Disparities in triage and management of the homeless and the elderly trauma patient

Abstract

Background: Trauma systems are designed to provide specialized treatment for the most severely injured. As populations change, it is imperative for trauma centers to remain dynamic to provide the best care to all members of the community. Methods: A retrospective review of all trauma patients treated at one Level II trauma center in Southern CA over 5 years. Three cohorts of patients were studied: geriatric (> 65 years), the homeless, and all other trauma patients. Triage, hospitalization, and outcomes were collected and analyzed. Results: Of 8431 patients treated, 30% were geriatric, 3% homeless and 67% comprised all other patients. Trauma activation criteria was met for 84% of all other trauma patients, yet only 61% of homeless and geriatric patients combined. Injury mechanism for homeless included falls (38%), pedestrian/bicycle related (27%) and assaults (24%), often while under the influence of alcohol and drugs. Average length of hospital stay (LOS) was greater for homeless and geriatric patients and frequently attributed to discharge planning challenges. Both the homeless and geriatric groups demonstrated increased complications, comorbidities, and death rates. Conclusions: Homeless trauma patients reflect similar challenges in care as with the elderly, requiring additional resources and more complex case management. It is prudent to identify and understand the issues surrounding patients transported to our trauma center requiring a higher level of care yet are under-triaged upon arrival to the Emergency Department. Although a monthly review is done for all under-triaged patients, and geriatric patients are acknowledged to be a cohort continually having delays, the homeless cohort continues to be under-triaged. The admitted homeless trauma patient has similar complex case management issues as the elderly related to preexisting health issues and challenges with discharge planning, both which can add to longer lengths of hospital stay as compared to other trauma patients. Given the lack of social support that is endemic to both populations, these cohorts represent a unique challenge to trauma centers. Further research into specialized care is required to determine best practices to address disparities evident in the homeless and elderly, and to promote health equity in marginalized populations.

Resource Deployment in Response to Trauma Patients

“…Within the subsample, there was a high ratio of patients who were assigned an ED RN and were subsequently left in the care of other ED RN team members when their primary ED RN was reallocated to a trauma patient. This supported previous studies’ suggestions that ED staffing models may need to incorporate coverage for non-trauma patients during a trauma response alert [ 1 , 4 , 12 ]. When analyzing whether registered nurses were deployed to lower-level acuity patients in the subsample, the majority of patients were a level 2, which would indicate a need for a revision to the trauma team or the ED staffing model for an appropriate trauma response [ 3 , 5 ].…”

“…Underdeployment of the trauma team in the emergency department (ED) can result in delays in patient triage and treatment, increased risk for complications, and increased mortality [3,8,9]; while overdeployment can also increase patient risk, staff burnout, and excess burden on trauma center resources [2,4,10]. Additionally, disparities in the deployment of resources have been noted within certain patient populations triaged to lower levels of trauma response (e.g., geriatric, blunt non-penetrating trauma victims) [11][12][13][14].…”

Morbidity and Length of Stay After Injury Among People Experiencing Homelessness in North America

“…The present study builds on existing literature of increased hospital resource use among people experiencing homelessness . Reasons for increased LOS among people experiencing homelessness are multifactorial.…”

“…The present study builds on existing literature of increased hospital resource use among people experiencing homelessness. 32 , 33 , 34 Reasons for increased LOS among people experiencing homelessness are multifactorial. It may be driven in part by low socioeconomic status; patients with social and/or material deprivation have been shown to have longer LOS compared with patients with higher socioeconomic status.…”

Prospective validation of a hospital triage predictive model to decrease undertriage: an EAST multicenter study

“…40 Certain populations including older adults, females, and patients belonging to racial and ethnic minority groups present an additional challenge to trauma triage. [41][42][43][44] Compared with appropriately triaged adult patients, undertriaged older adult patients have a twofold increased risk of mortality and a 50% increased risk of complications. 12 Prior studies have reported an undertriage rate of up to 61% for severely injured older adults, 42 and the TIP-NEI-6 undertriage rate was much closer to the suggested ACSCOT rate at 8.4%.…”