The Short and the Long of it: Timing of Mortality for Older Adults in a State Trauma System

Long-term health-related quality of life and independence among older survivors of serious injury

BACKGROUND

Little is known about the recovery experiences of older trauma intensive care unit (TICU) survivors and the relationship between geriatric trauma care and long-term functional ability and health-related quality of life (HRQOL).

METHODS

We conducted a prospective cohort study of 218 patients (age, ≥65 years) admitted to a Level 1 regional trauma center TICU before versus after implementation of a geriatric care bundle with protocolized geriatrics consultations (Geri-T). Survivors or their proxies were interviewed approximately 1 year after hospitalization. Outcomes included the Katz Index of Independence in Activities of Daily Living (ADLs), Lawton Instrumental Activities of Daily Living (IADLs), and EQ-5D-5L HRQOL survey. Two investigator-developed questions regarding recovery experiences were included. Differences in outcomes among survivors admitted before versus after Geri-T were analyzed using multivariable linear regression. Responses to questions about recovery experiences were qualitatively assessed using content analysis.

RESULTS

We reached 67% (146/218) of hospital survivors or their proxies across both groups; 126 patients were still alive and completed the survey. Mean age was 76 (SD, 8), 36% were female, and 90% were independent with ADLs preinjury. At follow-up, independence with ADLs was 76% and IADLs was 63%. The mean EQ-5D-5L index score was 0.78 (SD, 0.18). Most patients (65%) reported having not returned to preinjury functional status. Neither functional ability or HRQOL differed significantly among patients admitted before versus after Geri-T. Content analysis of open-ended questions revealed themes of activity limitations, persistent pain, and cognitive dysfunction.

CONCLUSION

Nearly one-fifth of TICU survivors experienced loss of ADL function 1 year after injury, and most reported having not returned to preinjury functional status. Nonetheless, patient-reported HRQOL was comparable to age-adjusted norms. Geri-T was not associated with differences in HRQOL or functional ability. Survivors reported persistent difficulty with activities beyond those of daily living, pain, and cognition.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic, Level III.

Social admissions in older trauma patients, not just a one night stay

PURPOSE

Older trauma patients (65 years or older), who suffer minor or moderate injury for which immediate hospitalization is not strictly indicated, are often admitted to the hospital due to a self-sufficiency problem. Although hospitalization is expensive and associated with risks, little is known about the course of such a social admission. Therefore, the aim of this study was to clarify the course and outcome of social admissions.

METHODS

A single centre retrospective cohort study was performed in a level II trauma centre. All hospitalized trauma patients aged 65 or older between 2015 and 2021 with an Abbreviated Injury Scale (AIS) code of 1 or 2 were included. The primary outcome was defined as the number of complications during admission (e.g. pneumonia, urinary tract infection, delirium, decubitus and, in-hospital mortality). Secondary outcomes were missed injury, length of stay, discharge location (home, with homecare or a skilled nursing facility), 30-day hospital return and 1-year mortality.

RESULTS

Out of 2900 older hospitalized trauma patients, 563 (19.4%) were included. Complications occurred in 99 patients (17.6%), eight patients (1.4%) died during admission, and in 17 patients (3.0%) a previously missed injury was found during the admission. The median length of stay was 5 days [IQR 2.00-9.00] and of all independent living patients, 49.1% could be discharged to their homes. After discharge, 4.4% of the patients returned within 30 days and, a total of 17.6% of all patients died within one year after discharge.

CONCLUSIONS

One out of five older trauma patients presenting at the emergency department were admitted because of social reasons. Social admissions are lengthy and are accompanied by a considerable amount of complications.

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.