Undertriage of the elderly major trauma patient continues in major trauma centre care: a retrospective cohort review

Abstract

BackgroundMajor trauma (Injury Severity Score (ISS) ≥16) in older people is increasing, but concerns persist that major trauma is not always recognised in older patients on triage. This study compared undertriage of older and younger adult major trauma patients in the major trauma centre (MTC) setting to investigate this concern.MethodsA retrospective review of Trauma Audit and Research Network data was conducted for three MTCs in the UK for 3 months in 2014. Age, ISS, injury mechanism and injured areas were examined for all severely injured patients (ISS ≥16) and appropriate major trauma triage rates measured via the surrogate markers of trauma team activation and the presence of a consultant first attender, as per standards for major trauma care set by National Confidential Enquiry into Patient Outcomes and Deaths, Royal College of Surgeons of England and the British Orthopaedic Association. Trends in older (age ≥65) and younger (ages 18–64) adult major trauma presentation, triage and reception were reviewed.ResultsOf 153 severely injured patients, 46 were aged ≥65. Older patients were significantly less likely to receive the attention of a consultant first attender or trauma team. Similar trends were also seen on subgroup analysis by mechanism of injury or number of injured body areas. Older major trauma patients exhibit a higher mortality, despite a lower median ISS (older patient ISS=20 (IQR 16–25), younger patient ISS=25 (IQR 18–29)).ConclusionOlder major trauma patients are at greater risk of undertriage, even in the MTC environment. Existing hospital trauma triage practices should be further investigated to explain and reduce undertriage of elderly trauma patients.

664 The ICON Trauma Study: The Impact of the COVID-19 Lockdown on Major Trauma Workload in the UK

“…This vulnerable patient group appear to sustain significant injuries even from falls less than 2 m and have a higher risk of mortality. This finding is consistent with other studies which demonstrate a twofold increased risk of mortality in the elderly population compared to younger patients [21,28].…”

Evaluation of elderly specific pre-hospital trauma triage criteria: a systematic review

“…The under-triage of elderly trauma patients and associated harm is well-reported, and improving sensitivity of elderly trauma triage is a priority [ 5 , 11 , 13 , 44 ]. The published elderly-specific triage criteria substantially improve upon adult triage tools, although the reported sensitivity is highly variable.…”

“…A broader inclusion is important to allow assessment of the effects of elderly-specific triage criteria across the whole elderly trauma population. The widely reported high under-triage rates of elderly trauma patients highlights the difficulties in identifying these patients [ 5 , 11 , 13 , 14 , 24 , 44 ]. A clinically implemented elderly-specific triage tool will therefore need to apply to the whole elderly trauma population in order to reduce this substantial under-triage rate.…”

“…Current pre-hospital triage tools are ineffective in identifying elderly major trauma patients [ 5 , 10 – 13 ]. Developing a pre-hospital triage tool with acceptable under- and over-triage rates, whilst also being useable in the pre-hospital environment, is challenging.…”

“…Globally, falls have been identified as a major public health concern and the WHO report that falls are the second leading cause of unintentional injury-related death [ 18 ]. These challenges result in high levels of under-triage of elderly trauma patients and the inability to quickly and effectively direct ongoing care [ 5 , 13 ]. Considering the mechanistic and physiological differences, major trauma triage tools specifically developed for the elderly patient population may be more efficacious.…”