Trends in Geriatric Ground-Level Falls: Report from the National Trauma Data Bank

Epidemiological analysis of 2106 geriatric trauma patients in a level I trauma center in Lanzhou City, Gansu Province, China

As the global population ages, geriatric trauma gains attention. Limited studies on geriatric trauma in developing countries necessitate comprehensive investigation. This study aims to delineate the epidemiological characteristics of geriatric trauma, providing insights for prevention and enhanced elderly trauma care. Clinical data of 2106 geriatric trauma patients (age ≥ 60) treated from November 1, 2020, to October 31, 2023, at the trauma center of the First Hospital of Lanzhou University were retrospectively analyzed. Descriptive statistics covered temporal and monthly distribution, trauma sites, causes, and length of stay. Inclusive were 2106 geriatric patients (941 males, 1165 females; male-to-female ratio 1:1.24). Trauma incidence was higher in summer and autumn (May-October) than winter (November-December). Peak incidents occurred between 14:00-16:00, with concentrations at 12:00-16:00 and 20:00-22:00. Falls (59.35%), road traffic accidents (16.62%), other traumas (14.10%), cutting/stabbing (4.56%), violence (3.42%), mechanical injuries (1.61%), winter sports injuries (0.14%), burns (0.14%), and animal bites (0.06%) were major causes. Extremity and skin injuries prevailed, with significant site distribution differences (P < .001). Average length of stay at the trauma center was 78.35 ± 48.32 minutes. The gender distribution, timing, causes, and sites of trauma in the elderly differ significantly from other age groups. Unlike the higher occurrence of trauma in young men compared to women, among the elderly, it is more prevalent in women than men, mainly attributed to falls. It is crucial to implement specific measures to prevent trauma in the elderly, and the advancement of information technology in the trauma care system could additionally improve the quality of care.

Development and Validation of Futility of Resuscitation Measure in Older Adult Trauma Patients

INTRODUCTION

This study aimed to develop and validate Futility of Resuscitation Measure (FoRM) for predicting the futility of resuscitation among older adult trauma patients.

METHODS

This is a retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2018) (derivation cohort) and American College of Surgeons level I trauma center database (2017-2022) (validation cohort). We included all severely injured (injury severity score >15) older adult (aged ≥60 y) trauma patients. Patients were stratified into decades of age. Injury characteristics (severe traumatic brain injury [Glasgow Coma Scale ≤ 8], traumatic brain injury midline shift), physiologic parameters (lowest in-hospital systolic blood pressure [≤1 h], prehospital cardiac arrest), and interventions employed (4-h packed red blood cell transfusions, emergency department resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta, emergency laparotomy [≤2 h], early vasopressor requirement [≤6 h], and craniectomy) were identified. Regression coefficient-based weighted scoring system was developed using the Schneeweiss method and subsequently validated using institutional database.

RESULTS

A total of 5562 patients in derivation cohort and 873 in validation cohort were identified. Mortality was 31% in the derivation cohort and FoRM had excellent discriminative power to predict mortality (area under the receiver operator characteristic = 0.860; 95% confidence interval [0.847-0.872], P < 0.001). Patients with a FoRM score of >16 had a less than 10% chance of survival, while those with a FoRM score of >20 had a less than 5% chance of survival. In validation cohort, mortality rate was 17% and FoRM had good discriminative power (area under the receiver operator characteristic = 0.76; 95% confidence interval [0.71-0.80], P < 0.001).

CONCLUSIONS

FoRM can reliably identify the risk of futile resuscitation among older adult patients admitted to our level I trauma center.

