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Koch MAGR, Arleth T, Rosenkrantz O, Rudolph SS, Steinmetz J. Interhospital transfers in elderly trauma patients. Injury 2025; 56:111998. [PMID: 39550344 DOI: 10.1016/j.injury.2024.111998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 10/01/2024] [Accepted: 10/26/2024] [Indexed: 11/18/2024]
Abstract
INTRODUCTION The elderly population is growing worldwide and is more likely to die from injuries that younger patients would likely survive. Furthermore, elderly trauma patients are often subjected to triage decisions that admit them to lower-level facilities. These patients may require interhospital transfer to a major trauma center for definitive care. The aim of this study was to investigate the time interval from arrival at the primary hospital to arrival at the trauma center among elderly trauma patients (≥65 years) as compared to younger, adult patients (18-64 years). We hypothesized that elderly trauma patients would endure a longer time interval. METHODS This was a retrospective quality assurance study based on patient data in our trauma registry at the Trauma Center of Copenhagen University Hospital, Rigshospitalet in Denmark. Data were extracted in the period between 2018 and 2023. We included all adult trauma patients (≥18 years) who underwent interhospital transfer to the trauma center. The primary outcome was minutes from arrival at the primary hospital to arrival at the trauma center. A quality standard of at least 90 % of patients arriving at the trauma center in <240 min after arrival at the primary hospital, was chosen. RESULTS In total, 565 patients were included and divided into an elderly cohort (n = 184) and a younger cohort (n = 381). The elderly cohort had a significantly longer median delay (247 vs. 197 min; estimated difference 50 min, 95 % confidence interval (CI) [28, 71]; p < 0.001). The elderly cohort met the quality standard less than the younger cohort (49 % vs. 68 %). The elderly cohort had a significantly higher injury severity score (17 [IQR 13, 25] vs. 16 [IQR 9, 21]; p < 0.001), and we found a significant difference in 30-day mortality, which was supported by an adjusted odds ratio of 6.35 (95 % CI [2.84, 15.7]; p < 0.001). CONCLUSIONS In conclusion, elderly trauma patients experienced significantly longer median delays from arrival at the primary hospital to arrival at the trauma center compared to younger adult trauma patients. The elderly trauma patients met the quality standard for transfer time at a lower rate than the younger group.
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Affiliation(s)
- Malte Andreas Groth-Rasmussen Koch
- Department of Anesthesia, Center of Head, Orthopedics and Trauma Center, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, 2100 Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark. Blegdamsvej 3B, 2200 København N, Denmark.
| | - Tobias Arleth
- Department of Anesthesia, Center of Head, Orthopedics and Trauma Center, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, 2100 Copenhagen, Denmark
| | - Oscar Rosenkrantz
- Department of Anesthesia, Center of Head, Orthopedics and Trauma Center, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, 2100 Copenhagen, Denmark; Department of Clinical Epidemiology, Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Olof Palmes Allé 43-45, Aarhus, 8200 Aarhus N, Denmark
| | - Søren Steemann Rudolph
- Department of Anesthesia, Center of Head, Orthopedics and Trauma Center, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, 2100 Copenhagen, Denmark
| | - Jacob Steinmetz
- Department of Anesthesia, Center of Head, Orthopedics and Trauma Center, Rigshospitalet, University of Copenhagen, Inge Lehmanns Vej 6, 2100 Copenhagen, Denmark; Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark. Blegdamsvej 3B, 33.5, Sektion A, 2200 København N, Denmark; Danish Air Ambulance, Aarhus, Denmark. Brendstrupgårdsvej 7, 2. th, 8200 Aarhus N, Denmark; Faculty of Health, Aarhus University, Aarhus, Denmark
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Aalberg I, Nordseth T, Klepstad P, Rosseland LA, Uleberg O. Incidence, severity and changes of abnormal vital signs in trauma patients: A national population-based analysis. Injury 2025; 56:111884. [PMID: 39327112 DOI: 10.1016/j.injury.2024.111884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 08/28/2024] [Accepted: 09/12/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Physiological criteria are used to assess the potential severity of injury in the early phase of a trauma patient's care trajectory. Few studies have described the extent of abnormality in vital signs and different combinations of these at a national level. Aim of the study was to identify physiologic abnormalities in trauma patients and describe different combinations of abnormalities and changes between the pre-hospital and emergency department (ED) settings. METHOD Norwegian Trauma Registry (NTR) data between 01.01.15 - 31.12.18, where evaluated on the prevalence and characteristics of abnormal physiologic variables. Primary outcome were rates of hypoventilation (respiratory rate [RR] < 10 breaths per min), hyperventilation (RR > 29 breaths per min), hypotension (systolic blood pressure [SBP] < 90 mmHg), and reduced level of consciousness (Glasgow Coma Scale [GCS] < 13). RESULTS A total of 24,482 patients were included. Documented values for RR, SBP and GCS were 77.6%, 78.5% and 81.9% in the pre-hospital phase, and the corresponding percentages in the ED were 95.5%, 99.2% and 98.6%, respectively. In the pre-hospital phase, 3,615 (14.8%) patients had at least one abnormal vital sign, whereas the corresponding numbers in the ED, were 3,616 (14.8%) patients. The most frequent combination was low GCS and hyperventilation. A worsened RTS-score from pre-hospital phase to the ED was observed for RR, SBP and GCS in 3.9%, 1.2% and 1.9% of incidents, respectively. Overall 30-day mortality was 3.1% (n=752). Of these, 60.8% had abnormal vital signs, with decreased GCS as the most prevalent (61.3%). CONCLUSION Most trauma patients had normal vital signs. According to the RTS-score, there were few deteriorations in RR, SBP and GCS between pre-hospital phase and the ED. The most frequent abnormality was low GCS, with a higher proportion in those who died within 30 days.
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Affiliation(s)
- Ingrid Aalberg
- Department of Circulation and Imaging, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway.
| | - Trond Nordseth
- Department of Circulation and Imaging, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway; Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Department of Anesthesia and Intensive Care, St. Olav`s University Hospital, NO-7006 Trondheim, Norway.
| | - Pål Klepstad
- Department of Circulation and Imaging, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway; Department of Anesthesia and Intensive Care, St. Olav`s University Hospital, NO-7006 Trondheim, Norway.
| | - Leiv Arne Rosseland
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, NO-0318 Oslo, Norway.
| | - Oddvar Uleberg
- Department of Circulation and Imaging, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway; Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; Department of Emergency Medicine and Pre-hospital Services, St. Olav's University Hospital, NO-7006 Trondheim, Norway.
