Geriatric outcomes for trauma patients in the state of Florida after the advent of a large trauma network

Identifying factors predicting outcomes after major trauma in older patients: Prognostic systematic review and meta-analysis

INTRODUCTION

Trauma is the most common cause of morbidity and mortality in older people, and it is important to determine the predictors of outcomes after major trauma in older people.

METHODS

MEDLINE, Embase, and Web of Science were searched, and manual search of relevant papers since 1987 to February 2023 was performed. Random-effects meta-analyses were performed. The primary outcome of interest was mortality, and secondary outcomes were medical complications, length of stay, discharge destination, readmission, and intensive care requirement.

RESULTS

Among 6,064 studies in the search strategy, 136 studies qualified the inclusion criteria. Forty-three factors, ranging from demographics to patient factors, admission measurements, and injury factors, were identified as potential predictors. Mortality was the commonest outcome investigated, and increasing age was associated with increased risk of in-hospital mortality (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.07) along with male sex (OR, 1.40; 95% CI, 1.24-1.59). Comorbidities of heart disease (OR, 2.59; 95% CI, 1.41-4.77), renal disease (OR, 2.52; 95% CI, 1.79-3.56), respiratory disease (OR, 1.40; 95% CI, 1.09-1.81), diabetes (OR, 1.35; 95% CI, 1.03-1.77), and neurological disease (OR, 1.42; 95% CI, 0.93-2.18) were also associated with increased in-hospital mortality risk. Each point increase in the Glasgow Coma Scale lowered the risk of in-hospital mortality (OR, 0.85; 95% CI, 0.76-0.95), while each point increase in Injury Severity Score increased the risk of in-hospital mortality (OR, 1.07; 95% CI, 1.04-1.09). There were limited studies and substantial variability in secondary outcome predictors; however, medical comorbidities, frailty, and premorbid living condition appeared predictive for those outcomes.

CONCLUSION

This review was able to identify potential predictors for older trauma patients. The identification of these factors allows for future development of risk stratification tools for clinicians.

LEVEL OF EVIDENCE

Systematic Review and Meta-Analysis; Level III.

Multiple Organ Dysfunction in Older Major Trauma Critical Care Patients: A Multicenter Prospective Observational Study

The objective was to explore the characteristics and outcomes of multiple organ dysfunction syndrome (MODS) in older trauma patients.

Background

Severely injured older people present an increasing challenge for trauma systems. Recovery for those who require critical care may be complicated by MODS. In older trauma patients, MODS may not be predictable based on chronological age alone and factors associated with its development and resolution are unclear.

Methods

Consecutive adult patients (aged ≥16 years) admitted to 4 level 1 major trauma center critical care units were enrolled and reviewed daily until discharge or death. MODS was defined by a daily total sequential organ failure assessment score of >5.

Results

One thousand three hundred sixteen patients were enrolled over 18 months and one-third (434) were aged ≥65 years. Incidence of MODS was high for both age groups (<65 years: 64%, ≥65 years: 70%). There were few differences in severity, patterns, and duration of MODS between cohorts, except for older traumatic brain injury (TBI) patients who experienced a prolonged course of MODS recovery (TBI: 9 days vs no TBI: 5 days, P < 0.01). Frailty rather than chronological age had a strong association with MODS development (odds ratio [OR], 6.9; 95% confidence intervals [CI], 3.0-12.4; P < 0.001) and MODS mortality (OR, 2.1; 95% CI, 1.31-3.38; P = 0.02). Critical care resource utilization was not increased in older patients, but MODS had a substantial impact on mortality (<65 years: 17%; ≥65 years: 28%). The majority of older patients who did not develop MODS survived and had favorable discharge outcomes (home discharge ≥65 years NoMODS: 50% vs MODS: 15%; P < 0.01).

Conclusions

Frailty rather than chronological age appears to drive MODS development, recovery, and outcome in older cohorts. Early identification of frailty after trauma may help to predict MODS and plan care in older trauma.