Impact of Vitamin D Status and Nutrition on the Occurrence of Long Bone Fractures Due to Falls in Elderly Subjects in the Vojvodina Region of Serbia

Bone fractures are a significant public health issue among elderly subjects. This study examines the impact of diet and vitamin D status on the risk of long bone fractures due to falls in elderly subjects in Vojvodina, Serbia. Conducted at the University Clinical Center of Vojvodina in autumn/winter 2022-2023, the study included 210 subjects >65 years: 105 (F: 80/M: 15) with long bone fractures due to falls and 105 (F: 80/M: 15) controls. Groups were similar regarding age and BMI. Dietary intakes (by two 24-h recalls) and serum vitamin D levels were analyzed. The fracture group had a significantly lower median daily vitamin D intake (1.4 μg/day vs. 5.8 μg/day), intake of calcium, energy, proteins, fats, fibers, dairy products, eggs, fish, edible fats/oils, and a higher intake of sweets (p < 0.001 for all). Serum vitamin D levels were significantly lower in the fracture group (40.0 nmol/L vs. 76.0 nmol/L, p < 0.001). Logistic regression identified serum vitamin D as the most important protective factor against fractures, and ROC curve analysis indicated that serum vitamin D levels > 50.5 nmol/L decreased fracture risk. Nutritional improvements (increased intake of vitamin D and protein sources such as fish, eggs, and dairy), increased sun exposure, and routine vitamin D supplementation during winter are advised.

The clinical implications of using a low threshold for computed tomography scans in older patients presenting with a proximal femur fracture

PURPOSE

Current guidelines recommend a low threshold for computerized tomography (CT) scanning in older patients presenting with low-energy trauma (LET). With the ageing of the population, this results in increased use of healthcare resources and costs. We aim to assess (1) the number of CT scans performed as part of the initial trauma screening, (2) their traumatic clinical implications, and (3) their non-traumatic clinical implications.

METHODS

A retrospective study in patients ≥ 70 years presenting at a Dutch trauma centre with a proximal femur fracture following a LET between 2021 and 2022. We collected data concerning demographics, Clinical Frailty Scale, Injury Severity Score, number of CT scans and whether the results of these scans altered clinical management.

RESULTS

We included 278 patients. Median age was 83.0 years (IQR 77.0-89.0), median ISS was 9 (IQR 9-10) and, most common mechanism of injury was a ground level fall (n = 159, 57.2%). In 49 patients (17.6%) one or more CT scans were performed. These scans did not reveal co-existing traumatic injuries altering clinical management. In 2 patients (0.7%) incidental findings were found that immediately affected treatment.

CONCLUSION

Our study concludes that (1) approximately one in five patients with a proximal femur fracture received a CT scan as part of the initial trauma screening, resulting in (2) no traumatic and (3) minimal non-traumatic clinical implications. Therefore, a restrictive policy can be justified in patients with no additional clinical signs or symptoms and admission to the hospital. Further prospective research would be valuable to confirm our results.

Breaking barriers in trauma research: A narrative review of opportunities to leverage veterinary trauma for accelerated translation to clinical solutions for pets and people

Trauma is a common cause of morbidity and mortality in humans and companion animals. Recent efforts in procedural development, training, quality systems, data collection, and research have positively impacted patient outcomes; however, significant unmet need still exists. Coordinated efforts by collaborative, translational, multidisciplinary teams to advance trauma care and improve outcomes have the potential to benefit both human and veterinary patient populations. Strategic use of veterinary clinical trials informed by expertise along the research spectrum (i.e., benchtop discovery, applied science and engineering, large laboratory animal models, clinical veterinary studies, and human randomized trials) can lead to increased therapeutic options for animals while accelerating and enhancing translation by providing early data to reduce the cost and the risk of failed human clinical trials. Active topics of collaboration across the translational continuum include advancements in resuscitation (including austere environments), acute traumatic coagulopathy, trauma-induced coagulopathy, traumatic brain injury, systems biology, and trauma immunology. Mechanisms to improve funding and support innovative team science approaches to current problems in trauma care can accelerate needed, sustainable, and impactful progress in the field. This review article summarizes our current understanding of veterinary and human trauma, thereby identifying knowledge gaps and opportunities for collaborative, translational research to improve multispecies outcomes. This translational trauma group of MDs, PhDs, and DVMs posit that a common understanding of injury patterns and resulting cellular dysregulation in humans and companion animals has the potential to accelerate translation of research findings into clinical solutions.

