Risk factors and mortality associated with undertriage at a level I safety-net trauma center: a retrospective study

Associations of Age, Preinjury Morbidity, Injury Severity, and Cognitive Impairment With Mortality and Length of Stay in Trauma Consultation Patients: A Retrospective Study

Background To the best of our knowledge, we have found no trauma consultation study investigating Injury Severity Score (ISS) ≥16, Glasgow Coma Scale score (GCS), intracranial hemorrhage (ICH), age, preexisting medical conditions (PEMC), and smoking as risk conditions for mortality. Objective We aimed to assess ISS ≥16 and other postinjury and preinjury conditions for associations with death and adverse outcomes (AO). Methodology Consecutive consultations of patients admitted to a trauma center over 18 months were investigated. Data were obtained from the trauma registry and the electronic medical record. AO were death, intensive care unit stay of two days or more, or hospital stay exceeding five days. Results Among 1,031 trauma consultations, 28 patients (2.7%) died and 258 (25.0%) had AO. The proportion of ISS ≥16 was greater with death (53.6% (15/28)) than with survival (20.2% (203/1,003); p<0.0001). Of 218 patients with ISS ≥16, 93.1% (n = 203) survived, whereas 46.4% (13/28) died with an ISS <16. The area under the receiver operating characteristic curve for ISS ≥16 and the death relationship was 0.7 (p<0.001). The proportion of GCS <15 was greater with death (42.9% (12/28)) than with survival (13.1% (131/1,003); p<0.0001). The incidence of ICH was greater with death (57.1% (16/28)) than with survival (32.5% (326/1,003); p=0.0063). The incidence of age ≥70 was greater with death (89.3% (25/28)) than with survival (48.2% (483/1,003); p<0.0001). The proportion of PEMC was greater with death (85.7% (24/28)) than with survival (50.8% (509/1,003); p=0.0002). The proportion of smoking history was similar with death (50.0% (14/28)) and survival (52.5% (527/1,003); p=0.7905). Death had independent associations with age (p=0.0019), GCS (p<0.0001), ISS ≥16 (p=0.0074), and PEMC (p=0.0137). AO had univariate associations with ISS ≥16 (p<0.0001), GCS <15 (p<0.0001), ICH (p=0.0004), and PEMC (p=0.0002). Area under the receiver operating characteristic curve for ISS ≥16 and the AO relationship was 0.6 (p<0.001). AO had independent associations with GCS (p<0.0001), ISS ≥16 (p<0.0001), and PEMC (p=0.0005). Conclusions ISS ≥16 alone is marginally accurate for classifying trauma consultation patients who died or had AO. Other postinjury and preinjury conditions, such as GCS, ICH, age, and PEMC, should also be considered when assessing one's risk of death and AO.

Failure to initiate trauma team activation for patients who meet the criteria in a level 1 paediatric trauma centre: which patients are missing out?

BACKGROUND

Trauma team activation (TTA) is paramount in the early hospital management of trauma patients. This study aimed to evaluate factors which contribute to failure to activate the Trauma team for management of paediatric trauma.

METHODS

A retrospective cohort study of Emergency Department (ED) presentations at the paediatric major trauma hospital in Adelaide, South Australia was conducted over a 16-month period. Data from the hospital's trauma registry, individual case files and digital medical records were evaluated to determine factors that were associated with no TTA.

RESULTS

During the study period, 617 trauma patients who met Level 1 or Level 2 TTA criteria attended the trauma centre. For 29 (4.7%) of these patients, there was no TTA. Predictors of no TTA included sustaining abdomen and/or pelvis injuries compared to limb injuries (unadjusted odds ratio [OR] = 10.59, 95% confidence interval [CI] 1.98-56.69, P = 0.006), sustaining non-accidental injury (NAI) versus an injury with vehicle involvement (OR = 30.13, 95% CI 6.43-141.21, P < 0.001), and arriving via emergency medical retrieval service compared to private vehicle (OR = 14.23, 95% CI 3.94-51.36, P < 0.001). No patients transferred directly to Paediatric Intensive Care Unit (PICU), or High Dependency Unit (HDU) received an appropriate TTA.

CONCLUSION

Multiple factors were associated with no TTA in paediatric trauma patients. The results highlight that even in PICU and HDU admissions and transfer patients, vigilant clarification of mechanism of injury and potential for occult injuries should be undertaken to ensure appropriate TTA and improve patient outcome.

