Multicenter study of trauma activation criteria and time-sensitive care in older versus younger adults

Abstract

Background: The applicability of existing trauma activation criteria (TAC) and the need for geriatric-specific TAC for this vulnerable population has been debated. The goal of this study was to determine whether existing TAC are equally effective at identifying the need for high-intensity time-sensitive (HITS) interventions in older versus younger adults and their relationship to outcomes.

Methods: This multicenter, retrospective, cohort study collected data (2017-2019) securely from participating centers as National Trauma Data Bank files with trauma activation (TA) status: full (fTA), partial (pTA), none (nTA). HITS were derived from Trauma Quality Improvement Program process of care measures as critical interventions requiring trauma expertise including emergent airway management/ventilation, hemorrhage control surgery, blood transfusion, intracranial pressure monitoring, chest tube placement, and angiography. Older adults (≥65 years) were compared with younger adults (<65 years) on demographics, injury characteristics, and HITS status by TAC status using χ² tests.

Results: Twenty-five level I and 11 level II US TCs enrolled 216 960 patients (87.9% blunt, 18.7% fTA, median age: 54 years, median Injury Severity Score: 9, in-hospital mortality 3.3%). Overall, 10.3% of patients received a HITS intervention. Older adults were less likely to receive HITS compared with younger adults (fTA: 35.4% vs 39.3%, p<0.001; pTA: 5.1% vs 6.1%, p<0.001), but this difference was not significant in the adjusted analysis for fTA (adjusted OR: 0.97, 95% CI 0.92 to 1.02, p=0.25). Compared with non-HITS, HITS were associated with increased total mortality (in-hospital mortality+hospice) in both fTA (25.6% vs 4.3%, p<0.001) and pTA (15.2% vs 2.0%, p<0.001). Rates of undertriage were high in both younger and older adults (25% and 47%, respectively).

Conclusions: Meeting current TAC for highest level activation identifies patients needing HITS equally for younger and older adults, but high undertriage and overtriage remain problematic in both groups. This research highlights opportunities to address significant deficiencies in the accuracy and/or application of TAC for both younger and older adults.

Level of evidence: Level III, therapeutic/care management.

Keywords: geriatrics; triage.

Figure 1. Consolidated Standards of Reporting Trials (CONSORT) flow diagram for selection of patients included in the study. ED, emergency department.

Figure 2. Comparison of performance metrics for full trauma activations predicting the use of high-intensity time-sensitive (HITS) interventions, by age group. This figure shows varying performance of full trauma activations by age group. Sensitivity was lower, and thus undertriage was higher, in the older adults, compared with the younger adults. PPV, positive predictive value; NPV, negative predictive value; undertriage was calculated as the proportion of patients who were not full trauma activations, out of all patients who received a HITS intervention; overtriage was calculated as the proportion of patients who were full trauma activations, out of all patients who did not receive a HITS intervention.