Improving geriatric trauma outcomes: A small step toward a big problem. J Trauma Acute Care Surg. 2016;81:162-167. [PMID: 27032005 DOI: 10.1097/ta.0000000000001063]

A scoping review of hospital-based geriatric-centered interventions on trauma surgery services

BACKGROUND

Millions of older adults (≥65) present to emergency departments for injury annually. As the population increases, so will the number of older adults admitted for trauma. Although treatment guidelines for older adults who sustain trauma exist, the evidence for quality improvement is limited. The purpose of this scoping review was to identify hospital-based geriatric-centered interventions that improve care for older adults admitted to trauma services.

METHODS

We searched MEDLINE, EMBASE, and CINAHL to identify studies related to geriatric-centered interventions on trauma surgery services (1993-2023). Five reviewers screened studies for full-text review based on these inclusion criteria: (1) older injured adults and/or their caregivers; (2) hospital-based clinical interventions directed to geriatric trauma patients (e.g., frailty assessments, geriatric co-management, triage criteria); and (3) measuring outcomes associated with geriatric trauma. We used the Donabedian quality improvement framework to categorize interventions as structures or processes.

RESULTS

Of 2243 abstracts, 66 studies met the criteria for full-text review, and 47 were included in the analysis. Most (64%) were single-site retrospective cohort studies at Level 1 trauma centers. The most frequent interventions (not mutually exclusive) included geriatric-centered teams (26%), geriatric consultation (23%), interdisciplinary rounds (17%), and medication review (11%). The most frequently measured clinical outcomes were length of stay (47%), discharge location (26%), and in-hospital mortality (21%). Two studies (4%) measured outcomes beyond 3 months. Patient-reported outcomes were rarely included (4%), and caregiver-specific outcomes were not measured.

CONCLUSIONS

This scoping review demonstrates the variability in the types of geriatric-centered interventions on trauma surgery services and their associated outcome measures. Furthermore, this review highlights evidence gaps in existing long-term, post-discharge outcomes and patient-/caregiver-reported outcomes. Given the increasing demand for high-quality geriatric trauma care, our findings emphasize the need for evidence-based national standards for geriatric trauma care and targeted study of outcomes germane to older adults and their caregivers.

Predictors of Clinical Outcomes and the Need for Massive Transfusion Protocols in Geriatric Trauma Patients With Hemorrhagic Shock: A Systematic Review

IntroductionThe current literature lacks a clear consensus on the predictors of mortality and outcomes of geriatric trauma patients in hemorrhagic shock. This systematic review aims to investigate predictors of clinical outcomes and the need for massive transfusion protocol in the geriatric trauma population with hemorrhagic shock.MethodsPubMed, EMBASE, Cochrane, ProQuest, and Google Scholar were searched for studies evaluating geriatric trauma patients in hemorrhagic shock or receiving MTP. Outcomes of interest included the effect of advanced age on clinical outcomes, the accuracy of SI and other variables in predicting mortality and need for MTP, and associations between blood product ratio and clinical outcomes.ResultsFifteen studies were included in this systematic review. In most studies, advanced age was an accurate predictor of mortality and complication rates in geriatric patients undergoing management of shock with MTP. SI along with other variables such as systolic blood pressure (SBP) were sensitive predictors of mortality and the need for MTP. Studies evaluating blood product ratio found an increased incidence of complications with higher plasma: red blood cell ratios.ConclusionAdvanced age among geriatric patients is associated with increased mortality and complications when undergoing MTP. Shock Index and age x Shock Index are accurate and reliable predictors of mortality and need for MTP in the geriatric trauma population with hemorrhagic shock suffering blunt and/or penetrating injuries. An increased plasma: RBC ratio was associated with more complications in geriatric patients.

Surgical stabilization of rib fractures in anticoagulated patients: Proceed with caution?

BACKGROUND

Surgical stabilization of rib fractures (SSRF) is increasingly performed, however the outcome of patients undergoing SSRF while on pre-injury antithrombotic therapy remains unknown. We compared surgical variables and outcomes of patients who were and were not on antithrombotic therapy. We hypothesize pre-injury anticoagulation is associated with delay in SSRF and worse outcomes.

METHODS

For this retrospective cohort study, we queried the Chest Injury International Database, for patients undergoing SSRF between 08/2018 and 03/2022. Antithrombotic therapy was categorized into antiplatelet and anticoagulant use. Primary outcome was time from admission to SSRF. Secondary outcomes included SSRF duration and complications. Numerical data were presented as median (IQR), categorical data as number (%). Inverse probability weighting was used to control for confounding.

RESULTS

Two hundred and eighteen SSRF patients were included, 25 (11 %) were on antithrombotic therapy. These patients were older (72 years, (65-80) versus 57 years, (43-66); p < 0.001) with lower ISS (14, (10-20) versus 21, (14-30); p = 0.002). Time from admission to SSRF was comparable (2 days, (1-4) versus 2 days, (1-4); p = 0.37) as was operative time (154 mins, (120.0-212.0) versus 177 mins, (143.0-210.0); p = 0.34). Patients using antithrombotics had fewer ICU-free days (24 (22-26) versus 28 (23-28); p = 0.003) but more ventilator free days (28, (28-28) versus 27 (27-28); p < 0.008). After adjusting for confounding, pre-injury anticoagulation was not significantly associated with delayed SSRF (Relative Risk, RR=1.37, 95 % CI 0.30-6.24), operative time (RR=1.07, 95 % CI0.88-1.31), IFD <=28 (RR=2.05, 95 %CI:0.33-12.67), VFD<=27 (RR=0.71, 95 %CI:0.15-3.48) or complications (RR=0.55, 95 % CI0.06-5.01).

CONCLUSION

Pre-injury antithrombotic drug use neither delayed SSRF nor impacted operative time in patients requiring SSRF and was not associated with increased risk of complications. Our data suggest SSRF can be safely performed without delay in patients who use anticoagulation pre-injury.

LEVEL OF EVIDENCE

IV.

STUDY TYPE

Therapeutic/care management.

Geriatric trauma triage: optimizing systems for older adults-a publication of the American Association for the Surgery of Trauma Geriatric Trauma Committee

Background

Geriatric trauma patients are an increasing population of the United States (US), sustaining a high incidence of falls, and suffer greater morbidity and mortality to their younger counterparts. Significant variation and challenges exist to optimize outcomes for this cohort, while being mindful of available resources. This manuscript provides concise summary of locoregional and national practices, including relevant updates in the triage of geriatric trauma in an effort to synthesize the results and provide guidance for further investigation.

Methods

We conducted a review of geriatric triage in the United States (US) at multiple stages in the care of the older patient, evaluating existing literature and guidelines. Opportunities for improvement or standardization were identified.

Results

Opportunities for improved geriatric trauma triage exist in the pre-hospital setting, in the trauma bay, and continue after admission. They may include physiologic criteria, biochemical markers, radiologic criteria and even age. Recent Trauma Quality Improvement Program (TQIP) Best Practices Guidelines for Geriatric Trauma Management published in 2024 support these findings.

Conclusion

Trauma systems must adjust to provide optimal care for older adults. Further investigation is required to provide pertinent guidance.

Strategies to improve care for older adults who present to the emergency department: a systematic review

BACKGROUND

The aim of this systematic review was to examine the relationship between strategies to improve care delivery for older adults in ED and evaluation measures of patient outcomes, patient experience, staff experience, and system performance.

