The influence of sociodemographic factors on trauma center transport for severely injured older adults.

OBJECTIVE: To examine sociodemographic predictors of trauma center (TC) transport of severely injured older adults. DATA SOURCES: The data source was the Healthcare Cost and Utilization Project, New York Inpatient Database (2014). STUDY DESIGN: This study was a secondary analysis of injured older adults. Key sociodemographic variables were age, gender, race/ethnicity, median household income, and primary payer. Confounding variables were injury severity, geographic location, number of chronic conditions, and injury mechanism. The outcome variable was TC transport. DATA COLLECTION/EXTRACTION METHODS: The database was filtered on the following criteria: age =/> 55 years, primary diagnosis of injury (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM], 800.0-957.9, excluding poisoning, late effects, and interfacility transfers), admitted to an acute care hospital in New York. PRINCIPAL FINDINGS: Records of 33 696 patients were included. Multivariate logistic regression analysis revealed that all variables were statistically significant predictors of TC transport except primary payer. Predictors of TC transport were as follows: higher injury severity (OR 2.1, CI 1.79-2.46; 3.39, CI 2.85-4.05); Asian/Pacific and Hispanic race/ethnicity (OR 2.51, CI 1.92-3.27; OR 1.1, CI 0.86-1.42), highest median household income (OR 1.24, CI 1.01-1.52), high population density (OR 1.32, CI 1.12-1.55; OR 3.2, CI 2.68-2.83), and vehicle crashes (OR 3.39, CI 2.79-4.11). Predictors of non-TC transport were as follows: older age groups (OR 0.92, CI 0.76-1.11; OR 0.79, CI 0.64-0.96; OR 0.77, CI 0.63-0.95), females (OR 0.65, CI 0.57-0.74), Black and "other" race (OR 0.75, CI 0.0.56-1.0; OR 0.96, CI 0.77-1.20), lower median household income (OR 0.76, CI 0.62-0.93; OR 0.86, CI 0.71-1.05), low population density (OR 0.96, CI 0.67-1.36; OR 0.89, CI 0.53-1.51), and number of chronic conditions (OR 0.89, CI 0.87-0.91). CONCLUSIONS: Sociodemographic factors are a source of disparity for access to TCs. Further research is needed to confirm bias and test bias reduction strategies. Comprehensive education and policies are needed to reduce disparities in access to trauma care.

Complications and Mortality Among Correctly Triaged and Undertriaged Severely Injured Older Adults With Traumatic Brain Injuries.

Determining differences in clinical outcomes of older adults treated at trauma centers (TCs) and nontrauma centers (NTCs) is imperative considering their persistent undertriage and the projected costs of fixing the problem. This study compared the incidence and predictors of complications and mortality among brain-injured older adults treated at TCs and NTCs. This secondary analysis of New York inpatient data included patients aged 55+ years, primary brain injury diagnosis, and acute care hospital admission. Interfacility transfers and nontraumatic brain injuries were excluded. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes identified complications and mortality. Injury severity was determined by mapping ICD-9-CM diagnoses to Abbreviated Injury Scale 2005 Revision 2008 dictionary scores. A subgroup analysis of 1,594 patients with New Injury Severity Scores greater than 15 was performed to examine complications and mortality. This study included 7,138 patients who met inclusion criteria. Predictors of subgroup complications included chronic renal failure, odds ratio (OR) = 2.251 (confidence interval [CI] = 1.470-3.447), p < .001; major operating room procedure, OR = 2.349 (CI = 1.679-3.285), p < .001; number of diagnoses, OR = 1.201 (CI = 1.158-1.245), p < .001; and number of procedures, OR = 1.119 (CI = 1.077-1.162), p £ .001. Mortality predictors included age, OR = 1.031 (CI = 1.017-1.045), p < .001; preexisting coagulopathy, OR = 1.753 (C = 1.130-2.719), p = .012; number of procedures, OR = 1.122 (CI = 1.081-1.166), p < .001; acute renal failure, OR = 3.114 (CI = 1.672-5.797), p < .001; systemic inflammatory response syndrome, OR = 4.058 (CI = 1.463-11.258), p = .007; adult respiratory distress syndrome, OR = 3.179 (CI = 1.673-6.041), p < .001; and subarachnoid bleed, OR = 2.667 (CI = 1.415-5.029), p = .002. Nearly 23% of the severely/critically injured patients experienced 1 or more complications. Incidence of complications was low and comparable for TCs and NTCs. The proportion of deaths was slightly higher at TCs but not significant. The most prevalent complications carry a high mortality risk.

Early neurological deterioration in older adults with traumatic brain injury.

