for improvement in the management of this special patient population.

Geriatric trauma, frailty, and ACS trauma center verification level: Are there any correlations with outcomes?

INTRODUCTION

It remains unclear whether geriatrics benefit from care at higher-level trauma centers (TCs). We aimed to assess the impact of the TC verification level on frail geriatric trauma patients' outcomes. We hypothesized that frail patients cared for at higher-level TCs would have improved outcomes.

STUDY DESIGN

Patients ≥65 years were identified from the Trauma Quality Improvement Program (TQIP) database (2017-2019). Patients transferred, discharged from emergency department (ED), and those with head abbreviated injury scale >3 were excluded. 11-factor modified frailty index was utilized. Propensity score matching (1:1) was performed. Outcomes included discharge to skilled nursing facility or rehab (SNF/rehab), withdrawal of life-supporting treatment (WLST), mortality, complications, failure-to-rescue, intensive care unit (ICU) admission, hospital length of stay (LOS), and ventilator days.

RESULTS

110,680 patients were matched (Frail:55,340, Non-Frail:55,340). Mean age was 79 (7), 90% presented following falls, and median ISS was 5 [2-9]. Level-I/II TCs had lower rates of discharge to SNF/rehab (52.6% vs. 55.8% vs. 60.9%; p < 0.001), failure-to-rescue (0.5% vs. 0.4% vs. 0.6%;p = 0.005), and higher rates of WLST (2.4% vs. 2.1% vs. 0.3%; p < 0.001) compared to level-III regardless of injury severity and frailty. Compared to Level-III centers, Level-I/II centers had higher complications among moderate-to-severely injured patients (4.1% vs. 3.3% vs. 2.7%; p < 0.001), and lower mortality only among frail patients regardless of injury severity (1.8% vs. 1.5% vs. 2.6%; p < 0.001). Patients at Level-I TCs were more likely to be admitted to ICU, and had longer hospital LOS and ventilator days compared to Level-II and III TCs (p < 0.05).

CONCLUSION

Frailty may play an important role when triaging geriatric trauma patients. In fact, the benefit of care at higher-level TCs is particularly evident for patients who are frail. Level III centers may be underperforming in providing access to palliative and end-of-life care.

Changes in Older Adult Trauma Quality When Evaluated Using Longer-Term Outcomes vs In-Hospital Mortality

Importance

Lack of knowledge about longer-term outcomes remains a critical blind spot for trauma systems. Recent efforts have expanded trauma quality evaluation to include a broader array of postdischarge quality metrics. It remains unknown how such quality metrics should be used.

Objective

To examine the utility of implementing recommended postdischarge quality metrics as a composite score and ascertain how composite score performance compares with that of in-hospital mortality for evaluating associations with hospital-level factors.

Design, Setting, and Participants

This national hospital-level quality assessment evaluated hospital-level care quality using 100% Medicare fee-for-service claims of older adults (aged ≥65 years) hospitalized with primary diagnoses of trauma, hip fracture, and severe traumatic brain injury (TBI) between January 1, 2014, and December 31, 2015. Hospitals with annual volumes encompassing 10 or more of each diagnosis were included. The data analysis was performed between January 1, 2021, and December 31, 2022.

Exposures

Reliability-adjusted quality metrics used to calculate composite scores included hospital-specific performance on mortality, readmission, and patients' average number of healthy days at home (HDAH) within 30, 90, and 365 days among older adults hospitalized with all forms of trauma, hip fracture, and severe TBI.

Main Outcomes and Measures

Associations with hospital-level factors were compared using volume-weighted multivariable logistic regression.

Results

A total of 573 554 older adults (mean [SD] age, 83.1 [8.3] years; 64.8% female; 35.2% male) from 1234 hospitals were included. All 27 reliability-adjusted postdischarge quality metrics significantly contributed to the composite score. The most important drivers were 30- and 90-day readmission, patients' average number of HDAH within 365 days, and 365-day mortality among all trauma patients. Associations with hospital-level factors revealed predominantly anticipated trends when older adult trauma quality was evaluated using composite scores (eg, worst performance was associated with decreased older adult trauma volume [odds ratio, 0.89; 95% CI, 0.88-0.90]). Results for in-hospital mortality showed inverted associations for each considered hospital-level factor and suggested that compared with nontrauma centers, level 1 trauma centers had a 17 times higher risk-adjusted odds of worst (highest quantile) vs best (lowest quintile) performance (odds ratio, 17.08; 95% CI, 16.17-18.05).

Conclusions and Relevance

The study results challenge historical notions about the adequacy of in-hospital mortality as the single measure of older adult trauma quality and suggest that, when it comes to older adults, decisions about how quality is evaluated can profoundly alter understandings of what constitutes best practices for care. Composite scores appear to offer a promising means by which postdischarge quality metrics could be used.

Time ratio disparities among ED patients undergoing head CT

PURPOSE

To assess if patients who underwent head computed tomography (CT) experienced disparities in the emergency department (ED) and if the indication for head CT affected disparities.

METHODS

This study employed a retrospective, IRB-approved cohort design encompassing four hospitals. All ED patients between January 2016 and September 2020 who underwent non-contrast head CTs were included. Furthermore, key time intervals including ED length of stay (LOS), ED assessment time, image acquisition time, and image interpretation time were calculated. Time ratio (TR) was used to compare these time intervals between the groups.

RESULTS

A total of 45,177 ED visits comprising 4730 trauma cases, 5475 altered mental status cases, 11,925 cases with head pain, and 23,047 cases with other indications were included. Females had significantly longer ED LOS, ED assessment time, and image acquisition time (TR = 1.012, 1.051, 1.018, respectively, P-value < 0.05). This disparity was more pronounced in female patients with head pain complaints compared to their male counterparts (TR = 1.036, 1.059, and 1.047, respectively, P-value < 0.05). Black patients experienced significantly longer ED LOS, image acquisition time, and image assessment time (TR = 1.226, 1.349, and 1.190, respectively, P-value < 0.05). These disparities persisted regardless of head CT indications. Furthermore, patients with Medicare/Medicaid insurance also faced longer wait times in all the time intervals (TR > 1, P-value < 0.001).

CONCLUSIONS

Wait times for ED head CT completion were longer for Black patients and Medicaid/Medicare insurance holders. Additionally, females experienced extended wait times, particularly when presented with head pain complaints. Our findings underscore the importance of exploring and addressing the contributing factors to ensure equitable and timely access to imaging services in the ED.

Changes in injury patterns, injury severity and hospital mortality in motorized vehicle accidents: a retrospective, cross-sectional, multicenter study with 19,225 cases derived from the TraumaRegister DGU®

PURPOSE

In the last 20 years, the number of fatalities due to road traffic accidents (RTA) in Germany has steadily decreased from 7503 to 2724 per year. Due to legal regulations, educational measures and the continuous development of safety technology the number of severe traumatic injuries and injury patterns are most likely to change. The aim of the study was to analyse severely injured motorcyclists (MC) and car occupants (CO) that were involved in RTAs in the last 15 years and investigate the development and changes of injury patterns, injury severity and hospital mortality.

METHODS

We retrospectively evaluated data from the TraumaRegister DGU® (TR-DGU) considering all RTA-related injured MCs and COs (n = 19,225) that were registered in the TR-DGU from 2006 to 2020 with a primary admission to a trauma center with continuous participation (14 of 15 years) in the TR-DGU, an Injury Severity Score (ISS) ≥ 16 and aged between 16 and 79 years. The observation period was divided into three 5-year interval subgroups for further analysis.

RESULTS

The mean age increased by 6.9 years and the ratio of severely injured MCs to COs changed from 1:1.92 to 1:1.45. COs were in 65.8% male and more often severely injured in the age groups under 30, while the majority of severely injured MCs were in the age group around 50 years and in 90.1% male. The ISS (- 3.1 points) as well as the mortality of both groups (CO: 14.4% vs. 11.8%; MC: 13.2% vs. 10.2%) steadily decreased over time. Nevertheless, the standardized mortality ratio (SMR) hardly changed and stayed < 1. Regarding the injury patterns, the greatest decline of injuries with AIS 3 + were to the head (CO: - 11.3%; MC: - 7.1%), in addition, a decrease of injuries to extremities (CO: - 1.5%; MC: - 3.3%), to the abdomen (CO: - 2.6%; MC: - 3.6%), to the pelvis in COs (- 4.7%) and to the spine (CO: + 0.1%; MC: - 2.4%) were observed. Thoracic injuries increased in both groups (CO: + 1.6%; MC: + 3.2%) and, furthermore, pelvic injuries in MCs (+ 1.7%). Another finding was the increase of the utilization of whole body CTs from 76.6 to 95.15%.

CONCLUSION

The severity of injuries and their incidence, especially head injuries, have decreased over the years and seem to contribute to a decreasing hospital mortality of polytraumatized MCs and COs injured in traffic accidents. Young drivers and an increasing number of seniors are the age groups at risk and require special attention and treatment.

All about the Benjamins: Efficacy of a modified triage protocol for trauma activation in geriatric patients

BACKGROUND

The geriatric triage protocol at the study institution was modified from SBP <90 mmHg to SBP <110 mmHg and then to SBP <100 mmHg. The purpose of this study is to evaluate the impact of adjusting geriatric triage protocols on patient outcomes.