METHODS

A systematic review of English language studies published since inception to December 2022, available from CINAHL, Embase, Medline, and Scopus was conducted. Studies were reviewed by pairs of independent reviewers and included if they met the following criteria: participant mean age of ≥ 65 years; ED setting or directly influenced provision of care in the ED; reported on improvement interventions and strategies; reported patient outcomes, patient experience, staff experience, or system performance. The methodological quality of the studies was assessed by pairs of independent reviewers using The Joanna Briggs Institute critical appraisal tools. Data were synthesised using a hermeneutic approach.

RESULTS

Seventy-six studies were included in the review, incorporating strategies for comprehensive assessment and multi-faceted care (n = 32), targeted care such as management of falls risk, functional decline, or pain management (n = 27), medication safety (n = 5), and trauma care (n = 12). We found a misalignment between comprehensive care delivered in ED for older adults and ED performance measures oriented to rapid assessment and referral. Eight (10.4%) studies reported patient experience and five (6.5%) reported staff experience.

CONCLUSION

It is crucial that future strategies to improve care delivery in ED align the needs of older adults with the purpose of the ED system to ensure sustainable improvement effort and critical functioning of the ED as an interdependent component of the health system. Staff and patient input at the design stage may advance prioritisation of higher-impact interventions aligned with the pace of change and illuminate experience measures. More consistent reporting of interventions would inform important contextual factors and allow for replication.

Trauma in the elderly: a bilateral rectus sheath haematoma

Life expectancy has more than doubled in the last century, and a new cohort of elderly and increasingly frail patients is presenting to emergency departments with new clinical challenges. When this patient cohort presents after injury, all aspects of clinical practice have to be recalibrated to provide safe and appropriate care. The prevalence of chronic disease, levels of organ failure, multiple comorbidities, greater use of anticoagulation and incidence of recurrent low- and high-impact trauma may delay and obscure diagnosis and, ultimately, increase mortality.Older age is a risk factor for rectus sheath haematoma (RSH), which is haemorrhage into the potential space surrounding the rectus abdominis muscle/s. It is a rare presentation following trauma but can provide diagnostic challenges and be fatal. Even more rare is bilateral RSH with only 12 reported in the literature since 1981.This case report describes bilateral RSH presenting in an elderly woman following a fall and the consequences of seemingly minor trauma in the elderly.

STRAUMA: A Novel Alert System for a Combined Stroke and Trauma

INTRODUCTION

Cerebrovascular accident (CVA) can lead to traumatic injury. While timely administration of tissue plasminogen activator (tPA) can be lifesaving in CVAs, it is contraindicated with active bleeding. A STRAUMA is a combined stroke and highest-level trauma activation for patients with suspected CVA and signs of trauma. The purpose of this study is to evaluate the impact of the STRAUMA activation on time to CT and patient outcomes.

METHODS

A retrospective review was conducted on adult patients presenting to a Level 1 trauma and comprehensive stroke center with signs of CVA between 01/2019 and 09/2020. Patients who had a STRAUMA activation were compared to patients who had a stroke alert.

RESULTS

Five hundred and eighty patients met the inclusion criteria. Of these, 111 had STRAUMA activations and 469 had stroke alerts. There were no differences in age, gender, or anticoagulation use. The STRAUMA group had a higher NIH stroke scale (NIHSS) (11 vs 5, P<.0001). The STRAUMA group had a longer time to CT (23.1 min vs 16.9 min, P<.0001) and a lower rate of tPA (13.5% vs 27.9%, P = .001). Time to tPA and thrombectomy were similar. The STRAUMA group had a 15% rate of traumatic injury with a median injury severity score of 9. Mortality was higher in the STRAUMA group (14.4% vs 6.0%, P = .003). Multivariable logistic regression identified NIHSS and time to CT as predictors of mortality. STRAUMA did not predict mortality.

CONCLUSION

The novel STRAUMA activation allows for an evaluation of both stroke and trauma to facilitate safe and timely administration of lifesaving interventions.

Trends in disparities research on trauma and acute care surgery outcomes: A 10-year systematic review of articles published in The Journal of Trauma and Acute Care Surgery

ABSTRACT

This is a 10-year review of The Journal of Trauma and Acute Care Surgery (JTACS) literature related to health care disparities, health care inequities, and patient outcomes. A retrospective review of articles published in JTACS between January 1, 2013, and July 15, 2022, was performed. Articles screened included both adult and pediatric trauma populations. Included articles focused on patient populations related to trauma, surgical critical care, and emergency general surgery. Of the 4,178 articles reviewed, 74 met the inclusion criteria. Health care disparities related to gender (n = 10), race/ethnicity (n = 12), age (n = 14), income status (n = 6), health literacy (n = 6), location and access to care (n = 23), and insurance status (n = 13) were described. Studies published on disparities peaked in 2016 and 2022 with 13 and 15 studies respectively but dropped to one study in 2017. Studies demonstrated a significant increase in mortality for patients in rural geographical regions and in patients without health insurance and a decrease in patients who were treated at a trauma center. Gender disparities resulted in variable mortality rates and studied factors, including traumatic brain injury mortality and severity, venous thromboembolism, ventilator-associated pneumonia, firearm homicide, and intimate partner violence. Under-represented race/ethnicity was associated with variable mortality rates, with one study demonstrating increased mortality risk and three finding no association between race/ethnicity and mortality. Disparities in health literacy resulted in decreased discharge compliance and worse long-term functional outcomes. Studies on disparities in JTACS over the last decade primarily focused on location and access to health care, age, insurance status, and race, with a specific emphasis on mortality. This review highlights the areas in need of further research and funding in the Journal of Trauma and Acute Care Surgery regarding health care disparities in trauma aimed at interventions to reduce disparities in patient care, ensure equitable care, and inform future approaches targeting health care disparities.

LEVEL OF EVIDENCE

Systematic Review; Level IV.

Trauma (Excluding Falls) in the Older Adult

Trauma in the older adult will increasingly become important to emergency physicians hoping to optimize their patient care. The geriatric patient population possesses higher rates of comorbidities that increase their risk for trauma and make their care more challenging. By considering the nuances that accompany the critical stabilization and injury-specific management of geriatric trauma patients, emergency physicians can decrease the prevalence of adverse outcomes.

Health-related quality of life in older women with injuries: a nationwide study

Objectives

This study aims to describe the health-related quality of life (HRQoL) and influencing factors of older women who experienced injuries.

Methods

This study is a secondary analysis of data from 4,217 women aged 65 years or older sampled from the Korea National Health and Nutrition Examination Survey (KNHANES) (2016-2020) database. Two-way analysis of variance was used to analyze the data.

Results

The mean HRQoL scores of older women with and without injuries were 0.81 ± 0.19 (n = 328) and 0.85 ± 0.17 (n = 3,889), respectively, which were significantly different (p < 0.001). The results of multiple regression analysis revealed that working, physical activity, BMI, osteoarthritis, stress, and subjective health status significantly affected the HRQoL of older women with injuries, and the explanatory power of the model was 29%.

Conclusion

The results of this study on factors affecting HRQoL can contribute to the understanding of the experience of older women with injuries and can be used as a reference to develop health promotion programs.

