Out-of-hospital and Inter-hospital Under-triage to Designated Tertiary Trauma Centers among Injured Older Adults: A 10-year Statewide Geospatial-Adjusted Analysis

Abstract

Objective While out-of-hospital under-triage of seriously injured older adults to tertiary trauma centers has long been acknowledged, no study has adjusted for place of injury or evaluated the extent of inter-facility under-triage. We sought to determine distance and confounder adjusted odds of treatment at a tertiary trauma center (TTC) for older adult trauma patients compared to younger trauma patients, for patients transported from the scene of injury and those transferred from a non-tertiary trauma (NTTC) center. Methods This was a retrospective cohort study utilizing data from a statewide trauma registry reported over a 10-year period (2005–2014). The outcome of interest was treatment at an American College of Surgeons or state-designated Level I/II trauma center (TTC). The predictor variable of interest was age group (>=55 years vs < 55 years). Covariates of interest included patient demographics, clinical characteristics and various distance measures calculated based on the patient’s injury location. Results 84 930 patients met study criteria. Of these 42% (35659) were 55 years and older with an average age of 74 years (SD, 11.6). Older adult patients were on average, injured slightly farther away from a TTC (median distance, 34 vs 29 miles, p<0.001). Among patients initially presenting to NTTCs, older adults were significantly more likely to be transferred to another NTTC (53% vs 34%). After adjusting for confounders and distance measures, older adults were less likely to be treated at TTCs overall (OR=0.54, 95% CI: 0.52–0.56), whether transported by EMS from the scene of injury (OR= 0.47, 95% CI: 0.44–0.50) or via inter-facility transfer (OR= 0.63, 95%CI: 0.59 – 0.68). Conclusions Injured older adults face significant under-triage to TTCs whether by EMS from the scene of injury or via transfer from NTTCs. Adjusting for proximity of injury to a TTC does not alter these findings.

Identifying Predictors of Undertriage in Injured Older Adults After Implementation of Statewide Geriatric Trauma Triage Criteria

“…This may have important implications in this population as the risk‐adjusted odds of death in Level III trauma centers has been reported to be 1.24‐fold higher than in Level I and II centers . This also suggests an area of focus for decreasing undertriage of older adults . In addition to rural areas specifically, although there is overlap, areas local Level III trauma centers should be a focus.…”

“…It was thought that there would be an inversely relationship between a trauma center in the county of residence and transport to a trauma center. A recent study by Garwe et al . concluded that geriatric trauma patients were undertriaged even after adjusting for proximity to a tertiary care center.…”

Building consensus to enhance research: A study protocol to determine the top issues to improve outcomes of Silver Trauma

“…Current literature has a complexity in determining research priorities in the field of improving outcomes for injured older adults. For example, several issues around the field of prehospital triage of silver trauma were identified in the literature (Chang et al, 2008;Cox et al, 2014;Garwe et al, 2017;Ichwan et al, 2015;Kodadek et al, 2015;Lehmann et al, 2009;Nakamura et al, 2012;Newgard et al, 2016;Staudenmayer et al, 2013), however, only some of them were assessed for their impact on outcomes (Caterino et al, 2016;Cox et al, 2014;Staudenmayer et al, 2013). Furthermore, those issues which were investigated for their impact on outcomes showed conflicting evidence.…”

“…There is an absence of strong evidence in silver trauma research. For example, all published studies that investigated the issue of prehospital triage for injured older adults applied a retrospective design (Caterino et al, 2016;Cox et al, 2014;Garwe et al, 2017;Ichwan et al, 2015;Kodadek et al, 2015;Lehmann et al, 2009;Nakamura et al, 2012;Newgard et al, 2016;Staudenmayer et al, 2013) or incorporated a survey for their retrospective analysis (Chang et al, 2008). This suggests a need for high-quality research in this field for better understanding of issues in this field and a more active intervention to improve the quality of trauma care for older people.…”

“…Lack of evidence from the UK for some issues in silver trauma represents an obstacle in current clinical practice. For instance, all published studies on prehospital triage of silver trauma were from the United States (US) and Australia (Caterino et al, 2016;Chang et al, 2008;Cox et al, 2014;Garwe et al, 2017;Ichwan et al, 2015;Kodadek et al, 2015;Lehmann et al, 2009;Nakamura et al, 2012;Newgard et al, 2016;Staudenmayer et al, 2013). There is a report that was published in 2017 from Trauma Audit and Research Network (TARN) about major trauma of older people in England and Wales which has a section about prehospital triage for this population (Trauma Audit and Research Network, 2017).…”