Retrospective Analysis of Geriatric Major Trauma Patients Admitted in the Shock Room of a Swiss Academic Hospital: Characteristics and Prognosis

Increased life expectancy exposes a great number of elderly people to serious accidents, thus increasing the amount of major geriatric trauma cases. The aim of our study was to determine the profile of elderly patients undergoing major trauma, and the contributing factors predicting mortality in this specific patient group, compared to the younger population. Retrospective analysis of 1051 patients with major trauma admitted over ten years in a Level-1 trauma center was performed. Data collected were: history, nature and type of trauma; age and sex; vital signs on admission; injury severity score; shock index; comorbidities; coagulation diathesis; injury patterns; emergency measures taken; main diagnosis; mortality; and length of hospital and intensive care unit (ICU) stay. Geriatric patients admitted for major trauma have a mortality rate almost four times greater (47%) than their younger counterparts (14%) with the same ISS. According to statistical regression analysis, anti-platelet therapy (OR 3.21), NACA (National Advisory Committee for Aeronautics) score (OR 2.23), GCS (OR 0.83), ISS (OR 1.07) and age (OR 1.06) are the main factors predicting mortality. Conclusion: Geriatric major trauma patients admitted to our trauma resuscitation area have a high mortality rate. Age, GCS, ISS and NACA scores as well as anti-platelet therapy are the main factors predicting mortality.

Clinical Outcome and Management for Geriatric Traumatic Injury: Analysis of 2688 Cases in the Emergency Department of a Teaching Hospital in Taiwan

Geriatric traumatic injuries in emergency departments are frequent and associated with higher mortality rates and catastrophic functional outcomes. Several prediction scores have been established to manage traumatic patients, including the shock index (SI), revised trauma score (RTS), injury severity score (ISS), trauma injury severity score (TRISS), and new injury severity score (NISS). However, it was necessary to investigate the effectiveness and efficiency of care for the geriatric traumatic population. In addition, image studies such as computed tomography and magnetic resonance imaging play an important role in early diagnosis and timely intervention. However, few studies focus on this aspect. The association between the benefit of carrying out more image studies and clinical outcomes remains unclear. In this study, we included a total of 2688 traumatic patients and analyzed the clinical outcomes and predicting factors in terms of geriatric trauma via pre-hospital and in-hospital analysis. Our evaluation revealed that a shock index ≥1 may be not a strong predictor of geriatric trauma due to the poor physical response in the aging population. This should be modified in geriatric patients. Other systems, like RTS, ISS, TRISS, and NISS, were significant in terms of predicting the clinical outcome.

Trauma transfers to a rural level 1 center: a retrospective cohort study

BACKGROUND

The regionalization of trauma care, the Emergency Medical Treatment and Active Labor Act of 1986, the advent of Accountable Care Organizations and bundled payments have brought Level 1 trauma centers (TC) to a new crossroads. By protocol, injured patients are preferentially transferred to designated TCs when a higher level of care is indicated. Trauma transfers frequently come during off hours and may not always appear to be related to injury severity. Based on this observation, we hypothesized patients transferred from regional hospitals to Level 1 TCs would have lower injury severity scores (ISS) and unfavorable payor status.

METHODS

We queried our TC registry to identify trauma transfers (TTP) and primary trauma patients (PTP) treated at our level 1 TC between 2004 and 2012. Demographics, payor status, length of stay (LOS), injury severity score (ISS), and discharging service were compared.

RESULTS

5699 TTP and 11147 PTP were identified. Uninsured patients comprised 11 % (n = 602) of TTP compared with 15 % (n = 1,721) of PTP (P < 0.0001). Surprisingly 52 % of TTP were Medicare or HMO (n = 3008) beneficiaries, versus 42 % of PTP being Medicare or HMO (n = 4614) recipients (P < 0.0001). Patients were discharged predominantly by neurosurgery and orthopedic surgery (i.e.: General Adult and General Pediatric comprised <50 % of discharges) for all trauma admissions. Adult and Pediatric Trauma services accounted for 29 % (n = 1674) of TTP versus 45 % of PTP (n = 5045) discharges (P < 0.0001). Mean Injury Severity Score of TTP was found to be 11.5 ± 0.11, in comparison to 11.6 ± 0.11 in PTP (P = 0.42), while mean LOS was 5.6 ± 0.1 days for TTP and 5.9 ± 0.1 days for PTP (P = 0.06).

CONCLUSIONS

These data suggest designated trauma centers should continue to encourage and accept appropriate transfer of trauma patients for surgical subspecialty care. The perception trauma transfers increase institutional fiscal burden is unsubstantiated.

What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review

Background

In 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.

Objective

The purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.

Data sources

MEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.

Methods

We have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.

Results

The review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.

Limitations

Although there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.

Conclusions

The evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.

Funding

The National Institute for Health Research Health Services and Delivery Research Programme.