Trauma Demographics and Injury Prevention

Traumatic injury is a leading cause of death in the United States. Risk of traumatic injury varies by sex, age, geography, and race/ethnicity. Understanding the nuances of risk for a particular population is essential in designing, implementing, and evaluating injury prevention initiatives.

Head Protection Device for Individuals at Risk for Head Injury due to Ground-Level Falls: Single Trauma Center User Experience Investigation

BACKGROUND

Falls represent a large percentage of hospitalized patients with trauma as they may result in head injuries. Brain injury from ground-level falls (GLFs) in patients is common and has substantial mortality. As fall prevention initiatives have been inconclusive, we changed our strategy to injury prevention. We identified a head protection device (HPD) with impact-resistant technology, which meets head impact criteria sustained in a GLF. HPDs such as helmets are ubiquitous in preventing head injuries in sports and industrial activities; yet, they have not been studied for daily activities.

OBJECTIVE

We investigated the usability of a novel HPD on patients with head injury in acute care and home contexts to predict future compliance.

METHODS

A total of 26 individuals who sustained head injuries, wore an HPD in the hospital, while ambulatory and were evaluated at baseline and 2 months post discharge. Clinical and demographic data were collected; a usability survey captured HPD domains. This user experience design revealed patient perceptions, satisfaction, and compliance. Nonparametric tests were used for intragroup comparisons (Wilcoxon signed rank test). Differences between categorical variables including sex, race, and age (age group 1: 55-77 years; age group 2: 78+ years) and compliance were tested using the chi-square test.

RESULTS

Of the 26 patients enrolled, 12 (46%) were female, 18 (69%) were on anticoagulants, and 25 (96%) were admitted with a head injury due to a GLF. The median age was 77 (IQR 55-92) years. After 2 months, 22 (85%) wore the device with 0 falls and no GLF hospital readmissions. Usability assessment with 26 patients revealed positive scores for the HPD post discharge regarding satisfaction (mean 4.8, SD 0.89), usability (mean 4.23, SD 0.86), effectiveness (mean 4.69, SD 0.54), and relevance (mean 4.12, SD 1.10). Nonparametric tests showed positive results with no significant differences between 2 observations. One issue emerged in the domain of aesthetics; post discharge, 8 (30%) patients had a concern about device weight. Analysis showed differences in patient compliance regarding age (χ12=4.27; P=.04) but not sex (χ12=1.58; P=.23) or race (χ12=0.75; P=.60). Age group 1 was more likely to wear the device for normal daily activities. Patients most often wore the device ambulating, and protection was identified as the primary benefit.

CONCLUSIONS

The HPD intervention is likely to have reasonably high compliance in a population at risk for GLFs as it was considered usable, protective, and relevant. The feasibility and wearability of the device in patients who are at risk for GLFs will inform future directions, which includes a multicenter study to evaluate device compliance and effectiveness. Our work will guide other institutions in pursuing technologies and interventions that are effective in mitigating injury in the event of a fall in this high-risk population.

Re-thinking the value of cross-sectional torso imaging for ground-level fall patients with altered mental status: Outcomes from a level 1 trauma center

INTRODUCTION

Patients with altered mental status (AMS) are often excluded from studies evaluating the utility of computed tomography of the torso (CTT) after ground level falls (GLF). It is not known whether CTT identifies otherwise undetectable injuries in patients with AMS after GLF. We sought to describe the value of performing CTT in patients with AMS after GLF, and hypothesized that CTT would not identify new, clinically significant injuries in patients with a normal torso physical exam (PE) and normal chest and pelvic radiographs (CXR/PXR).

METHODS

Single-institution retrospective cohort study of GLF patients (≤1 m) with and without AMS (GCS <15, blood alcohol level >150 mg/dL, intubation prior to hospital evaluation), 2015-2019. Traumatic injury identification on CTT was evaluated in the context of normal/abnormal torso PE (based on provider documentation) and normal CXR/PXR.

