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

Abstract

Background It is argued that many older trauma patients are under-triaged in prehospital care which may adversely affect their outcomes. This systematic review aimed to assess prehospital under-triage rates for older trauma patients, the accuracy of the triage criteria, and the impact of prehospital triage decisions on outcomes. Methods A computerised literature search using MEDLINE, Scopus, and CINHAL databases was conducted for studies published between 1966 and 2021 using a list of predetermined index terms and their associated alternatives. Studies which met the inclusion criteria were included and critiqued using the Critical Appraisal Skills Programme tool. Due to the heterogeneity of the included studies, narrative synthesis was used in this systematic review. Results Of the 280 identified studies, 23 met the inclusion criteria. Current trauma triage guidelines have poor sensitivity to identify major trauma and the need for TC care for older adults. Although modified triage tools for this population have improved sensitivity, they showed significantly decreased specificity or were not applied to all older people. The issue of low rates of TC transport for positively triaged older patients is not well understood. Furthermore, the benefits of TC treatment for older patients remain uncertain. Conclusions This systematic review showed that under-triage is an ongoing issue for older trauma patients in prehospital care and its impact on their outcomes is still uncertain. Further high-quality prospective research is needed to assess the accuracy of prehospital triage criteria, the factors other than the triage criteria that affect transport decisions, and the impact of under-triage on outcomes.

Characteristics associated with delays in decision to transfer injured patients

“…The under triage of geriatric trauma patients has been demonstrated numerous times. [12][13][14] Reasons for under triage are likely multifactorial, including comorbidities, medications blunting physiologic response, and frailty. Standard trauma scoring systems and triage guidelines may not be sensitive enough for this population.…”

The association between major trauma centre care and outcomes of adult patients injured by low falls in England and Wales

“…Similar findings have been reported in other economically developed nations. [3][4][5][6] There is evidence that the emerging cohort are at greater risk of being under-triaged, 7,8 are less likely to receive care at a higher-level trauma facility, 9,10 are more likely to be treated by junior clinicians, more likely to have longer waits for CT scans, and are less likely to be transferred to a neurosciences unit. 11,12 A recent systematic review has demonstrated that higher-level trauma centres are associated with lower mortality than lower-level trauma centres in patients with major trauma (adjusted odds ratio, AOR, 0.77; 95% CI 0.69-0.87).…”

“…Similar findings have been reported in other economically developed nations. 3–6 There is evidence that the emerging cohort are at greater risk of being under-triaged, 7,8 are less likely to receive care at a higher-level trauma facility, 9,10 are more likely to be treated by junior clinicians, more likely to have longer waits for CT scans, and are less likely to be transferred to a neurosciences unit. 11,12…”

Triage tools: a cautious (and critical) view towards their use in old patients

“…It has been described repeatedly how current triage methods produce inadequately low results in older patients [9][10][11]. This risk of underestimation of urgency translates into longer waiting times and a higher risk of adverse outcomes due to the delay [12][13][14]. Therefore, despite the usefulness of triage tools, we recognize inconsistencies and notable room for improvement that force us to be cautious in their interpretation and to consider their critical review.…”

“…Relevant to geriatric medicine is the fact that all triage methods show, in older adults, lower levels of efficacy than in the global population [9][10][11]. In consequence, old patients are at greater risk of being assigned an inappropriately low triage level, which translates into longer waiting times and a higher risk of adverse outcomes [12][13][14]. The poorer performance of traditional triage tools in the older population, which underestimate the urgency [23,24], is often explained by a high frequency of atypical presentations of acute conditions, due to associated factors, such as polypharmacy, delirium or dementia that may cloud the clinical presentation of diseases [25], by the non-inclusion in scores of agecorrection factors of vital signs, and by ageism, which can also contribute to poor care and lack of compliance with evidence-based practices [26].…”