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Ghneim MH, Stein DM. Age-related disparities in older adults in trauma. Surgery 2024:S0039-6060(24)00674-3. [PMID: 39317516 DOI: 10.1016/j.surg.2024.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 07/06/2024] [Accepted: 08/18/2024] [Indexed: 09/26/2024]
Abstract
As the population of older adults (≥65 years of age) continues to grow, the incidence of traumatic injuries in this demographic is also increasing nationwide. It has been well established that older adults experience worse outcomes, that is, an increased morbidity and mortality, when compared to younger adults. Moreover, survivors often experience accelerated cognitive and functional decline, loss of independence, and recurring injuries and hospitalizations. This manuscript examines the multifaceted challenges and disparities faced by older adults in trauma care. Factors such as age-related physiological changes, racial disparities, access to health care, and structural ageism that contribute to poor outcomes in geriatric patients who experience trauma. This is exacerbated by the sparsity of geriatric-specific practice management guidelines, thier poor implementation, and the critical under-representation of older adults in trauma research. However, significant efforts are being made to improve the care of older adults, including geriatric patients who experience trauma, through age-friendly systems, and initiatives aimed at promoting inclusive and effective care. These endeavors hold promise for a future where trauma care for older adults is comprehensive and equitable.
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Affiliation(s)
- Mira H Ghneim
- Program in Trauma, University of Maryland School of Medicine, R Adam Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD.
| | - Deborah M Stein
- Program in Trauma, University of Maryland School of Medicine, R Adam Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD. https://twitter.com/SteinSister
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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: 14.0] [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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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: 0.5] [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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Uribe-Leitz T, Jarman MP, Sturgeon DJ, Harlow AF, Lipsitz SR, Cooper Z, Salim A, Newgard CD, Haider AH. National Study of Triage and Access to Trauma Centers for Older Adults. Ann Emerg Med 2019; 75:125-135. [PMID: 31732372 DOI: 10.1016/j.annemergmed.2019.06.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 06/17/2019] [Accepted: 06/18/2019] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To identify predictors of undertriage among older injured Medicare beneficiaries, identify any regions in which undertriage is more likely to occur, and examine additional factors associated with undertriage at a national level. METHODS Using 2009 to 2014 Medicare claims data, we identified older adults (≥65 years) receiving a diagnosis of traumatic injury, and linked claims with trauma center designation records from the American Trauma Society. Undertriage was defined as nontrauma centers treatment with an Injury Severity Score greater than or equal to 16, consistent with the American College of Surgeons Committee on Trauma benchmark. We used multivariable logistic regression to estimate odds of undertriage by census region, adjusting for sex, race, age, Injury Severity Score, trauma center proximity, and mode of transportation. RESULTS Forty-six percent of severely injured patients (n=125,731) were treated at a nontrauma center. Compared with that for patients in the Midwest, adjusted odds of undertriage were 100% higher for patients in Southern states (odds ratio [OR] 2.00; 95% confidence interval [CI] 2.00 to 2.04) and 78% higher in Western states (OR 1.78; 95% CI 1.73 to 1.82). Compared with that for patients aged 65 to 69 years, odds of undertriage gradually increased in all age groups, reaching 57% for patients older than 80 years (OR 1.57; 95% CI 1.52 to 1.61). Distance to a trauma center was associated with increasing odds of undertriage, with 37% higher odds (OR 1.37; 95% CI 1.15 to 1.40) for older adults living more than 30 miles from a trauma center compared with patients living within 15 miles. CONCLUSION Nearly half of older adult trauma patients are undertriaged; it increases with age and distance to care and is most common in Southern and Western states. Improvements to field triage and trauma center access for older patients are urgently needed.
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Affiliation(s)
| | - Molly P Jarman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Daniel J Sturgeon
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Alyssa F Harlow
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Ali Salim
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Craig D Newgard
- Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
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van Rein EAJ, Jochems D, Lokerman RD, van der Sluijs R, Houwert RM, Lichtveld RA, van Es MA, Leenen LPH, van Heijl M. Diagnostic value of emergency medical services provider judgement in the identification of head injuries among trauma patients. Eur J Neurol 2018; 26:274-280. [DOI: 10.1111/ene.13804] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- E. A. J. van Rein
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - D. Jochems
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - R. D. Lokerman
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - R. van der Sluijs
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - R. M. Houwert
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
- Trauma Centre Utrecht; Utrecht
| | | | - M. A. van Es
- Department of Neurology; University Medical Centre Utrecht; Utrecht
| | - L. P. H. Leenen
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
| | - M. van Heijl
- Department of Traumatology; University Medical Centre Utrecht; Utrecht
- Department of Surgery; Diakonessenhuis Utrecht/Zeist/Doorn; Utrecht The Netherlands
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van Rein EA, van der Sluijs R, Houwert RM, Gunning AC, Lichtveld RA, Leenen LP, van Heijl M. Effectiveness of prehospital trauma triage systems in selecting severely injured patients: Is comparative analysis possible? Am J Emerg Med 2018; 36:1060-1069. [DOI: 10.1016/j.ajem.2018.01.055] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/16/2018] [Accepted: 01/18/2018] [Indexed: 10/18/2022] Open
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Magnone S, Ghirardi A, Ceresoli M, Ansaloni L. Trauma patients centralization for the mechanism of trauma: old questions without answers. Eur J Trauma Emerg Surg 2017; 45:431-436. [PMID: 29127439 DOI: 10.1007/s00068-017-0873-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 11/04/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Centralization of trauma patients has become the standard of care. Unfortunately, overtriage can overcome the capability of Trauma Centres. This study aims to analyse the association of different mechanisms of injury with severe or major trauma defined as Injury Severity Score (ISS) greater than 15 and an estimation of overtriage upon our Trauma Centre. METHODS A retrospective review of our prospective database was undertaken from March 2014 to August 2016. Univariate and multivariable logistic regression models were used to estimate the association between covariates (gender, age, and mechanisms of injury) and the risk of major trauma. RESULTS The trauma team (TT) treated 1575 patients: among the 1359 (86%) were triaged only because of dynamics or mechanism of trauma. Overtriage according to an ISS < 15, was 74.6% on all trauma team activation (TTA) and 83.2% among the TTA prompted by the mechanism of injury. Patients aged 56-70 years had an 87% higher risk of having a major trauma than younger patients (OR 1.87, 95% CI 1.29-2.71) while for patients aged more than 71 years OR was 3.45, 95% CI 2.31-5.15. Car head-on collision (OR 2.50, 95% CI 1.27-4.92), intentional falls (OR 5.61, 95% CI 2.43-12.97), motorbike crash (OR 1.67, 95% CI 1.06-2.65) and pedestrian impact (OR 2.68, 95% CI 1.51-4.74) were significantly associated with a higher risk of major trauma in a multivariate analysis. CONCLUSIONS Significant association with major trauma was demonstrated in the multivariate analysis of different mechanisms of trauma in patients triaged only for dynamics. A revision of our field triage protocol with a prospective validation is needed to improve overtriage that is above the suggested limits.
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Affiliation(s)
- S Magnone
- General Surgery Unit, Ospedale Papa Giovani XXIII, Piazza OMS 1, 24127, Bergamo, Italy.
| | - A Ghirardi
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - M Ceresoli
- General Surgery Unit, Ospedale Papa Giovani XXIII, Piazza OMS 1, 24127, Bergamo, Italy
| | - L Ansaloni
- General Surgery Unit, Ospedale Papa Giovani XXIII, Piazza OMS 1, 24127, Bergamo, Italy
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