Patients with the most severe injuries can be taken to trauma centers that offer immediate specialized resources. However, instead of going to a trauma center, many elderly patients receive care in facilities without specialized expertise in trauma care. Research has shown that elderly patients are frequently undertriaged, but little is known about the associations between triage patterns and outcomes.

Analyzing Undertriage

In a study published in the Journal of the American College of Surgeons, Kristan L. Staudenmayer, MD, MS, FACS, and colleagues assessed how undertriaging elderly patients affects outcomes and whether they survived an injury 60 days later. This time frame is important because elderly patients often die after leaving the hospital rather than during hospitalization. Using in-hospital mortality can underestimate the true impact of injuries in this population.

The study group reviewed data from emergency medical services in California and Utah from 6,015 patients aged 55 and older. There were no significant differences in 60-day mortality between trauma centers and non-trauma centers for patients who were severely injured in both unadjusted and adjusted analyses. Unadjusted 60-day mortality rates were 16% to 17%. Despite the lack of mortality benefit, severely injured elderly patients treated at trauma centers incurred greater costs. After adjusting for patient and injury characteristics, the median costs for patients at trauma centers were approximately 20% higher than at non-trauma centers.

“It’s known that elderly patients don’t do as well as the young after injuries, but it’s difficult to argue that this is purely due to undertriage,” says Dr. Staudenmayer.  “In analyzing all deaths in the elderly, we found that mortality was more commonly associated with falls and age rather than physiology and injury severity. This suggests that injury-related deaths in the elderly are likely driven to a large degree by baseline health rather than just the injury itself.”

Questions Remain

Dr. Staudenmayer says the fact that no differences were observed in mortality rates for severely injured patients at trauma centers leads to more questions that need to be answered. “There are likely elderly patients who benefit from the specialized care provided at trauma centers, but identification of those subgroups is obscured by deaths in frail individuals who ultimately would have never survived their injuries. We need to determine which patients benefit from trauma center care to ensure that these individuals make it to the right hospital.”

Future research should also look at how pre-hospitalization health status factors into outcomes when care is not received at a trauma center. “Undertriage will continue to cost lives and dollars if this issue is left unaddressed,” Dr. Staudenmayer explains. “We must find effective strategies to improve outcomes and identify those who can benefit most from receiving care at trauma centers.”

References

Staudenmayer KL, Hsia RY, Mann NC, Spain DA, Newgard CD. Triage of elderly trauma patients: a population-based perspective. J Am Coll Surg. 2013;217:569-576. Available at: http://www.sciencedirect.com/science/article/pii/S1072751513004869.

Sugerman DE, Xu L, Pearson WS, Faul M. Patients with severe traumatic brain injury transferred to a Level I or II trauma center: United States, 2007 to 2009. J Trauma Acute Care Surg. 2012; 73:1491-1499.

Davis JS, Allan BJ, Sobowale O, Ivascu F, Orion K, Schulman CI. Evaluation of a new elderly trauma triage algorithm. South Med J. 2012;105:447-451.

Mohan D, Barnato AE, Rosengart MR, et al. Trauma triage in the emergency departments of nontrauma centers: an analysis of individual physician caseload on triage patterns. J Trauma Acute Care Surg. 2013;74:1541-1547.