Research priorities for prehospital care of older patients with injuries: scoping review

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.

Evaluation of elderly specific pre-hospital trauma triage criteria: a systematic review

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.

Factors associated with the undertriage of patients with abdominal pain in an emergency room

INTRODUCTION

The triage process lasts for a very short time, which can result in over-triage and under-triage. Studies have explored factors related to under-triage among trauma patients. In Korea, the clinical characteristics and severity of cases of under-triaged patients have been investigated. However, there is limited research on the under-triage of patients experiencing abdominal pain. Therefore, this study aimed to determine the under-triage rate of emergency department (ED) patients with abdominal pain, as well as the factors associated with their under-triage.

METHODS

The participants of this retrospective cohort study were 3,030 adult patients at a single tertiary hospital in Korea, who were brought to the ED for abdominal pain as the chief complaint. Participants' general characteristics, pain-related information, and environmental information were obtained from their electronic medical records.

RESULTS

The under-triage rate of ED patients with abdominal pain was 31.0%. Factors related to the under-triage of these patients were sex, age, visit route, time from the onset of the pain to the visit, location of pain, and intensity of pain.

CONCLUSION

These findings provide a foundation for the understanding and mitigation of under-triage in EDs through the identification of factors associated with under-triage in patients with abdominal pain.

The impact of delayed time to first CT head in traumatic brain injury

Purpose

Trauma team activation (TTA) criteria trigger early mobilization of resources for the sickest trauma patients. Patients with moderately depressed GCS who do not trigger the highest level activation are at risk for adverse outcomes, potentially from delayed time to intervention. The study objective was to define the impact of time to first CT Head (CTH) on outcomes among blunt trauma patients with moderately depressed GCS.

Methods

Patients from the Trauma Quality Improvement Program (TQIP) databank (2013–2016) with first ED GCS 9–12 were included. Transfers, penetrating mechanisms, death < 24 h, AIS = 6 in any body region, and patients with severe associated injuries were excluded. Study groups were defined by time to first CTH after ED arrival: immediate (≤ 1 h) vs. delayed (1–6 h). Primary outcomes were time to neurosurgical intervention and time to ED discharge.

Results

After exclusions, 4997 patients were identified. Of these, 79% (n = 3,954) underwent immediate CTH and 21% (n = 1,043) had delayed CTH. Median GCS was 11 [10–12] in both groups and there was no difference in median Head AIS (4 [3–4] vs. 4 [3–4], p = 0.586). Time to craniotomy and ICP monitor insertion were longer in the delayed group (4.2 h [3.0–7.6] vs. 3.1 h [2.1–8.7], p = 0.001; and 5.7 h [3.8–13.0] vs. 4.4 h [2.6–12.0], p = 0.008), as was time in the ED (4.3 h [2.7–6.5] vs. 2.1 h [1.2–3.7], p < 0.001). There was no difference in need for craniotomy (11% vs. 10%, p = 0.287), need for ICP monitor (12% vs. 12%, p = 0.899), or mortality (11% vs. 9%, p = 0.160). On multivariate analysis, age > 65 (OR 2.813, p < 0.001), SBP < 90 mmHg (OR 2.934, p < 0.001), ED intubation (OR 1.486, p = 0.001), and Head AIS scores of 4 (OR 1.884, p < 0.001) and 5 (OR 6.729, p < 0.001) were independently associated with death.

Conclusions

Immediate CTH for blunt trauma patients with moderately depressed GCS decreases time to intervention and reduces ED time. A protocol to shorten time to CTH may be beneficial for both patients and hospitals.