METHODS

A single-center retrospective review was conducted on trauma patients 65 years or older. Three study periods with different geriatric specific trauma team activation (TTA) protocols (Group 1-SBP<90 mmHg; Group 2-SBP<110 mmHg; Group 3-SBP<100 mmHg) were compared.

RESULTS

2016 patients were included. There were no differences in mortality rates or need for trauma intervention (NFTI) rates among the three groups. The SBP <100 mmHg and SBP <110 mmHg groups had similar under-triage rates. The NFTI over-triage rate in the SBP <100 mmHg group was lower than the SBP <110 mmHg group.

CONCLUSION

Using SBP <100 mmHg threshold for TTA criteria in geriatric trauma patients improves over-triage without leading to under-triage.

Older Adults, the "Social Admission," and Nonspecific Complaints in the Emergency Department: Protocol for a Scoping Review

BACKGROUND

Older adults have a higher visit rate and poorer health outcomes in the emergency department (ED) compared to their younger counterparts. Older adults are more likely to require additional resources and hospital admission. The nonspecific, atypical, and complex nature of disease presentation in older adults challenges current ED triage systems. Acute illness in older adults is often missed or commonly disguised in the ED as a social or functional issue. If diagnostic clarity is lacking or safe discharge from the ED is not feasible, then older adults may be labelled a "social admission" (or another synonymous term), often leading to negative health consequences.

OBJECTIVE

This scoping review aims to describe and synthesize the available evidence on patient characteristics, adverse events, and health outcomes for older adults labelled as "social admission" (and other synonymously used terms), as well as those with nonacute or nonspecific complaints in the ED or hospital setting.

METHODS

A literature search of MEDLINE, Embase, Scopus, PsycINFO, and CINAHL was completed. Relevant reference lists were screened. Data have been managed using EndNote software and the Covidence web application. Original data have been included if patients are aged ≥65 years and are considered a "social admission" (or other synonymously used term) or if they present to the ED with a nonacute or nonspecific complaint. Two review team members have reviewed titles and abstracts and will review full-text articles. Disagreements are resolved by consensus or in discussion with a third reviewer. This review does not require research ethics approval.

RESULTS

As of January 2023, we have completed the title and abstract screening and have started the full-text screening. Some remaining full-text articles are being retrieved and/or translated. We are extracting data from included studies. Data will be presented in a narrative and descriptive manner, summarizing key concepts, patient characteristics, and health outcomes of patients labelled as a "social admission" (and other synonymously used terms) and of those with nonacute and nonspecific complaints. We expect the first results for publication in Spring 2023.

CONCLUSIONS

Acute illness in the older adult is not always easily identified. We hope to better understand patient characteristics, adverse events, and health outcomes of older adults labelled as a "social admission," as well as those with nonacute or nonspecific complaints. We aim to identify priorities for future research and identify knowledge gaps that may inform health care providers caring for these vulnerable patients.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38246.

Development of Imaging Criteria for Geriatric Blunt Trauma Patients

INTRODUCTION

Current decision tools to guide trauma computed tomography (CT) imaging were not validated for use in older patients. We hypothesized that specific clinical variables would be predictive of injury and could be used to guide imaging in this population to minimize risk of missed injury.

METHODS

Blunt trauma patients aged 65 y and more admitted to a Level 1 trauma center intensive care unit from January 2018 to November 2020 were reviewed for histories, physical examination findings, and demographic information known at the time of presentation. Injuries were defined using the patient's final abbreviated injury score codes, obtained from the trauma registry. Abbreviated injury score codes were categorized by corresponding CT body region: Head, Face, Chest, C-Spine, Abdomen/Pelvis, or T/L-Spine. Variable groupings strongly predictive of injury were tested to identify models with high sensitivity and a negative predictive value.

RESULTS

We included 608 patients. Median age was 77 y (interquartile range, 70-84.5) and 55% were male. Ground-level fall was the most common injury mechanism. The most commonly injured CT body regions were Head (52%) and Chest (42%). Variable groupings predictive of injury were identified in all body regions. We identified models with 97.8% sensitivity for Head and 98.8% for Face injuries. Sensitivities more than 90% were reached for all except C-Spine and Abdomen/Pelvis.

CONCLUSIONS

Decision aids to guide imaging for older trauma patients are needed to improve consistency and quality of care. We have identified groupings of clinical variables that are predictive of injury to guide CT imaging after geriatric blunt trauma. Further study is needed to refine and validate these models.

Differences in time-critical interventions and radiological examinations between adult and older trauma patients: A national register-based study

BACKGROUND

Older trauma patients are reported to receive lower levels of care than younger adults. Differences in clinical management between adult and older trauma patients hold important information about potential trauma system improvement targets. The aim of this study was to compare prehospital and early in-hospital management of adult and older trauma patients, focusing on time-critical interventions and radiological examinations.

METHODS

Retrospective analysis of the Norwegian Trauma Registry for 2015 through 2018. Trauma patients 16 years or older met by a trauma team and with New Injury Severity Score of 9 or greater were included, dichotomized into age groups 16 years to 64 years and 65 years or older. Prehospital and emergency department clinical management, advanced airway management, chest decompression, and admission radiological examinations was compared between groups applying descriptive statistics and appropriate statistical tests.

RESULTS

There were 9543 patients included, of which 28% (n = 2711) were 65 years or older. Older patients, irrespective of injury severity, were less likely attended by a prehospital doctor/paramedic team (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.57-0.71), conveyed by air ambulance (OR, 0.65; 95% CI, 0.58-0.73), and transported directly to a trauma center (OR, 0.86; 95% CI, 0.79-0.94). Time-critical intervention and primary survey radiological examination rates only differed between age groups among patients with New Injury Severity Score of 25 or greater, showing lower rates for older adults (advanced airway management: OR, 0.60; 95% CI, 0.47-0.76; chest decompression: OR, 0.46; 95% CI, 0.25-0.85; x-ray chest: OR, 0.54; 95% CI, 0.39-0.75; x-ray pelvis: OR, 0.69; 95% CI, 0.57-0.84). However, for the patients attended by a doctor/paramedic team, there were no management differences between age groups.

CONCLUSION

Older trauma patients were less likely to receive advanced prehospital care compared with younger adults. Older patients with very severe injuries received fewer time-critical interventions and radiological examinations. Improved dispatch of doctor/paramedic teams to older adults and assessment of the impact the observed differences have on outcome are future research priorities.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Utilization of trauma nurse screening procedure for triage of the injured patient

PURPOSE

The treatment of trauma patients requires significant hospital resources. Numerous protocols exist to triage the injured patient and determine the level of care they may require. The purpose of this work is to describe an institutional trauma nurse screening procedure and to evaluate its effectiveness in triaging injured patients.

METHODS

This retrospective study was conducted at a large, tertiary trauma center from January to June 2021. Patients were assessed by trauma nurse clinicians (TNC) utilizing a standardized screening process to determine suitability for trauma activation. If the patient did not meet activation criteria, they were sent to the main Emergency Department for evaluation and treatment. Patients could be activated later by the emergency physician. The primary variables of interest were number of activations after initial "rule out," injury severity score (ISS) for patients who were activated, mechanism of injury, and disposition.

RESULTS

A total of 1874 TNC screenings were performed. Of these, 1449 (77%) patients did not meet trauma activation criteria. Only 41 (2.8%) patients initially ruled out were later activated by the emergency physician and admitted for treatment of injuries. The average ISS of all activated patients was 9 ± 6. Thirty-six patients had an ISS ≤ 15, four between 16 and 25, and only one patient had an ISS > 25. Twenty-seven patients were admitted to the ward, five went to step-down units, and five required intensive care unit admission. Four patients required operative intervention for their injuries.

CONCLUSION

These results suggest that nursing screening protocols can be safe, effective tools for triage of trauma patients.

Evaluation of mechanism of injury criteria for field triage of occupants involved in motor vehicle collisions

OBJECTIVE

The mechanism of injury (MOI) criteria assist in determining which patients are at high risk of severe injury and would benefit from direct transport to a trauma center. The goal of this study was to determine whether the prognostic performance of the Centers for Disease Control's (CDC) MOI criteria for motor vehicle collisions (MVCs) has changed during the decade since the guidelines were approved. Secondary objectives were to evaluate the performance of these criteria for different age groups and evaluate potential criteria that are not currently in the guidelines.

METHODS

Data were obtained from NASS and Crash Investigation Sampling System (CISS) for 2000-2009 and 2010-2019. Cases missing injury severity were excluded, and all other missing data were imputed. The outcome of interest was Injury Severity Score (ISS) ≥16. The area under the receiver operator characteristic (AUROC) and 95% confidence intervals (CIs) were obtained from 1,000 bootstrapped samples using national case weights. The AUROC for the existing CDC MOI criteria were compared between the 2 decades. The performance of the criteria was also assessed for different age groups based on accuracy, sensitivity, and specificity. Potential new criteria were then evaluated when added to the current CDC MOI criteria.

RESULTS

There were 150,683 (weighted 73,423,189) cases identified for analysis. There was a small but statistically significant improvement in the AUROC of the MOI criteria in the later decade (2010-2019; AUROC = 0.77, 95% CI [0.76-0.78]) compared to the earlier decade (2000-2009; AUROC = 0.75, 95% CI [0.74-0.76]). The accuracy and specificity did not vary with age, but the sensitivity dropped significantly for older adults (0-18 years: 0.62, 19-54 years: 0.59, ≥55 years: 0.37, and ≥65 years: 0.36). The addition of entrapment improved the sensitivity of the existing criteria and was the only potential new criterion to maintain a sensitivity above 0.95.