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Rafieezadeh A, Zangbar B, Rodriguez G, Kirsch J, Samson D, Shnaydman I, Jose A, Prabhakaran K. Decreasing Trends of Traumatic Brain Injury Despite a Surge in Anticoagulant Use in the Elderly. J Surg Res 2024; 303:663-669. [PMID: 39442294 DOI: 10.1016/j.jss.2024.09.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 09/18/2024] [Accepted: 09/22/2024] [Indexed: 10/25/2024]
Abstract
BACKGROUND In recent years, with the introduction of new anticoagulants there has been a rise in their usage among elderly population who are at risk for traumatic brain injury (TBI) at the same time. We assessed the change in use of anticoagulant in elderly trauma patients and its association with TBI outcomes. MATERIAL AND METHODS We performed a 5-y retrospective analysis of Trauma Quality Improvement Program (2017-2021) of trauma patients ≥65 y. Patient who had TBI were identified. We queried the preexisting comorbid conditions for anticoagulant use. The primary outcome was mortality, and the secondary outcome was TBI admissions during study period. We conducted a linear regression analysis to assess for trends in data. We also utilized a propensity score matching in 1:1 ratio to compare patients on prehospital anticoagulant versus nonreceivers. RESULTS A total of 1,688,157 patients were included. The trend of TBI admission over the study period has been decreasing significantly (P < 0.001). Prehospital anticoagulant use has been increasing over the study period with the slope of 0.078 (P = 0.043). After propensity score matching, patients with TBI who used anticoagulants before hospitalization had a higher mortality rate compared to nonreceivers (9.1% versus 6.8%, P < 0.001). The mortality rate in patients with anticoagulant use decreased from 2017 to 2019 and increased from 2019 to 2021. However this change was not significant in a linear fashion. CONCLUSIONS Despite increasing trends of anticoagulant usage, which is associated with a higher mortality risk after TBI in elderly, the rate of TBI admissions has been decreasing over the years. Meanwhile, the trend of mortality in patients with anticoagulant use appears to remain unchanged.
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Affiliation(s)
- Aryan Rafieezadeh
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Bardiya Zangbar
- Westchester Medical Center, New York Medical College, Valhalla, New York.
| | - Gabriel Rodriguez
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Jordan Kirsch
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - David Samson
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Ilya Shnaydman
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Anna Jose
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Kartik Prabhakaran
- Westchester Medical Center, New York Medical College, Valhalla, New York
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Yildirim O, Sahin A, Tatar SD, Gok MY, Avci A, Seven SY. Comparison of Manchester, qSOFA, emergency severity index, and national early warning scores for prognostic estimation and effective triage system in geriatric patients. Ir J Med Sci 2024; 193:2051-2059. [PMID: 38483773 DOI: 10.1007/s11845-024-03664-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 03/06/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Triage refers to classifying and prioritizing patients based on the severity of their injuries or illnesses in the health care setting. The increasing number of elderly patients seeking care in emergency departments (EDs) highlights the need for special attention to the unique needs of this patient population. AIM We aimed to compare the qSOFA, Emergency Severity Index (ESI), National Early Warning Score (NEWS), and Manchester Triage System (MTS) scores to assist ED physicians in assessing the severity of elderly patients' clinical conditions and triaging them appropriately. METHODS This cross-sectional study included 1066 patients aged 65 and over who presented to our ED as outpatients or by ambulance between September 1, 2022, and August 30, 2023. Scoring systems at the time of admission to the ED were recorded separately for outpatients and arriving by ambulance. RESULTS According to the qSOFA, patients with a score of 0 were 0.976 times less likely to arrive by ambulance compared to those scoring 1 and above (OR = 0.976, p = .934). According to the NEWS, patients in the moderate-risk category were 0.447 times less likely to arrive by ambulance (OR = 0.447, p = .054). According to the ESI score, patients requiring high resource use with normal vital signs were 146.758 times more likely to arrive by ambulance (OR = 146.758, p = .001). CONCLUSION Significant differences in patients' methods of presentation to the ED were observed based on the MTS, qSOFA, NEWS, and ESI scores.
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Affiliation(s)
- Ozge Yildirim
- Department of Emergency, Health Science University, Adana City Reseach and Training Hospital, 01060, Adana, Turkey
| | - Aysun Sahin
- Department of Emergency, Health Science University, Adana City Reseach and Training Hospital, 01060, Adana, Turkey
| | - Senem Derya Tatar
- Department of Emergency, Health Science University, Adana City Reseach and Training Hospital, 01060, Adana, Turkey
| | - Mustafa Yilmaz Gok
- Department of Emergency, Health Science University, Adana City Reseach and Training Hospital, 01060, Adana, Turkey
| | - Akkan Avci
- Department of Emergency, Health Science University, Adana City Reseach and Training Hospital, 01060, Adana, Turkey.
| | - Sadiye Yolcu Seven
- Department of Emergency, Health Science University, Adana City Reseach and Training Hospital, 01060, Adana, Turkey
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Wycech Knight J, Fokin AA, Menzione N, Rabinowitz SR, Viitaniemi SA, Puente I. Are geriatric transfer patients with traumatic brain injury at risk for worse outcomes compared to non-geriatric? Propensity-matched study. Brain Inj 2024; 38:659-667. [PMID: 38568043 DOI: 10.1080/02699052.2024.2337904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 03/28/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE To compare outcomes between geriatric and non-geriatric patients with traumatic brain injury (TBI) transferred to trauma center and effects of anticoagulants/antiplatelets (AC/AP) and reversal therapy. METHODS A retrospective review of 1,118 patients with TBI transferred from acute care facilities to level 1 trauma center compared in groups: geriatric versus non-geriatric, geriatric with AC/AP therapy versus without, and geriatric AC/AP with AC/AP reversal therapy versus without. RESULTS Patients with TBI constituted 54.4% of trauma transfers. Mean transfer time was 3.9 h. Propensity matched by Injury Severity Score and Abbreviated Injury Score (AIS) head geriatric compared to non-geriatric patients had more AC/AP use (53.9% vs 8.8%), repeat head computed tomography (93.7% vs 86.1%), intensive care unit (ICU) admissions (57.4% vs 45.7%) and mortality (9.8% vs 3.2%), all p < 0.004. Patients on AC/AP versus without had more ICU admissions (69.1% vs 51.8%, p < 0.001). Patients with AC/AP reversals compared to without reversals had more AIS head 5 (32.0% vs 13.1%), brain surgeries (17.8% vs 3.5%) and ICU admissions (84.8% vs 57.1%), all p < 0.001. CONCLUSION TBI constituted half of trauma transfers and 10% required surgery. Based on higher ICU admissions, mortality, and prevalence of AC/AP therapy requiring reversal, geriatric patients with TBI on anticoagulants/antiplatelets should be considered for direct trauma center admission.
