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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Systematic Review and Meta-Analysis; Level III.

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

BACKGROUND

The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.

METHODS

Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.

RESULTS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.

CONCLUSIONS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

Data-Driven Blood Transfusion Thresholds for Severely Injured Patients During Blood Shortages

INTRODUCTION

Crises like the COVID-19 pandemic create blood product shortages. Patients requiring transfusions are placed at risk and institutions may need to judiciously administer blood during massive blood transfusions protocols (MTP). The purpose of this study is to provide data-driven guidance for the modification of MTP when the blood supply is severely limited.

METHODS

This is a retrospective cohort study of 47 Level I and II trauma centers (TC) within a single healthcare system whose patients received MTP from 2017 to 2019. All TC used a unifying MTP protocol for balanced blood product transfusions. The primary outcome was mortality as a function of volume of blood transfused and age. Hemoglobin thresholds and measures of futility were also estimated. Risk-adjusted analyses were performed using multivariable and hierarchical regression to account for confounders and hospital variation.

RESULTS

Proposed MTP maximum volume thresholds for three age groupings are as follows: 60 units for ages 16-30 y, 48 units for ages 31-55 y, and 24 units for >55 y. The range of mortality under the transfusion threshold was 30%-36% but doubled to 67-77% when the threshold was exceeded. Hemoglobin concentration differences relative to survival were clinically nonsignificant. Prehospital measures of futility were prehospital cardiac arrest and nonreactive pupils. In hospital risk factors of futility were mid-line shift on brain CT and cardiopulmonary arrest.

CONCLUSIONS

Establishing MTP threshold practices under blood shortage conditions, such as the COVID pandemic, could sustain blood availability by following relative thresholds for MTP use according to age groups and key risk factors.

The safety of continuous fascia iliaca block in patients with hip fracture taking pre-injury anticoagulant and/or antiplatelet medications

BACKGROUND

Fascia iliaca compartment block (FICB) is an effective method to treat pain in adult trauma patients with hip fracture. Of importance is the high prevalence of preinjury anticoagulants and antiplatelet medications in this population. To date, we have not identified any literature that has specifically evaluated the safety of FICB with continuous catheter infusion in patients on antiplatelet and/or anticoagulant therapy. The purpose of this study is to quantify the complication rate associated with FICB in patients who are actively taking prescribed anticoagulant and/or antiplatelet medications prior to injury and identify factors that may predispose patients to an adverse event.

METHODS

This retrospective study included consecutive adult trauma patients (age ≥18) with hip fracture who underwent placement of FICB within 24 h of admission and had been taking anticoagulant and/or antiplatelet medications pre-injury. Patients were excluded if their catheter was placed more than 24 h post-hospital admission. Patients were evaluated for demographics, injury severity, laboratory values, medication history, receipt of coagulation-related reversal medications, and complications related to FICB placement. Complications included bleeding at the insertion site requiring catheter removal and 30-day catheter site infection. The incidence of complications was reported and risk factors for complications were identified using univariate and multivariate statistics.

RESULTS

There were 124 patients included. The mean age was 81 ± 10 years, and the most common mechanism was ground level fall (94%). Most patients were taking single antiplatelet therapy (65%), followed by anticoagulant alone (21%), combined antiplatelet and anticoagulant therapy (7.3%) and dual antiplatelet therapy (7.3%). The most common antiplatelet was aspirin (88%) and the most common anticoagulant was warfarin (60%). Of the patients taking warfarin, the average INR on admission was 2.3 ± 0.8. Only 1 bleeding complication (0.8%) was noted in a patient prescribed clopidogrel pre-injury which occurred 5 days post-catheter placement. This same patient was noted to have superficial surgical site bleeding most likely secondary to the use of enoxaparin for post-operative deep venous thrombosis prophylaxis. There were 4 orthopedic superficial surgical site infections (3.2%), all remote from the catheter site. The pre-injury medication prescribed in these patients was aspirin 81 mg, aspirin 325 mg, rivaroxaban and dabigatran, respectively. No factors were associated with a complication thus multivariate analysis was not performed.