CONCLUSIONS

The MOI criteria for MVCs in the current CDC guidelines still perform well even as vehicle design has changed. However, the sensitivity of these criteria for older adults is much lower than for younger occupants. The addition of entrapment improved sensitivity while maintaining high specificity and could be considered as a potential modification to current MOI criteria.

The predictive value of serum lactate to forecast injury severity in trauma-patients increases taking age into account

BACKGROUND

Two-tier trauma team activation (TTA)-protocols often fail to safely identify severely injured patients. A possible amendment to existing triage scores could be the measurement of serum lactate. The aim of this study was to determine the ability of the combination of serum lactate and age to predict severe injuries (ISS > 15).

METHODS

We conducted a retrospective cohort study in a single level one trauma center in a 20 months study-period and analyzed every trauma team activation (TTA) due to the mechanism of injury (MOI). Primary endpoint was the correlation between serum lactate (and age) and ISS and mortality. The validity of lactate (LAC) and lactate contingent on age (LAC + AGE) were assessed using the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. We used a logistic regression model to predict the probability of an ISS > 15.

RESULTS

During the study period we included 325 patients, 75 met exclusion criteria. Mean age was 43 years (Min.: 11, Max.: 90, SD: 18.7) with a mean ISS of 8.4 (SD: 8.99). LAC showed a sensitivity of 0.82 with a specificity of 0.62 with an optimal cutoff at 1.72 mmol/l to predict an ISS > 15. The AUC of the ROC for LAC was 0.764 (95% CI: 0.67-0.85). The LAC + AGE model provided a significantly improved predictive value compared to LAC (0.765 vs. 0.828, p < 0.001).

CONCLUSIONS

The serum lactate concentration is able to predict injury severity. The prognostic value improves significantly taking the patients age into consideration. The combination of serum lactate and age could be a suitable Ad-on to existing two-tier triage protocols to minimize undertriage.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Undertriage of Geriatric Trauma Patients in Florida

INTRODUCTION

Elderly undertriage rates are estimated up to 55% in the United States. This study examined risk factors for undertriage among hospitalized trauma patients in a state with high volumes of geriatric trauma patients.

MATERIALS AND METHODS

This is a population-based retrospective cohort study of 62,557 patients admitted to Florida hospitals between 2016 and 2018 from the Agency for Healthcare Administration database. Severely injured trauma patients were defined by American College of Surgeons definitions and an International Classification of Disease Injury Severity Score <0.85. Undertriage was defined as definitive care of these severely injured patients at any Florida hospital other than a state-designated trauma center (TC). Univariate analyses were used to identify risk factors associated with inpatient mortality and undertriage. Multiple variable regression was used to estimate risk-adjusted odds of mortality after admission to either a designated or nondesignated TC.

RESULTS

Undertriaged patients were more likely to have isolated traumatic brain injuries, lower International Classification of Disease Injury Severity Scores, multiple comorbidities, and older age. Trauma patients aged 65 and older were more than twice as likely to be undertriaged (34% versus 15.7%, P < 0.0001). Undertriaged patients of all ages were also more likely to suffer from pneumonia, urinary tract infection, arrhythmias, and sepsis. After risk adjustment, severely injured trauma patients admitted to non-TC were also more likely to be at risk for mortality (adjusted odds ratio, 1.27; 95% confidence interval, 1.17-1.38).

CONCLUSIONS

Age and multiple comorbidities are significant predictors of mortality among undertriage of trauma patients. As a result, trauma triage guidelines should account for high-risk geriatric trauma patients who would benefit from definitive treatment at designated TCs.

Impact of Modified Geriatric Trauma Activation Criteria on patient outcomes at a level 1 trauma center

Background

The American College of Surgeons Trauma Quality Improvement Program recommends a lower threshold for trauma activation on geriatric patients. We implemented the Modified Geriatric Trauma Activation Criteria (MGTAC) and assessed the clinical impact on geriatric trauma patients.

Methods

Geriatric trauma patients aged 65 years and over presenting between 1/1/2014 and 12/31/2020 were identified through the Trauma Registry. MGTAC were implemented on 3/1/2017, where patients aged 65 and above were rendered as Highest Level activations when presenting with no prior work-up. Those presenting from 1/1/2014 to 2/28/2017 were grouped as Standard Activation Criteria (SAC), and those presenting between 3/1/2017 and 12/31/2020 were grouped as MGTAC. Patient demographics, mechanism of injury, level of activation, operative intervention, intensive care unit (ICU) admission, length of stay, survival, and undertriage rates were reviewed. Chi square, ANOVA, and unpaired t-test were used for analysis to compare SAC and MGTAC patient outcomes.

Results

2582 patients were identified: 1293 (50.1%) in SAC and 1289 (49.9%) in MGTAC. Highest Level trauma activations for SAC vs. MGTAC were 9.3% vs. 30.4%, p < .01. Between SAC and MGTAC, ICU admission was 24.1% vs. 16.5%, p<0.01; operative intervention was 10.3% vs. 12.9%, p = .04; undertriage rates were 6.1% vs. 3.8%, p = .01; and average length of stay was 7 days for SAC vs. 6.4 days for MGTAC, p = .54. Overall mortality was 9% for SAC and 9.5% for MGTAC, p = .66.

Conclusion

Implementation of MGTAC did not improve geriatric trauma patient mortality. However, it decreased ICU admission and undertriage, and increased operative intervention during the first 24 hours.

Evaluating pre-hospital triage and decision-making in patients who died within 30 days post-trauma: A multi-site, multi-center, cohort study

INTRODUCTION

Evaluating pre-hospital triage and decision-making in patients who died post-trauma is crucial to decrease undertriage and improve future patients' chances of survival. A study that has adequately investigated this is currently lacking. The aim of this study was therefore to evaluate pre-hospital triage and decision-making in patients who died within 30 days post-trauma.

MATERIALS AND METHODS

A multi-site, multi-center, cohort study was conducted. Trauma patients who were transported from the scene of injury to a trauma center by ambulance and died within 30 days post-trauma, were included. The main outcome was undertriage, defined as erroneously transporting a severely injured patient (Injury Severity Score ≥ 16) to a lower-level trauma center.

RESULTS

Between January 2015 and December 2017, 2116 patients were included, of whom 765 (36.2%) were severely injured. A total of 103 of these patients (13.5%) were undertriaged. Undertriaged patients were often elderly with a severe head and/or thoracic injury as a result of a minor fall (< 2 m). A majority of the undertriaged patients were triaged without assistance of a specialized physician (100 [97.1%]), did not meet field triage criteria for level-I trauma care (81 [78.6%]), and could have been transported to the nearest level-I trauma center within 45 min (93 [90.3%]).

CONCLUSION

Approximately 14% of the severely injured patients who died within 30 days were undertriaged and could have benefited from treatment at a level-I trauma center (i.e., specialized trauma care). Improvement of pre-hospital triage is needed to potentially increase future patients' chances of survival.

Predicting mortality in elderly trauma patients: a review of the current literature

PURPOSE OF REVIEW

Advances in medical care allow patients to live longer, translating into a larger geriatric patient population. Adverse outcomes increase with older age, regardless of injury severity. Age, comorbidities, and physiologic deterioration have been associated with the increased mortality seen in geriatric trauma patients. As such, outcome prediction models are critical to guide clinical decision making and goals of care discussions for this population. The purpose of this review was to evaluate the various outcome prediction models for geriatric trauma patients.

RECENT FINDINGS

There are several prediction models used for predicting mortality in elderly trauma patients. The Geriatric Trauma Outcome Score (GTOS) is a validated and accurate predictor of mortality in geriatric trauma patients and performs equally if not better to traditional scores such as the Trauma and Injury Severity Score. However, studies recommend medical comorbidities be included in outcome prediction models for geriatric patients to further improve performance.

SUMMARY

The ideal outcome prediction model for geriatric trauma patients has not been identified. The GTOS demonstrates accurate predictive ability in elderly trauma patients. The addition of medical comorbidities as a variable in outcome prediction tools may result in superior performance; however, additional research is warranted.

Association of Trauma Center Designation With Postdischarge Survival Among Older Adults With Injuries

Importance

Trauma centers improve outcomes for young patients with serious injuries. However, most injury-related hospital admissions and deaths occur in older adults, and it is not clear whether trauma center care provides the same benefit in this population.

Objective

To examine whether 30- and 365-day mortality of injured older adults is associated with the treating hospital's trauma center level.

Design, Setting, and Participants

This prospective, population-based cohort study used Medicare claims data from January 1, 2013, to December 31, 2016, for all fee-for-service Medicare beneficiaries 66 years or older with inpatient admission for traumatic injury in 2014 to 2015. Data analysis was performed from January 1 to June 31, 2021. Preinjury health was measured using 2013 claims, and outcomes were measured through 2016. The population was stratified by anatomical injury pattern. Propensity scores for level I trauma center treatment were estimated using the Abbreviated Injury Scale, age, and residential proximity to trauma center and then used to match beneficiaries from each trauma level (I, II, III, and IV/non-trauma centers) by injury type.

Exposure

Admitting hospital's trauma center level.

Main Outcomes and Measures

Case fatality rates (CFRs) at 30 and 365 days after injury, estimated in the matched sample using multivariable, hierarchical logistic regression models.

