Geriatric patients often sustain life-threatening injuries from minor trauma. A growing body of research suggests that these patients are often under-triaged in the emergency setting.The purpose of this research was to evaluate whether or not geriatric trauma patients are under-triaged at a community based level II trauma center.
1434 trauma patients over the age of 65 presenting from 2010-2015 were retrospectively reviewed from the Cabell Huntington Hospital trauma registry and analyzed for age, gender, arrival type, ED response, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), injury cause, ICD-9 diagnosis codes, and mortality. Under-triage and over-triage rates were determined using the Cribari method (under-triage = ISS ≥ 16 without full trauma team activation [TTA]; Over-triage = ISS ≤ 15 with full TTA).
The under-triage rate was 9.5% (132/1393) with the majority of under-triaged patients having head trauma (n=423). There were 371 head trauma patients with a recorded GCS and analysis shows those with a GCS ≥ 13 had a 1.2% mortality risk (n=326; ISS 10.2), but that risk drastically increases to 60% with GSC ≤ 12 (n=45; ISS 21.5). Of the 45 patients with GSC ≤ 12, only 4% had priority 1 TTA using the current protocol (2/45).
The American College of Surgeons-Committee of Trauma (ACS-COT) recommends an acceptable under-triage rate of < 5%. In order to improve geriatric care and reduce under-triage rates, we recommend that an age-based criteria be added to our TTA protocol at our community based Level II trauma center: priority 1 TTA for all patients 65 years or older sustaining head trauma with a GCS ≤ 12 or suspicion of intracranial hemorrhage.
Conflict(s) of Interest
Dr. Shuler serves on the editorial committee of the Marshall Journal of Medicine. Other authors have no conflicts of Interest to disclose.
References with DOI
1. Werner CA. The Old Population: 2010. In: Bureau USC, ed2011.
2. Spaniolas K, Cheng JD, Gestring ML, Sangosanya A, Stassen NA, Bankey PE. Ground level falls are associated with significant mortality in elderly patients. The Journal of trauma. 2010;69(4):821-825. https://doi.org/10.1097/ta.0b013e3181efc6c6
3. Goodmanson NW, Rosengart MR, Barnato AE, Sperry JL, Peitzman AB, Marshall GT. Defining geriatric trauma: when does age make a difference? Surgery. 2012;152(4):668-674; discussion 674-665. https://doi.org/10.1016/j.surg.2012.08.017
4. Werman HA, Erskine T, Caterino J, Riebe JF, Valasek T. Development of statewide geriatric patients trauma triage criteria. Prehospital and disaster medicine. 2011;26(3):170-179. https://doi.org/10.1017/s1049023x11006315
5. Ichwan B, Darbha S, Shah MN, et al. Geriatric-specific triage criteria are more sensitive than standard adult criteria in identifying need for trauma center care in injured older adults. Annals of emergency medicine. 2015;65(1):92-100.e103. https://doi.org/10.1016/j.annemergmed.2014.04.019
6. Bonne S, Schuerer DJ. Trauma in the older adult: epidemiology and evolving geriatric trauma principles. Clinics in geriatric medicine. 2013;29(1):137-150. https://doi.org/10.1016/j.cger.2012.10.008
7. Maxwell CA. Trauma in the geriatric population. Critical care nursing clinics of North America. 2015;27(2):183-197. https://doi.org/10.1016/j.cnc.2015.02.006
8. Demetriades D, Sava J, Alo K, et al. Old age as a criterion for trauma team activation. The Journal of trauma. 2001;51(4):754-756; discussion 756-757. https://doi.org/10.1097/00005373-200110000-00022
9. Demetriades D, Karaiskakis M, Velmahos G, et al. Effect on outcome of early intensive management of geriatric trauma patients. The British journal of surgery. 2002;89(10):1319-1322. https://doi.org/10.1046/j.1365-2168.2002.02210.x
10. Lehmann R, Beekley A, Casey L, Salim A, Martin M. The impact of advanced age on trauma triage decisions and outcomes: a statewide analysis. American journal of surgery. 2009;197(5):571-574; discussion 574-575. https://doi.org/10.1016/j.amjsurg.2008.12.037
11. Rogers A, Rogers F, Bradburn E, et al. Old and undertriaged: a lethal combination. The American surgeon. 2012;78(6):711-715.
12. Calland JF, Ingraham AM, Martin N, et al. Evaluation and management of geriatric trauma: an Eastern Association for the Surgery of Trauma practice management guideline. The journal of trauma and acute care surgery. 2012;73(5 Suppl 4):S345-350.
13. Taylor MD, Tracy JK, Meyer W, Pasquale M, Napolitano LM. Trauma in the elderly: intensive care unit resource use and outcome. The Journal of trauma. 2002;53(3):407-414. https://doi.org/10.1097/00005373-200209000-00001
14. Maxwell CA, Mion LC, Mukherjee K, et al. Preinjury physical frailty and cognitive impairment among geriatric trauma patients determine postinjury functional recovery and survival. The journal of trauma and acute care surgery. 2016;80(2):195-203. https://doi.org/10.1097/ta.0000000000000929
15. St John AE, Rowhani-Rahbar A, Arbabi S, Bulger EM. Role of trauma team activation in poor outcomes of elderly patients. The Journal of surgical research. 2016;203(1):95-102. https://doi.org/10.1016/j.jss.2016.01.036
16. Mena JH, Sanchez AI, Rubiano AM, et al. Effect of the modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction: comparing classic and modified Glasgow Coma Scale score model scores of 13. The Journal of trauma. 2011;71(5):1185-1192; discussion 1193. https://doi.org/10.1097/ta.0b013e31823321f8
17. Stevenson M, Segui-Gomez M, Lescohier I, Di Scala C, McDonald-Smith G. An overview of the injury severity score and the new injury severity score. Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention. 2001;7(1):10-13. https://doi.org/10.1136/ip.7.1.10
18. Samin OA, Civil ID. The New Injury Severity Score Versus the Injury Severity Score in Predicting Patient Outcome: A Comparative Evaluation on Trauma Service Patients of the Auckland Hospital. Annu Proc Assoc Adv Automot Med. 1999;43:1-15.
