The geriatric trauma patient: A neglected individual in a mature trauma system

Abstract

BACKGROUND Those older than 65 years represent the fastest growing demographic in the United States. As such, their care has been emphasized by trauma entities such as the American College of Surgeons Committee on Trauma. Unfortunately, much of that focus has been of their care once they reach the hospital with little attention on the access of geriatric trauma patients to trauma centers (TCs). We sought to determine the rate of geriatric undertriage (UT) to TCs within a mature trauma system and hypothesized that there would be variation and clustering of the geriatric undertriage rate (UTR) within a mature trauma system because of the admission of geriatric trauma patient to nontrauma centers (NTCs). METHODS From 2003 to 2015, all geriatric (age >65 years) admissions with an Injury Severity Score of greater than 9 from the Pennsylvania Trauma Systems Foundation (PTSF) registry and those meeting trauma criteria (International Classification of Diseases, Ninth Revision: 800–959) from the Pennsylvania Health Care Cost Containment Council (PHC4) database were included. Undertriage rate was defined as patients not admitted to TCs (n = 27) divided by the total number of patients as from the PHC4 database. The PHC4 contains all inpatient admissions within Pennsylvania (PA), while PTSF reports admissions to PA TCs. The zip code of residence was used to aggregate calculations of UTR as well as other aggregate patient and census demographics, and UTR was categorized into lower, middle box, and upper quartiles. ArcGIS Desktop: Version 10.7, ESRI, Redlands, CA and GeoDa: Version 1.14.0, Open source license were used for geospatial mapping of UT with a spatial empirical Bayesian smoothed UTR, and Stata: Version 16.1, Stata Corp., College Station TX was used for statistical analyses. RESULTS Pennsylvania Trauma Systems Foundation had 58,336 cases, while PHC4 had 111,626 that met the inclusion criteria, resulting in a median (Q1–Q3) smoothed UTR of 50.5% (38.2–60.1%) across PA zip code tabulation areas. Geospatial mapping reveals significant clusters of UT regions with high UTR in some of the rural regions with limited access to a TC. The lowest quartile UTR regions tended to have higher population density relative to the middle or upper quartile UTR regions. At the patient level, the lowest UTR regions had more racial and ethnic diversity, a higher injury severity, and higher rates of treatment at a TC. Undertriage rate regions that were closer to NTCs had a higher odds of being in the upper UTR quartile; 4.48 (2.52–7.99) for NTC with less than 200 beds and 8.53 (4.70–15.47) for NTC with 200 beds or greater compared with zip code tabulation areas with a TC as the closest hospital. CONCLUSION There are significant clusters of geriatric UT within a mature trauma system. Increased emphasis needs to focus prehospital on identifying the severely injured geriatric patient including specific geriatric triage protocols. LEVEL OF EVIDENCE Epidemiological, Level III.

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

“…Most of the included studies were conducted in the USA (n = 21) [36,[38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57]. Eleven studies were published in the last five years [41, 43-45, 47, 50, 52, 55-58], four of which were published in 2020 [41,[55][56][57]. All studies were retrospective cohort studies and only one study additionally included a survey (Table 1).…”

“…Most common examples of prehospital triage tools are Field Triage Decision Scheme in the USA [59] and the Major Trauma Triage Tool in the UK [60]. Different triage tools are applied in different countries even some states, cities, or trusts within [58] The majority of injured younger patients were transported to a TC (n = 578, 55%) whereas the majority of injured older patients were transported to a non-TC (n = 232 [40%], P < 0.001) The odds of transporting older trauma patients to TCs in Australia decreased with age as those who aged 65 to 74 years had a 48% reduction in the rate of TC transport (adjusted OR 0.52, 95% CI 0.35-0.78) compared to 63% reduction for others aged ≥ 85 years (adjusted OR 0.37, 95% CI 0.24-0.55) Overall, a fall from standing resulted in more than 53% reduced odds of TC transport (adjusted OR 0.47, 95% CI 0.33-0.67) Positive predictors of TC transport included motor vehicle crash (adjusted OR 2.5, 95% CI 1.6-4.0) and male gender (adjusted OR 1.4, 95% CI 1.1-1.8) Chang et al (2008) [46] The rate of under-triage among older trauma patients was 50% compared to 18% for younger trauma patients (P < 001) Older trauma patients who aged ≥ 65 years had a 52% reduced chance to be transported to TCs (OR, 0.48; 95% CI 0.30-0.76) after controlling of possible confounding factors (year, sex, physiology, injury, or mechanism criteria, transport reasons, prehospital care provider training level, presence or absence of 18 specific injuries, and jurisdictional region) Cox et al ( 2014) [37] In a univariate logistic analysis, with each increase of age by one year, the chance of being transported to TCs decreased by 2 percent (OR 0.982, 95% CI 0.982-0.983) The unadjusted odds of transporting injured older adults to a TC was 57% lower (OR 0.431; 95% CI 0.416, 0.446) than for injured younger adults Davis et al (2012) [38] For [47] Older injured adults had a higher chance of being transferred to non-TCs in comparison with younger trauma patients (53% vs. 34%, p < 0.05) Older injured patients also had a less chance to be transported by HEMS (14.6% vs. 20%, p < 0.05) After controlling for confounding factors and distance measures, the study showed that older trauma patients had a significantly less chance of being transported to and treated at TCs (OR = 0.54, 95% CI 0.52-0.56), whether they were initially transported by ambulance from the scene (OR = 0.47, 95% CI 0.44-0.50) or through inter-facility transfers from non-TCs (OR = 0.63, 95%CI 0.59-0.68) Garwe et al (2020) [55] The results of this study showed that 57% of older trauma patients were treated at non-TCs compared to 43% at TCs Patients treated at TCs were younger, predominantly (P < 0.05) male, had traffic-related or penetrating injuries, more likely to be transported by ambulance from the injury scene, and injured to place close from tertiary or level III TCs Patients aged ≥ 65 years had a disproportionately higher rate of treatment at non-TCs than that at TCs (82% vs 64%) and the majority of the injuries (82%) were fall-related Horst et al (2020) [56] The median under-triage rate for older trauma patients was 50.5% (Inter-quartile Range [IQR], 38.2-60.1%)…”

The incidence of geriatric trauma is increasing and comparison of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients

“…However, along with the aging population, geriatric trauma is rapidly becoming a major public health concern [3]. Geriatric trauma patients are more prone to poor prognosis due to complicated underlying diseases, various medication use, and limited physiological reserve [4][5][6][7][8]. A growing number of countries have pay attention to these populations, and some researchers even suggested it is necessary to build specific geriatric trauma centers [9][10][11].…”

The incidence of geriatric trauma is increasing and comparison of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients

“…However, along with the aging population, geriatric trauma is rapidly becoming a major public health concern [3]. Geriatric trauma patients are more prone to poor prognosis due to complicated underlying diseases, various medication use, and limited physiological reserve [4][5][6][7][8]. A growing number of countries have pay attention to these populations, and some researchers even suggested it is necessary to build speci c geriatric trauma centers [9][10][11].…”