Results

A total of 433 169 Medicare beneficiaries (mean [SD] age, 82.9 [8.3] years; 68.4% female; 91.5% White) were included in the analysis. A total of 206 275 (47.6%) were admitted to non-trauma centers and 161 492 (37.3%) to level I or II trauma centers. Patients with isolated extremity fracture had the fewest deaths (365-day CFR ranged from 16.1% [95% CI, 11.2%-22.4%] to 17.4% [95% CI, 11.8%-24.6%] by trauma center status). Patients with both hip fracture and traumatic brain injury had the most deaths (365-day CFRs ranged from 33.4% [95% CI, 25.8%-42.1%] to 35.8% [95% CI, 28.9%-43.5%]).

Conclusions and Relevance

These findings suggest that older adults do not benefit from existing trauma center care, which is designed with younger patients in mind. There is a critical need to improve trauma care practices to address common injury mechanisms and types of injury in older adults.

Extending Trauma Quality Improvement Beyond Trauma Centers: Hospital Variation in Outcomes Among Nontrauma Hospitals

OBJECTIVE

The American College of Surgeons (ACS) conducts a robust quality improvement program for ACS-verified trauma centers, yet many injured patients receive care at non-accredited facilities. This study tested for variation in outcomes across non-trauma hospitals and characterized hospitals associated with increased mortality.

SUMMARY BACKGROUND DATA

The study included state trauma registry data of 37,670 patients treated between January 1, 2013, and December 31, 2015. Clinical data were supplemented with data from the American Hospital Association and US Department of Agriculture, allowing comparisons among 100 nontrauma hospitals.

METHODS

Using Bayesian techniques, risk-adjusted and reliability-adjusted rates of mortality and interfacility transfer, as well as Emergency Departments length-of-stay (ED-LOS) among patients transferred from EDs were calculated for each hospital. Subgroup analyses were performed for patients ages >55 years and those with decreased Glasgow coma scores (GCS). Multiple imputation was used to address missing data.

RESULTS

Mortality varied 3-fold (0.9%-3.1%); interfacility transfer rates varied 46-fold (2.1%-95.6%); and mean ED-LOS varied 3-fold (81-231 minutes). Hospitals that were high and low statistical outliers were identified for each outcome, and subgroup analyses demonstrated comparable hospital variation. Metropolitan hospitals were associated increased mortality [odds ratio (OR) 1.7, P = 0.004], decreased likelihood of interfacility transfer (OR 0.7, P ≤ 0.001), and increased ED-LOS (coef. 0.1, P ≤ 0.001) when compared with nonmetropolitan hospitals and risk-adjusted.

CONCLUSIONS

Wide variation in trauma outcomes exists across nontrauma hospitals. Efforts to improve trauma quality should include engagement of nontrauma hospitals to reduce variation in outcomes of injured patients treated at those facilities.

Elevated serum lactate levels and age are associated with an increased risk for severe injury in trauma team activation due to trauma mechanism

BACKGROUND

The identification of risk factors for severe injury is crucial in trauma triage and trauma team activation (TTA) depends on a sufficient triage. The aim of this study was to determine whether or not elevated serum lactate levels and age are risk factors for severe injury in TTA due to trauma mechanism.

METHODS

We conducted a retrospective cohort study in a single level one trauma center between September 2019 and May 2021 and analysed every TTA due to trauma mechanism. Primary endpoint of interest was the association of serum lactate as well as age with injury severity assessed by the injury severity score (ISS).

RESULTS

During the study period, we included 250 patients. Mean age was 43.3 years (Min.: 11, Max.: 90, SD: 18.7) and the initial lactate level was 1.7 mmol/L (SD: 0.95) with a mean ISS of 8.4 (SD: 8.99). The adjusted odds ratio (OR) for age > 65 being associated with an ISS > 16 is 9.7 (p < 0.001; 95% CI 4.01-25.58) and for lactate > 2.2 mmol/L being associated with an ISS > 16 is 6.29 (p < 0.001; 95% CI 2.93-13.48). A lactate level of > 4 mmol/L results in a 36-fold higher risk of severe injury with an ISS > 16 (OR 36.06; 95% CI 4-324.29).

CONCLUSION

This study identifies age (> 65) and lactate (> 2.2 mmol/L) as independent risk factors for severe injury in a TTA due to trauma mechanism. Existing triage protocols might benefit from congruous amendments.

Disparity in prehospital scene time for geriatric trauma patients

BACKGROUND

Geriatric patients face disparities in prehospital trauma care. We hypothesized that geriatric trauma patients are more likely to experience prolonged prehospital scene time than younger adults.

METHODS

Retrospective analysis of the 2017 National Emergency Medical Services Information System. Patients who met anatomic or physiologic trauma criteria based on national triage guidelines were included (n = 16,356). Geriatric patients (age≥65, n = 3594) were compared to younger adults (age 18-64). The primary outcome was prolonged scene time (>10 min). Multivariable logistic regression was performed, controlling for patient demographics, on-scene treatments, and injury severity.

RESULTS

Geriatric patients were more likely to experience prolonged scene time than younger adults after controlling for other factors (OR 1.78, 95% CI 1.57-2.04, p < 0.001). The likelihood of prolonged scene time reached OR 2.29 (95% CI 1.85-2.84) for patients age 70-79 and OR 2.66 (95% CI 2.07-3.42) for patients age 80-89, relative to age 18-29.

CONCLUSIONS

Geriatric trauma patients are more likely than younger adults to have prolonged prehospital scene time. This disparity may be caused by delayed recognition of injury severity or age-related cognitive biases.

The elderly age criterion for increased in-hospital mortality in trauma patients: a retrospective cohort study

Background

With an aging population, the number of elderly individuals exposed to traumatic injuries is increasing. The elderly age criterion for traumatic injuries has been inconsistent in the literature. This study aimed at specifying the elderly age criterion when the traumatic mortality rate increases.

Methods

This is a multicenter retrospective cohort study that was conducted utilizing the data from the Emergency Department-based Injury In-depth Surveillance Registry of the Korea Disease Control and Prevention Agency, collected between January 2014 and December 2018 from 23 emergency departments. The outcome variable was in-hospital mortality. Multivariable logistic regression analysis was used to calculate the adjusted mortality rate for each age group. By using the shape-restricted regression splines method, the relationship between age and adjusted traumatic mortality was plotted and the point where the gradient of the graph had the greatest variation was calculated.

Results

A total of 637,491 adult trauma patients were included. The number of in-hospital deaths was 6504 (1.0%). The age at which mortality increased the most was 65.06 years old. The adjusted odds ratio for the in-hospital mortality rate with age in the ≤ 64-year-old subgroup was 1.038 (95% confidence interval (CI) 1.032–1.044) and in the ≥ 65-year-old subgroup was 1.059 (95% CI 1.050–1.068). The adjusted odds ratio for in-hospital mortality in the ≥ 65-year-old compared to the ≤ 64-year-old subgroup was 4.585 (95% CI 4.158–5.055, p < 0.001).

Conclusions

This study found that the in-hospital mortality rate rose with increasing age and that the increase was the most rapid from the age of 65 years. We propose to define the elderly age criterion for traumatic injuries as ≥ 65 years of age.

Recalibrating the Glasgow Coma Score as an Age-Adjusted Risk Metric for Neurosurgical Intervention

BACKGROUND

The Glasgow Coma Scale (GCS) score is the most frequently used neurologic assessment in traumatic brain injury (TBI). The risk for neurosurgical intervention based on GCS is heavily modified by age. The objective is to create a recalibrated Glasgow Coma Scale (GCS) score that accounts for an interaction by age and determine the predictive performance of the recalibrated GCS (rGCS) compared to the standard GCS for predicting neurosurgical intervention.

METHODS

This retrospective cohort study utilized the National Trauma Data Bank and included all patients admitted from 2010-2015 with TBI (ICD9 diagnosis code 850-854.19). The study population was divided into 2 subsets: a model development dataset (75% of patients) and a model validation dataset (remaining 25%). In the development dataset, logistic regression models were used to calculate conditional probabilities of having a neurosurgical intervention for each combination of age and GCS score, to develop a point-based risk score termed the rGCS. Model performance was examined in the validation dataset using area under the receiver operating characteristic (AUROC) curves and calibration plots.

RESULTS

There were 472,824 patients with TBI. The rGCS ranged from 1-15, where rGCS 15 denotes the baseline risk for neurosurgical intervention (4.4%) and rGCS 1 represents the greatest risk (62.6%). In the validation dataset there was a statistically significant improvement in predictive performance for neurosurgical intervention for the rGCS compared to the standard GCS (AUROC: 0.71 versus 0.67, difference, -0.04, P<0.001), overall and by trauma level designation. The rGCS was better calibrated than the standard GCS score.

CONCLUSIONS

The relationship between GCS score and neurosurgical intervention is significantly modified by age. A revision to the GCS that incorporates age, the rGCS, provides risk of neurosurgical intervention that has better predictive performance than the standard ED GCS score.

Under-triage of older trauma patients in prehospital care: a systematic review

Aim

The systematic review aimed to assess the under-triage rate for older trauma patients in prehospital care and its impact on their outcomes.

Findings

Older trauma patients were significantly under-triaged in prehospital care and the benefits of triaging these patients to Tauma Centres (TCs) are still uncertain. Current triage criteria and developed geriatric-specific criteria lacked acceptable accuracy and when patients met the criteria, they had a low chance of being transported to TCs.