19. Surgeons ACo. ACS Committee on Trauma, Resources for the optimal care of the injured patient. 2014.
20. Nance M. National Trauma Data Bank 2011 Annual report. 2011.
21. Vincent G VV. The Next Four Decades the Older Population in the United States: 2010 to 2050. In: U.S. Dept. of Commerce EaSA, U.S. Censur Bureau, ed2010:25-1138.
22. Hildebrand F, Pape HC, Horst K, et al. Impact of age on the clinical outcomes of major trauma. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2016;42(3):317-332. https://doi.org/10.1007/s00068-015-0557-1
23. Escobar MA, Jr., Morris CJ. Using a multidisciplinary and evidence-based approach to decrease undertriage and overtriage of pediatric trauma patients. Journal of pediatric surgery. 2016. https://doi.org/10.1016/j.jpedsurg.2016.04.010
24. Sammy I, Lecky F, Sutton A, Leaviss J, O'Cathain A. Factors affecting mortality in older trauma patients-Asystematic review and meta-analysis. Injury. 2016;47(6):1170-1183. 8 Marshall Journal of Medicine, Vol. 3 , Iss. 3, Art. 7 http://mds.marshall.edu/mjm/vol3/iss3/7 DOI: http://dx.doi.org/10.18590/mjm.2017.vol3.iss3.7 ; https://doi.org/10.1016/j.injury.2016.02.027
25. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752-762. https://doi.org/10.1016/s0140-6736(12)62167-9
26. Chehade M, Gill TK, Visvanathan R. Low Energy Trauma in Older Persons: Where to Next? The open orthopaedics journal. 2015;9:361-366. https://doi.org/10.2174/1874325001509010361
27. Bhattacharya B, Maung A, Schuster K, Davis KA. The older they are the harder they fall: Injury patterns and outcomes by age after ground level falls. Injury. 2016. https://doi.org/10.1016/j.injury.2016.06.019
28. Bradburn E, Rogers FB, Krasne M, et al. High-risk geriatric protocol: improving mortality in the elderly. The journal of trauma and acute care surgery. 2012;73(2):435-440. https://doi.org/10.1097/ta.0b013e31825c7cf4
29. Oreskovich MR, Howard JD, Copass MK, Carrico CJ. Geriatric trauma: injury patterns and outcome. The Journal of trauma. 1984;24(7):565-572. https://doi.org/10.1097/00005373-198307000-00087
30. Parker S, Afsharpad A. Ground-Level Geriatric Falls: A Not-So-Minor Mechanism of Injury. Case Reports in Orthopedics. 2014;2014. https://doi.org/10.1155/2014/164632
31. Reddy S, Sharma R, Grotts J, Ferrigno L, Kaminski S. Incidence of intracranial hemorrhage and outcomes after ground-level falls in geriatric trauma patients taking preinjury anticoagulants and antiplatelet agents. The American surgeon. 2014;80(10):975-978.
32. Cheng PL, Lin HY, Lee YK, Hsu CY, Lee CC, Su YC. Higher mortality rates among the elderly with mild traumatic brain injury: a nationwide cohort study. Scandinavian journal of trauma, resuscitation and emergency medicine. 2014;22:7. https://doi.org/10.1186/1757-7241-22-7
33. Hukkelhoven CW, Steyerberg EW, Rampen AJ, et al. Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients. Journal of neurosurgery. 2003;99(4):666-673. https://doi.org/10.3171/jns.2003.99.4.0666
34. Selassie AW, Cao Y, Church EC, Saunders LL, Krause J. Accelerated death rate in population-based cohort of persons with traumatic brain injury. The Journal of head trauma rehabilitation. 2014;29(3):E8-e19. https://doi.org/10.1097/htr.0b013e3182976ad3
35. Brooks JC, Strauss DJ, Shavelle RM, Paculdo DR, Hammond FM, Harrison-Felix CL. Long-term disability and survival in traumatic brain injury: results from the National Institute on Disability and Rehabilitation Research Model Systems. Archives of physical medicine and rehabilitation. 2013;94(11):2203-2209. https://doi.org/10.1016/j.apmr.2013.07.005
36. McIntyre A, Mehta S, Aubut J, Dijkers M, Teasell RW. Mortality among older adults after a traumatic brain injury: a meta-analysis. Brain injury. 2013;27(1):31-40. https://doi.org/10.3109/02699052.2012.700086
Buchanan, Grant S.; Kahn, Daniel Scott; Burke, Harry; Czarkowski, Brian; Boe, Richard; Modarresi, Milad; and Shuler, Franklin D.
"Trauma Team Activation for Geriatric Trauma at a Level II Trauma Center: Are the Elderly Under-triaged?,"
Marshall Journal of Medicine:
3, Article 7.
Available at: http://mds.marshall.edu/mjm/vol3/iss3/7