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Affiliation(s)
- Joanna Wycech Knight
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
- Broward Health Medical Center, Division of Trauma and Critical Care Services, Fort Lauderdale, Florida, USA
| | - Alexander A Fokin
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
- Charles E. Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, Florida, USA
| | - Nicholas Menzione
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
| | - Sarah R Rabinowitz
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
- Charles E. Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, Florida, USA
| | - Sari A Viitaniemi
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
| | - Ivan Puente
- Delray Medical Center, Division of Trauma and Critical Care Services, Delray Beach, Florida, USA
- Broward Health Medical Center, Division of Trauma and Critical Care Services, Fort Lauderdale, Florida, USA
- Charles E. Schmidt College of Medicine, Department of Surgery, Florida Atlantic University, Boca Raton, Florida, USA
- Herbert Wertheim College of Medicine, Department of Surgery, Florida International University, Miami, Florida, USA
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Ramgopal S, Sepanski RJ, Crowe RP, Okubo M, Callaway CW, Martin-Gill C. Correlation of vital sign centiles with in-hospital outcomes among adults encountered by emergency medical services. Acad Emerg Med 2024; 31:210-219. [PMID: 37845192 DOI: 10.1111/acem.14821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Vital signs are a critical component of the prehospital assessment. Prior work has suggested that vital signs may vary in their distribution by age. These differences in vital signs may have implications on in-hospital outcomes or be utilized within prediction models. We sought to (1) identify empirically derived (unadjusted) cut points for vital signs for adult patients encountered by emergency medical services (EMS), (2) evaluate differences in age-adjusted cutoffs for vital signs in this population, and (3) evaluate unadjusted and age-adjusted vital signs measures with in-hospital outcomes. METHODS We used two multiagency EMS data sets to derive (National EMS Information System from 2018) and assess agreement (ESO, Inc., from 2019 to 2021) of vital signs cutoffs among adult EMS encounters. We compared unadjusted to age-adjusted cutoffs. For encounters within the ESO sample that had in-hospital data, we compared the association of unadjusted cutoffs and age-adjusted cutoffs with hospitalization and in-hospital mortality. RESULTS We included 13,405,858 and 18,682,684 encounters in the derivation and validation samples, respectively. Both extremely high and extremely low vital signs demonstrated stepwise increases in admission and in-hospital mortality. When evaluating age-based centiles with vital signs, a gradual decline was noted at all extremes of heart rate (HR) with increasing age. Extremes of systolic blood pressure at upper and lower margins were greater in older age groups relative to younger age groups. Respiratory rate (RR) cut points were similar for all adult age groups. Compared to unadjusted vital signs, age-adjusted vital signs had slightly increased accuracy for HR and RR but lower accuracy for SBP for outcomes of mortality and hospitalization. CONCLUSIONS We describe cut points for vital signs for adults in the out-of-hospital setting that are associated with both mortality and hospitalization. While we found age-based differences in vital signs cutoffs, this adjustment only slightly improved model performance for in-hospital outcomes.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Robert J Sepanski
- Department of Quality & Safety, Children's Hospital of The King's Daughters, Norfolk, Virginia, USA
- Department of Pediatrics, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | | | - Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Benhamed A, Batomen B, Boucher V, Yadav K, Isaac CJ, Mercier E, Bernard F, Blais-L'écuyer J, Tazarourte K, Emond M. Relationship between systolic blood pressure and mortality in older vs younger trauma patients - a retrospective multicentre observational study. BMC Emerg Med 2023; 23:105. [PMID: 37726708 PMCID: PMC10508012 DOI: 10.1186/s12873-023-00863-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 08/02/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND The population of older trauma patients is increasing. Those patients have heterogeneous presentations and need senior-friendly triaging tools. Systolic blood pressure (SBP) is commonly used to assess injury severity, and some authors advocated adjusting SBP threshold for older patients. We aimed to describe and compare the relationship between mortality and SBP in older trauma patients and their younger counterparts. METHODS We included patients admitted to three level-I trauma centres and performed logistic regressions with age and SBP to obtain mortality curves. Multivariable Logistic regressions were performed to measure the association between age and mortality at different SBP ranges. Subgroup analyses were conducted for major trauma and severe traumatic brain injury admissions. RESULTS A total of 47,661 patients were included, among which 12.9% were aged 65-74 years and 27.3% were ≥ 75 years. Overall mortality rates were 3.9%, 8.1%, and 11.7% in the groups aged 16-64, 65-74, and ≥ 75 years, respectively. The relationship between prehospital SBP and mortality was nonlinear (U-shape), mortality increased with each 10 mmHg SBP decrement from 130 to 50 mmHg and each 10-mmHg increment from 150 to 220 mmHg across all age groups. Older patients were at higher odd for mortality in all ranges of SBP. The highest OR in patients aged 65-74 years was 3.67 [95% CI: 2.08-6.45] in the 90-99 mmHg SBP range and 7.92 [95% CI: 5.13-12.23] for those aged ≥ 75 years in the 100-109 mmHg SBP range. CONCLUSION The relationship between SBP and mortality is nonlinear, regardless of trauma severity and age. Older age was associated with a higher odd of mortality at all SBP points. Future triage tools should therefore consider SBP as a continuous rather than a dichotomized predictor.
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Affiliation(s)
- Axel Benhamed
- CHU de Québec-Université Laval Research Centre, Québec, Québec, Canada
- Département de Médecine Familiale et de Médecine d'urgence, Université Laval, Québec, Québec, Canada
- Hospices Civils de Lyon, Service d'Accueil des Urgences - SAMU 69, Centre Hospitalier Universitaire Edouard Herriot, Lyon, 69003, France
| | - Brice Batomen
- CHU de Québec-Université Laval Research Centre, Québec, Québec, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Valérie Boucher
- CHU de Québec-Université Laval Research Centre, Québec, Québec, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Eric Mercier
- CHU de Québec-Université Laval Research Centre, Québec, Québec, Canada
- Département de Médecine Familiale et de Médecine d'urgence, Université Laval, Québec, Québec, Canada
| | - Francis Bernard
- Critical Care Unit, Hopital du Sacre-Coeur de Montreal, Montreal, QC, Canada
| | - Julien Blais-L'écuyer
- Département de Médecine Familiale et de Médecine d'urgence, Université Laval, Québec, Québec, Canada
| | - Karim Tazarourte
- Hospices Civils de Lyon, Service d'Accueil des Urgences - SAMU 69, Centre Hospitalier Universitaire Edouard Herriot, Lyon, 69003, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, 69003, France
| | - Marcel Emond
- CHU de Québec-Université Laval Research Centre, Québec, Québec, Canada.
- Département de Médecine Familiale et de Médecine d'urgence, Université Laval, Québec, Québec, Canada.