Factors associated with undertriage in patients classified by the need to visit a hospital by telephone triage: a retrospective cohort study

BACKGROUND

Prehospital telephone triage stratifies patients into five categories, "need immediate hospital visit by ambulance," "need to visit a hospital within 1 hour," "need to visit a hospital within 6 hours," "need to visit a hospital within 24 hours," and "do not need a hospital visit" in Japan. However, studies on whether present and past histories cause undertriage are limited in patients triaged as need an early hospital visit. We investigated factors associated with undertriage by comparing patient assessed to be appropriately triaged with those assessed undertriaged.

METHODS

We included all patients classified by telephone triage as need to visit a hospital within 1 h and 6 h who used a single after-hours house call (AHHC) medical service in Tokyo, Japan, between November 1, 2019, and November 31, 2020. After home consultation, AHHC doctors classified patients as grade 1 (treatable with over-the-counter medications), 2 (requires hospital or clinic visit), or 3 (requires ambulance transportation). Patients classified as grade 2 and 3 were defined as appropriately triaged and undertriaged, respectively.

RESULTS

We identified 10,742 eligible patients triaged as need to visit a hospital within 1 h and 6 h, including 10,479 (97.6%) appropriately triaged and 263 (2.4%) undertriaged patients. Multivariable logistic regression analyses revealed patients aged 16-64, 65-74, and ≥ 75 years (adjusted odds ratio [OR], 2.40 [95% confidence interval {CI} 1.71-3.36], 8.57 [95% CI 4.83-15.2], and 14.9 [95% CI 9.65-23.0], respectively; reference patients aged < 15 years); those with diabetes mellitus (2.31 [95% CI 1.25-4.26]); those with dementia (2.32 [95% CI 1.05-5.10]); and those with a history of cerebral infarction (1.98 [95% CI 1.01-3.87]) as more likely to be undertriaged.

CONCLUSIONS

We found that older adults and patients with diabetes mellitus, dementia, or a history of cerebral infarction were at risk of undertriage in patients triaged as need to visit a hospital within 1 h and 6 h, but further studies are needed to validate these findings.

Early predictors of discharge to home among severely injured geriatric patients: A single-system retrospective cohort study

Background

Injured geriatric patients experience significant functional decline during their hospitalization, limiting their ability to be discharged home which is a valuable outcome among this vulnerable population. We therefore sought to evaluate the clinical characteristics of injured elderly patients managed within our trauma system and identify early predictors for discharge to home.

Methods

In this single-system retrospective cohort study, we evaluated significantly injured (Injury Severity Score ≥12) geriatric (age ≥65 y) patients admitted from Northern Alberta between 2011 and 2016. The primary outcome was discharge disposition to home. Data was analyzed with descriptive statistics, and univariable and multivariable logistic regression modelling. P values less than 0.05 were considered statistically significant.

Results

We identified 1548 patients with a median age of 77. Falls accounted for 47% of injuries with median injury severity score of 22; 47% of patients were discharged home with a median hospital length of stay of 8 days. All-cause in-hospital mortality was 19%. On multivariable regression, age, injury severity score, heart rate, systolic blood pressure, and Glasgow Coma Score were independent predictors for discharge home, as well as hospital and intensive care unit length of stay.

Conclusion

Nearly half of severely injured geriatric trauma patients were discharged home. The identified predictors provide clues to disposition on admission that trauma providers may use to guide in-hospital care planning, disposition planning, and stimulate early goals of care discussions.

Undertriage Despite Use of Geriatric-Specific Trauma Team Activation Guidelines : Who Are We Missing?

BACKGROUND

Elderly trauma patients are at risk for undertriage, resulting in substantial morbidity and mortality. The objective of this study was to determine whether implementation of geriatric-specific trauma team activation (TTA) protocols appropriately identified severely-injured elderly patients.

METHODS

This single-center retrospective study evaluated all severely injured (injury severity score [ISS] >15), geriatric (≥65 years) patients admitted to our Level 1 tertiary-care hospital between January 2014 and September 2017. Undertriage was defined as the lack of TTA despite presence of severe injuries. The primary outcome was all-cause in-hospital mortality; secondary outcomes were mortality within 48 hours of admission and urgent hemorrhage control. A multivariable logistic regression analysis was performed to identify predictors of appropriate triage in this study.

RESULTS

Out of 1039 severely injured geriatric patients, 628 (61%) did not undergo TTA. Undertriaged patients were significantly older and had more comorbidities. In-hospital mortality was 5% and 31% in the undertriaged and appropriately triaged groups, respectively (P < .0001). One percent of undertriaged patients needed urgent hemorrhage control, compared to 6% of the appropriately triaged group (P < .0001). One percent of undertriaged patients died within 48 hours compared to 19% in the appropriately triaged group (P < .0001). Predictors of appropriate triage include GCS, heart rate, systolic blood pressure, lactic acid, ISS, shock, and absence of dementia, stroke, or alcoholism.