Provision of acute care pathways for older major trauma patients in the UK

BACKGROUND

The introduction of specific pathways of care for older trauma patients has been shown to decrease hospital length of stay and the overall rate of complications. The extent and scope of pathways and services for older major trauma patients in the UK is not currently known.

OBJECTIVE

The primary objective of this study was to map the current care pathways and provision of services for older people following major trauma in the UK.

METHODS

A cross-sectional survey of UK hospitals delivering care to major trauma patients (major trauma centres and trauma units). Data were collected on respondent and site characteristics, and local definitions of older trauma patients. To explore pathways for older people with major trauma, four clinical case examples were devised and respondents asked to complete responses that best illustrated the admission pathway for each.

RESULTS

Responses from 56 hospitals were included in the analysis, including from 25 (84%) of all major trauma centres (MTCs) in the UK. The majority of respondents defined 'old' by chronological age, most commonly patients 65 years and over. The specialty team with overall responsibility for the patient in trauma units was most likely to be acute medicine or acute surgery. Patients in MTCs were not always admitted under the care of the major trauma service. Assessment by a geriatrician within 72 hours of admission varied in both major trauma centres and trauma units and was associated with increased age.

CONCLUSIONS

This survey highlights variability in the admitting specialty team and subsequent management of older major trauma patients across hospitals in the UK. Variability appears to be related to patient condition as well as provision of local resources. Whilst lack of standardisation may be a result of local service configuration this has the potential to impact negatively on quality of care, multi-disciplinary working, and outcomes.

Age as the Impact on Mortality Rate in Trauma Patients

Background

Globally, the fastest-growing population is that of older adults. Geriatric trauma patients pose a unique challenge to trauma teams because the aging process reduces their physiologic reserve. To date, no agreed-upon definition exists for the geriatric trauma patients, and the appropriate age cut point to consider patients at increased risk of mortality is unclear.

Objectives

To determine the age cut point at which age impacts the mortality rate in trauma patients in Thailand.

Materials and Methods

This was a retrospective cohort and prognostic analysis study conducted in trauma patients ≥40 years. Patient data were retrieved from the trauma registry database and hospital information system in Songklanagarind Hospital. The estimated sample size of 1,509 patients was calculated based on the trauma registry data. The age with the maximum mortality rate was used as the cut point to define the elderly population. Hospital cost, intensive care unit (ICU) length of stay, gender, precomorbidity, mechanism of injury, injury severity score (ISS), and trauma and injury severity score were analyzed for any correlation with mortality, and whether or not they were associated with elderly trauma patients.

Results

A total of 1,523 trauma patients ≥40 years were included in the study. The median age in both the survival and death groups was 61 years, with gender in both groups being similar (p value = 0.259). In the multivariate logistic regression analyses, the adjusted odds ratio (OR) showed that increasing age was significantly associated with mortality (OR = 1.05; 95% CI, 1.02–1.07; p value <0.001). In the age group of 70 to 79 years and >80 years, the odds of mortality were significantly increased (OR 3.29, 95% CI, 1.24–8.68; p value = 0.016 and OR 3.29, 95% CI, 1.27–12.24; p value = 0.018, respectively).

Conclusion

Age is a significant risk factor for mortality in trauma patients. The mortality significantly increased at the age of 70 and higher.

All elderly are fragile, but some are more fragile than others: an epidemiological study from one of the busiest trauma centers in Italy

As the older population increases, the number of elderly accessing the emergency department following a trauma increases accordingly. High-level trauma enters together with the identification of predictive parameters for poor outcome and mortality, may result in a death rate improvement of up to 30% in this group of patients. This study analyzes the epidemiology of major trauma admissions at Niguarda Trauma Center in Milan, Italy, focusing on the geriatric population and aiming to discriminate the trauma outcomes in the range of population between 65 and 75 years old (Senior Adult) and to compare it with the outcomes among people over 75 years old (Elderly). The variables analyzed included mortality, mechanism of injury, body district injured, Injury Severity Score (ISS), Trauma Injury Severity Score (TRISS), Geriatric Trauma Score (GTO), and outcome. Head trauma remains the main cause of mortality with falls and road accidents being the most common mechanism of injury. Frailty and associated use of anticoagulant and antiplatelet therapy increased the risk of death by 42%. The subdivision of the elder patients into two groups (65-75 and > 75) showed a difference in the probability of death and effective mortality rate.

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.

Team Approach: Management of Geriatric Acetabular Fractures

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Geriatric acetabular fractures are defined as fractures sustained by patients who are ≥60 years old. With the rapidly aging American populace and its increasingly active lifestyle, the prevalence of these injuries will continue to increase.

»

An interdisciplinary approach is necessary to ensure successful outcomes. This begins in the emergency department with hemodynamic stabilization, diagnosis of the fracture, identification of comorbidities and concomitant injuries, as well as early consultation with the orthopaedic surgery service. This multifaceted approach is continued when patients are admitted, and trauma surgery, geriatrics, and cardiology teams are consulted. These teams are responsible for the optimization of complex medical conditions and risk stratification prior to operative intervention.

»

Treatment varies depending on a patient's preinjury functional status, the characteristics of the fracture, and the patient's ability to withstand surgery. Nonoperative management is recommended for patients with minimally displaced fractures who cannot tolerate the physiologic stress of surgery. Percutaneous fixation is a treatment option most suited for patients with minimally displaced fractures who are at risk for displacing the fracture or are having difficulty mobilizing because of pain. Open reduction and internal fixation is recommended for patients with displaced acetabular fractures who are medically fit for surgery and have a displaced fracture pattern that would do poorly without operative intervention. Fixation in combination with arthroplasty can be done acutely or in delayed fashion. Acute fixation combined with arthroplasty benefits patients who have poorer bone quality and fracture characteristics that make healing unlikely. Delayed arthroplasty is recommended for patients who have had failure of nonoperative management, have a fracture pattern that is not favorable to primary total hip arthroplasty, or have developed posttraumatic arthritis.

Geriatric trauma prognosis trends over 10 years: analysis of a nationwide trauma registry

Purpose

With Japan’s population rapidly skewing toward aging, the number of geriatric trauma patients is expected to increase. Since we need to continue to improve the quality of geriatric trauma patient care, this study aimed to evaluate in-hospital mortality trends among geriatric trauma patients in Japan over a recent 10-year period.

Methods

This was a retrospective cohort study of data from a Japanese nationwide trauma registry (the Japan National Trauma Data Bank) on patients admitted between January 1, 2008 and December 31, 2017. Geriatric patients were defined as those 65 years old and older. The primary outcome was to clarify in-hospital mortality trends and changes over these 10 years.

Results

We identified 265 268 eligible trauma patients. Excluding those under 65 years old and those with inadequate or unknown age data, missing prognosis, out-of-hospital cardiac arrest, and burns, 107 766 patients were enrolled in this study. The total trauma patient in-hospital mortality trend was evaluated using the Cochran-Armitage test and showed a significant decrease (p<0.001). Although severe trauma patients (Injury Severity Score (ISS) ≥16) showed a significant decreasing trend (p<0.001) over time (from 26.1% to 14.5%), less-severe trauma patients (ISS <16) did not (p=0.41) (from 2.7% to 2.1%). Mixed logistic regression analysis showed that the number of year patients stayed in the hospital was significantly associated with mortality.

Conclusions

While recognizing the limitations of the current analysis, our data demonstrated that prognoses for severe trauma patients over 65 years old improved dramatically over these 10 years, especially in those with severe trauma.