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Benhamed A, Isaac CJ, Boucher V, Yadav K, Mercier E, Moore L, D'Astous M, Bernard F, Dubucs X, Gossiome A, Emond M. Effect of age on the association between the Glasgow Coma Scale and the anatomical brain lesion severity: a retrospective multicentre study. Eur J Emerg Med 2023; 30:271-279. [PMID: 37161755 DOI: 10.1097/mej.0000000000001041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background and importance Older adults are at higher risk of undertriage and mortality following a traumatic brain injury (TBI). Early identification and accurate triage of severe cases is therefore critical. However, the Glasgow Coma Scale (GCS) might lack sensitivity in older patients. Objective This study investigated the effect of age on the association between the GCS and TBI severity. Design, settings, and participants This multicentre retrospective cohort study (2003-2017) included TBI patients aged ≥16 years with an Abbreviated Injury Scale (AIS of 3, 4 or 5). Older adults were defined as aged 65 and over. Outcomes measure and analysis Median GCS score were compared between older and younger adults, within subgroups of similar AIS. Multivariable logistic regressions were computed to assess the association between age and mortality. The primary analysis comprised patients with isolated TBI, and secondary analysis included patients with multiple trauma. Main results A total of 12 562 patients were included, of which 9485 (76%) were isolated TBIs. Among those, older adults represented 52% ( n = 4931). There were 22, 27 and 51% of older patients with an AIS-head of 3, 4 and 5 respectively compared to 32, 25 and 43% among younger adults. Within the different subgroups of patients, median GCS scores were higher in older adults: 15 (14-15) vs. 15 (13-15), 15 (14-15) vs. 14 (13-15), 15 (14-15) vs. 14 (8-15), for AIS-head 3, 4 and 5 respectively (all P < 0.0001). Older adults had increased odds of mortality compared to their younger counterparts at all AIS-head levels: AIS-head = 3 [odds ratio (OR) = 2.9, 95% confidence interval (CI) 1.6-5.5], AIS-head = 4, (OR = 2.7, 95% CI 1.6-4.7) and AIS-head = 5 (OR = 2.6, 95% CI 1.9-3.6) TBI (all P < 0.001). Similar results were found among patients with multiple trauma. Conclusions In this study, among TBI patients with similar AIS-head score, there was a significant higher median GCS in older patients compared to younger patients.
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Affiliation(s)
- Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot-Université Claude Bernard Lyon 1, Lyon, France
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | | | - Valérie Boucher
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | - Krishan Yadav
- Department of Emergency Medicine-University of Ottawa
- Ottawa Hospital Research Institute, Ottawa, Ontario
| | - Eric Mercier
- CHU de Québec-Université Laval Research Centre, Québec, Québec
- Département de médecine d'urgence et médecine familiale, Université Laval
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec, Québec
| | | | - Francis Bernard
- Services de soins intensifs, Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM)-Université de Montréal, Montréal, Québec, Canada
| | - Xavier Dubucs
- Service d'urgence, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Amaury Gossiome
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot-Université Claude Bernard Lyon 1, Lyon, France
- CHU de Québec-Université Laval Research Centre, Québec, Québec
| | - Marcel Emond
- CHU de Québec-Université Laval Research Centre, Québec, Québec
- Département de médecine d'urgence et médecine familiale, Université Laval
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Benhamed A, Emond M, Mercier E, Heidet M, Gauss T, Saint-Supery P, Yadav K, David JS, Claustre C, Tazarourte K. Accuracy of a Prehospital Triage Protocol in Predicting In-Hospital Mortality and Severe Trauma Cases among Older Adults. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1975. [PMID: 36767343 PMCID: PMC9916137 DOI: 10.3390/ijerph20031975] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 06/18/2023]
Abstract
Background: Prehospital trauma triage tools are not tailored to identify severely injured older adults. Our trauma triage protocol based on a three-tier trauma severity grading system (A, B, and C) has never been studied in this population. The objective was to assess its accuracy in predicting in-hospital mortality among older adults (≥65 years) and to compare it to younger patients. Methods: A retrospective multicenter cohort study, from 2011 to 2021. Consecutive adult trauma patients managed by a mobile medical team were prospectively graded A, B, or C according to the initial seriousness of their injuries. Accuracy was evaluated using sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. Results: 8888 patients were included (14.1% were ≥65 years). Overall, 10.1% were labeled Grade A (15.2% vs. 9.3% among older and younger adults, respectively), 21.9% Grade B (27.9% vs. 20.9%), and 68.0% Grade C (56.9% vs. 69.8%). In-hospital mortality was 7.1% and was significantly higher among older adults regardless of severity grade. Grade A showed lower sensitivity (50.5 (43.7; 57.2) vs. 74.6 (69.8; 79.1), p < 0.0001) for predicting mortality among older adults compared to their younger counterparts. Similarly, Grade B was associated with lower sensitivity (89.5 (84.7; 93.3) vs. 97.2 (94.8; 98.60), p = 0.0003) and specificity (69.4 (66.3; 72.4) vs. 74.6 (73.6; 75.7], p = 0.001) among older adults. Conclusions: Our prehospital trauma triage protocol offers high sensitivity for predicting in-hospital mortality including older adults.
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Affiliation(s)
- Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 69123 Lyon, France
| | - Marcel Emond
- Centre de Recherche, CHU de Québec-Université Laval, Québec, QC G1J 1Z4, Canada
| | - Eric Mercier
- Centre de Recherche, CHU de Québec-Université Laval, Québec, QC G1J 1Z4, Canada
| | - Matthieu Heidet
- SAMU 94, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), 75610 Paris, France
| | - Tobias Gauss
- Anaesthesia Critical Care, Grenoble Alpes University Hospital, 38700 Grenoble, France
| | - Pierre Saint-Supery
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 69123 Lyon, France
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON K1Y 4E9, Canada
| | - Jean-Stéphane David
- Service d’Anesthésie-Réanimation, Centre Hospitalier Universitaire Lyon Sud, Hospices Civils de Lyon, 69310 Pierre-Bénite, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, 69100 Lyon, France
| | - Clement Claustre
- RESUVal Trauma Network, Centre Hospitalier Lucien Hussel, 38200 Vienne, France
| | - Karim Tazarourte
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 69123 Lyon, France
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, 69100 Lyon, France
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Lupton JR, Davis-O'Reilly C, Jungbauer RM, Newgard CD, Fallat ME, Brown JB, Mann NC, Jurkovich GJ, Bulger E, Gestring ML, Lerner EB, Chou R, Totten AM. Under-Triage and Over-Triage Using the Field Triage Guidelines for Injured Patients: A Systematic Review. PREHOSP EMERG CARE 2023; 27:38-45. [PMID: 35191799 DOI: 10.1080/10903127.2022.2043963] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES The Field Triage Guidelines (FTG) are used across North America to identify seriously injured patients for transport to appropriate level trauma centers, with a goal of under-triaging no more than 5% and over-triaging between 25% and 35%. Our objective was to systematically review the literature on under-triage and over-triage rates of the FTG. METHODS We conducted a systematic review of the FTG performance. Ovid Medline, EMBASE, and the Cochrane databases were searched for studies published between January 2011 and February 2021. Two investigators dual-reviewed eligibility of abstracts and full-text. We included studies evaluating under- or over-triage of patients using the FTG in the prehospital setting. We excluded studies not reporting an outcome of under- or over-triage, studies evaluating other triage tools, or studies of triage not in the prehospital setting. Two investigators independently assessed the risk of bias for each included article. The primary accuracy measures to assess the FTG were under-triage, defined as seriously injured patients transported to non-trauma hospitals (1-sensitivity), and over-triage, defined as non-injured patients transported to trauma hospitals (1-specificity). Due to heterogeneity, results were synthesized qualitatively. RESULTS We screened 2,418 abstracts, reviewed 315 full-text publications, and identified 17 studies that evaluated the accuracy of the FTG. Among eight studies evaluating the entire FTG (steps 1-4), under-triage rates ranged from 1.6% to 72.0% and were higher for older (≥55 or ≥65 years) adults (20.1-72.0%) and pediatric (<15 years) patients (15.9-34.8%) compared to all ages (1.6-33.8%). Over-triage rates ranged from 9.9% to 87.4% and were higher for all ages (12.2-87.4%) compared to older (≥55 or ≥65 years) adults (9.9-48.2%) and pediatric (<15 years) patients (28.0-33.6%). Under-triage was lower in studies strictly applying the FTG retrospectively (1.6-34.8%) compared to as-practiced (10.5-72.0%), while over-triage was higher retrospectively (64.2-87.4%) compared to as-practiced (9.9-48.2%). CONCLUSIONS Evidence suggests that under-triage, while improved if the FTG is strictly applied, remains above targets, with higher rates of under-triage in both children and older adults.