INTRODUCTION: Traumatic brain injuries (TBIs) and resulting fatalities among older adults increased considerably in recent years. Neurological deterioration often goes unrecognized at the injury scene and patients arrive at emergency departments with near-normal Glasgow Coma Scale (GCS) scores. This study examined the proportion of older adults experiencing early neurological deterioration (prehospital to emergency department), associated factors, and association of the magnitude of neurological deterioration with TBI severity. METHODS: This secondary analysis of National Trauma Data Bank Research Datasets included patients who were age ⩾65, sustained a TBI, and transported from the injury scene to an emergency department. Data analysis included chi-square analysis, t-tests, and logistic regression. Long-term anticoagulant/antiplatelet therapy was not associated with deterioration. RESULTS: Of the sample of 91,886 patients, 13,913 (15.1%) experienced early neurological deterioration. Adjusting for covariates, age, gender, head AISmax injury severity, and probability of death were associated with early deterioration. Patients with severe and critical head injuries had the highest odds of early neurological deterioration (OR=1.41 [CI=1.22-1.63] and OR=1.98 [CI=1.63-2.40], p<0.001). DISCUSSION/CONCLUSIONS: Prehospital providers, nurses, physicians, and other providers have opportunities to optimize outcomes from older adult TBI through early recognition of neurological deterioration, rapid transport to facilities for definitive treatment, and targeted rehabilitation.

One for the Road: A Comparison of Drinking and Driving Behavior Among Younger and Older Adults Involved in Fatal Crashes.

Driving while intoxicated has been widely studied, but little is known about the differences in driving behaviors between the youngest and oldest drivers who consume alcohol but are not intoxicated. This study examined factors leading to fatal crashes in younger and older drivers who consumed alcohol, with a focus on drivers whose blood alcohol concentration was less than 0.08%. This was a secondary analysis of the Fatality Analysis Reporting System. Mean blood alcohol for both age groups was nearly double the legal limit. Within the low alcohol group, a higher proportion of older drivers crashed compared with younger drivers. Continued efforts are needed to screen and educate drivers regarding drinking and driving.

Injury patterns, severity and outcomes among older adults who sustained brain injury following a same level fall: a retrospective analysis.

INTRODUCTION: The objectives of this study were to: identify the incidence and types of brain injuries; classify brain injury severity; identify additional injuries; and identify predictors of length of stay, mortality and trauma center admission. METHODS: This secondary analysis used the NY State Inpatient Databases Healthcare Cost and Utilization Project. Inclusion criteria were: age 65 years and older, admitted to a hospital following a same level fall, primary hospital discharge diagnosis of traumatic brain injury. Descriptive and regression analyses were performed. RESULTS: 3331 patient records were analyzed. Intracranial hemorrhage accounted for 70% of the brain injuries. Younger age, higher household income, insurance status, ethnicity, patient location, increasing number of chronic diseases and diagnoses predicted trauma center admission. Age, trauma center admission, comorbidities, and brain injury severity predicted mortality. Age, race, major surgery, and number of diagnoses predicted length of stay. DISCUSSION: Brain injuries are common sequelae from falls among older adults. Additional research is needed to understand sociodemographic factors that are associated with trauma center admission.

Comparison of type and severity of major injuries among undertriaged and correctly triaged older patients.

BACKGROUND: Despite the use of prehospital triage algorithms and other trauma scoring methods, a substantial proportion of older patients with life-threatening injuries are undertriaged, increasing the risk of preventable death and disability. STUDY OBJECTIVE: The primary objective of this study was to describe the injury types, injury severity, and short-term survival outcomes of undertriaged older adults injured in motor vehicle collisions, compared to a group of correctly triaged older adults. METHODS: This secondary analysis of records extracted from the National Automotive Sampling System Crashworthiness Data System for the years 2004 through 2008 compared persons aged 65 years and older who sustained maximum Abbreviated Injury Scale (mAIS) 3, 4, and 5 injuries and were transported to non-trauma center hospitals to those with mAIS 3, 4, and 5 injuries who were transported to trauma center hospitals. RESULTS: Records of 66,445 patients were analyzed. Females comprised 61.8% (n=41,085) of the total sample. There were 6846 fatalities (10.3%) within 30 days of the crash, with 5708 (83.3%) of these attributed to injuries. Most patients sustained multiple injuries. Among the 17,403 undertriaged patients, brain injuries were the most common injury (n=5401, 31.1%), followed by thoracic fractures (n=5167, 29.7%), lower extremity fractures (n=4405, 25.3%), cervical spine fractures (n=3720, 21.4%), and thoracic-lumbar spine fractures (n=3513, 20.2%). Undertriaged patients also sustained an additional 2232 chest injuries, including contusions, vascular lacerations, diaphragm rupture, and unspecified injuries across all three AIS groups. The most common AIS 4 and 5 injuries were thoracic fractures. CONCLUSION: The large number of undertriaged patients with AIS 3, 4, and 5 injuries underscores the need for a thorough search for life-threatening injuries among older adults who present to non-trauma center Emergency Departments after motor vehicle collisions.