RESULTS

1195 patients met inclusion criteria; 344 had AMS, of which 129 (37.5 %) underwent CTT. A further 851 patients had normal mental status, of which 180 (21.2 %) underwent CTT. Patients with a normal PE with AMS (N = 79) and without AMS (N = 38) had a similar rate of new injury discovery on CTT (6.3% vs. 7.9 %, p = 1.00). Negative PE had a negative predictive value (NPV) for identification of a new, acute traumatic injury of 92.4 % (95 % CI: 0.84-0.96) in patients with AMS while normal PE, CXR, and PXR had a NPV of 96.0 % (95 % CI: 0.80-0.99). Among patients with CTT, patients with AMS had a significantly lower rate of acute traumatic injury on CTT compared to alert patients (26.4 % vs. 48.9 %, p < 0.001). On multivariate analysis, AMS was not positively associated with likelihood of identifying acute traumatic injury on CTT.

CONCLUSIONS

In patients sustaining GLFs who present with AMS and who otherwise have a negative PE, CXR, and PXR, CTT is very unlikely to identify new traumatic injuries. Strong consideration should be given to forego cross-sectional imaging in this patient population.

Radiographic cervical spine injury patterns in admitted blunt trauma patients with and without prehospital spinal motion restriction

Objectives

Selective prehospital cervical spine motion restriction (C-SMR) following blunt trauma has increasingly been used by emergency medical service (EMS) providers. We determined rates of prehospital C-SMR and concomitant radiographic injury patterns.

Methods

A retrospective trauma registry and chart review was conducted for all adult blunt trauma patients who were transported by EMS and hospitalized with radiographic cervical spine injuries from 2011 to 2019 at a level 1 trauma center.

Results

Of 658 admitted blunt trauma patients with confirmed cervical spine injury by imaging, 117 (17.8%) did not receive prehospital C-SMR. Patients without prehospital C-SMR were significantly older (76 vs 54 years), more often had low fall as mechanism of injury (59.8% vs 15.9%) and had lower Injury Severity Score (10 vs 17). Patients without C-SMR (Non-SMR) experienced the full array of cervical spine injury types and locations. While the non-SMR patients most often had dens fractures,C-SMR patients most often had C7 fractures; frequencies of fractures at the remaining vertebral levels were comparable. On MRI, cervical spinal cord (8.5% vs 19.6%) and ligamentous injuries (5.1% vs 12.6%) occurred less often in non-SMR patients. Approximately 8.5% of non-SMR patients and 20% of C-SMR patients required cervical spine surgery.

Conclusion

Patients without prehospital C-SMR demonstrate a broad array of cervical spine injuries. While the rates of certain cervical injuries are lower in prehospital non-SMR patients, they are not insignificant.

Level of evidence

Level III.

Hospitalization and readmission after single-level fall: a population-based sample

BACKGROUND

Single-level falls (SLFs) in the older US population is a leading cause of hospital admission and rates are increasing. Unscheduled hospital readmission is regarded as a quality-of-care indication and a preventable burden on healthcare systems. We aimed to characterize the predictors of 30-day readmission following admission for SLF injuries among patients 65 years and older.

METHODS

We conducted a retrospective cohort study using the Nationwide Readmission Database from 2018 to 2019. Included patients were 65 and older, admitted emergently following a SLF with a primary injury diagnosis. Hierarchical logit regression was used to model factors associated with readmission within 30 days of discharge.

RESULTS

Of 1,338,905 trauma patients, 65 years or older, 61.3% had a single-level fall as the mechanism of injury. Among fallers, the average age was 81.1 years and 68.5% were female. SLF patients underwent more major therapeutic procedures (56.3% vs. 48.2%), spent over 2 million days in the hospital and incurred total charges of over $28 billion annually. Over 11% of SLF patients were readmitted within 30 days of discharge. Increasing income had a modest effect, where the highest zip code quartile was 9% less likely to be readmitted. Decreasing population density had a protective effect of readmission of 16%, comparing Non-Urban to Large Metropolitan. Transfer to short-term hospital, brain and vascular injuries were independent predictors of 30-day readmission in multivariable analysis (OR 2.50, 1.31, and 1.42, respectively). Palliative care consultation was protective (OR 0.41). The subsequent hospitalizations among those 30-day readmissions were primarily emergent (92.9%), consumed 260,876 hospital days and a total of $2.75 billion annually.