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Affiliation(s)
- Joshua R Lupton
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Cynthia Davis-O'Reilly
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Rebecca M Jungbauer
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Craig D Newgard
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Mary E Fallat
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - N Clay Mann
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | - Eileen Bulger
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Mark L Gestring
- Department of Surgery, University of Rochester, Rochester, NY, USA
| | - E Brooke Lerner
- Department of Emergency Medicine, University at Buffalo, Buffalo, NY, USA
| | - Roger Chou
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Annette M Totten
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
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11
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Lupton JR, Davis‐O'Reilly C, Jungbauer RM, Newgard CD, Fallat ME, Brown JB, Mann NC, Jurkovich GJ, Bulger E, Gestring ML, Lerner EB, Chou R, Totten AM. Mechanism of injury and special considerations as predictive of serious injury: A systematic review. Acad Emerg Med 2022; 29:1106-1117. [PMID: 35319149 PMCID: PMC9545392 DOI: 10.1111/acem.14489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/17/2022] [Accepted: 03/19/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The Centers for Disease Control and Prevention's field triage guidelines (FTG) are routinely used by emergency medical services personnel for triaging injured patients. The most recent (2011) FTG contains physiologic, anatomic, mechanism, and special consideration steps. Our objective was to systematically review the criteria in the mechanism and special consideration steps that might be predictive of serious injury or need for a trauma center. METHODS We conducted a systematic review of the predictive utility of mechanism and special consideration criteria for predicting serious injury. A research librarian searched in Ovid Medline, EMBASE, and the Cochrane databases for studies published between January 2011 and February 2021. Eligible studies were identified using a priori inclusion and exclusion criteria. Studies were excluded if they lacked an outcome for serious injury, such as measures of resource use, injury severity scores, mortality, or composite measures using a combination of outcomes. Given the heterogeneity in populations, measures, and outcomes, results were synthesized qualitatively focusing on positive likelihood ratios (LR+) whenever these could be calculated from presented data or adjusted odds ratios (aOR). RESULTS We reviewed 2418 abstracts and 315 full-text publications and identified 42 relevant studies. The factors most predictive of serious injury across multiple studies were death in the same vehicle (LR+ 2.2-7.4), ejection (aOR 3.2-266.2), extrication (LR+ 1.1-6.6), lack of seat belt use (aOR 4.4-11.3), high speeds (aOR 2.0-2.9), concerning crash variables identified by vehicle telemetry systems (LR+ 4.7-22.2), falls from height (LR+ 2.4-5.9), and axial load or diving (aOR 2.5-17.6). Minor or inconsistent predictors of serious injury were vehicle intrusion (LR+ 0.8-7.2), cardiopulmonary or neurologic comorbidities (LR+ 0.8-3.1), older age (LR+ 0.6-6.8), or anticoagulant use (LR+ 1.1-1.8). CONCLUSIONS Select mechanism and special consideration criteria contribute positively to appropriate field triage of potentially injured patients.
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Affiliation(s)
- Joshua R. Lupton
- Department of Emergency MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Cynthia Davis‐O'Reilly
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Rebecca M. Jungbauer
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Craig D. Newgard
- Department of Emergency MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Mary E. Fallat
- Department of SurgeryUniversity of Louisville School of MedicineLouisvilleKentuckyUSA
| | - Joshua B. Brown
- Department of SurgeryUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - N. Clay Mann
- Department of PediatricsUniversity of UtahSalt Lake CityUtahUSA
| | | | - Eileen Bulger
- Department of SurgeryUniversity of WashingtonSeattleWashingtonUSA
| | - Mark L. Gestring
- Department of SurgeryUniversity of RochesterRochesterNew YorkUSA
| | - E. Brooke Lerner
- Department of Emergency MedicineUniversity at BuffaloBuffaloNew YorkUSA
| | - Roger Chou
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
| | - Annette M. Totten
- Pacific Northwest Evidence‐based Practice Center, Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregonUSA
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12
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Newgard CD, Fischer PE, Gestring M, Michaels HN, Jurkovich GJ, Lerner EB, Fallat ME, Delbridge TR, Brown JB, Bulger EM. National guideline for the field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2021. J Trauma Acute Care Surg 2022; 93:e49-e60. [PMID: 35475939 PMCID: PMC9323557 DOI: 10.1097/ta.0000000000003627] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/09/2022] [Accepted: 03/15/2022] [Indexed: 11/26/2022]
Abstract
This work details the process of developing the updated field triage guideline, the supporting evidence, and the final version of the 2021 National Guideline for the Field Triage of Injured Patients.
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Affiliation(s)
- Craig D. Newgard
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Peter E. Fischer
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Mark Gestring
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Holly N. Michaels
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Gregory J. Jurkovich
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - E. Brooke Lerner
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Mary E. Fallat
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Theodore R. Delbridge
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Joshua B. Brown
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - Eileen M. Bulger
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
| | - the Writing Group for the 2021 National Expert Panel on Field Triage
- From the Department of Emergency Medicine (C.D.N., J.R.L.), Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, Portland, Oregon; Department of Surgery (P.E.F.), University of Tennessee Health Science Center, Memphis, Tennessee; Department of Surgery (M.G.), University of Rochester, Rochester, New York; Committee on Trauma (H.N.M., M.N., M.D., J.D.), American College of Surgeons, Chicago, Illinois; Department of Surgery (G.J.J.), UC Davis Health, Sacramento, California; Department of Emergency Medicine (E.B.L.), University at Buffalo, Buffalo, New York; Department of Surgery (M.E.F.), University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky; Maryland Institute for Emergency Medical Services Systems (T.R.D.), Baltimore, Maryland; Division of Trauma and General Surgery, Department of Surgery (J.B.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington
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Harthi N, Goodacre S, Sampson F, Alharbi R. Research priorities for prehospital care of older patients with injuries: scoping review. Age Ageing 2022; 51:afac108. [PMID: 35604804 PMCID: PMC9126200 DOI: 10.1093/ageing/afac108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 01/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE There is increasing recognition of the importance of prehospital trauma care for older patients, but little systematic research to guide practice. We aimed to review the published evidence on prehospital trauma care for older patients, determine the scope of existing research and identify research gaps in the literature. METHODS We undertook a systematic scoping review guided by the Arksey and O'Malley framework and reported in line with the PRISMA-ScR checklist. A systematic search was conducted of Scopus, CINAHL, MEDLINE, PubMed and Cochrane library databases to identify articles published between 2001 and 2021. Study selection criteria were applied independently by two reviewers. Data were extracted, charted and summarised from eligible articles. A data-charting form was then developed to facilitate thematic analysis. Narrative synthesis then involved identifying major themes and subthemes from the data. RESULTS We identified and reviewed 65 studies, and included 25. We identified five categories: 'field triage', 'ageing impacts', 'decision-making', 'paramedic' awareness' and 'paramedic's behaviour'. Undertriage and overtriage (sensitivity and specificity) were commonly cited as poorly investigated field-triage subthemes. Ageing-related physiologic changes, comorbidities and polypharmacy were the most widely researched. Inaccurate decision-making and poor early identification of major injuries were identified as potentially influencing patient outcomes. CONCLUSION This is the first study reviewing the published evidence on prehospital trauma care for older patients and identifying research priorities for future research. Field-triage tools, paramedics' knowledge about injuries in the older population, and understanding of paramedics' negative behaviours towards older patients were identified as key research priorities.