Life-threatening injuries in older adults.

Unintentional injuries are among the leading causes of death and disability in older adults. Although older adults account for approximately 12% of the US population, in 2008, they accounted for 15% of all traffic fatalities, 14% of all vehicle occupant fatalities, and 18% of all pedestrian fatalities. Severely injured older adults have far worse outcomes than younger adults. Despite this difference, many survive with aggressive resuscitation and goal-directed therapy. This article describes the impact of life-threatening injuries in the older adult population, specifically injuries sustained in motor vehicle collisions, and how these injuries relate to anatomic and physiologic changes of aging, the metabolic response to injury, the role of preexisting diseases and medications taken to treat these diseases, and complications.

Trends in the accuracy of older person trauma triage from 2004 to 2008.

BACKGROUND: Older injured persons are frequently undertriaged, increasing the risk for preventable mortality and morbidity in an already-vulnerable population. Changes made in 2006 to the American College of Surgeons Committee on Trauma (ACS-COT) Field Triage Decision Scheme might improve triage accuracy for this population. OBJECTIVE: This study examined triage accuracy before and after the 2006 revisions. METHODS: This secondary analysis of 2004, 2007, and 2008 data from the National Automotive Sampling System Crashworthiness Data System included persons aged 55 years and older who were transported to a hospital and had a maximum injury severity of uninjured or an Abbreviated Injury Scale score of 1 to 5. Trauma center and non-trauma center admission was a proxy for triage accuracy. Frequencies, means, standard deviations, sensitivities, specificities, positive predictive values (PPVs), and negative predictive values (NPVs) were calculated. RESULTS: Although triage accuracy has improved from 2004 to 2008, the undertriage rate still remains higher than the ACS-COT target of 5-10%. Overtriage rates have remained slightly above or within an acceptable range, suggesting that gains in triage accuracy have not unduly overburdened trauma centers. Both PPV and NPV have improved since 2004. CONCLUSIONS: There is a positive trend in triage accuracy for older injured persons since 2004. Ongoing funding, continued trauma system development with more training emphasis on scene evaluation of older adults, and the use of the ACS-COT triage decision scheme are essential for further improvement of triage accuracy. More research is needed to identify and validate additional triage criteria that are sensitive to severe injuries in older persons.

Prehospital factors associated with severe injury in older adults.

INTRODUCTION: Globally, injury is amongst the leading causes of death and disability in all age groups. Despite the use of prehospital trauma triage guidelines, identification of older persons with severe,potentially life-threatening injuries has been problematic. The purpose of this paper is to review prehospital factors associated with severe injuries amongst older adults. SEARCH STRATEGY: MEDLINE, CINAHL, Embase, and Cochrane databases were searched using key word searches of natural language and MeSH vocabulary. Criteria for final retention of the articles included: a focus on adults 50 years and older, single or multisystem injury and identification of prehospital (injury scene) factors associated with severe injury. Severe injury was defined as a maximum Abbreviated Injury Score (MAIS) ≥ 3 or an injury severity score ≥ 16, including fatal injury. RESULTS: The database searches yielded 469 unduplicated citations. Snowball searching yielded an additional 17 citations. Of these 486 citations, 19 research studies and 2 reviews with practice guidelines met the retention criteria. All of the research studies were secondary analyses, involving the use of hospital trauma registries, injury databases, patient medical records, and statewide hospital discharge data. These studies were conducted in the United States (US), Canada, and the United Kingdom (UK).Factors associated with severe injury included age, sex, systolic blood pressure, pulse, Glasgow ComaScale (GCS) score, use of anticoagulant and antiplatelet agents, angle of impact, restraint systems,occupant mobility at the scene, and number of persons injured. DISCUSSION AND CONCLUSIONS: The literature has two significant limitations: the lack of prospective studies of older trauma patient triage indicators and a lack of clarity in many published discussions related to the cause of injury mortality, i.e., whether deaths resulted from the direct effects of the injury or from complications, the effect of comorbidities, or a combination of these. The strongest evidence available at this time consists of retrospective analyses. There might be additional unidentified prehospital factors associated with severe injury in this population that have greater sensitivity, specificity, and predictive validity than current indicators. Seeking and validating such factors and validating existing triage indicators must assume priority amongst investigators and funding agencies.