CONCLUSIONS

SLFs exact costs to patients, health systems, and society. Transfer to short-term hospitals at discharge, along with brain and vascular injuries were strong predictors of 30-day readmission and warrant mitigation strategy development with consideration of expanded palliative care consultation.

Follow-up analysis of quality of life in elderly patients with bone trauma: a longitudinal observational study

BACKGROUND

The quality of life (QoL) of elderly patients with bone trauma is significantly decreased and is affected by many complex factors. This study aims to conduct a half-year follow-up survey to clarify QoL and its influencing factors in elderly patients with bone trauma in order to provide targeted care measures for elderly patients with bone trauma.

METHODS

This was a longitudinal observational study. We used the 36-Item Short Form Health Survey (SF-36) to investigate and evaluate the QoL of 100 patients with bone trauma at the time of hospital discharge and 1 month, 3 months, and 6 months after discharge. Our previous study confirmed that the SF-36 had higher reliability and validity for evaluating the QoL of elderly patients with bone trauma. At the same time, we also investigated the age, gender, location of bone trauma, and destination after discharge of those patients. Those factors that might affect the QoL of elderly patients with bone trauma were identified by univariate and multivariate analyses.

RESULTS

The total physiological function, role-physical, bodily pain, vitality, social functioning, role-emotional, and mental health scores of elderly patients with bone trauma gradually increased from the time of discharge to 1 month, 3 months, and 6 months after discharge, and there were significant differences (p < 0.001). However, there was no significant difference in the general health score in the different periods (P = 0.095). The total QoL scores also significantly differed (F = 118.61, P < 0.001) at the time of discharge (335.252 ± 127.572) and 1 month (285.149 ± 112.827), 3 months (479.344 ± 153.663), and 6 months after discharge (544.396 ± 166.536). The univariate analysis results showed that the location of bone trauma (P < 0.005) and the destination after discharge (P < 0.001) were the main factors affecting QoL in different periods. The results of the multivariate analysis showed that the location of bone trauma was an important factor affecting QoL (P < 0.005 in different periods). Whether to undergo surgery was a factor affecting the patients' long-term QoL (P < 0.005 at 6 months after discharge).

CONCLUSIONS

Although the QoL of elderly patients with bone trauma gradually improves after injury, their recovery time is long, and the influencing factors are complex. Follow-up services should continue for at least six months for these patients, and comprehensive treatment and long-term rehabilitation services should be provided.

Epidemiology, injury pattern and outcome of older trauma patients: A 15-year study of level-I trauma centers

BACKGROUND

Older adults have become a significant portion of the trauma population. Exploring their specificities is crucial to better meet their specific needs. The primary objective was to evaluate the temporal changes in the incidence, demographic and trauma characteristics, injury pattern, in-hospital admission, complications, and outcome of older trauma patients.

METHODS

A multicenter retrospective cohort study was conducted using the Quebec Trauma Registry. Patients aged ≥16 years admitted to one of the three adult level-I trauma centers between 2003 and 2017 were included. Descriptive analyses and trend-tests were performed to describe temporal changes.

RESULTS

A total of 53,324 patients were included, and 24,822 were aged ≥65 years. The median [IQR] age increased from 57[36-77] to 67[46-82] years, and the proportion of older adults rose from 41.8% in 2003 to 54.1% in 2017. Among those, falls remain the main mechanism (84.7%-88.3%), and the proportion of severe thorax (+8.9%), head (+8.7%), and spine (+5%) injuries significantly increased over time. The proportion of severely injured older patients almost doubled (17.6%-32.3%), yet their mortality decreased (-1.0%). Their average annual bed-days consumption also increased (+15,004 and +1,437 in non-intensive care wards and ICU, respectively).