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Affiliation(s)
- Naif Harthi
- School of Health and Related-Research, University of Sheffield, Sheffield City, UK
- Faculty of Applied Medical Sciences, Jazan University, Jazan City, Saudi Arabia
| | - Steve Goodacre
- School of Health and Related-Research, University of Sheffield, Sheffield City, UK
| | - Fiona Sampson
- School of Health and Related-Research, University of Sheffield, Sheffield City, UK
| | - Rayan Alharbi
- Faculty of Applied Medical Sciences, Jazan University, Jazan City, Saudi Arabia
- School of Nursing and Midwifery, La Trobe University, Melbourne City, Australia
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14
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Pandor A, Fuller G, Essat M, Sabir L, Holt C, Buckley Woods H, Chatha H. Individual risk factors predictive of major trauma in pre-hospital injured older patients: a systematic review. Br Paramed J 2022; 6:26-40. [PMID: 35340581 PMCID: PMC8892449 DOI: 10.29045/14784726.2022.03.6.4.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background Older adults with major trauma are frequently under-triaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to identify which individual risk factors and predictors are likely to increase the risk of major trauma in elderly patients presenting to emergency medical services (EMS) following injury, to inform future elderly triage tool development. Methods Several electronic databases (including Medline, EMBASE, CINAHL and the Cochrane Library) were searched from inception to February 2021. Prospective or retrospective diagnostic studies were eligible if they examined a prognostic factor (often termed predictor or risk factor) for, or diagnostic test to identify, major trauma. Selection of studies, data extraction and risk of bias assessments using the Quality in Prognostic Studies (QUIPS) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarise the findings. Results Nine studies, all performed in US trauma networks, met review inclusion criteria. Vital signs (Glasgow Coma Scale (GCS) score, systolic blood pressure, respiratory rate and shock index with specific elderly cut-off points), EMS provider judgement, comorbidities and certain crash scene variables (other occupants injured, occupant not independently mobile and head-on collision) were identified as significant pre-hospital variables associated with major trauma in the elderly in multi-variable analyses. Heart rate and anticoagulant were not significant predictors. Included studies were at moderate or high risk of bias, with applicability concerns secondary to selected study populations. Conclusions Existing pre-hospital major trauma triage tools could be optimised for elderly patients by including elderly-specific physiology thresholds. Future work should focus on more relevant reference standards and further evaluation of novel elderly relevant triage tool variables and thresholds.
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Affiliation(s)
- Abdullah Pandor
- The University of Sheffield ORCID iD: https://orcid.org/0000-0003-2552-5260
| | - Gordon Fuller
- The University of Sheffield ORCID iD: https://orcid.org/0000-0001-8532-3500
| | - Munira Essat
- The University of Sheffield ORCID iD: https://orcid.org/0000-0003-2397-402X
| | - Lisa Sabir
- The University of Sheffield ORCID iD: https://orcid.org/0000-0001-6488-3314
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15
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Maughan BC, Lin A, Caughey AB, Bulger EM, McConnell KJ, Malveau S, Griffiths D, Newgard CD. Field Trauma Triage among Older Adults: A Cost-Effectiveness Analysis. J Am Coll Surg 2022; 234:139-154. [PMID: 35213435 DOI: 10.1097/xcs.0000000000000025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND National guidelines for prehospital trauma triage aim to identify seriously injured patients who may benefit from transport to trauma centers. These guidelines have poor sensitivity for serious injury among older adults. We evaluated the cost-effectiveness of a high-sensitivity triage strategy for older adults. STUDY DESIGN We developed a Markov chain Monte Carlo microsimulation model to estimate the cost-effectiveness of high-sensitivity field triage criteria among older adults compared with current practice. The model used a retrospective cohort of 3621 community-dwelling Medicare beneficiaries who were transported by emergency medical services after an acute injury in 7 counties in the northwestern US during January to December 2011. These data informed model estimates of emergency medical services triage assessment, hospital transport patterns, and outcomes from index hospitalization up to 1 year after discharge. Outcomes beyond 1 year were modeled using published literature. Differences in cost and quality-adjusted life years (QALYs) were calculated for both strategies using a lifetime analytical horizon. We calculated the incremental cost-effectiveness ratio (cost per QALY gained) to assess cost-effectiveness, which we defined using a threshold of less than $100,000 per QALY. RESULTS High-sensitivity trauma field triage for older adults would produce a small incremental benefit in average trauma system effectiveness (0.0003 QALY) per patient at a cost of $1,236,295 per QALY. Sensitivity analysis indicates that the cost of initial hospitalization and emergency medical services adherence to triage status (ie transporting triage-positive patients to a trauma center) had the largest influence on overall cost-effectiveness. CONCLUSIONS High-sensitivity trauma field triage is not cost-effective among older adults.