Level of evidence

Ⅲ—retrospective cohort study.

Improving mortality in older adult trauma patients: Are we doing better?

BACKGROUND

Older adult trauma is associated with high morbidity and mortality. Individuals older than 65 years are expected to make up more than 21% of the total population and almost 39% of trauma admissions by 2050. Our objective was to perform a national review of older adult trauma mortality and identify associated risk factors to highlight potential areas for improvement in quality of care.

MATERIALS AND METHODS

This is a retrospective cohort study of the National Trauma Data Bank including all patients age ≥65 years with at least one International Classification of Diseases, Ninth Revision, Clinical Modification trauma code admitted to a Level I or II US trauma center between 2007 and 2015. Variables examined included demographics, comorbidities, emergency department vitals, injury characteristics, and trauma center characteristics. Multilevel mixed-effect logistic regression was performed to identify independent risk factors of in-hospital mortality.

RESULTS

There were 1,492,759 patients included in this study. The number of older adult trauma patients increased from 88,056 in 2007 to 158,929 in 2015 (p > 0.001). Adjusted in-hospital mortality decreased in 2014 to 2015 (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.86-0.91) when compared with 2007 to 2009. Admission to a university hospital was protective (OR, 0.83; 95% CI, 0.74-0.93) as compared with a community hospital admission. There was no difference in mortality risk between Level II and Level I admission (OR, 1.00; 95% CI, 0.92-1.08). The strongest trauma-related risk factor for in-patient mortality was pancreas/bowel injury (OR, 2.25; 95% CI, 2.04-2.49).

CONCLUSION

Mortality in older trauma patients is decreasing over time, indicating an improvement in the quality of trauma care. The outcomes of university based hospitals can be used as national benchmarks to guide quality metrics.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level IV.

Geriatric Trauma in a High-Volume Trauma Centre in Cape Town: How Do We Compare?

BACKGROUND

Little is known about the injury profile of older persons from low-and-middle-income countries, such as South Africa, where violence is prevalent. This study aimed to identify common mechanisms of injury (MOI), severity, complications, and outcomes in elderly patients admitted to a referral trauma centre in Cape Town.

METHODS

A retrospective review was performed of all patients ≥60 years presenting at Tygerberg hospital trauma centre over an eight-month period. Descriptive statistics were computed for all variables of interest, and the relationship between the MOI, injury severity score (ISS), complications, and outcomes were assessed.

RESULTS

Of the total 7,635 trauma cases admitted, patients ≥60 years accounted for 4% (n = 275). The most frequent MOI was low falls (58%). Of these 11% of injuries were intentionally inflicted. Among them 35% of the patients experienced complications. The ISS was positively associated with the number of complications (p < 0.01). The mortality rate was 6.5%. An ISS of ≥10 was associated with increased mortality (p < 0.01). The number of complications was positively associated with mortality (p < 0.01).

CONCLUSIONS

In contrast to high-income countries (HICs), the cohort of elderly patients admitted to the trauma centre made up a relatively small portion of the total admissions. Compared to HICs, intentionally inflicted injuries and preventable MOI were common in our sample, underscoring the importance of addressing causative factors. Notably, the ISS was strongly associated with the number of complications and an ISS ≥10 was associated with mortality, highlighting the utility of the ISS in identifying elderly trauma patients most at risk of negative outcomes.

Characteristics associated with delays in decision to transfer injured patients

Introduction

The regionalized nature of trauma care necessitates interfacility transfer which is vulnerable to delays given its complexity. Little is known about the interval of time a patient spends at the sending hospital prior to when the transfer is initiated—the “decision to transfer” time. This primary objective of the study was to explore the impact of patient, environmental, and institutional characteristics on decision to transfer time.

Methods

This was a retrospective cohort study of injured adult patients who underwent emergent interfacility transfer by a provincial critical care transport organization over a 31-month period. Quantile regression was used to evaluate the impact of patient, environmental, and institutional characteristics on the time to decision to transfer.

Results

A total of 1128 patients were included. The median decision to transfer time was 2.42 h and the median total transport time was 3.12 h. The following variables were associated with an increase in time to decision to transfer at the 90th percentile of time: age >75 (+2.47 h), age 66–75 (+3.70 h), age 56–65 (+1.20 h), transfer between 00:00 and 07:59 (+2.08 h), and transfer in the summer (+2.25 h). The following variables were associated with a decrease in time to decision to transfer at the 90th percentile of time: Glasgow Coma Scale 3–8 (−2.21 h), respiratory rate >30 (−2.01 h), sending site being a community hospital with <100 beds (−4.11 h), or the sending site being a nursing station (−5.66 h).

Conclusion

Time to decision to transfer was a sizable proportion of the patients interfacility transfer. Older patients were associated with a delay in decision to transfer as were patients transferred overnight and in the summer. These findings may be used to support the implementation of geriatric trauma triage guidelines and promote ongoing education and quality improvement initiatives to decrease delay.

Novel Trauma Composite Score is superior to Injury Severity Score in predicting mortality across all ages

BACKGROUND

Injury Severity Score (ISS) is a widely used metric for trauma research and center verification; however, it does not account for age-related physiologic parameters. We hypothesized that a novel age-based injury severity metric would better predict mortality.

METHODS

Adult patients (≥18 years) sustaining blunt trauma (BT) or penetrating trauma (PT) were abstracted from the 2010 to 2016 National Trauma Data Bank. Admission vitals, Glasgow Coma Scale, ISS, mechanism, and outcomes were analyzed. Patients with incomplete/non-physiologic vital signs were excluded. For each age: (1) a cut point analysis was used to determine the ISS with the highest specificity and sensitivity for predicting mortality and (2) a linear discriminant analysis was performed using ISS, ISS greater than 16, Trauma and Injury Severity Score, and Revised Trauma Scale to compare each scoring system's mortality prediction. A novel injury severity metric, the trauma component score (TCS), was developed for each age using significant (p < 0.05) variables selected from Abbreviated Injury Scale scores, Glasgow Coma Scale, vital signs, and gender. Receiver operator curves were developed and the areas under the curve were compared between the TCS and other systems.

RESULTS

There 777,794 patients studied (BT, 91.1%; PT, 8.9%). Blunt trauma patients were older (53.6 ± 21.3 years vs. 34.4 ± 13.8 years), had higher ISS scores (11.1 ± 8.5 vs. 8.5 ± 8.9), and lower mortality (2.9% vs. 3.4%) than PT patients (p < 0.05). When assessing the entire PT and BT cohort the optimal ISS cut point was 16. The optimal ISS was between 20 and 25 for BT younger than 70 years. For those older than 70 years, the optimal BT ISS steadily declined as age increased PT's cut point was 16 or less for all ages assessed. When the injury metrics were compared by area under the curve, our novel TCS more accurately predicted mortality across all ages in both BT and PT (p < 0.001).

CONCLUSION

Injury Severity Score is a poor mortality predictor in older patients and those sustaining penetrating trauma. The age-based TCS is a superior metric for mortality prediction across all ages.

LEVEL OF EVIDENCE

Clinical outcomes, Level IV.

