Geriatric-Specific Triage Criteria Are More Sensitive Than Standard Adult Criteria in Identifying Need for Trauma Center Care in Injured Older Adults

doi:10.1016/j.annemergmed.2014.04.019

Annals of Emergency Medicine

Volume 65, Issue 1, January 2015, Pages 92-100.e3

Presented at the 2013 American College of Emergency Physicians Research Forum, October 2013, Seattle, WA.

https://doi.org/10.1016/j.annemergmed.2014.04.019 Get rights and content

Study objective

We evaluate the sensitivity of Ohio's 2009 emergency medical services (EMS) geriatric trauma triage criteria compared with the previous adult triage criteria in identifying need for trauma center care among older adults.

Methods

We studied a retrospective cohort of injured patients aged 16 years or older in the 2006 to 2011 Ohio Trauma Registry. Patients aged 70 years or older were considered geriatric. We identified whether each patient met the geriatric and the adult triage criteria. The outcome measure was need for trauma center care, defined by surrogate markers: Injury Severity Score greater than 15, operating room in fewer than 48 hours, any ICU stay, and inhospital mortality. We calculated sensitivity and specificity of both triage criteria for both age groups.

Results

We included 101,577 patients; 33,379 (33%) were geriatric. Overall, 57% of patients met adult criteria and 68% met geriatric criteria. Using Injury Severity Score, for older adults geriatric criteria were more sensitive for need for trauma center care (93%; 95% confidence interval [CI] 92% to 93%) than adult criteria (61%; 95% CI 60% to 62%). Geriatric criteria decreased specificity in older adults from 61% (95% CI 61% to 62%) to 49% (95% CI 48% to 49%). Geriatric criteria in older adults (93% sensitivity, 49% specificity) performed similarly to the adult criteria in younger adults (sensitivity 87% and specificity 44%). Similar patterns were observed for other outcomes.

Conclusion

Standard adult EMS triage guidelines provide poor sensitivity in older adults. Ohio's geriatric trauma triage guidelines significantly improve sensitivity in identifying Injury Severity Score and other surrogate markers of the need for trauma center care, with modest decreases in specificity for older adults.

Introduction

The population of older adults in the United States has been increasing significantly, and this growth is associated with an increasing number of traumatic injuries in this population. Injury is currently the fifth leading cause of death in older adults.1, 2, 3 Adults older than 65 years currently account for almost a quarter of all trauma admissions in the United States.1, 2, 3 This is a unique population of injured patients, different from younger adults. They have increased rates of comorbidities, adverse functional outcomes, other morbidities, and mortality compared with younger adults.4, 5, 6, 7, 8, 9, 10, 11, 12

Editor's Capsule Summary

What is already known on this topic

Older adults with life-threatening injuries are at risk of undertriage.

What question this study addressed

The authors used a 101,577-patient database to compare the sensitivity and specificity of the Ohio geriatric trauma triage criteria and standard adult criteria in identifying markers of the need for trauma center care.

What this study adds to our knowledge

The geriatric criteria are more sensitive but less specific than standard criteria for identifying older patients with serious injuries, need for operative or ICU care, or death.

How this is relevant to clinical practice

These criteria should reduce undertriage in older patients. The cost of this change and whether this change improves outcomes are unknown.

A key determinant of outcome after injury is appropriate triage by emergency medical services (EMS) providers, with transport to a trauma center when needed. For both the general trauma population and the older adult population, trauma center care improves mortality and other outcomes.13, 14, 15, 16, 17 Field triage guidelines followed by US EMS providers generally follow recommendations of national organizations.¹⁸ Although age can be a consideration in these guidelines, specific criteria aimed at the older adult population have not generally been used. Several authors have demonstrated that application of standard criteria to older adults results in high rates of undertriage.19, 20, 21, 22 As a result, older adults with severe injury are less likely to be transported to a trauma center than younger adults. For example, undertriage rates begin increasing at aged 60 years, and rates as high as 60% have been demonstrated for patients aged 90 years and older.¹⁹

