Physiologic Field Triage Criteria for Identifying Seriously Injured Older Adults

Newgard, Craig D.; Richardson, Derek; Holmes, James F.; Rea, Thomas D.; Hsia, Renee Y.; Mann, N. Clay; Staudenmayer, Kristan; Barton, Erik D.; Bulger, Eileen M.; Haukoos, Jason S.

doi:10.3109/10903127.2014.912707

Cited by 54 publications

(87 citation statements)

References 32 publications

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“…Recent studies have reconfirmed these special considerations by suggesting a change in the physiological criteria for older adults 22 and that older adults, in general, are often under-triaged. 23 The literature indicates that older age is known to negatively influence TBI outcomes 24 ; however, not much is known about the treatment paths for TBI for any population.…”

Section: Introductionmentioning

confidence: 97%

Hospitalized Traumatic Brain Injury: Low Trauma Center Utilization and High Interfacility Transfers among Older Adults

Faul¹,

Xu²,

Sasser³

2016

Prehospital Emergency Care

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Objective Guidelines suggest that Traumatic Brain Injury (TBI) related hospitalizations are best treated at Level I or II trauma centers because of continuous neurosurgical care in these settings. This population-based study examines TBI hospitalization treatment paths by age groups. Methods Trauma center utilization and transfers by age groups were captured by examining the total number of TBI hospitalizations from National Inpatient Sample (NIS) and the number of TBI hospitalizations and transfers in the Trauma Data Bank National Sample Population (NTDB-NSP). TBI cases were defined using diagnostic codes. Results Of the 351,555 TBI related hospitalizations in 2012, 47.9% (n = 168,317) were directly treated in a Level I or II trauma center, and an additional 20.3% (n = 71,286) were transferred to a Level I or II trauma center. The portion of the population treated at a trauma center (68.2%) was significantly lower than the portion of the U.S. population who has access to a major trauma center (90%). Further, nearly half of all transfers to a Level I or II trauma center were adults aged 55 and older (p < 0.001) and that 20.2% of pediatric patients arrive by non-ambulatory means. Conclusion Utilization of trauma center resources for hospitalized TBIs may be low considering the established lower mortality rate associated with treatment at Level I or II trauma centers. The higher transfer rate for older adults may suggest rapid decline amid an unrecognized initial need for a trauma center care. A better understanding of hospital destination decision making is needed for patients with TBI.

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Section: Introductionmentioning

confidence: 97%

Hospitalized Traumatic Brain Injury: Low Trauma Center Utilization and High Interfacility Transfers among Older Adults

Faul¹,

Xu²,

Sasser³

2016

Prehospital Emergency Care

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“…29 A similar study by Newgard et al that evaluated a revised physiologic criteria for prehospital identification of seriously injured older adults also concluded that the revised criteria would increase sensitivity, reduce specificity, and increase the proportion of patients without serious injuries transported to TTCs by 60%. 30 Wasserman et al has also proposed a new algorithm to detect older adult patients with TBI derived from previously established scales (GCS, level of alertness, etc. ), however this algorithm needs further evaluation before it can be adopted.…”

Section: Discussionmentioning

confidence: 99%

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

Garwe

Stewart

Stoner³

et al. 2017

Prehospital Emergency Care

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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.

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“…Thus, the one-size-fits-all approach to field triage guidelines may be inadequate for injured elderly patients. Previous studies have explored elderly-specific triage criteria, 19–21 although there is a need to pull these modifications together in a manner that allows integration with the current national triage guidelines and to compare with current triage processes. Defining “serious injury” in older adults also remains unclear, as definitions used for younger populations may not be appropriate.…”

Section: Introductionmentioning

confidence: 99%

“…This study builds upon recent work developing triage guidelines specific to injured older adults. 19–21 Sixteen Institutional Review Boards at 7 sites approved this protocol and waived the requirement for informed consent.…”

Section: Introductionmentioning

confidence: 99%

Improving early identification of the high-risk elderly trauma patient by emergency medical services

Newgard

Holmes

Haukoos

et al. 2016

Injury

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Study Objective We sought to (1) define the high-risk elderly trauma patient based on prognostic differences associated with different injury patterns and (2) derive alternative field trauma triage guidelines that mesh with national field triage guidelines to improve identification of high-risk elderly patients. Methods This was a retrospective cohort study of injured adults ≥ 65 years transported by 94 EMS agencies to 122 hospitals in 7 regions from 1/1/2006 through 12/31/2008. We tracked current field triage practices by EMS, patient demographics, out-of-hospital physiology, procedures and mechanism of injury. Outcomes included Injury Severity Score ≥ 16 and specific anatomic patterns of serious injury using Abbreviated Injury Scale score ≥ 3 and surgical interventions. In-hospital mortality was used as a measure of prognosis for different injury patterns. Results 33,298 injured elderly patients were transported by EMS, including 4.5% with ISS ≥ 16, 4.8% with serious brain injury, 3.4% with serious chest injury, 1.6% with serious abdominal-pelvic injury and 29.2% with serious extremity injury. In-hospital mortality ranged from 18.7% (95% CI 16.7–20.7) for ISS ≥ 16 to 2.9% (95% CI 2.6–3.3) for serious extremity injury. The alternative triage guidelines (any positive criterion from the current guidelines, GCS ≤ 14 or abnormal vital signs) outperformed current field triage practices for identifying patients with ISS ≥ 16: sensitivity (92.1% [95% CI 89.6–94.1%] vs. 75.9% [95% CI 72.3–79.2%]), specificity (41.5% [95% CI 40.6–42.4%] vs. 77.8% [95% CI 77.1–78.5%]). Sensitivity decreased for individual injury patterns, but was higher than current triage practices. Conclusions High-risk elderly trauma patients can be defined by ISS ≥ 16 or specific non-extremity injury patterns. The field triage guidelines could be improved to better identify high-risk elderly trauma patients by EMS, with a reduction in triage specificity.

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Physiologic Field Triage Criteria for Identifying Seriously Injured Older Adults

Cited by 54 publications

References 32 publications

Hospitalized Traumatic Brain Injury: Low Trauma Center Utilization and High Interfacility Transfers among Older Adults

Hospitalized Traumatic Brain Injury: Low Trauma Center Utilization and High Interfacility Transfers among Older Adults

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

Improving early identification of the high-risk elderly trauma patient by emergency medical services

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