Message

Future worldwide research is needed to assess the following aspects: (1) the accuracy of current trauma triage criteria, (2) developing more accurate triage criteria, (3) destination compliance rates for patients meeting the triage criteria, (4) factors leading to destination non-compliance and their impact on outcomes, and (5) the benefits of TC access for older trauma patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00512-5.

Background

It is argued that many older trauma patients are under-triaged in prehospital care which may adversely affect their outcomes. This systematic review aimed to assess prehospital under-triage rates for older trauma patients, the accuracy of the triage criteria, and the impact of prehospital triage decisions on outcomes.

Methods

A computerised literature search using MEDLINE, Scopus, and CINHAL databases was conducted for studies published between 1966 and 2021 using a list of predetermined index terms and their associated alternatives. Studies which met the inclusion criteria were included and critiqued using the Critical Appraisal Skills Programme tool. Due to the heterogeneity of the included studies, narrative synthesis was used in this systematic review.

Results

Of the 280 identified studies, 23 met the inclusion criteria. Current trauma triage guidelines have poor sensitivity to identify major trauma and the need for TC care for older adults. Although modified triage tools for this population have improved sensitivity, they showed significantly decreased specificity or were not applied to all older people. The issue of low rates of TC transport for positively triaged older patients is not well understood. Furthermore, the benefits of TC treatment for older patients remain uncertain.

Conclusions

This systematic review showed that under-triage is an ongoing issue for older trauma patients in prehospital care and its impact on their outcomes is still uncertain. Further high-quality prospective research is needed to assess the accuracy of prehospital triage criteria, the factors other than the triage criteria that affect transport decisions, and the impact of under-triage on outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00512-5.

The impact of delayed management of fall-related hip fracture management on health outcomes for African American older adults

BACKGROUND

Black hip fracture patients experience worse health outcomes than otherwise similar White patients, but causes of these disparities are not known. We sought to determine if delays in hip fracture surgery and/or hospital structures contribute to racial disparities in hip fracture outcomes.

METHODS

Using 2006 to 2016 Trauma Quality Program Public Use Files, we identified hip fracture patients with primary mechanisms of fall from standing and determined surgical treatment category (no surgery, surgery within 24 hours after arrival, surgery 24-48 hours after arrival, surgery more than 48 hours after arrival) as well as hospital structure characteristics (trauma center designation, teaching status, profit status, bed size). We used generalized structural equation models to conduct path analyses and determine if hip fracture treatment and hospital characteristics mediated the relationship between race (non-Hispanic Black/non-Hispanic White) and outcomes (complications, length of stay, disposition).

RESULTS

Non-Hispanic Black patients were more likely than non-Hispanic White patients to receive treatment at an academic medical center (49.1% vs. 28.0%), at a hospital with >600 inpatient beds (39.5% vs. 25.3%), and at a level I or II trauma center (86.8% vs. 77.7%); were more likely to go without hip fracture repair surgery (22.8% vs. 21.4%); and were more likely to have delayed surgery >48 hours after hospital arrival (15.5% vs. 10.6%). Path analysis suggests hip fracture treatment group and hospital characteristics mediate the relationship with complications, length of stay, and disposition.

CONCLUSION

Non-Hispanic Black patients with fall-related hip fracture are more likely to experience delays in care, complications, and longer inpatient stays. Hospital characteristics contribute to increased risk of complications and longer length of stay, both as independent determinants of outcomes and as determinants of delays in hip fracture surgery.

LEVEL OF EVIDENCE

Prognostic and epidemiologic, level III.

Field-Triage, Hospital-Triage and Triage-Assessment: A Literature Review of the Current Phases of Adult Trauma Triage

ABSTRACT

Despite major improvements in the United States trauma system over the past two decades, prehospital trauma triage is a significant challenge. Undertriage is associated with increased mortality, and overtriage results in significant resource overuse. The American College of Surgeons Committee on Trauma benchmarks for undertriage and overtriage are not being met. Many barriers to appropriate field triage exist, including lack of a formal definition for major trauma, absence of a simple and widely applicable triage mode, and emergency medical service adherence to triage protocols. Modern trauma triage systems should ideally be based on the need for intervention rather than injury severity. Future studies should focus on identifying the ideal definition for major trauma and creating triage models that can be easily deployed. This narrative review article presents challenges and potential solutions for prehospital trauma triage.

Ability of prehospital NEWS to predict 1-day and 7-day mortality is reduced in the older adult patients

BACKGROUND

National Early Warning Score (NEWS) does not include age as a parameter despite age is a significant independent risk factor of death. The aim of this study was to examine whether age has an effect on predictive performance of short-term mortality of NEWS in a prehospital setting. We also evaluated whether adding age as an additional parameter to NEWS improved its short-term mortality prediction.

METHODS

We calculated NEWS scores from retrospective prehospital electronic patient record data for patients 18 years or older with sufficient prehospital data to calculate NEWS. We used area under receiver operating characteristic (AUROC) to analyse the predictive performance of NEWS for 1 and 7 day mortalities with increasing age in three different age groups: <65 years, 65-79 years and ≥80 years. We also explored the ORs for mortality of different NEWS parameters in these age groups. We added age to NEWS as an additional parameter and evaluated its effect on predictive performance.

RESULTS

We analysed data from 35 800 ambulance calls. Predictive performance for 7-day mortality of NEWS decreased with increasing age: AUROC (95% CI) for 1-day mortality was 0.876 (0.848 to 0.904), 0.824 (0.794 to 0.854) and 0.820 (0.788 to 0.852) for first, second and third age groups, respectively. AUROC for 7-day mortality had a similar trend. Addition of age as an additional parameter to NEWS improved its ability to predict short-term mortality when assessed with continuous Net Reclassification Improvement.

CONCLUSIONS

Age should be considered as an additional parameter to NEWS, as it improved its performance in predicting short-term mortality in this prehospital cohort.

New Horizons in Understanding Appropriate Prehospital Identification and Trauma Triage for Older Adults

Caring for older people is an important part of prehospital practice, including appropriate triage and transportation decisions. However, prehospital triage criteria are designed to predominantly assess injury severity or high-energy mechanism which is not the case for older people who often have injuries compounded by multimorbidity and frailty. This has led to high rates of under-triage in this population. This narrative review aimed to assess aspects other than triage criteria to better understand and improve prehospital triage decisions for older trauma patients. This includes integrating frailty assessment in prehospital trauma triage, which was shown to predict adverse outcomes for older trauma patients. Furthermore, determining appropriate outcome measures and the benefits of Major Trauma Centers (MTCs) for older trauma patients should be considered in order to direct accurate and more beneficial prehospital trauma triage decisions. It is still not clear what are the appropriate outcome measures that should be applied when caring for older trauma patients. There is also no strong consensus about the benefits of MTC access for older trauma patients with regards to survival, in-hospital length of stay, discharge disposition, and complications. Moreover, looking into factors other than triage criteria such as distance to MTCs, patient or relative choice, training, unfamiliarity with protocols, and possible ageism, which were shown to impact prehospital triage decisions but their impact on outcomes has not been investigated yet, should be more actively assessed and investigated for this population. Therefore, this paper aimed to discuss the available evidence around frailty assessment in prehospital care, appropriate outcome measures for older trauma patients, the benefits of MTC access for older patients, and factors other than triage criteria that could adversely impact accurate prehospital triage decisions for older trauma patients. It also provided several suggestions for the future.

The Whole is Greater Than the Sum of its Parts: GCS Versus GCS-Motor for Triage in Geriatric Trauma

BACKGROUND

Trauma field triage matches injured patients to the appropriate level of care. Prior work suggests the Glasgow Coma Scale motor (GCSm) is as accurate as the total GCS (GCSt) and easier to use. However, older patients present with higher GCS for a given injury, and as such, it is unclear if this substitution is advisable. Our objective was to compare the GCS deficit patterns between geriatric and adult patients presenting with severe traumatic brain injury (TBI), as well as the diagnostic performance of the GCSm versus GCSt within the field triage criteria in these populations.

MATERIALS AND METHODS

We conducted a retrospective, observational cohort study of patients ≥16 y in the National Trauma Data Bank 2007-2015. GCS deficit patterns were compared between adults (16-65) and geriatric patients (>65). Measures of diagnostic performance of GCSt≤13 versus GCSm≤5 criteria to predict trauma center need (TCN) were compared.

RESULTS

In total, 4,480,185 patients were analyzed (28% geriatric). Geriatric patients more frequently presented with non-motor-only deficits than adults (16.4% versus 12.4%, P < 0.001), and these patients demonstrated higher severe TBI (40.3% versus 36.7%, P < 0.001) and craniotomy (5.8% versus 5.1%, P < 0.001) rates. GCSt was more sensitive and accurate in predicting TCN for geriatric patients and had lower rates of undertriage as compared to GCSm.

CONCLUSIONS

Geriatric patients more frequently present with non-motor-only deficits after injury, and this is associated with severe head injury. Substitution of GCSm for GCSt would exacerbate undertriage in geriatric patients and, thus, the total GCS should be maintained for field triage in geriatric patients.

Factors associated with the undertriage of patients with abdominal pain in an emergency room

INTRODUCTION

The triage process lasts for a very short time, which can result in over-triage and under-triage. Studies have explored factors related to under-triage among trauma patients. In Korea, the clinical characteristics and severity of cases of under-triaged patients have been investigated. However, there is limited research on the under-triage of patients experiencing abdominal pain. Therefore, this study aimed to determine the under-triage rate of emergency department (ED) patients with abdominal pain, as well as the factors associated with their under-triage.