CONCLUSION

The incidence of complications associated with fascia iliaca compartment block (FICB) in adult trauma patients prescribed pre-injury anticoagulants or antiplatelet medications is low. In this retrospective review, we did not identify any complications that were directly associated with the FICB procedure. Fascia iliaca block with continuous infusion catheter placement can be safely performed on patients who are on therapeutic anticoagulant and/or antiplatelet agents.

Characteristics of thromboprophylaxis in elderly patients before and after orthopedic hip and knee surgery

Elderly patients with a hip fracture are at significantly higher risk for developing venous thromboembolism (VTE). The incidence of fatal pulmonary embolism (PE) occurs in 2-3% of patients after elective hip and knee surgery and about 6-7% after hip fracture surgery, with a higher risk in men (10,2%) than in women (4,7%). The use of pharmacological prophylaxis significantly reduces the incidence of symptomatic VTE. Pharmacological prophylaxis includes the use of antiplatelet drugs (aspirin), unfractionated heparin (UFH), low molecular weight heparins (LMWH), vitamin K antagonists (VKA), Fondaparinux and direct oral anticoagulants (DOAC). The use of low molecular weight heparins (LMWH) - enoxaparin, represents the gold standard of thromboprophylaxis in orthopedic surgery, and for now, they are the only drugs that are recommended for thromboprophylaxis in hip fracture surgery. Rivaroxaban is used in the prophylaxis of VTE in elective hip and knee surgeries at a fixed dose of 10 mg once daily, and apixaban at a dose of 2,5 mg twice daily in knee arthroplasty for at least 14 days, and after hip arthroplasty for at least 35 days. Early hip fracture surgery as soon as possible, preferably within 24 hours, and no later than 48 hours after admission to the hospital, significantly reduces the morbidity and mortality of elderly patients.

Preinjury warfarin does not cause failure of nonoperative management in patients with blunt hepatic, splenic or renal injuries

BACKGROUND

For patients sustaining major trauma, preinjury warfarin use may make adequate haemostasis difficult. This study aimed to determine whether preinjury warfarin would result in more haemostatic interventions (transarterial embolization [TAE] or surgeries) and a higher failure rate of nonoperative management for blunt hepatic, splenic or renal injuries.

METHODS

This was a retrospective cohort study from the Taiwan National Health Insurance Research Database (NHIRD) from 2003 to 2015. Patients with hepatic, splenic or renal injuries were identified. The primary outcome measurement was the need for invasive procedures to stop bleeding. One-to-two propensity score matching (PSM) was used to minimize selection bias.

RESULTS

A total of 37,837 patients were enrolled in the study, and 156 (0.41%) had preinjury warfarin use. With proper 1:2 PSM, patients who received warfarin preinjury were found to require more haemostatic interventions (39.9% vs. 29.1%, p=0.016). The differences between the two study groups were that patients with preinjury warfarin required more TAE than the controls (16.3% vs 8.2%, p = 0.009). No significant increases were found in the need for surgeries (exploratory laparotomy (5.2% vs 3.6%, p = 0.380), hepatorrhaphy (9.2% vs 7.2%, p = 0.447), splenectomy (13.1% vs 13.7%, p = 0.846) or nephrectomy (2.0% vs 0.7%, p = 0.229)). Seven out of 25 patients (28.0%) in the warfarin group required further operations after TAE, which was not significantly different from that in the nonwarfarin group (four out of 25 patients, 16.0%, p = 0.306) CONCLUSION: Preinjury warfarin increases the need for TAE but not surgeries. With proper haemostasis with TAE and resuscitation, nonoperative management can still be applied to patients with preinjury warfarin sustaining blunt hepatic, splenic or renal injuries. Patients with preinjury warfarin had a higher risk for surgery after TAE.