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Affiliation(s)
- Brandon C Maughan
- From the Center for Policy and Research in Emergency Medicine (Maughan, Lin, Malveau, Griffiths, Newgard), Oregon Health & Science University, Portland, OR
| | - Amber Lin
- From the Center for Policy and Research in Emergency Medicine (Maughan, Lin, Malveau, Griffiths, Newgard), Oregon Health & Science University, Portland, OR
| | - Aaron B Caughey
- Department of Emergency Medicine, and Department of Obstetrics and Gynecology (Caughey), Oregon Health & Science University, Portland, OR
| | - Eileen M Bulger
- the Department of Surgery, University of Washington, Seattle, WA (Bulger)
| | - K John McConnell
- Center for Health Systems Effectiveness (McConnell), Oregon Health & Science University, Portland, OR
| | - Susan Malveau
- From the Center for Policy and Research in Emergency Medicine (Maughan, Lin, Malveau, Griffiths, Newgard), Oregon Health & Science University, Portland, OR
| | - Denise Griffiths
- From the Center for Policy and Research in Emergency Medicine (Maughan, Lin, Malveau, Griffiths, Newgard), Oregon Health & Science University, Portland, OR
| | - Craig D Newgard
- From the Center for Policy and Research in Emergency Medicine (Maughan, Lin, Malveau, Griffiths, Newgard), Oregon Health & Science University, Portland, OR
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Boulton AJ, Peel D, Rahman U, Cole E. Evaluation of elderly specific pre-hospital trauma triage criteria: a systematic review. Scand J Trauma Resusc Emerg Med 2021; 29:127. [PMID: 34461976 PMCID: PMC8404299 DOI: 10.1186/s13049-021-00940-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 08/18/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pre-hospital identification of major trauma in elderly patients is key for delivery of optimal care, however triage of this group is challenging. Elderly-specific triage criteria may be valuable. This systematic review aimed to summarise the published pre-hospital elderly-specific trauma triage tools and evaluate their sensitivity and specificity and associated clinical outcomes. METHODS MEDLINE and EMBASE databases were searched using predetermined criteria (PROSPERO: CRD42019140879). Two authors independently assessed search results, performed data extraction, risk of bias and quality assessments following the Grading of Recommendations, Assessment, Development and Evaluation system. RESULTS 801 articles were screened and 11 studies met eligibility criteria, including 1,332,300 patients from exclusively USA populations. There were eight unique elderly-specific triage criteria reported. Most studies retrospectively applied criteria to trauma databases, with few reporting real-world application. The Ohio Geriatric Triage Criteria was reported in three studies. Age cut-off ranged from 55 to 70 years with ≥ 65 most frequently reported. All reported existing adult criteria with modified physiological parameters using higher thresholds for systolic blood pressure and Glasgow coma scale, although the values used varied. Three criteria added co-morbidity or anti-coagulant/anti-platelet use considerations. Modifications to anatomical or mechanism of injury factors were used by only one triage criteria. Criteria sensitivity ranged from 44 to 93%, with a median of 86.3%, whilst specificity was generally poor (median 54%). Scant real-world data showed an increase in patients meeting triage criteria, but minimal changes to patient transport destination and mortality. All studies were at risk of bias and assessed of "very low" or "low" quality. CONCLUSIONS There are several published elderly-specific pre-hospital trauma triage tools in clinical practice, all developed and employed in the USA. Consensus exists for higher thresholds for physiological parameters, however there was variability in age-cut offs, triage criteria content, and tool sensitivity and specificity. Although sensitivity was improved over corresponding 'adult' criteria, specificity remained poor. There is a paucity of published real-world data examining the effect on patient care and clinical outcomes of elderly-specific triage criteria. There is uncertainty over the optimal elderly triage tool and further study is required to better inform practice and improve patient outcomes.
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Affiliation(s)
- Adam J Boulton
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B9 5SS, UK.
- Warwick Medical School, University of Warwick, Coventry, UK.
| | - Donna Peel
- Brighton & Sussex University Hospitals NHS Trust, Brighton, UK
| | - Usama Rahman
- Academic Department of Anaesthesia, Critical Care, Pain and Resuscitation, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B9 5SS, UK
| | - Elaine Cole
- Centre for Trauma Sciences, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Alshibani A, Alharbi M, Conroy S. Under-triage of older trauma patients in prehospital care: a systematic review. Eur Geriatr Med 2021; 12:903-919. [PMID: 34110604 PMCID: PMC8463357 DOI: 10.1007/s41999-021-00512-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/05/2021] [Indexed: 01/07/2023]
Abstract
Aim The systematic review aimed to assess the under-triage rate for older trauma patients in prehospital care and its impact on their outcomes. Findings Older trauma patients were significantly under-triaged in prehospital care and the benefits of triaging these patients to Tauma Centres (TCs) are still uncertain. Current triage criteria and developed geriatric-specific criteria lacked acceptable accuracy and when patients met the criteria, they had a low chance of being transported to TCs. Message Future worldwide research is needed to assess the following aspects: (1) the accuracy of current trauma triage criteria, (2) developing more accurate triage criteria, (3) destination compliance rates for patients meeting the triage criteria, (4) factors leading to destination non-compliance and their impact on outcomes, and (5) the benefits of TC access for older trauma patients. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00512-5. Background It is argued that many older trauma patients are under-triaged in prehospital care which may adversely affect their outcomes. This systematic review aimed to assess prehospital under-triage rates for older trauma patients, the accuracy of the triage criteria, and the impact of prehospital triage decisions on outcomes. Methods A computerised literature search using MEDLINE, Scopus, and CINHAL databases was conducted for studies published between 1966 and 2021 using a list of predetermined index terms and their associated alternatives. Studies which met the inclusion criteria were included and critiqued using the Critical Appraisal Skills Programme tool. Due to the heterogeneity of the included studies, narrative synthesis was used in this systematic review. Results Of the 280 identified studies, 23 met the inclusion criteria. Current trauma triage guidelines have poor sensitivity to identify major trauma and the need for TC care for older adults. Although modified triage tools for this population have improved sensitivity, they showed significantly decreased specificity or were not applied to all older people. The issue of low rates of TC transport for positively triaged older patients is not well understood. Furthermore, the benefits of TC treatment for older patients remain uncertain. Conclusions This systematic review showed that under-triage is an ongoing issue for older trauma patients in prehospital care and its impact on their outcomes is still uncertain. Further high-quality prospective research is needed to assess the accuracy of prehospital triage criteria, the factors other than the triage criteria that affect transport decisions, and the impact of under-triage on outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00512-5.
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Affiliation(s)
- Abdullah Alshibani
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, LE1 7HA, UK. .,Emergency Medical Services Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Meshal Alharbi
- Emergency Medical Services Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Simon Conroy
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, LE1 7HA, UK
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Alshibani A, Banerjee J, Lecky F, Coats TJ, Alharbi M, Conroy S. New Horizons in Understanding Appropriate Prehospital Identification and Trauma Triage for Older Adults. Open Access Emerg Med 2021; 13:117-135. [PMID: 33814934 PMCID: PMC8009532 DOI: 10.2147/oaem.s297850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/26/2021] [Indexed: 12/22/2022] Open
Abstract
Caring for older people is an important part of prehospital practice, including appropriate triage and transportation decisions. However, prehospital triage criteria are designed to predominantly assess injury severity or high-energy mechanism which is not the case for older people who often have injuries compounded by multimorbidity and frailty. This has led to high rates of under-triage in this population. This narrative review aimed to assess aspects other than triage criteria to better understand and improve prehospital triage decisions for older trauma patients. This includes integrating frailty assessment in prehospital trauma triage, which was shown to predict adverse outcomes for older trauma patients. Furthermore, determining appropriate outcome measures and the benefits of Major Trauma Centers (MTCs) for older trauma patients should be considered in order to direct accurate and more beneficial prehospital trauma triage decisions. It is still not clear what are the appropriate outcome measures that should be applied when caring for older trauma patients. There is also no strong consensus about the benefits of MTC access for older trauma patients with regards to survival, in-hospital length of stay, discharge disposition, and complications. Moreover, looking into factors other than triage criteria such as distance to MTCs, patient or relative choice, training, unfamiliarity with protocols, and possible ageism, which were shown to impact prehospital triage decisions but their impact on outcomes has not been investigated yet, should be more actively assessed and investigated for this population. Therefore, this paper aimed to discuss the available evidence around frailty assessment in prehospital care, appropriate outcome measures for older trauma patients, the benefits of MTC access for older patients, and factors other than triage criteria that could adversely impact accurate prehospital triage decisions for older trauma patients. It also provided several suggestions for the future.