METHODS

The participants of this retrospective cohort study were 3,030 adult patients at a single tertiary hospital in Korea, who were brought to the ED for abdominal pain as the chief complaint. Participants' general characteristics, pain-related information, and environmental information were obtained from their electronic medical records.

RESULTS

The under-triage rate of ED patients with abdominal pain was 31.0%. Factors related to the under-triage of these patients were sex, age, visit route, time from the onset of the pain to the visit, location of pain, and intensity of pain.

CONCLUSION

These findings provide a foundation for the understanding and mitigation of under-triage in EDs through the identification of factors associated with under-triage in patients with abdominal pain.

Mortality of trauma patients treated at trauma centers compared to non-trauma centers in Sweden: a retrospective study

Objective

The main objective was to compare the 30-day mortality rate of trauma patients treated at trauma centers as compared to non-trauma centers in Sweden. The secondary objective was to evaluate how injury severity influences the potential survival benefit of specialized care.

Methods

This retrospective study included 29,864 patients from the national Swedish Trauma Registry (SweTrau) during the period 2013–2017. Three sampling exclusion criteria were applied: (1) Injury Severity Score (ISS) of zero; (2) missing data in any variable of interest; (3) data falling outside realistic values and duplicate registrations. University hospitals were classified as trauma centers; other hospitals as non-trauma centers. Logistic regression was used to analyze the effect of trauma center care on mortality rate, while adjusting for other factors potentially affecting the risk of death.

Results

Treatment at a trauma center in Sweden was associated with a 41% lower adjusted 30-day mortality (odds ratio 0.59 [0.50–0.70], p < 0.0001) compared to non-trauma center care, considering all injured patients (ISS ≥ 1). The potential survival benefit increased substantially with higher injury severity, with up to > 70% mortality decrease for the most critically injured group (ISS ≥ 50).

Conclusions

There exists a potentially substantial survival benefit for trauma patients treated at trauma centers in Sweden, especially for the most severely injured. This study motivates a critical review and possible reorganization of the national trauma system, and further research to identify the characteristics of patients in most need of specialized care.

Undertriage in trauma: an ignored quality indicator?

BACKGROUND

Early identification of life-threatening injuries is essential to reduce morbidity and mortality in trauma patients. Failure to detect severe injury may cause delayed diagnosis and therapeutic interventions and is associated with increased morbidity. A national trauma system will contribute to ensure the optimal care for seriously injured patients throughout the treatment chain by, among other things, defining a sensitive triage tool for identifying severe injury and contribute to correct treatment destination. In 2017, a National trauma plan was implemented in Norway and several quality indicators were recommended to ensure an evaluation of potential gaps between achieved and desired quality, and thereby highlighting areas with potential for quality improvement. With this commentary, we want to draw attention to, what we believe is, an ignoring of an important quality indicator: undertriage in trauma.

MAIN BODY

Severely injured patients not met by a trauma team is commonly referred to as undertriage. An undertriage rate below 5 % is an internationally recognized quality indicator in trauma care and is emphasized in the Norwegian national trauma plan. However, whether hospitals measure and report data about undertriage, have received little attention. Therefore, a national survey was performed among Norwegian hospitals, where thirty-seven of forty trauma receiving hospitals contributed. The results of the survey showed that only half of Norwegian trauma hospitals were capable of providing these data. The results of this survey show that currently the national trauma system is not equipped to obtain important data on an important and specific quality indicator. An ongoing discussion at a national level is how to define severe injury, which may alter future definitions on undertriage.

CONCLUSIONS

Knowledge of undertriage in trauma is important to enhance patient safety, increase the precision of the triage tool and provide valuable learning information to individual hospitals and prehospital services. Currently only half of Norwegian hospitals who receive trauma patients report undertriage rates and unfortunately, only few hospital administrators request these data.

Geriatric Trauma - A Rising Tide. Assessing Patient Safety Challenges in a Vulnerable Population Using Norwegian Trauma Registry Data and Focus Group Interviews: Protocol for a Mixed Methods Study

BACKGROUND

Elderly trauma patients constitute a vulnerable group, with a substantial risk of morbidity and mortality even after low-energy falls. As the world's elderly population continues to increase, the number of elderly trauma patients is expected to increase. Limited data are available about the possible patient safety challenges that elderly trauma patients face. The outcomes and characteristics of the Norwegian geriatric trauma population are not described on a national level.

OBJECTIVE

The aim of this project is to investigate whether patient safety challenges exist for geriatric trauma patients in Norway. An important objective of the study is to identify risk areas that will facilitate further work to safeguard and promote quality and safety in the Norwegian trauma system.

METHODS

This is a population-based mixed methods project divided into 4 parts: 3 quantitative retrospective cohort studies and 1 qualitative interview study. The quantitative studies will compare adult (aged 16-64 years) and elderly (aged ≥65 years) trauma patients captured in the Norwegian Trauma Registry (NTR) with a date of injury from January 1, 2015, to December 31, 2018. Descriptive statistics and relevant statistical methods to compare groups will be applied. The qualitative study will comprise focus group interviews with doctors responsible for trauma care, and data will be analyzed using a thematic analysis to identify important themes.

RESULTS

The project received funding in January 2019 and was approved by the Oslo University Hospital data protection officer (No. 19/16593). Registry data have been extracted for 33,344 patients, and the analysis of these data has begun. Focus group interviews will be conducted from spring 2020. Results from this project are expected to be ready for publication from fall 2020.

CONCLUSIONS

By combining data from the NTR with interviews with doctors responsible for treatment and transfer of elderly trauma patients, we will provide increased knowledge about trauma in Norwegian geriatric patients on a national level that will form the basis for further research aiming at developing interventions that hopefully will make the trauma system better equipped to manage the rising tide of geriatric trauma.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/15722.

Geriatric Screening, Triage Urgency, and 30-Day Mortality in Older Emergency Department Patients

BACKGROUND

Urgency triage in the emergency department (ED) is important for early identification of potentially lethal conditions and extensive resource utilization. However, in older patients, urgency triage systems could be improved by taking geriatric vulnerability into account. We investigated the association of geriatric vulnerability screening in addition to triage urgency levels with 30‐day mortality in older ED patients.

DESIGN

Secondary analysis of the observational multicenter Acutely Presenting Older Patient (APOP) study.

SETTING

EDs within four Dutch hospitals.

PARTICIPANTS

Consecutive patients, aged 70 years or older, who were prospectively included.

MEASUREMENTS

Patients were triaged using the Manchester Triage System (MTS). In addition, the APOP screener was used as a geriatric screening tool. The primary outcome was 30‐day mortality. Comparison was made between mortality within the geriatric high‐ and low‐risk screened patients in every urgency triage category. We calculated the difference in explained variance of mortality by adding the geriatric screener (APOP) to triage urgency (MTS) by calculating Nagelkerke R².

RESULTS

We included 2,608 patients with a median age of 79 (interquartile range = 74‐84) years, of whom 521 (20.0%) patients were categorized as high risk according to geriatric screening. Patients were triaged on urgency as standard (27.2%), urgent (58.5%), and very urgent (14.3%). In total, 132 (5.1%) patients were deceased within a period of 30 days. Within every urgency triage category, 30‐day mortality was threefold higher in geriatric high‐risk compared to low‐risk patients (overall = 11.7% vs 3.4%; P < .001). The explained variance of 30‐day mortality with triage urgency was 1.0% and increased to 6.3% by adding the geriatric screener.

CONCLUSION

Combining triage urgency with geriatric screening has the potential to improve triage, which may help clinicians to deliver early appropriate care to older ED patients. J Am Geriatr Soc 68:1755‐1762, 2020.

Characteristics of scene trauma patients discharged within 24-hours of air medical transport

Introduction

Helicopters play an important role in trauma; however, this service comes with safety risks, high transport costs, and downstream care charges.

Objective

Our objective was to determine the characteristics of early discharged trauma patients (<24 h length of stay) in order to reduce overtriage.

Methodology

Data were obtained from the trauma registries at one of two Level 1 trauma centers. Eligible patients included all scene trauma patients transported by helicopter to the Level 1 trauma centers from January 1, 2016, to December 31, 2017, who had a length of stay of 24 h or less. Patient factors such as age, gender, scene location, loaded miles, and transportation costs were collected. Trauma type, mechanism of injury, Abbreviated Injury Scale (AIS), Injury Severity Score, Revised Trauma Score, and prehospital vital signs were documented. Driving distances between the accident scene to local hospital, home of record to local hospital, and home of record to the Level I trauma center were also calculated for patients transported to Level 1 trauma center.

Results

Two hundred and twenty-six of 1042 total patients (21.7%) were discharged within 24 h of helicopter transport from the accident scene to trauma center. Less than 2% of patients were in the age group of 70 years or older. Only 2 (0.88%) patients discharged within 24 h had a prehospital systolic blood pressure <90 mmHg. For patients transported to Level 1 trauma center, the average loaded miles were 50.51 ± 14.99, with average transport charges being $27,921.19± $3536.61. Twenty-one percent of Level 1 trauma center patients were self-pay, and families typically drove 71.7 ± 123.23 miles to Level 1 trauma center versus 28.74 ± 40.62 to their local emergency department.