Understanding Preventable Deaths in the Geriatric Trauma Population: Analysis of 3,452,339 Patients From the Center of Medicare and Medicaid Services Database

BACKGROUND

Patient safety indicators (PSIs) are avoidable complications that can impact outcomes. Geriatric patients have a higher mortality than younger patients with similar injuries, and understanding the etiology may help reduce mortality. We aim to estimate preventable geriatric trauma mortality in the United States and identify PSIs associated with increased preventable mortality.

METHODS

A retrospective cohort study of patients aged ≥65 years, in the CMS database, 2017-second quarter of 2020. Risk-adjusted multivariable regression was performed to calculate observed-to-expected (O/E) mortality ratios for failure-to-prevent and failure-to-rescue PSIs with significance defined as P < .05.

RESULTS

3,452,339 geriatric patients were analyzed. Patients aged 75-84 years had 33% higher odds of preventable mortality (adjusted odds ratio [aOR] = 1.33 and 95% confidence interval [CI] = 1.31, 1.36), whereas patients aged ≥85 years had 91% higher odds of preventable mortality (aOR = 1.91 and 95% CI = 1.87, 1.94) compared to patients aged 65-74 years. Failure-to-prevent O/E were >1 for all PSIs evaluated with central line-related blood stream infection having a high O/E (747.93). Failure-to-rescue O/E were >1 for 10/11 (91%) PSIs with physiologic and metabolic derangements having the highest O/E (5.98). United States' states with higher quantities of geriatric trauma patients experienced reduced preventable mortality.

CONCLUSION

Odds of preventable mortality increases with age. Perioperative venous thrombotic events, hemorrhage or hematoma, and postoperative physiologic/metabolic derangements produce significant preventable mortalities. United States' states differ in their failure-to-prevent and failure-to-rescue PSIs. Utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy especially anticoagulation, ensuring operative and procedure-based competencies, and greater incorporation of inpatient geriatricians may serve to reduce preventable mortality in elderly trauma patients.

Aspirin does not increase the need for haemostatic interventions in blunt liver and spleen injuries

PURPOSE

The prohemorrhagic effect of aspirin may cause concern about worse prognoses when treating blunt hepatic or splenic injuries. This study investigated whether preinjury aspirin yields an increasing need for haemostatic interventions.

METHODS

Admission and outpatient records were extracted from the Taiwan National Health Insurance Research Database (NHIRD) from 2003 to 2015. Patients with splenic or hepatic injuries were identified, and those with preinjury nonaspirin APAC or with penetrating injuries were excluded. The primary outcome measurement was the necessity of invasive procedures to stop bleeding, including transarterial embolization (TAE) and surgeries. One-to-two propensity score matching (PSM) was used to minimize selection bias. Multilogistic regression (MLR) analysis was used to identify factors associated with haemostatic interventions.

RESULTS

A total of 20,470 patients had blunt hepatic injuries, and 15,235 had blunt splenic injuries, of whom 691 (3.4%) and 667 (4.4%) used preinjury aspirin, respectively. In the blunt hepatic injury cohort, there was no significant difference in the need for haemostatic procedures (TAE (6.1% vs 6.1%, p = 1.000), exploratory laparotomy (3.3% vs 4.3%, p = 0.312), hepatectomy (3.0% vs 2.7%, p = 0.686) or hepatorrhaphy (14.3% vs 15.0%, p = 0.683)). Regarding the blunt splenic injury cohort, there was no significant difference in the need for haemostatic procedures (TAE (11.5% vs 10.6%, p = 0.553), splenectomy (43.5% vs 41.4%, p = 0.230) or splenorrhaphy (3.0% vs 3.3%, p = 0.117)). An MLR analysis showed that preinjury aspirin did not increase the need for haemostatic interventions in either cohort.

CONCLUSIONS

Preinjury aspirin use is not associated with increased haemostatic procedures in blunt hepatic or splenic injuries.