CONCLUSIONS

Since 2014, older adults have represented the majority of admissions in Level-I trauma centers in Québec. Their bed-days consumption has greatly increased, and their injury pattern and severity have deeply evolved, while we showed a decrease in mortality.

China trauma treatment statistics 2019: A national retrospective study based on hospitalized cases

Objective

Trauma is China's fifth leading cause of death and ranked first among youths. Trauma databases have been well-established in many countries to announce the current state of trauma rescue, treatment and care. Nevertheless, China hasn't yet established a comparable database. This paper included two national-level databases in China to describe the current situation of trauma treatment and the epidemiological characteristics of trauma incidence, which sought to provide data support for decision-making, resource allocation, trauma prevention, trauma management, and other aspects.

Methods

This study used the diagnosis and treatment data from the Hospital Quality Monitoring System (HQMS) and the China Trauma Rescue and Treatment Association (CTRTA) in 2019. A descriptive analysis was conducted to explore the demographic characteristics, trauma causes, injury degrees of trauma patients, disease burden and mortality rates in the abstracted hospitalized cases.

Results

A total of 4,532,029 trauma patients were included, of which 4,436,653 were from HQMS and 95,376 from CTRTA respectively. The age group with the highest proportion is 50-54 years old (493,320 [11.12%] in HQMS and 12,025 [12.61%] in CTRTA). Fall was the most frequent cause of trauma hospitalization, accounting for 40.51% of all cases, followed by traffic injuries, accounting for 25.22%. However, for trauma patients aged between 20 and 24 years old, the most common cause of injury was traffic accidents (28.20%). Hospital expenses for trauma patients in 2019 exceeded 100.30 billion yuan, which increases significantly with age, and fall costs the most. The mortality rate of trauma inpatients was 0.77%, which gradually increased with age after 30-year-old, and was the highest in the age group above 85 (1.86%).

Conclusion

This paper summarizes the demographic characteristics, trauma causes distribution, disease burden, mortality rate, and other relative data of inpatients in 2019, which can now be used as an up-to-date clinical evidence base for national healthcare prevention and management in China.

Change in outcomes for trauma patients over time: Two decades of a state trauma system

BACKGROUND

Trauma center mortality rates are benchmarked to expected rates of death based on patient and injury characteristics. The expected mortality rate is recalculated from pooled outcomes across a trauma system each year, obscuring system-level change across years. We hypothesized that risk-adjusted mortality would decrease over time within a state-wide trauma system.

METHODS

We identified adult trauma patients presenting to Level I and II Pennsylvania trauma centers, 1999-2018, using the Pennsylvania Trauma Outcomes Study. Multivariable logistic regression generated risk-adjusted models for mortality in all patients, and in key subgroups: penetrating torso injury, blunt multisystem trauma, and patients presenting in shock.

RESULTS

Of 162,646 included patients, 123,518 (76.1%) were white and 108,936 (67.0%) were male. The median age was 49 (interquartile range [IQR] 29-70), median injury severity score was 16 (IQR 10-24), and 87.5% of injuries were blunt. Overall, 9.9% of patients died, and compared to 1999, no year had significantly higher adjusted odds of mortality. Overall mortality was significantly lower in 2007-2009 and 2011-2018. Of patients with blunt, multisystem injuries, 17.7% died, and adjusted mortality improved over time. Mortality rates were 24.9% for penetrating torso injury, and 56.9% for shock, with no significant change. Mortality improved for patients with ISS < 25, but not for the most severely injured.

CONCLUSIONS

Over 20 years, Pennsylvania trauma centers demonstrated improved risk-adjusted mortality rates overall, but improvement remains lacking in high-risk groups despite numerous innovations and practice changes in this time period. Identifying change over time can help guide focus to these critical gaps.