Conclusions

A significant number of patients transported from the scene are discharged within 24 h of admission to a trauma center. These patients rarely have prehospital hypotension, do not receive significant volumes of crystalloid resuscitation, and are infrequently over 70 years of age. One in five patients has no third-party coverage and assumes $27,921.19 in average transport charges.

The influence of sociodemographic factors on trauma center transport for severely injured older adults

OBJECTIVE

To examine sociodemographic predictors of trauma center (TC) transport of severely injured older adults.

DATA SOURCES

The data source was the Healthcare Cost and Utilization Project, New York Inpatient Database (2014).

STUDY DESIGN

This study was a secondary analysis of injured older adults. Key sociodemographic variables were age, gender, race/ethnicity, median household income, and primary payer. Confounding variables were injury severity, geographic location, number of chronic conditions, and injury mechanism. The outcome variable was TC transport.

DATA COLLECTION/EXTRACTION METHODS

The database was filtered on the following criteria: age =/> 55 years, primary diagnosis of injury (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM], 800.0-957.9, excluding poisoning, late effects, and interfacility transfers), admitted to an acute care hospital in New York.

PRINCIPAL FINDINGS

Records of 33 696 patients were included. Multivariate logistic regression analysis revealed that all variables were statistically significant predictors of TC transport except primary payer. Predictors of TC transport were as follows: higher injury severity (OR 2.1, CI 1.79-2.46; 3.39, CI 2.85-4.05); Asian/Pacific and Hispanic race/ethnicity (OR 2.51, CI 1.92-3.27; OR 1.1, CI 0.86-1.42), highest median household income (OR 1.24, CI 1.01-1.52), high population density (OR 1.32, CI 1.12-1.55; OR 3.2, CI 2.68-2.83), and vehicle crashes (OR 3.39, CI 2.79-4.11). Predictors of non-TC transport were as follows: older age groups (OR 0.92, CI 0.76-1.11; OR 0.79, CI 0.64-0.96; OR 0.77, CI 0.63-0.95), females (OR 0.65, CI 0.57-0.74), Black and "other" race (OR 0.75, CI 0.0.56-1.0; OR 0.96, CI 0.77-1.20), lower median household income (OR 0.76, CI 0.62-0.93; OR 0.86, CI 0.71-1.05), low population density (OR 0.96, CI 0.67-1.36; OR 0.89, CI 0.53-1.51), and number of chronic conditions (OR 0.89, CI 0.87-0.91).

CONCLUSIONS

Sociodemographic factors are a source of disparity for access to TCs. Further research is needed to confirm bias and test bias reduction strategies. Comprehensive education and policies are needed to reduce disparities in access to trauma care.

Do elderly trauma patients receive the required treatment? Epidemiology and outcome of geriatric trauma patients treated at different levels of trauma care

PURPOSE

In an ageing society, geriatric trauma displays an increasing challenge in trauma care. Due to comorbidities and reduced physiologic reserves, these patients might benefit from an immediate specialised care. The current study aims to clarify the prevalence and outcome of geriatric trauma depending on the level of the primary trauma centre.

METHODS

Data sets of 124,641 patients entered in the TR-DGU between 2009 and 2016 were included. Geriatric trauma was defined above 65 years and ISS ≥ 9. Analysing the prevalence, the age structure of all trauma cases registered in 2014 was compared to demographic data of the German Federal Statistical Office. Differences in injury pattern, in-hospital care and outcome between the primary levels of care were analysed.

RESULTS

In comparison to their share of population, geriatric patients are highly overrepresented in the TR-DGU. Despite minor injury mechanisms, severe head injuries are common. A tendency to under-triage can be observed, as level II and III trauma centres receive a higher percentage of older patients. Nevertheless, there is no effect on the mortality. 10% of these patients require an early transfer to a higher levelled trauma centres mainly due to severe head and spine injuries. Surprisingly, pre-clinical available signs such as GCS or blood pressure were not altered in these patients.

CONCLUSION

Patients above the age of 65 years represent a second group with high risk for traumatic injuries besides younger adults. Despite low-energy trauma mechanisms, these patients are prone to suffer from severe injuries, which require specialised care. Current admission practice appears adequate, as pre-clinical available symptoms did not correlate with injuries that demanded an early inter-hospital transfer. Specialised geriatric triage scores might further improve admission practice.

Accuracy of algorithms to predict injury severity in older adults for trauma triage

Objective: Older adults make up a rapidly increasing proportion of motor vehicle occupants and previous studies have demonstrated that this population is more susceptible to traumatic injuries. The CDC recommends that patients anticipated to have severe injuries (Injury Severity Score [ISS] ≥ 16) be transported to a trauma center. The recommended target rate for undertriage is ≤ 5% and for overtriage is ≤ 50%. Several regression-based algorithms for injury prediction have been developed in order to predict severe injury in occupants involved in a motor vehicle collision (MVC). The objective of this study to was to determine if the accuracy of regression-based injury severity prediction algorithms decreases for older adults.Methods: Data were obtained from the National Automotive Sampling System - Crashworthiness Data System (NASS-CDS) from the years 2000-2015. Adult occupants involved in non-rollover MVCs were included. Regression-based injury risk models to predict severe injury (ISS ≥ 16) were developed using random split-samples with the following variables: age, delta-V, direction of impact, belt status, and number of impacts. Separate models were trained using data from the following age groups: (1) all adults, (2) 15-54 years, (3) ≥45 years, (4) ≥55 years, and (5) ≥65 years. The models were compared using the mean receiver operating characteristic area under curve (ROC-AUC) after 1,000 iterations of training and testing. The predicted rates of overtriage were then determined for each group in order to achieve an undertriage rate of 5%.Results: There were 24,577 occupants (6,863,306 weighted) included in this analysis. The injury prediction model trained using data from all adults did not perform as well when tested on older adults (ROC-AUC: 15-54 years: 0.874 [95% CI: [0.851-0.895]; 45+ years: 0.837 [95% CI: 0.802-869]; 55+ years: 0.821 [95% CI: 0.775-0.864]; and 65+ years: 0.813 [95% CI: 0.754-0.866]). The accuracy of this model decreased in each decade of life. The performance did not change significantly when age-specific data were used to train the prediction models (ROC-AUC: 18-54 years: 0.874 [95% CI: 0.851-0.896]; 45+ years: 0.836 [95% CI: 0.798-0.871]; 55+ years: 0.822 [95% CI: 0.779-0.864]; and 65+ years: 0.808 [95% CI: 0.748-0.868]). In order to achieve an undertriage rate of 5%, the predicted overtriage rate by these models were 50% for occupants 15-54 years, 61% for occupants ≥ 55 years, 70% for occupants ≥ 55 years, and 71% for occupants ≥ 65 years.Conclusion: The results of this study indicate that it is more difficult to accurately predict severe injury in older adults involved in MVCs, which has the potential to result in significant overtriage. This decreased accuracy is likely due to variations in fragility in older adults. These findings indicate that special care should be taken when using regression-based prediction models to determine the appropriate hospital destination for older occupants.

National Study of Triage and Access to Trauma Centers for Older Adults

STUDY OBJECTIVE

To identify predictors of undertriage among older injured Medicare beneficiaries, identify any regions in which undertriage is more likely to occur, and examine additional factors associated with undertriage at a national level.

METHODS

Using 2009 to 2014 Medicare claims data, we identified older adults (≥65 years) receiving a diagnosis of traumatic injury, and linked claims with trauma center designation records from the American Trauma Society. Undertriage was defined as nontrauma centers treatment with an Injury Severity Score greater than or equal to 16, consistent with the American College of Surgeons Committee on Trauma benchmark. We used multivariable logistic regression to estimate odds of undertriage by census region, adjusting for sex, race, age, Injury Severity Score, trauma center proximity, and mode of transportation.

RESULTS

Forty-six percent of severely injured patients (n=125,731) were treated at a nontrauma center. Compared with that for patients in the Midwest, adjusted odds of undertriage were 100% higher for patients in Southern states (odds ratio [OR] 2.00; 95% confidence interval [CI] 2.00 to 2.04) and 78% higher in Western states (OR 1.78; 95% CI 1.73 to 1.82). Compared with that for patients aged 65 to 69 years, odds of undertriage gradually increased in all age groups, reaching 57% for patients older than 80 years (OR 1.57; 95% CI 1.52 to 1.61). Distance to a trauma center was associated with increasing odds of undertriage, with 37% higher odds (OR 1.37; 95% CI 1.15 to 1.40) for older adults living more than 30 miles from a trauma center compared with patients living within 15 miles.

CONCLUSION

Nearly half of older adult trauma patients are undertriaged; it increases with age and distance to care and is most common in Southern and Western states. Improvements to field triage and trauma center access for older patients are urgently needed.

Crash Telemetry-Based Injury Severity Prediction is Equivalent to or Out-Performs Field Protocols in Triage of Planar Vehicle Collisions

INTRODUCTION

With the increasing availability of vehicle telemetry technology, there is great potential for Advanced Automatic Collision Notification (AACN) systems to improve trauma outcomes by detecting patients at-risk for severe injury and facilitating early transport to trauma centers.