Challenges in the PREHOSPITAL emergency management of geriatric trauma patients - a scoping review

BACKGROUND

Despite a widely acknowledged increase in older people presenting with traumatic injury in western populations there remains a lack of research into the optimal prehospital management of this vulnerable patient group. Research into this cohort faces many uniqu1e challenges, such as inconsistent definitions, variable physiology, non-linear presentation and multi-morbidity. This scoping review sought to summarise the main challenges in providing prehospital care to older trauma patients to improve the care for this vulnerable group.

METHODS AND FINDINGS

A scoping review was performed searching Google Scholar, PubMed and Medline from 2000 until 2020 for literature in English addressing the management of older trauma patients in both the prehospital arena and Emergency Department. A thematic analysis and narrative synthesis was conducted on the included 131 studies. Age-threshold was confirmed by a descriptive analysis from all included studies. The majority of the studies assessed triage and found that recognition and undertriage presented a significant challenge, with adverse effects on mortality. We identified six key challenges in the prehospital field that were summarised in this review.

CONCLUSIONS

Trauma in older people is common and challenges prehospital care providers in numerous ways that are difficult to address. Undertriage and the potential for age bias remain prevalent. In this Scoping Review, we identified and discussed six major challenges that are unique to the prehospital environment. More high-quality evidence is needed to investigate this issue further.

Trauma resource pit stop: increasing efficiency in the evaluation of lower severity trauma patients

Background

Overtriage of trauma patients is unavoidable and requires effective use of hospital resources. A 'pit stop' (PS) was added to our lowest tier trauma resource (TR) triage protocol where the patient stops in the trauma bay for immediate evaluation by the emergency department (ED) physician and trauma nursing. We hypothesized this would allow for faster diagnostic testing and disposition while decreasing cost.

Methods

We performed a before/after retrospective comparison after PS implementation. Patients not meeting trauma activation (TA) criteria but requiring trauma center evaluation were assigned as a TR for an expedited PS evaluation. A board-certified ED physician and trauma/ED nurse performed an immediate assessment in the trauma bay followed by performance of diagnostic studies. Trauma surgeons were readily available in case of upgrade to TA. We compared patient demographics, Injury Severity Score, time to physician evaluation, time to CT scan, hospital length of stay, and in-hospital mortality. Comparisons were made using 95% CI for variance and SD and unpaired t-tests for two-tailed p values, with statistical difference, p<0.05.

Results

There were 994 TAs and 474 TRs in the first 9 months after implementation. TR's preanalysis versus postanalysis of the TR group shows similar mean door to physician evaluation times (6.9 vs. 8.6 minutes, p=0.1084). Mean door to CT time significantly decreased (67.7 vs. 50 minutes, p<0.001). 346 (73%) TR patients were discharged from ED; 2 (0.4%) were upgraded on arrival. When admitted, TR patients were older (61.4 vs. 47.2 years, p<0.0001) and more often involved in a same-level fall (59.5% vs. 20.1%, p<0.0001). Undertriage was calculated using the Cribari matrix at 3.2%.

Discussion

PS implementation allowed for faster door to CT time for trauma patients not meeting activation criteria without mobilizing trauma team resources. This approach is safe, feasible, and simultaneously decreases hospital cost while improving allocation of trauma team resources.

Level of evidence

Level II, economic/decision therapeutic/care management study.

Geriatric Trauma

Geriatric trauma patients will continue to increase in prevalence as the population ages, and many specific considerations need to be made to provide appropriate care to these patients. This article outlines common presentations of trauma in geriatric patients, with consideration to baseline physiologic function and patterns of injury that may be more prevalent in geriatric populations. Additionally, the article explores specific evidence-based management practices, the significance of trauma team and geriatrician involvement, and disposition decisions.

The effect of geriatric comanagement (GC) in geriatric trauma patients treated in a level 1 trauma setting: A comparison of data before and after the implementation of a certified geriatric trauma center

INTRODUCTION

Improvements in life expectancy imply that an increase of geriatric trauma patients occurs. These patients require special attention due to their multiple comorbidity issues. The aim of this study was to assess the impact of the implementation of geriatric comanagement (GC) on the allocation and clinical outcome of geriatric trauma patients.

METHODS

This observational cohort study aims to compare the demographic development and the clinical outcome in geriatric trauma patients (aged 70 years and older) before and after implementation of a certified geriatric trauma center (GC). Geriatric trauma patients admitted between January 1, 2010 and December 31, 2010 were stratified to group pre-GC and admissions between January 1, 2018 and December 31, 2018 to Group post-GC. We excluded patients requiring end-of-life treatment and those who died within 24 h or due to severe traumatic brain injury. Outcome parameters included demographic changes, medical complexity (measured by American Society of Anaesthesiology Score (ASA) and Charlson Comorbidity Index (CCI)), in-hospital mortality and length of hospitalization.

RESULTS

This study includes 626 patients in Group pre-GC (mean age 80.3 ± 6.7 years) and 841 patients in Group post-GC (mean age 81.1 ± 7.3 years). Group pre-GC included 244 (39.0%) males, group post-GC included 361 (42.9%) males. The mean CCI was 4.7 (± 1.8) points in pre-GC and 5.1 (± 2.0) points in post-GC (p <0.001). In Group pre-GC, 100 patients (16.0%) were stratified as ASA 1 compared with 47 patients (5.6%) in Group post-GC (p <0.001). Group pre-GC had significantly less patients stratified as ASA 3 or higher (n = 235, 37.5%) compared with Group post-GC (n = 389, 46.3%, p <0.001). Length of stay (LOS) decreased significantly from 10.4 (± 20.3) days in Group pre-GC to 7.9 (±22.9) days in Group post-GC (p = 0.011). The 30-day mortality rate was comparable amongst these groups (pre-GC 8.8% vs. post-GC 8.9%).

CONCLUSION

This study appears to support the implementation of a geriatric trauma center, as certain improvements in the patient care were found: Despite a higher CCI and a higher number of patients with higher ASA classifications, Hospital LOS, complication rates and mortality did were not increased after implementation of the CG. The increase in the case numbers supports the fact that a higher degree of specialization leads to a response by admitting physicians, as it exceeded the expectable trend of demographic ageing. We feel that a larger data base, hopefully in a multi center set up should be undertaken to verify these results.

Early predictors of discharge to home among severely injured geriatric patients: A single-system retrospective cohort study

Background

Injured geriatric patients experience significant functional decline during their hospitalization, limiting their ability to be discharged home which is a valuable outcome among this vulnerable population. We therefore sought to evaluate the clinical characteristics of injured elderly patients managed within our trauma system and identify early predictors for discharge to home.

Methods

In this single-system retrospective cohort study, we evaluated significantly injured (Injury Severity Score ≥12) geriatric (age ≥65 y) patients admitted from Northern Alberta between 2011 and 2016. The primary outcome was discharge disposition to home. Data was analyzed with descriptive statistics, and univariable and multivariable logistic regression modelling. P values less than 0.05 were considered statistically significant.

Results

We identified 1548 patients with a median age of 77. Falls accounted for 47% of injuries with median injury severity score of 22; 47% of patients were discharged home with a median hospital length of stay of 8 days. All-cause in-hospital mortality was 19%. On multivariable regression, age, injury severity score, heart rate, systolic blood pressure, and Glasgow Coma Score were independent predictors for discharge home, as well as hospital and intensive care unit length of stay.

Conclusion

Nearly half of severely injured geriatric trauma patients were discharged home. The identified predictors provide clues to disposition on admission that trauma providers may use to guide in-hospital care planning, disposition planning, and stimulate early goals of care discussions.