In light of these studies, the Ohio Department of Public Safety established geriatric trauma triage criteria for statewide implementation by EMS providers on December 29, 2008.²³ These geriatric criteria modified the state's adult triage criteria for application in the geriatric population. The methods of their development have been described elsewhere.4, 24 Although proposed age cutoffs for designating injured patients as “geriatric” have ranged from 55 to 70 years, the Ohio criteria use 70 years as the cutoff, based on analysis of the Ohio Trauma Registry.⁴ The geriatric triage criteria include modifications to the standard adult triage criteria, including consideration of systolic blood pressure less than 100 mm Hg, any abnormality in Glasgow Coma Scale (GCS) score, fracture of any long bone in a motor vehicle crash, injury to 2 or more body regions, pedestrian struck by motor vehicle, and any fall with evidence of traumatic brain injury (Table 1). Studies have proven validity for select elements of the new geriatric triage criteria.25, 26 However, the accuracy of the Ohio geriatric triage criteria has not yet been systematically evaluated. If proven to more accurately identify older patients needing trauma center care, the geriatric triage criteria could be reproduced in other locales and potentially improve outcomes for this vulnerable population.

The goal of this study was to evaluate the sensitivity of the Ohio geriatric trauma triage criteria compared with the adult triage criteria in identifying need for trauma center care among injured older adults. Our primary hypothesis was that the geriatric triage criteria would offer improved sensitivity for the need for trauma center care compared with the adult triage criteria in the older adult population. We used surrogate markers of need for trauma center care, including Injury Severity Score greater than 15, operating room visit within 48 hours, any ICU stay, and inhospital mortality.

Section snippets

Study Design and Setting

We conducted a retrospective observational cohort study of injured patients in the 2006 through 2011 Ohio Trauma Registry. Hospital institutional review board approval was obtained. For reporting, we adhered to the Strengthening the Reporting of Observational Studies in Epidemiology statement.²⁷ Local institutional review board approval was obtained.

Selection of Participants

The Ohio Trauma Registry is a statewide database maintained by the Ohio Department of Public Safety.²⁸ Because participation is required by law,

Results

The flow diagram for study enrollment is shown in the Figure. Initial review revealed 20,887 records indicating a transfer from an initial ED to another receiving ED and 20,854 receiving ED records indicating arrival from an initial ED. Of these, 15,195 (73%) could be linked by Ohio Department of Public Safety. After addition of records with only 1 site of care and applying study exclusion criteria, there were 101,577 patients eligible for study inclusion. These included 13,716 (13%) linked

Limitations

Study limitations include those inherent in the use of a large, preexisting database. Data abstraction is performed by local hospitals whose personnel are trained and who use a data dictionary, but this may result in variable skill levels at data abstraction. The use of the Ohio Department of Public Safety Trauma Registry could also result in selection bias because only injured patients who died, were transferred, or were admitted for greater than or equal to 48 hours are included in the

Discussion

Using a statewide trauma registry, we demonstrated that application of Ohio's geriatric trauma triage guidelines to the older adult population would result in improved sensitivity, with acceptable decreases in specificity for older adults. We showed that current standard adult triage guidelines provide poor sensitivity in identifying older adults with moderate to severe injury who need trauma center care. In addition, we found that using the geriatric trauma triage guidelines in younger adults