DISCUSSION

Geriatric-specific TTA guidelines continue to undertriage elderly trauma patients when using ISS as a metric to measure undertriage. However, undertriaged patients have much lower morbidity and mortality, suggesting the geriatric-specific TTA guidelines identify those patients at highest risk for poor outcomes.

Accuracy of algorithms to predict injury severity in older adults for trauma triage

Objective: Older adults make up a rapidly increasing proportion of motor vehicle occupants and previous studies have demonstrated that this population is more susceptible to traumatic injuries. The CDC recommends that patients anticipated to have severe injuries (Injury Severity Score [ISS] ≥ 16) be transported to a trauma center. The recommended target rate for undertriage is ≤ 5% and for overtriage is ≤ 50%. Several regression-based algorithms for injury prediction have been developed in order to predict severe injury in occupants involved in a motor vehicle collision (MVC). The objective of this study to was to determine if the accuracy of regression-based injury severity prediction algorithms decreases for older adults.Methods: Data were obtained from the National Automotive Sampling System - Crashworthiness Data System (NASS-CDS) from the years 2000-2015. Adult occupants involved in non-rollover MVCs were included. Regression-based injury risk models to predict severe injury (ISS ≥ 16) were developed using random split-samples with the following variables: age, delta-V, direction of impact, belt status, and number of impacts. Separate models were trained using data from the following age groups: (1) all adults, (2) 15-54 years, (3) ≥45 years, (4) ≥55 years, and (5) ≥65 years. The models were compared using the mean receiver operating characteristic area under curve (ROC-AUC) after 1,000 iterations of training and testing. The predicted rates of overtriage were then determined for each group in order to achieve an undertriage rate of 5%.Results: There were 24,577 occupants (6,863,306 weighted) included in this analysis. The injury prediction model trained using data from all adults did not perform as well when tested on older adults (ROC-AUC: 15-54 years: 0.874 [95% CI: [0.851-0.895]; 45+ years: 0.837 [95% CI: 0.802-869]; 55+ years: 0.821 [95% CI: 0.775-0.864]; and 65+ years: 0.813 [95% CI: 0.754-0.866]). The accuracy of this model decreased in each decade of life. The performance did not change significantly when age-specific data were used to train the prediction models (ROC-AUC: 18-54 years: 0.874 [95% CI: 0.851-0.896]; 45+ years: 0.836 [95% CI: 0.798-0.871]; 55+ years: 0.822 [95% CI: 0.779-0.864]; and 65+ years: 0.808 [95% CI: 0.748-0.868]). In order to achieve an undertriage rate of 5%, the predicted overtriage rate by these models were 50% for occupants 15-54 years, 61% for occupants ≥ 55 years, 70% for occupants ≥ 55 years, and 71% for occupants ≥ 65 years.Conclusion: The results of this study indicate that it is more difficult to accurately predict severe injury in older adults involved in MVCs, which has the potential to result in significant overtriage. This decreased accuracy is likely due to variations in fragility in older adults. These findings indicate that special care should be taken when using regression-based prediction models to determine the appropriate hospital destination for older occupants.

High-Risk Prehospital Mechanisms in Tier II Trauma Codes: An Analysis of Under-Triage at a Level II Trauma Center

Under-triage is used as a surrogate for trauma quality. We sought to analyze factors that may impact under-triage at our institution by a detailed analysis of prehospital mechanisms and patient factors that were associated with the need for invasive intervention, intensive care unit monitoring, or death. Patients admitted to our Level II trauma center who met the criteria for under-triage using the Cribari method were studied, n = 160, and prominent mechanisms were motor vehicle collisions (MVCs). Patient demographics, detailed mechanism characteristics, ED vital signs, operative intervention, and outcomes were studied. The age of the study group and injury severity score were 42 ± 20 and 22 ± 6, respectively. Alcohol or drug use was common as were high-speed frontal collisions. Overall, 38 per cent of patients required surgery, and a monitored bed was required in 60 per cent of patients. Logistic regression identified drug use as predictive of mortality and MVC speeds ≥40 mph as predictive of intensive care unit admission. Patients requiring surgery had a high incidence of frontal collisions, 40 per cent. MVCs were predominant in under-triaged trauma patients. Operative intervention, intensive care unit monitoring, and deaths were associated with frontal impacts, high speeds, and drug use. Further study is warranted to assess the incorporation of high-risk injury patterns in triage algorithms aimed at enhancing trauma quality.