Undertriage Despite Use of Geriatric-Specific Trauma Team Activation Guidelines : Who Are We Missing?

BACKGROUND

Elderly trauma patients are at risk for undertriage, resulting in substantial morbidity and mortality. The objective of this study was to determine whether implementation of geriatric-specific trauma team activation (TTA) protocols appropriately identified severely-injured elderly patients.

METHODS

This single-center retrospective study evaluated all severely injured (injury severity score [ISS] >15), geriatric (≥65 years) patients admitted to our Level 1 tertiary-care hospital between January 2014 and September 2017. Undertriage was defined as the lack of TTA despite presence of severe injuries. The primary outcome was all-cause in-hospital mortality; secondary outcomes were mortality within 48 hours of admission and urgent hemorrhage control. A multivariable logistic regression analysis was performed to identify predictors of appropriate triage in this study.

RESULTS

Out of 1039 severely injured geriatric patients, 628 (61%) did not undergo TTA. Undertriaged patients were significantly older and had more comorbidities. In-hospital mortality was 5% and 31% in the undertriaged and appropriately triaged groups, respectively (P < .0001). One percent of undertriaged patients needed urgent hemorrhage control, compared to 6% of the appropriately triaged group (P < .0001). One percent of undertriaged patients died within 48 hours compared to 19% in the appropriately triaged group (P < .0001). Predictors of appropriate triage include GCS, heart rate, systolic blood pressure, lactic acid, ISS, shock, and absence of dementia, stroke, or alcoholism.

DISCUSSION

Geriatric-specific TTA guidelines continue to undertriage elderly trauma patients when using ISS as a metric to measure undertriage. However, undertriaged patients have much lower morbidity and mortality, suggesting the geriatric-specific TTA guidelines identify those patients at highest risk for poor outcomes.

Managing the multiply injured patient: the impact of multidisciplinary teams

Management of trauma has been tackled at a national level to improve patient care and mortality. Decision making through a multidisciplinary team approach has resulted in improved patient outcomes through a complex combination of changes. While the focus of trauma care delivery has been towards establishing an effective multidisciplinary trauma service, there are still improvements which can be made. This article reviews the history of trauma care in the UK, and the impact that multidisciplinary teams have had on the management of the multiply injured patient.

Implementation of the best practice guidelines on geriatric trauma care: a Canadian perspective

BACKGROUND

traumatic injuries are increasingly affecting older patients who are prone to more complications and poorer recovery compared to younger patients. Practices of trauma health care providers therefore need to be adapted to meet the needs of geriatric trauma patients.

OBJECTIVE

to assess the implementation of the American College of Surgeons best practice guidelines on geriatric trauma management across level I to III Canadian trauma centres.

METHODS

69 decision-makers working in Canadian trauma centres were approached to complete a web-based practice survey. Percentages and means were calculated to describe the level of best practice guideline implementation.

RESULTS

50 decision-makers completed the survey for a response rate of 72%. Specialised geriatric trauma resources were utilised in 37% of centres. Implementation of mechanisms to evaluate common geriatric issues (e.g. frailty, malnutrition and delirium) varied from 28 to 78% and protocols for the optimisation of geriatric care (e.g. Beers criteria to adjust medication, anticoagulant reversal and early mobilisation) from 8 to 56%. Guideline recommendations were more often implemented in level I and level II trauma centres. The adjustment of trauma team activation criteria to the geriatric population and transition of care protocols were more frequently used by level III centres.

CONCLUSION

despite the growing number of older patients admitted in Canadian trauma centres annually, the implementation of best practice guidelines on geriatric trauma management is still limited. Prospective multicentre studies are required to develop and evaluate interdisciplinary knowledge translation initiatives that will promote the uptake of guidelines by trauma centres.

Success Of An Expedited Emergency Department Triage Evaluation System For Geriatric Trauma Patients Not Meeting Trauma Activation Criteria

Background

Geriatric patients are at increased risk of injury following low-energy mechanisms and are less tolerant of injury. Current criteria for trauma team activation (TTA) often miss these injuries. We evaluated a novel triage process for an expedited Emergency Medicine Physician evaluation protocol (T3) for at-risk geriatric sub-populations not meeting trauma team activation (TTA) criteria.

Methods

Retrospective review of injured patients (≥65 years) from a Level II Trauma Center with an Injury Severity Score (ISS < 16), prior to (Pre-T3, Jan 2007-Oct 2009), and after (Post-T3, Jan 2010-Oct 2012), implementation of T3, as well as a contemporary period (CP, Jan 2013-Oct 2015). Demographics, physiologic variables, and timeliness of care were measured. Rates of ICU admission, operative procedures and lengths of stay and in-hospital mortality were compared for all periods. Logistic regression analysis determined variables independently associated with mortality.

Results

Post-T3, 49.2% of geriatric registry patients underwent T3 with a reduction in key time intervals. Median time to evaluation (42.1 mins vs 61.7 min, p<0.001), median time to CT (161.3 mins vs 212.9 mins, p<0.001) and EDLOS (364.6 mins vs 451.5 mins, p=0.023) were all reduced compared to non-expedited evaluations. There was no change in mortality after the implementation of the protocol.

Conclusion

The T3 protocol expedited patient evaluation of at-risk geriatric patients that would not otherwise meet TTA criteria. The new process met the goals of the American College of Surgeons Trauma Quality Improvement Program while conserving resources.

Flail Chest: Less Deadly than Originally Thought

INTRODUCTION

Flail chest is considered a highly morbid condition with reported mortality ranging from 10 to 20%. It is often associated with other severe injuries, which may complicate management and interpretation of outcomes. The physiologic impact and prognosis of isolated flail chest injury is poorly defined.

METHODS

This is a National Trauma Databank study. All patients from 1/2007 to 12/2014 admitted with flail chest were extracted. Patients with head or abdominal AIS ≥3, dead on arrival, or transferred, were excluded. Primary outcome was mortality; secondary outcomes were need for mechanical ventilation and pneumonia.

RESULTS

Of the 1,047,519 patients with blunt chest injury, 14,718 (1.4%) patients presented with flail chest, and 8098 (0.77%) met inclusion criteria. The most commonly associated intrathoracic injuries were hemothorax (57.9%) and lung contusions (63.0%), while sternal fracture (8.8%) and cardiac contusion (2.5%) were less common. In total, 29.8% of patients required mechanical ventilation, and 11.2% developed pneumonia. Overall mortality was 5.6%. On multivariable analysis, age >65 and need for mechanical ventilation were independent risk factors for mortality (OR 6.02, 3.75, respectively, p < 0.001). Independent predictors for mechanical ventilation included cardiac or pulmonary contusion and sternal fractures (OR 3.78, 2.38, 2.29, respectively, p < 0.001). Need for mechanical ventilation was an independent predictor of pneumonia (OR 13.18, p < 0.001).

CONCLUSIONS

Mortality in isolated flail chest is much lower than previously reported. Fewer than 30% of patients require mechanical ventilation. Need for mechanical ventilation, however, is independently associated with mortality and pneumonia. Age >65 is an independent risk factor for adverse outcomes, and these patients may benefit by more aggressive monitoring and treatment.

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.

Geriatric patients on antithrombotic therapy as a criterion for trauma team activation leads to over triage

BACKGROUND

Our institution amended its trauma activation criteria to require a Level II activation for patients ≥65 years old on antithrombotic medication presenting with suspected head trauma.