The GERtality Score: The Development of a Simple Tool to Help Predict in-Hospital Mortality in Geriatric Trauma Patients

Feasible and predictive scoring systems for severely injured geriatric patients are lacking. Therefore, the aim of this study was to develop a scoring system for the prediction of in-hospital mortality in severely injured geriatric trauma patients. The TraumaRegister DGU^® (TR-DGU) was utilized. European geriatric patients (≥65 years) admitted between 2008 and 2017 were included. Relevant patient variables were implemented in the GERtality score. By conducting a receiver operating characteristic (ROC) analysis, a comparison with the Geriatric Trauma Outcome Score (GTOS) and the Revised Injury Severity Classification II (RISC-II) Score was performed. A total of 58,055 geriatric trauma patients (mean age: 77 years) were included. Univariable analysis led to the following variables: age ≥ 80 years, need for packed red blood cells (PRBC) transfusion prior to intensive care unit (ICU), American Society of Anesthesiologists (ASA) score ≥ 3, Glasgow Coma Scale (GCS) ≤ 13, Abbreviated Injury Scale (AIS) in any body region ≥ 4. The maximum GERtality score was 5 points. A mortality rate of 72.4% was calculated in patients with the maximum GERtality score. Mortality rates of 65.1 and 47.5% were encountered in patients with GERtality scores of 4 and 3 points, respectively. The area under the curve (AUC) of the novel GERtality score was 0.803 (GTOS: 0.784; RISC-II: 0.879). The novel GERtality score is a simple and feasible score that enables an adequate prediction of the probability of mortality in polytraumatized geriatric patients by using only five specific parameters.

The Effect of Anticoagulation and Antiplatelet Use in Trauma Patients on Mortality and Length of Stay

BACKGROUND

Though many trauma patients are on anticoagulation or antiplatelet therapy (AAT), there are few generalizable data on the risks for these patients. The purpose of this study was to analyze the impact of anticoagulation (AC) and antiplatelet (AP) therapy on mortality and length of stay (LOS) in general trauma patients.

METHODS

A retrospective review was performed of patients in the institutional trauma registry during 2019 to determine AAT use on admission and discharge. Outcomes were compared using standard statistics.

RESULTS

Of 2261 patients who met the inclusion criteria, 2 were excluded due to an incomplete medication reconciliation, resulting in 2259 patients. Patients on AAT had a higher mortality (4.5% vs 2.1%). On multivariable analysis, preadmission AC (odds ratio OR, 3.325, P = .001), age (OR 1.040, P < .001), and injury severity score ((ISS) 1.094, P < .001) were associated with mortality. Anticoagulation use was also associated with longer LOS on multivariable analysis (OR: 1.626, P = .005). Antiplatelet use was not associated with higher mortality or longer LOS. More patients on AAT were unable to be discharged home. However, patients on AAT did not have a greater blood transfusion requirement or need more hemorrhage control procedures. Lastly, 23.7% of patients on preadmission AAT were not discharged on any AAT.

DISCUSSION

These data demonstrate that patients on AC, but not AP, have greater mortality and longer hospital LOS. This may provide guidance for those being newly started on AAT. Further work to determine which patients benefit most from restarting AAT would lead to improvement in the care of trauma patients.

Delayed Intracranial Hemorrhage After Blunt Head Injury With Direct Oral Anticoagulants

INTRODUCTION

Patients presenting to the Emergency Department (ED) following head injury are frequently evaluated with an initial computed tomography scan (CT) of the brain. Imaging is particularly important in patients who are receiving medications that alter normal blood hemostasis. As an imaging modality, CT has a high negative predictive value when used to rule out clinically significant acute intracranial hemorrhage. Patients receiving anticoagulant or antiplatelet therapy have both an increased risk of initial hemorrhage, as well as an increased risk of mortality above nonanticoagulated patients, should they suffer hemorrhage. Multiple studies of delayed intracranial hemorrhage have placed the risk among the patients taking warfarin at the time of head injury in the range of 0.6-6.0%. However, data regarding the risk of delayed intracranial hemorrhage in patients taking the class of agents referred to as Direct-Acting Oral Anticoagulants (DOACs) remains limited. This study aims to estimate this risk.