Classification tree modeling to identify severe and moderate vehicular injuries in young and middle-aged adults.

OBJECTIVES: Motor vehicle crashes are a leading cause of mortality and morbidity worldwide. Even though trauma centers provide the gold standard of care for motor vehicle crash patients with life- or limb-threatening injuries, many whose lives might be saved by trauma center care are treated instead at non-trauma center hospitals. Triage algorithms, designed to identify patients with life- or limb-threatening injuries who should be transported to a trauma center, lack appropriate sensitivity to many of these injuries. The challenge to the trauma community is differentiating patients with life- or limb-threatening injuries from those with less severe injuries at the crash scene so that the patients can be transported to the most appropriate level of care. The purpose of this study was to use crash scene data available to emergency responders to classify adults with moderate and severe injuries. These classifiers might be useful to guide triage decision making. METHODS AND MATERIAL: Records of 74,626 adults, age 18-64 years, from the National Automotive Sampling System Crashworthiness Data Systems database were analyzed using classification and regression trees (CART) analysis. Both CART models (moderate injury and severe injury) included 13 predictor variables. The response variables were the targeted injury severity score cut points for moderate and severe injury. Two final classification trees were developed: one that classified occupants based on moderate injury and the other on severe injury. Misclassification costs were manipulated to achieve the best model fit for each tree. RESULTS: The moderate injury classification tree had three splitters: police-estimated injury severity, restraint use, and number of persons injured. The severe injury classification tree had four splitters: police-estimated injury severity, manner of collision, number of persons injured in the crash, and age. Sensitivity and specificity of the classification trees were 93.70%, 77.53% (moderate) and 99.18%, 73.96% (severe), respectively. CONCLUSIONS: CART analysis can be used to classify injury severity using crash scene information that is available to emergency responders. This procedure offers an opportunity to examine alternative methods of identifying injury severity that might assist emergency responders to differentiate more accurately persons who should receive trauma center care from those who can be treated safely at a non-trauma center hospital.

Evaluation of injury databases as a preliminary step to developing a triage decision rule.

PURPOSE: To evaluate accessibility and appropriateness of the Crash Outcomes Data Evaluation Systems (CODES) databases for prehospital trauma triage decision-rule development for people age 65 years and older. DESIGN AND METHODS: This informatics feasibility study included five steps for evaluating the accessibility of CODES databases. Eight criteria were used to evaluate the appropriateness of these databases for older person prehospital trauma triage decision-rule development. FINDINGS: Only 4 of the 33 states funded for CODES database development released their data to the study team during the 13-month data-acquisition period. Potential predictor variables (of life-threatening injury) and outcome variables (need for trauma center care) were identified for each database. Several databases had large amounts of missing data. Codebooks were available but descriptions of data validation procedures were unavailable. CONCLUSIONS: At this time, limited access to and development of CODES databases and missing data preclude the usefulness of these databases for older person triage decision rule development. Although adequate funding must be appropriated for continued CODES development, and commitment from individual states is essential, these databases offer great promise as a mechanism for decision-rule development to guide triage decision-making. Investigators should systematically evaluate large databases before using them in secondary analyses for clinical decision rule development. CLINICAL RELEVANCE: Nurses participate in the planning, development, and implementation of health information systems in various settings. They also assume important roles in prehospital care as direct care providers, EMS administrators, participants of local and state EMS councils where emergency care problems are discussed and policies are formulated, and through use at state and federal levels.

Using crash scene variables to predict the need for trauma center care in older persons.

Current trauma triage protocols lack sensitivity to occult injuries in older persons, resulting in unacceptable undertriage rates. We identified crash scene information that could be used by emergency personnel to identify the need for trauma center care in older persons injured in motor vehicle crashes. Crash records of 7,883 persons 65 years and older were explored using classification and regression trees (CART) analysis. CART analysis of 26 crash scene variables resulted in two classification trees from which triage decision rules were stated for persons with severe and moderate injuries. Sensitivity and specificity of the rules were 95.15% and 76.47% for severe injury and 83.1% and 81.5% for moderate injury.

Relationship of age, injury severity, injury type, comorbid conditions, level of care, and survival among older motor vehicle trauma patients.