METHODS

Our institutional trauma registry was queried for geriatric patients on antithrombotic medication in the year before and after this criteria change. Demographics, presentation metrics, level of activation, and outcomes were compared between groups.

RESULTS

After policy change, a greater proportion of patients received a trauma activation (19.9 vs. 74.9%, P < 0.001) and a greater proportion of these patients were discharged directly home without injury (4.3 vs. 44%, P < 0.001). However, a smaller proportion of patients with a critical Emergency Department disposition or traumatic intracranial hemorrhage failed to receive a trauma activation (65.1 vs. 23.5%, P < 0.001; 70.7% vs. 27.3%, P < 0.001). There was no change in mortality (4.3 vs. 2.0%, P = 0.21).

CONCLUSIONS

Implementing new criteria increased overtriage, decreased undertriage, and had little effect on mortality.

Emergency general surgery in geriatric patients: A statewide analysis of surgeon and hospital volume with outcomes

BACKGROUND

Geriatric patients undergoing emergency general surgery (EGS) face significant morbidity and mortality. We assessed how surgeon and hospital volumes affected these outcomes.

METHODS

We identified patients at least 65 years old in Maryland's Health Services Cost Review Commission database from 2012 to 2014 who underwent one of 12 EGS procedures, as defined by the American Association for the Surgery of Trauma, and then calculated four outcomes: mortality rate, the incidence of at least one of eight common in-hospital EGS complications, failure-to-rescue (death after experiencing a postoperative complication), and the 30-day readmission rate. Median annual volumes of geriatric-EGS procedures divided both surgeons and hospitals into two groups (low volume and high volume). Multivariable logistic regressions calculated associations between the volume groups and outcomes after adjusting for patient, surgeon, and hospital factors, and hospital clusters.

RESULTS

We identified 3,832 patients who had an EGS procedure by 302 surgeons (median: 8 geriatric-EGS/year, IQR: 3-18) at 44 hospitals (median: 82 geriatric-EGS/year, IQR: 35-132). While operating on 16.5% of all geriatric-EGS patients, low-volume surgeons had higher risk-adjusted adverse outcomes: mortality (7.0% vs. 4.0%, p = 0.005), in-hospital complications (22.1% vs. 19.7%, p = 0.13), failure-to-rescue (17.3% vs. 12.1%, p = 0.021), and 30-day readmissions (11.2% vs. 10.0%, p = 0.55). After adjustment, low-volume surgeons were associated with higher mortality (adjusted odds ratio [aOR] 1.86, 95% CI [1.21-2.86]) and failure-to-rescue rates (aOR 1.74 [1.09-2.80]) but not in-hospital complications (aOR 1.20 [0.95-1.51]) or 30-day readmissions (aOR 1.07 [0.85-1.34]). In contrast, low-volume hospitals relative to high-volume hospitals, and hospitals serving lower proportions of geriatric-EGS patients, were not associated with adverse outcomes.

CONCLUSION

Relative to their higher-volume counterparts, surgeons performing eight or fewer geriatric-EGS procedures annually were associated with an 86% higher odds of death and 74% higher odds of failure-to-rescue in this elderly EGS patient population. These findings underscore the need for focused care of elderly surgical patients.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level IV.

Evaluating the ability of a trauma team activation tool to identify severe injury: a multicentre cohort study

Background

Sensitive decision making tools should assist prehospital personnel in the triage of injured patients, identifying those who require immediate lifesaving interventions and safely reducing unnecessary under- and overtriage. In 2014 a new trauma team activation (TTA) tool was implemented in Central Norway. The overall objective of this study was to evaluate the ability of the new TTA tool to identify severe injury.

Methods

This was a multi-center observational cohort study with retrospective data analysis. All patients received by trauma teams at seven hospitals in Central Norway between 01.01.2015 to 31.12.2015 were included. Severe injury was defined as Injury Severity Score (ISS) > 15. Overtriage was defined as the rate of patients with TTA and ISS < 15, whilst patients with TTA and ISS > 15 were defined as correctly triaged.

Results

A total of 1141 patients were identified, of which 998 were eligible for triage criteria analysis. Median age was 35 years (IQR 20–58) and the male proportion was 67%. Mechanism of injury was predominantly blunt trauma (96%) with transport related accidents (62%) followed by falls (22%) the most common. Overall, median injury severity score (ISS) was low and severely injured patients (ISS > 15) comprised 13% of the cohort. Utility of specific TTA criteria were: physiology 20%, anatomical injury 21%, mechanism of injury (MOI) 53% and special causes 6%. Overtriage among all patients was 87%, and for those with physiologic criteria 66%, anatomical injury 82%, mechanism of injury 97% and special causes criteria 92%, respectively.

Conclusions

Severe injury was infrequent and there was a substantial rate of overtriage. The ability of the TTA tool was relatively insensitive in identifying severe injury, but showed increased performance when utilizing physiologic and anatomical injury criteria. Many of the TTA mechanism of injury criteria might be considered for removal from the triage tool due to substantial rates of overtriage. This has relevance for the proposed development of national Norwegian TTA criteria.

Anticoagulated Trauma Patients: A Level I Trauma Center's Response to a Growing Geriatric Population

BACKGROUND

Injured older adults often receive delayed care in the emergency department (ED) because they do not meet criteria for trauma team activation (TTA). This is particularly dangerous for the increasing number of patients taking anticoagulant or antiplatelet (AC/AP) medication at the time of injury.

OBJECTIVES

The present study examined improvements in processes of care and triage accuracy when TTA criteria include an escalated response for older anticoagulated patients.

METHODS

A retrospective study was performed at a Level I trauma center. The study population (referred to as A55) included patients aged 55 years or older who were taking an AC/AP medication at the time of injury. Study periods included 11 months prior to the criteria change (Phase 1: July 2013-May 2014; n = 107) and 11 months after the change (Phase 2: July 2014-May 2015; n = 211). Differences were assessed with Kruskal-Wallis and chi-squared tests.

RESULTS

More A55 patients received a full or limited TTA after criteria were revised (70% vs. 26%, p < 0.001). Undertriage was reduced from 13% to 2% (p < 0.001). The trauma center significantly decreased time to first laboratory result, time to first computed tomography scan, and total time in ED prior to admission for A55 patients arriving from the scene of injury or by private vehicle.

CONCLUSION

Criteria that escalated the trauma response for A55 patients led to reductions in undertriage for anticoagulated older adults, as well as more timely mobilization of important clinical resources.

Longer-term quality of life following major trauma: age only significantly affects outcome after the age of 80 years

Aim

Against the background of conflicting data on the topic, this study aimed to determine the differences in longer-term patient outcomes following major trauma with regard to age.

Materials and methods

A prospective trauma center survey of survivors of trauma (≥16 years) was carried out employing a New Injury Severity Score (NISS) ≥8 to investigate the influence of age on working capacity and several outcome scores, such as the trauma medical outcomes study Short Form-36 (physical component [PCS] and mental component [MCS]), the Euro Quality of Life (EuroQoL), or the Trauma Outcome Profile (TOP) at least 1 year following injury. Chi square tests, t-tests, and Pearson correlations were used as univariate; stepwise regression as multivariate analysis. Significance was set at p<0.05.