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Affiliation(s)
- Abdullah Alshibani
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK.,Emergency Medical Services Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Jay Banerjee
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK.,University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, University of Sheffield, Sheffield, UK
| | - Timothy J Coats
- University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Meshal Alharbi
- Emergency Medical Services Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Simon Conroy
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
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Fuller G, Pandor A, Essat M, Sabir L, Buckley-Woods H, Chatha H, Holt C, Keating S, Turner J. Diagnostic accuracy of prehospital triage tools for identifying major trauma in elderly injured patients: A systematic review. J Trauma Acute Care Surg 2021; 90:403-412. [PMID: 33502151 DOI: 10.1097/ta.0000000000003039] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Older adults with major trauma are frequently undertriaged, increasing the risk of preventable morbidity and mortality. The aim of this systematic review was to evaluate the diagnostic performance of prehospital triage tools to identify suspected elderly trauma patients in need of specialized trauma care. METHODS Several electronic databases (including MEDLINE, EMBASE, and the Cochrane Library) were searched from inception to February 2019. Prospective or retrospective diagnostic studies were eligible if they examined prehospital triage tools as index tests (either scored theoretically using observed patient variables or evaluated according to actual paramedic transport decisions) compared with a reference standard for major trauma in elderly adults who require transport by paramedics following injury. Selection of studies, data extraction, and risk of bias assessments using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool were undertaken independently by at least two reviewers. Narrative synthesis was used to summarize the findings. RESULTS Fifteen studies met the inclusion criteria, with 11 studies examining theoretical accuracy, three evaluating real-life transport decisions, and one assessing both (of 21 individual index tests). Estimates for sensitivity and specificity were highly variable with sensitivity estimates ranging from 19.8% to 95.5% and 57.7% to 83.3% for theoretical accuracy and real life triage performance, respectively. Specificity results were similarly diverse ranging from 17.0% to 93.1% for theoretical accuracy and 46.3% to 78.9% for actual paramedic decisions. Most studies had unclear or high risk of bias and applicability concerns. There were no obvious differences between different triage tools, and findings did not appear to vary systematically with major trauma prevalence, age, alternative reference standards, study designs, or setting. CONCLUSION Existing prehospital triage tools may not accurately identify elderly patients with serious injury. Future work should focus on more relevant reference standards, establishing the best trade-off between undertriage and overtriage, optimizing the role prehospital clinician judgment, and further developing geriatric specific triage variables and thresholds. LEVEL OF EVIDENCE Systematic review, level III.
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Affiliation(s)
- Gordon Fuller
- From the School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, South Yorkshire, United Kingdom
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Alshibani A, Singler B, Conroy S. Towards improving prehospital triage for older trauma patients. Z Gerontol Geriatr 2021; 54:125-129. [PMID: 33507358 DOI: 10.1007/s00391-021-01844-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/05/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The proportion of older adults with major trauma is increasing. High-quality care for this population requires accurate and effective prehospital trauma triage decisions. OBJECTIVE Anatomical and physiological changes with age, comorbidities, and medication use for older adults may affect the accuracy of prehospital trauma triage. MATERIAL AND METHODS This narrative review focusses on age-related anatomical and physiological changes, comorbidities, and medication use for older adults with an emphasis on their impact on the accuracy of prehospital trauma triage tools. It also addresses the efforts to develop alternative triage criteria to reduce undertriage. RESULTS Age-related anatomical and physiological changes, comorbidities, and medication use were shown to affect physiological responses to injury and mechanism of injury for older people. Current triage tools poorly predicted injury severity. Geriatric-specific physiological measures and comorbidities significantly improved sensitivity with much lower specificity. Assessing anticoagulant or antiplatelet use in head injury notably improved sensitivity to identify traumatic intracranial hemorrhage, neurosurgery or death with modest decrease in specificity. CONCLUSION Improving prehospital providers' knowledge about the challenges of assessing older people with trauma may reduce undertriage. Assessing frailty could help in improving prehospital providers' judgments. Future research is needed to improve triage decisions for this population.
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Affiliation(s)
- Abdullah Alshibani
- Department of Health Sciences, College of Life Sciences, University of Leicester, LE1 7HA, Leicester, UK.
- Emergency Medical Services Department, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Boris Singler
- Zweckverband für Rettungsdienst und Feuerwehralarmierung, Hauptmarkt 16, 90403, Nürnberg, Germany
- Klinik Hallerwiese/Cnopfsche Kinderklinik, Sankt-Johannis-Mühlgasse 19, 90419, Nürnberg, Germany
| | - Simon Conroy
- Department of Health Sciences, College of Life Sciences, University of Leicester, LE1 7HA, Leicester, UK
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Hagebusch P, Faul P, Naujoks F, Klug A, Hoffmann R, Schweigkofler U. Trauma-team-activation in Germany: how do emergency service professionals use the activation due to trauma mechanism? Results from a nationwide survey. Eur J Trauma Emerg Surg 2020; 48:393-399. [PMID: 32583072 DOI: 10.1007/s00068-020-01425-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/19/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Trauma team activation (TTA) requires significant human and financial resources. The implemented German guidelines reduced the mortality of severe injured patients significantly over the last decade. Up to now there is no two-tier trauma team activation protocol in Germany. A two-tier TTA [often activated due to trauma mechanism (TM)] is thought to be a reasonable way to maintain patient safety while increasing cost efficiency. METHODS We created an online survey addressed at the Emergency Medical Service in Germany to conduct a cross-sectional study. Both physicians and rescue service professionals (RSPs) were included. A minimum of 1550 participants answered questions in 4 different categories concerning the aspects of limited-TTA (L-TTA). Case studies were presented to evaluate the usage of TTA due to TM in the daily routine. RESULTS Eighty percent (n:1233) of the respondents wish for a possibility to activate a limited trauma team. Seventy-two percent (n: 1109) of the participants consider a L-TTA due to TM to be adequate. There were significant differences (p < 0.05) in the assessment and opinion on L-TTA among physicians and RSPs as well as different medical professions. The evaluated case studies showed diverse answers: depending on the profession, the same patient was ranked as severely injured by 54% and as minorly injured by 46% of the 1550 participants. CONCLUSIONS Members of the German Emergency Medical Service call for a two-tier TTA-protocol. Up to now we cannot fully recommend an automatic reduction of the trauma team when activated due to TM in Germany with the guidelines implemented. The profession might affect the L-TTA-behavior. Criteria for a L-TTA in Germany have to be defined and evaluated. LEVEL OF EVIDENCE IV, cross-sectional study.
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Affiliation(s)
- Paul Hagebusch
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt, Germany.
| | - Philipp Faul
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt, Germany
| | - Frank Naujoks
- Ministry of Health, City of Frankfurt, Breite Gasse 28, 60313, Frankfurt, Germany
| | - Alexander Klug
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt, Germany
| | - Uwe Schweigkofler
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt, Germany
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