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A cohort study of severely injured adult trauma patients admitted to the intensive care unit 2014-2018 was performed using trauma registry data. Random forest algorithms predicting poor outcomes (death or complication) were built and validated using three cohorts: (1) patients of all ages, (2) younger patients, and (3) older patients. Older patients were defined as aged 55 y or more to maintain consistency with prior trauma literature. Complications assessed included acute renal failure, acute respiratory distress syndrome, cardiac arrest, unplanned intubation, unplanned intensive care unit admission, and unplanned return to the operating room, as defined by the trauma quality improvement program. Mean decrease in model accuracy (MDA), if each variable was removed and scaled to a Z-score, was calculated. MDA change ≥4 standard deviations between age cohorts was considered significant.
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Logistic regression showed a significant association between being seen in a standard initial assessment area (referred to as pitstop in this article) vs the resuscitation room as a first location (p = 0.007) with a delayed diagnosis; and a significant association between plain film imaging vs CT imaging (p = 0.000) and no trauma call vs trauma call (p = 0.009) with a missed diagnosis of major trauma.
The findings of this service evaluation suggest that service improvement initiatives should be aimed at the early stages of the patient journey to improve missed or delayed diagnoses of major trauma in this patient group.
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The geriatric triage protocol at the study institution was modified from SBP <90 mmHg to SBP <110 mmHg and then to SBP <100 mmHg. The purpose of this study is to evaluate the impact of adjusting geriatric triage protocols on patient outcomes.
A single-center retrospective review was conducted on trauma patients 65 years or older. Three study periods with different geriatric specific trauma team activation (TTA) protocols (Group 1-SBP<90 mmHg; Group 2-SBP<110 mmHg; Group 3-SBP<100 mmHg) were compared.
2016 patients were included. There were no differences in mortality rates or need for trauma intervention (NFTI) rates among the three groups. The SBP <100 mmHg and SBP <110 mmHg groups had similar under-triage rates. The NFTI over-triage rate in the SBP <100 mmHg group was lower than the SBP <110 mmHg group.
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Decision aids to guide imaging for older trauma patients are needed to improve consistency and quality of care. We have identified groupings of clinical variables that are predictive of injury to guide CT imaging after geriatric blunt trauma. Further study is needed to refine and validate these models.
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: Mr. Darbha was formerly affiliated with the Department of Emergency Medicine, The Ohio State University, Columbus, OH.

: Please see page 93 for the Editor's Capsule Summary of this article.

: Supervising editor: Timothy F. Platts-Mills, MD, MSc

: Author contributions: BI, SD, and JMC conceived and designed the study and acquired the data. BI, SD, MNS, and JMC analyzed and interpreted the data. BI and JMC drafted the article. MNS, LT, DCE, and CTB reviewed the article for important intellectual content. SD, MNS, and JMC provided statistical expertise. JMC takes responsibility for the paper as a whole.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. This study was funded by a 2013 Trauma Grant from the Ohio Department of Public Safety. Mr. Ichwan was supported by an Ohio State University College of Medicine Roessler Scholarship. Dr. Caterino was supported in part by 1K23AG038351-01 from the National Institute on Aging.

: The sponsors had no input on the analysis or reporting of results.

: A feedback survey is available with each research article published on the Web at www.annemergmed.com.

: A podcast for this article is available at www.annemergmed.com.

View full text

Geriatrics/original researchGeriatric-Specific Triage Criteria Are More Sensitive Than Standard Adult Criteria in Identifying Need for Trauma Center Care in Injured Older Adults

Study objective

Methods

Results

Conclusion

Introduction

Editor's Capsule Summary

Section snippets

Study Design and Setting

Selection of Participants

Results

Limitations

Discussion

Clin Geriatr Med

Am J Emerg Med

J Am Coll Surg

Ann Emerg Med

J Clin Epidemiol

J Am Coll Surg

J Emerg Nurs

Geriatric trauma: demographics, injuries, and mortality

J Orthop Trauma

Traumatic brain injury in older adults: epidemiology, outcomes, and future implications

J Am Geriatr Soc

Characteristics and outcomes of serious traumatic injury in older adults

J Am Geriatr Soc

Mortality in trauma patients: the interaction between host factors and severity

J Trauma

Preventable complications and death from multiple organ failure among geriatric trauma victims

J Trauma

Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death

J Trauma

Evaluation and management of geriatric trauma: an Eastern Association for the Surgery of Trauma practice management guideline

J Trauma Acute Care Surg

A simple clinical risk nomogram to predict mortality-associated geriatric complications in severely injured geriatric patients

J Trauma Acute Care Surg

Mortality factors in geriatric blunt trauma patients: creation of a highly predictive statistical model for mortality using 50,765 consecutive elderly trauma admissions from the National Sample Project

Am Surg

Trauma in the very elderly: a community-based study of outcomes at trauma and nontrauma centers

J Trauma

Evaluation of a mature trauma system

Ann Surg

Assessing effectiveness of a mature trauma system: association of trauma center presence with lower injury mortality rate

J Trauma

The effect of trauma center designation and trauma volume on outcome in specific severe injuries

Ann Surg

Direct transport within an organized state trauma system reduces mortality in patients with severe traumatic brain injury

J Trauma

Geriatrics/original research
Geriatric-Specific Triage Criteria Are More Sensitive Than Standard Adult Criteria in Identifying Need for Trauma Center Care in Injured Older Adults