Results

In all, 718 major trauma patients (53.4±19.4 years; NISS 18.4±9.2) participated in the study. Multivariate analysis showed only low associations of patient or trauma characteristics with longer-term outcome scores, highest for the Injury Severity Score of the extremities with the PCS (R²=0.08) or the working capacity of employed patients (n=383; R²=0.04). For age, overall associations were even lower (best with the PCS, R²=0.04) or could not be revealed at all (TOP or MCS). Subgroup analysis with regard to decennia revealed the age effect to be mainly attributable to patients aged ≥80, who presented with a significantly worse outcome compared to younger people in all overall and physical component scores (p<0.001). In patients under 80 years an association of age was only found for EuroQoL (R²=0.01) and the PCS (R²=0.03).

Conclusion

Given the small impact of age on the longer-term outcomes of major trauma patients, at least up to the age of 80 years, resuscitation as well as rehabilitation strategies should be adapted accordingly.

The Age of Undertriage: Current Trauma Triage Criteria Underestimate The Role of Age and Comorbidities in Early Mortality

BACKGROUND

National guidelines recommend that prehospital and emergency department (ED) criteria identify patients who might benefit from trauma center triage and highest-level trauma team activation. However, some patients who are seemingly "stable" in the field and do not meet the standard criteria for trauma activation still die.

OBJECTIVES

The purpose of this study was to identify these at-risk patients to potentially improve triage algorithms.

METHODS

Patients enrolled in the National Trauma Data Bank (2007-2012) were included. All adult blunt trauma patients that were stable in the field and upon arrival to the ED (defined as a Glasgow Coma Scale score of 13-15, a heart rate ≤120 beats/min, systolic blood pressure ≥90 mm Hg, and diastolic blood pressure ≤200 mm Hg) and did not meet the standard criteria for the highest-level trauma team activation as defined by the American College of Surgeons were included. Demographic, clinical, and injury data including comorbidities, ED vitals, and outcome were collected. Regression models were used to identify independent risk factors for mortality.

RESULTS

A total of 1,003,350 patients were stable in both the field and ED. Of these 11,010 (1.1%) died, including 1785 (0.2%) who died within 24 hours of hospital admission. The mortality in patients ≥60 years of age was 2.6%, and in patients ≥60 years of age with either a cerebrovascular accident (CVA) or congestive heart failure (CHF) was 5.4%. Age ≥60 years was a significant independent predictor of early mortality (odds ratio [OR] 4.53, p < 0.001). CHF (OR 1.88, p < 0.001) and a history of stroke (OR 1.52, p < 0.001) were also significant independent predictors of mortality.

CONCLUSIONS

Despite apparent evidence of both prehospital stability and stability upon arrival to the ED, patients ≥60 years of age and with a history of CHF or CVA have a significantly increased risk of early mortality after blunt trauma. These patients are at risk for subsequent clinical deterioration and should be considered for early transfer to a trauma center with highest-level activation.

Using emergency trauma team activations to measure trauma activity and injury severity: 10 years of experience using an Australian major trauma centre registry

OBJECTIVES

To describe the outcomes of Emergency Department trauma team activations over a 10-year period with respect to injury severity and hospital length of stay.

METHODS

This was a retrospective study using trauma registry data at a single Major Trauma Centre in Australia. All trauma team activations and arrivals on pre-hospital major trauma (T1) protocol recorded in the trauma registry between June 2006 and July 2016 were included. The outcome of interest was major trauma, defined as an Injury Severity Score (ISS) >12 or length of stay >3 days or requiring urgent operative intervention or admission to the Intensive Care Unit following trauma.

RESULTS

A total of 9876 hospital trauma activations were analysed from January 2006 to June 2016. Of these 53.3% were admitted as an in-patient and 16.6% were classified as having an ISS >15. Major trauma occurred in 38% of cases. With respect to hospital utilisation, patients with an ISS <16 accounted for around half of total cumulative in-patient bed-days.

CONCLUSIONS

Analysis of data from trauma team activations in ED has allowed a description of trauma activity and hospital bed day utilisation as a function of injury severity. The results confirm that those with minor trauma accounted for the vast majority of cases and around half of all hospital in-patient bed-days.

Trauma resource designation: an innovative approach to improving trauma system overtriage

Background

Effective triage of injured patients is often a balancing act for trauma systems. As healthcare reimbursements continue to decline,¹ innovative programs to effectively use hospital resources are essential in maintaining a viable trauma system. The objective of this pilot intervention was to evaluate a new triage model using 'trauma resource' (TR) as a new category in our existing Tiered Trauma Team Activation (TA) approach with hopes of decreasing charges without adversely affecting patient outcome.

Methods

Patients at one Level II Trauma Center (TC) over seven months were studied. Patients not meeting American College of Surgeons criteria for TA were assigned as TR and transported to a designated TC for expedited emergency department (ED) evaluation. Such patients were immediately assessed by a trauma nurse, ED nurse, and board-certified ED physician. Diagnostic studies were ordered, and the trauma surgeon (TS) was consulted as needed. Demographics, injury mechanism, time to physician evaluation, time to CT scan, time to disposition, hospital length of stay (LOS), and in-hospital mortality were analyzed.

Results

Fifty-two of the 318 TR patients were admitted by the TS and were similar to TA patients (N=684) with regard to gender, mean Injury Severity Score, mean LOS and in-hospital mortality, but were older (60.4 vs 47.2 years, p<0.0001) and often involved in a fall injury (52% vs 35%, p=0.0170). TR patients had increased door to physician evaluation times (11.5 vs 0.4 minutes, p<0.0001) and increased door to CT times (76.2 vs 25.9 minutes, p<0.0001). Of the 313 TR patients, 52 incurred charges totaling US$253 708 compared with US$1 041 612 if patients had been classified as TA.

Conclusions

Designating patients as TR prehospital with expedited evaluation by an ED physician and early TS consultation resulted in reduced use of resources and lower hospital charges without increase in LOS, time to disposition or in-hospital mortality.

Level of evidence

Level II.

Challenges in the Management of Geriatric Trauma: A Case Report

This article describes geriatric trauma and commonly associated difficulties emphasizing both the epidemiology and assessment of geriatric trauma. There is little data guiding decisions for trauma patients 65 years or older, as there are many unique characteristics to the geriatric population, including comorbidities, medications, and the aging physiology. The geriatric population in the United States has been steadily climbing for the last 20 years and is projected to continue on this trend. Although each patient presents differently, there remains a need for the consistent utilization of standard guidelines to help dictate care for geriatric patients, particularly for patients not receiving care at a trauma center. This review uses a case study about an elderly woman with many comorbidities, followed by a comprehensive discussion of geriatric trauma and the challenges that result from a lack of guideline utilization to direct management.

Severe trauma in the geriatric population

Geriatric trauma constitutes an increasingly recognized problem. Aging results in a progressive decline in cellular function which leads to a loose of their capacity to respond to injury. Some medications commonly used in this population can mask or blunt the response to injury. Falls constitute the most common cause of trauma and the leading cause of trauma-related deaths in this population. Falls are complicated by the widespread use of antiplatelets and anticoagulants, especially in patients with brain injury. Under-triage is common in this population. Evaluation of frailty could be helpful to solve this issue. Appropriate triaging and early aggressive management with correction of coagulopathy can improve outcome. Limitation of care and palliative measures must be considered in cases with a clear likelihood of poor prognosis.