METHODS

A retrospective chart review was performed to identify patients on DOACs who presented to our Level I trauma center following blunt head injury between January 2017 and August 2018. Patients with a negative initial head CT were selected. From this subset, data regarding demographics, injury characteristics, anticoagulant use, and antiplatelet use were collected.

RESULTS

Overall, 314 patients were included; 129 patients taking rivaroxaban, 182 patients taking apixaban, and four patients taking dabigatran. In approximately 29% of the patients, the sole indication for admission was close monitoring following head injury while taking an anticoagulant agent. The mechanism of injury for the majority of the patients was fall. Of the 314 patients, three were found to have delayed intracranial hemorrhage on the repeated head CT (0.95%). Two of these three patients were on concomitant antiplatelet medication. None of the three individuals required neurosurgical intervention.

CONCLUSIONS

at the time of submission, this is the largest study estimating the risk of delayed intracranial hemorrhage among patients on DOACs. Based on the results of this study, patients who sustain a blunt head injury while taking only DOACs; that is, without concurrent antiplatelet medication, admission, and repeat head CT may not be necessary after confirming a negative initial CT scan.

The effect of preinjury anticoagulation on mortality in trauma patients: A systematic review and meta-analysis

OBJECTIVES

To assess the effect of preinjury anticoagulation on mortality in trauma patients.

METHODS

A search of electronic information sources was conducted to identify all observational studies comparing preinjury anticoagulation with no preinjury anticoagulation in trauma patients. The primary outcome measure was overall mortality (overall mortality, in-hospital mortality and 30-day mortality). The secondary outcome measures included the length of hospital stay, length of intensive care unit (ICU) stay, incidence of intracranial haemorrhage (ICH), and need for operation. Fixed effect or random effects modelling was applied as appropriate to calculate pooled outcome data.

RESULTS

Nineteen comparative studies enrolling a total of 1,365,446 patients were included. Preinjury anticoagulation was associated with higher risk of overall mortality (OR 2.12, 95%CI 1.79 - 2.51, p < 0.00001), in-hospital mortality (OR 2.04, 95%CI 1.66 - 2.52, p < 0.00001), ICH (OD 1.99, 95%CI 1.61 - 2.45, p < 0.00001), and shorter length of hospital stay (MD 0.50, 95%CI 0.03 - 0.97, p = 0.04) in comparison to no preinjury anticoagulation. We found no difference between the two groups in 30-day mortality (OR 1.61, 95%CI 0.91 - 2.85, p = 0.10), length of ICU stay (MD 0.62, 95%CI -0.13 - 1.36, p = 0.11), and need for operation (OR 1.73, 95%CI 0.71 - 4.20, p = 0.23). The quality of the available evidence was moderate.

CONCLUSION

Preinjury anticoagulation is a significant predictor of mortality in trauma patients. Future studies should focus on strategies required to reduce such a significant risk of mortality in these high-risk patients. This may include adaptation of primary, secondary and tertiary trauma surveys for patients on preinjury anticoagulation.

The Impact of Anticoagulation on Trauma Outcomes : An National Trauma Data Bank Study

BACKGROUND

Increased prevalence of patients on anticoagulants and the advent of new therapies raise concern over how these patients fare if they sustain a traumatic injury. We investigated the role of prehospitalization anticoagulation therapy in trauma-related mortality and postacute disposition.

METHODS

A retrospective analysis was performed on patients who sustained traumatic injury identified in the 2017 National Trauma Data Bank (NTDB). Patients with and without anticoagulation therapy were analyzed to identify differences in demographics, injury type, Injury Severity Score (ISS), and trauma outcomes including hospital length of stay, ER, final hospital disposition, and mortality. Logistic regression was used to correlate anticoagulation to mortality and facility discharge.

RESULTS

Of the 1 000 596 patients included, 73 602 (7%) patients were on anticoagulants at the time of their trauma. Increased age was the strongest predictor for anticoagulation therapy (odds ratio 5.54, 95% CI 5.44-5.63), but being female and white were also independent predictors of anticoagulation (P < .001). Patients on anticoagulants had a significantly longer length of stay (5.11 days; 95% CI 5.06-5.15) than those who were not (4.37 days, 95% CI 4.36-4.39), were 2.20 times more likely to die (95% CI 2.12-2.28, P < .001), and were 2.77 times more likely to be discharged to a facility (95% CI 2.73-2.81, P < .001). Anticoagulation remained a significant predictor of worse trauma outcomes even when accounting for age and ISS in multivariate analysis.