The purpose of this secondary data analysis was to compare age, injury severity, injury types, selected comorbidities, level of care (at trauma center [TC] and non-trauma center [NTC] hospitals), and survival among older motor vehicle trauma patients (N = 1,478). Patients admitted to both levels of care had similar comorbid conditions. TC patients had a higher injury severity, whereas NTC patients had a greater proportion of soft tissue injuries. Results of logistic regression analyses subsequent to group comparisons revealed that higher injury severity was associated with TC admission. The likelihood of TC admission of severely injured patients decreased in the presence of spinal, internal, and head injuries. Internal injuries, liver, renal, and cardiovascular diseases were associated with non-survival while hypertension was associated with survival. Special attention is needed when triaging older trauma patients because their injuries may be covert, thus putting them at risk for admission to a level of care that may be inappropriate given the extent of their injuries.

Differences in survival, length of stay, and discharge disposition of older trauma patients admitted to trauma centers and nontrauma center hospitals.

PURPOSE: To examine the relationship of level of care (trauma center [TC], nontrauma center [NTC] hospitals) on three outcomes: survival, length of stay, and discharge disposition. DESIGN: Retrospective secondary analysis of a subset of data (1,418 patients age 65 to 99 years) from a large statewide study in which the purpose was to compare admission patterns (TCs and NTCs) of motor vehicle (MV) trauma patients according to age and sex. The New Jersey UB-92 Patient Discharge Data for 2000 were used in this analysis. METHODS: Demographic and clinical variables were compared using descriptive data, independent samples t tests, Pearson chi square, and Mann-Whitney U analyses. Logistic regression and multiple regression analyses were performed to examine relationships between level of care and three outcome variables, survival, length of stay, and discharge disposition, while controlling for age and severity of injury. RESULTS: NTC admission was the only predictor of survival and discharge to home, but injury severity was the strongest predictor of length of stay, followed by NTC care. The odds of survival and discharge home decreased slightly as age and injury severity increased. CONCLUSIONS: This analysis indicated preliminary evidence that level of care influences survival, length of stay, and discharge disposition. Studies are warranted for researchers to examine the influence of postinjury variables, including complications, stress reaction, and depression on outcomes.

Trauma center versus non-trauma center admissions in adult trauma victims by age and gender.

OBJECTIVE: The admission types and appropriateness of admission of adults with differing levels of injury severity were compared, based on patient age and gender. METHODS: This retrospective study used a statewide hospital discharge dataset. The patients included adults who had sustained trauma related to motor vehicles and were admitted to trauma center (TCs) and non-trauma center (NTCs) hospitals. Using injury severity scores (ISSs) >or= 16 to denote major trauma, the proportion of patients with major traumatic injuries who were admitted to TCs and NTCs was determined. Types of admission (TC versus NTC) were compared by age and gender for four subgroups of men and women, aged 25 to 64 years, and aged 65 years and older. RESULTS: The sample included 5,712 patients. Of those patients with ISS >or= 16, younger men were most likely to be admitted to a TC (82%), and older women were least likely to be admitted to a TC (60%). The proportions of older men and women with ISS >or= 16 who were admitted to a TC were comparable. Among patients with ISS < 16 admitted to NTCs, older women were the highest proportion (65%), and younger men were the lowest proportion (43%). Overall, more older men and women with ISS >or= 16 were admitted to NTCs than would have been expected. Conversely, a statistically significant proportion of younger men and women with ISS<16 were admitted to TCs. CONCLUSION: Findings suggest that older trauma victims whose injuries appear to be serious are admitted to NTCs more often than are younger trauma victims with similarly serious injuries. Additional studies to examine this phenomenon are warranted.

Effectiveness of prehospital trauma triage guidelines for the identification of major trauma in elderly motor vehicle crash victims.

INTRODUCTION: Undertriage of older trauma victims has been a persistent and serious problem. Because of physiologic changes and pre-existing disease, blunt trauma in older persons is often covert. Prehospital trauma triage guidelines developed for use with a general adult population may not be sensitive enough to detect covert injuries in elderly trauma patients. This study examined the sensitivity and specificity of one state's prehospital trauma triage guidelines for adults, with a particular focus on the triage of elderly persons. METHODS: This retrospective study used patient discharge data to examine the sensitivity (a measure of undertriage) and specificity (a measure of overtriage) of the adult prehospital trauma triage guidelines in 3 counties with level I trauma centers. Sensitivity and specificity of young and middle-aged adults was compared with that of older adults. RESULTS: Undertriage was 8% for young and middle-aged men, 12% for young and middle-aged women, 18% for older men, and 15% for older women. Overtriage was present in all age groups, indicating that many motor vehicle crash victims who were admitted to trauma centers could have been admitted to nontrauma center hospitals. DISCUSSION: Low sensitivity and specificity of trauma triage guidelines results in undertriage and overtriage. These guidelines should include age as a decision point to avoid placing older persons at risk for undertriage. Although some degree of overtriage is unavoidable without increasing undertriage, efforts should be made to minimize this costly occurrence.