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

Abstract

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.

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

“…The treatment at TCs was, however, shown to increase the length of in-hospital stay and costs. These findings were consistent with other research findings which showed an inconclusive survival benefit of TC access for this population [62].…”

“…This could adversely affect the accuracy of prehospital trauma triage tools even when geriatric-specific triage criteria were developed to adjust for age-related anatomical and physiological changes, comorbidities, and medication use [61], as shown in this review. Therefore, integrating other assessment tools, such as frailty, into the trauma triage tool may improve the identification of high-risk patients and reduce under-triage [62]. However, paramedics' compliance to trauma triage tools was shown to decrease with patients aged ≥ 55 years compared to younger adults [63], which is consistent with our findings.…”

“…No standardised Patient-Reported Outcome Measures (PROMs) were used to assess patient outcomes. A recent review highlighted the importance of assessing outcomes beyond mortality for older trauma patients [62]. It also argued that assessing both clinical and patient outcomes are important for this population to strike an ethical balance between paternalism (in healthcare provision) and autonomy (of the patient in what they expect and seek) when caring for this population [62].…”

“…A recent review highlighted the importance of assessing outcomes beyond mortality for older trauma patients [62]. It also argued that assessing both clinical and patient outcomes are important for this population to strike an ethical balance between paternalism (in healthcare provision) and autonomy (of the patient in what they expect and seek) when caring for this population [62]. Therefore, it is important to determine appropriate Clinician-Reported Outcome Measures (CROMs) and PROMs to appropriately assess the impact of prehospital trauma triage decisions and the benefits TC care for this population.…”

Frailty Identification in Prehospital Care: A Scoping Review of the Literature

“… 7 Current triage and management guidelines in prehospital care and are not clear about how to optimise the level of care provided to this population. 8 For example, recent evidence showed that most current and developed geriatric-specific trauma triage criteria applied in prehospital care were not accurate in identifying older patients who had high injury severity and/or required trauma center care. 9 This is potentially due to the fact that prehospital triage criteria and paramedics’ judgments on how to manage patients are predominantly reliant on physiological variables.…”