DISCUSSION

Anticoagulation preceding trauma-related admission is associated with higher mortality and an increased likelihood of the need for a posthospital care facility.

Geriatric Patients on Antithrombotic Agents who Fall: Does Trauma Team Activation Improve Outcomes?

Despite the incorporation of anticoagulant and antiplatelet (ACAP) drugs in our trauma triage criteria, it is unclear whether trauma team activation (TTA) impacts outcomes in geriatric patients on ACAP drugs sustaining falls. We hypothesized that TTA in this cohort was associated with improved outcomes. The hospital electronic database was queried to identify normotensive, awake patients aged ≥65 years on ACAP agent from 2014 to 2018 presenting to the emergency department after falls. The outcome was in-hospital mortality. The association between TTA and mortality was examined using logistic regression analysis and 1:1 propensity score matching analysis. In this study, 4540 patients on ACAP drugs were analyzed, with TTA occurring in 500 (11%). TTA occurred in younger but more severely injured patients with lower Glasgow Coma Score. Logistic regression revealed that TTA was not associated with mortality (odds ratio [95% confidence intervals], 2.04 [0.89–4.25]). The 1:1 propensity score analysis revealed similar mortality for the matched groups (non-TTA, 1.6% vs TTA, 2.2%, P = 0.64). In the elderly patients on ACAP agents, the current triage criteria resulted in the appropriate use of TTA for more severely injured patients. The lack of outcome benefit suggests that ACAP drug use as a criterion for TTA should be re-evaluated.

A Comparison of Scoring Systems for Predicting Short- and Long-term Survival After Trauma in Older Adults

OBJECTIVES

Early identification of geriatric patients at high risk for mortality is important to guide clinical care, medical decision making, palliative discussions, quality assurance, and research. We sought to identify injured older adults at highest risk for 30-day mortality using an empirically derived scoring system from available data and to compare it with current prognostic scoring systems.

METHODS

This was a retrospective cohort study of injured adults ≥ 65 years transported by 44 emergency medical services (EMS) agencies to 49 emergency departments in Oregon and Washington from January 1, 2011, through December 31, 2011, with follow-up through December 31, 2012. We matched data from EMS to Medicare, inpatient, trauma registries, and vital statistics. Using a primary outcome of 30-day mortality, we empirically derived a new risk score using binary recursive partitioning and compared it to the Charlson Comorbidity Index (CCI), modified frailty index, geriatric trauma outcome score (GTOS), GTOS II, and Injury Severity Score (ISS).

RESULTS

There were 4,849 patients, of whom 234 (4.8%) died within 30 days and 1,040 (21.5%) died within 1 year. The derived score, the geriatric trauma risk indicator (GTRI; emergent airway or CCI ≥ 2), had 87.2% sensitivity (95% confidence interval [CI] = 83.0% to 91.5%) and 30.6% specificity (95% CI = 29.3% to 31.9%) for 30-day mortality (area under the receiving operating characteristic curve [AUROC] = 0.589, 95% CI = 0.566 to 0.611). AUROC values for other scoring systems ranged from 0.592 to 0.678. When the sensitivity for each existing score was held at 90%, specificity values ranged from 7.5% (ISS) to 30.6% (GTRI).

CONCLUSIONS

Older, injured adults transported by EMS to a large variety of trauma and nontrauma hospitals were more likely to die within 30 days if they required emergent airway management or had a higher comorbidity burden. When compared to other risk measures and holding sensitivity constant near 90%, the GTRI had higher specificity, despite a lower AUROC. Using GTOS II or the GTRI may better identify high-risk older adults than traditional scores, such as ISS, but identification of an ideal prognostic tool remains elusive.