METHODS

National Automotive Sampling System Crashworthiness Data System (NASS-CDS) data from 1999-2013 were used to construct a logistic regression model (injury severity prediction [ISP] model) predicting the probability that one or more occupants in planar, non-rollover motor vehicle collisions (MVCs) would have Injury Severity Score (ISS) 15+ injuries. Variables included principal direction of force (PDOF), change in velocity (Delta-V), multiple impacts, presence of any older occupant (≥55 years old), presence of any female occupant, presence of right-sided passenger, belt use, and vehicle type. The model was validated using medical records and 2008-2011 crash data from AACN-enabled Michigan (USA) vehicles identified from OnStar (OnStar Corporation; General Motors; Detroit, Michigan USA) records. To compare the ISP to previously established protocols, a literature search was performed to determine the sensitivity and specificity of first responder identification of ISS 15+ for MVC occupants.

RESULTS

The study population included 924 occupants in 836 crash events. The ISP model had a sensitivity of 72.7% (95% Confidence Interval [CI] 41%-91%) and specificity of 93% (95% CI 92%-95%) for identifying ISS 15+ occupants injured in planar MVCs. The current standard 2006 Field Triage Decision Scheme (FTDS) was 56%-66% sensitive and 75%-88% specific in identifying ISS 15+ patients.

CONCLUSIONS

The ISP algorithm comparably is more sensitive and more specific than current field triage in identifying MVC patients at-risk for ISS 15+ injuries. This real-world field study shows telemetry data transmitted before dispatch of emergency medical systems can be helpful to quickly identify patients who require urgent transfer to trauma centers.

Impact of age on the discriminative ability of an emergency triage system: A cohort study

BACKGROUND

Emergency triage systems optimize resources in emergency departments (EDs) for those who need urgent care. Five-level triage systems, such as the Canadian Triage and Acuity Scale (CTAS), have been used worldwide. We examined whether the discriminative ability of an emergency triage system varies according to age group using a patient cohort triaged with the Japan Triage and Acuity Scale (JTAS), a validated system based on the CTAS.

METHODS

We conducted a cohort study of 27 120 self-presenting patients aged 16 years and older who were triaged with (JTAS) between June 2013 and May 2014 at a Japanese tertiary care hospital. Outcome measures were admission to intensive care units (ICUs) as the primary and in-hospital death as the secondary. We described the trends of the discriminative ability of JTAS using areas under the curve of the receiver operating characteristic (AUROC), sensitivity, specificity, positive predictive value, and negative predictive value of JTAS for seven age categories.

RESULTS

The AUROC of JTAS for ICU admission decreased with age (maximum 0.85 to minimum 0.71), sensitivity non-significantly decreased (maximum 0.67 to minimum 0.32), and specificity declined with age (maximum 0.96 to minimum 0.88). The positive and negative predictive value increased (minimum 0.03 to maximum 0.09) and decreased (minimum 0.98 to maximum 0.99), respectively, with age. Overall misclassification increased across age groups (P < 0.001). This trend was mostly consistent with the analysis of in-hospital death.

CONCLUSION

Our study suggests that the discriminative ability of an emergency triage system decreases as patient age increases, corresponding to a decrease in specificity. Undertriage may not significantly increase, but misclassification significantly increases as patient age increases.

Development of Trauma Level Prediction Models Using Emergency Medical Service Vital Signs to Reduce Over- and Undertriage Rates in Penetrating Wounds and Falls of the Elderly

Determining triage activation levels in geriatric patients who fall (GF), and patients with penetrating wounds can be difficult and inaccurate, resulting in excessive overtriage (OT) and undertriage (UT) rates. We developed trauma activation prediction models using field data to predict with greater accuracy trauma activation level and triage rates consistent with the ACS recommendations. Using data from the 2014 National Trauma Data Bank, we created binary regression equations for each type of injury (GF and penetrating wounds). The 2014 data were randomized and divided into two halves. The first half for each injury type was used to generate prediction models, whereas the second half of the 2014 data were combined with 2013 and 2015 National Trauma Data Bank data for model verification. Binary regression equations were generated from vital signs collected by EMS. A Cribari grid with ISS ≥ 15 was used to determine the appropriateness of activation level. Chi-square analysis was used to determine significant differences between OT, UT, and accuracy predictions. Using our triage models, we were able to obtain UTrates of less than 4 per cent for GF with OT rates of less than 40 per cent, UT rates less than 4.1 per cent and OT of less than 50 per cent for patients with gunshot wounds, and UTrates less than 4 per cent and OT rates less than 25 per cent for patients who had stab wounds. Our developed trauma level prediction models enable health providers to predict trauma activation levels that can result in OT and UT rates in the recommended ranges by the ACS.

Improvement in geriatric trauma outcomes in an evolving trauma system

Background

The elderly trauma patient has increased mortality compared with younger patients. During the last 15 years, initial treatment of severely injured patients at Oslo University Hospital Ulleval (OUHU) has changed resulting in overall improved outcomes. Whether this holds true for the elderly trauma population needs exploration and was the aim of the present study.

Methods

We performed a retrospective study of 2628 trauma patients 61 years or older admitted to OUHU during the 12-year period, 2002-2013. The population was stratified based on age (61-70 years, 71-80 years, 81 years and older) and divided into time periods: 2002-2009 (P1) and 2010-2013 (P2). Multiple logistic regression models were constructed to identify clinically relevant core variables correlated with mortality and trauma team activation rate.

Results

Crude mortality decreased from 19% in P1 to 13% in P2 (p<0.01) with an OR of 0.77 (95 %CI 0.65 to 0.91) when admitted in P2. Trauma team activation rates increased from 53% in P1 to 72% in P2 (p<0.01) with an OR of 2.16 (95% CI 1.93 to 2.41) for being met by a trauma team in P2. Mortality increased from 10% in the age group 61-70 years to 26% in the group above 80 years. Trauma team activation rates decreased from 71% in the age group 61-70 years to 50% in the age group older than 80 years. Median ISS were 17 in all three age groups and in both time periods.

Discussion

Development of a multidisciplinary dedicated trauma service is associated with increased trauma team activation rate as well as survival in geriatric trauma patients. As expected, mortality increased with age, although inversely related to the likelihood of being met by a trauma team. Trauma team activation should be considered for all trauma patients older than 70 years.

Level of evidence

Level IV.

Complications and Mortality Among Correctly Triaged and Undertriaged Severely Injured Older Adults With Traumatic Brain Injuries

Determining differences in clinical outcomes of older adults treated at trauma centers (TCs) and nontrauma centers (NTCs) is imperative considering their persistent undertriage and the projected costs of fixing the problem. This study compared the incidence and predictors of complications and mortality among brain-injured older adults treated at TCs and NTCs. This secondary analysis of New York inpatient data included patients aged 55+ years, primary brain injury diagnosis, and acute care hospital admission. Interfacility transfers and nontraumatic brain injuries were excluded. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes identified complications and mortality. Injury severity was determined by mapping ICD-9-CM diagnoses to Abbreviated Injury Scale 2005 Revision 2008 dictionary scores. A subgroup analysis of 1,594 patients with New Injury Severity Scores greater than 15 was performed to examine complications and mortality. This study included 7,138 patients who met inclusion criteria. Predictors of subgroup complications included chronic renal failure, odds ratio (OR) = 2.251 (confidence interval [CI] = 1.470-3.447), p < .001; major operating room procedure, OR = 2.349 (CI = 1.679-3.285), p < .001; number of diagnoses, OR = 1.201 (CI = 1.158-1.245), p < .001; and number of procedures, OR = 1.119 (CI = 1.077-1.162), p £ .001. Mortality predictors included age, OR = 1.031 (CI = 1.017-1.045), p < .001; preexisting coagulopathy, OR = 1.753 (C = 1.130-2.719), p = .012; number of procedures, OR = 1.122 (CI = 1.081-1.166), p < .001; acute renal failure, OR = 3.114 (CI = 1.672-5.797), p < .001; systemic inflammatory response syndrome, OR = 4.058 (CI = 1.463-11.258), p = .007; adult respiratory distress syndrome, OR = 3.179 (CI = 1.673-6.041), p < .001; and subarachnoid bleed, OR = 2.667 (CI = 1.415-5.029), p = .002. Nearly 23% of the severely/critically injured patients experienced 1 or more complications. Incidence of complications was low and comparable for TCs and NTCs. The proportion of deaths was slightly higher at TCs but not significant. The most prevalent complications carry a high mortality risk.

The role of emergency medical service providers in the decision-making process of prehospital trauma triage

PURPOSE

Severely injured patients should be treated at higher-level trauma centres, to improve chances of survival and avert life-long disabilities. Emergency medical service (EMS) providers must try to determine injury severity on-scene, using a prehospital trauma triage protocol, and decide the most appropriate type of trauma centre. The objective of this study is to investigate the role of EMS provider judgment in the prehospital triage process of trauma patients, by analysing the compliance rate to the protocol and administering a questionnaire among EMS providers.

METHODS

All trauma patients transported to a trauma centre in two different regions of the Netherlands were analysed. Compliance rate was based on the number of patients meeting the triage criteria and transported to the corresponding level trauma centre. The questionnaire was administered among EMS providers. Descriptive statistics were used to analyse the data.

RESULTS

For adult patients, the compliance rate to the level I criteria of the triage protocol was 72% in Central Netherlands and 42% in Brabant. For paediatric patients, this was 63% and 38% in Central Netherlands and Brabant, respectively. The judgment on injury severity was mostly based on the injury-type criteria. Additionally, the distance to a level I trauma centre influenced the decision for destination facility in the Brabant region.

CONCLUSION

The compliance rate varied between regions. Improvement of prehospital trauma triage depends on the accuracy of the protocol and compliance rate. A new protocol, including EMS provider judgment, might be the key to improvement in the prehospital trauma triage quality.