Abstract
Background
Older age is associated with high rates of morbidity and mortality after injury. Statewide
studies suggest significantly injured patients aged ≥55 y are commonly undertriaged
to lower level trauma centers (TCs) or nontrauma centers (NTCs). This study determines
whether undertriage is a national phenomenon.
Materials and methods
Using the 2011 Nationwide Emergency Department Sample, significantly injured patients
aged ≥55 y were identified by diagnosis and new injury severity score (NISS) ≥9. Undertriage
was defined as definitive care anywhere other than level I or II TCs. Weighted descriptive
analysis compared characteristics of patients by triage status. Multivariable logistic
regression determined predictors of undertriage, controlling for hospital characteristics,
injury severity, and comorbidities.
Results
Of 4,152,541 emergency department (ED) visits meeting inclusion criteria, 74.0% were
treated at lower level TCs or NTCs. Patients at level I and II TCs more commonly had
NISS ≥9 (22.2% versus 12.3%, P < 0.001), but among all patients with NISS ≥9, 61.3% were undertriaged to a lower
level TC or a NTC. On multivariable logistic regression, factors independently associated
with higher odds of being undertriaged were increasing age, female gender, and fall-related
injuries. A subgroup analysis examined urban and suburban areas only where access
to a TC is more likely and found that 55.8% of patients' age were undertriaged.
Conclusions
There is substantial undertriage of patients aged ≥55 y nationwide. Over half of significantly
injured older patients are not treated at level I or II TCs. The impact of undertriage
should be determined to ensure older patients receive trauma care at the optimal site.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Surgical ResearchAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Web-based Injury Statistics Query and Reporting System (WISQARS) [Online].National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2003 (Available from: URL) ([2014 Nov 15])
- Resources for optimal care of the injured patient.American College of Surgeons, Chicago, IL2014
- Evaluation and management of geriatric trauma: an Eastern Association for the Surgery of Trauma practice management guideline.J Trauma Acute Care Surg. 2012; 73: S345
- Trauma in the older adult epidemiology and evolving geriatric trauma principles.Clin Geriatr Med. 2013; 29: 137
- The next four decades. The older population in the United States: 2010 to 2050 population estimates and projections P25-1138.U.S. Department of Commerce Economics and Statistics Administration, U.S. Census Bureau, Washington, DC2010 (Available from: URL) ([2014 Nov 15])
- Epidemiologic trend in elderly domestic injury.J Surg Res. 2012; 173: 206
- Redefining hypotension in the elderly: normotension is not reassuring.Arch Surg. 2011; 146: 865
- Pre-existing disease in trauma patients: a predictor of fate independent of age and injury severity score.J Trauma. 1992; 31: 236
- When is an elder old? Effect of preexisting conditions on mortality in geriatric trauma.J Trauma. 2002; 52: 242
- Comorbidity-polypharmacy scoring facilitates outcome prediction in older trauma patients.J Am Geriatr Soc. 2012; 60: 1465
- Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department.Ann Emerg Med. 2001; 38: 666
- Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death.J Trauma. 1998; 45: 805
- Traumatic brain injury in the elderly: increased mortality and worse functional outcome at discharge despite lower injury severity.J Trauma. 2002; 53: 219
- Pelvic fracture in geriatric patients: a distinct clinical entity.J Trauma. 2002; 53: 15
- A national evaluation of the effect of trauma-center care on mortality.N Engl J Med. 2006; 354: 366
- Trauma in the very elderly: a community-based study of outcomes at trauma and nontrauma centers.J Trauma. 2002; 52: 79
- Mortality in trauma patients: the interaction between host factors and severity.J Trauma. 1990; 30: 1476
- Guidelines for field triage of injured patients recommendations of the National Expert Panel on Field Triage, 2011.MMWR Recomm Rep. 2012; 61: 1
- Do trauma centers improve outcome over non-trauma centers: the evaluation of regional trauma care using discharge abstract data and patient management categories.J Trauma. 1990; 30: 1533
- Compliance with prehospital triage protocols for major trauma patients.J Trauma. 1999; 46: 168
- Undertriage of elderly trauma patients to state-designated trauma centers.Arch Surg. 2008; 143: 776
- Triage of elderly trauma patients: a population-based Perspective.J Am Coll Surg. 2013; 217: 569
Healthcare Cost and Utilization Project. Overview of the Nationwide Emergency Department Sample [NEDS]. Available from: URL: http://www.hcup-us.ahrq.gov/nedsoverview.jsp. [2014 Nov 15].
National Trauma Data Standard of the National Trauma Data Bank. Available from: URL: http://www.ntdsdictionary.org/index.html. [2014 Nov 15].
- Progress in characterizing anatomic injury.J Trauma. 1990; 30: 1200
Clark DE, Osler TM, Hahn DR. ICDPIC: STATA module to provide methods for translating International Classification of Diseases (Ninth Revision) diagnosis codes into standard injury categories and/or scores. Available from: URL: https://ideas.repec.org/c/boc/bocode/s457028.html. [2014 Nov 16].
- A modification of the injury severity score that both improves accuracy and simplifies scoring.J Trauma. 1997; 43: 922
- Should the ICD-9 trauma mortality prediction model become the new paradigm for benchmarking trauma outcomes?.J Trauma Acute Care Surg. 2012; 72: 1695
- An overview of the injury severity score and the new injury severity score.Inj Prev. 2001; 7: 10
Stagg V. CHARLSON: STATA module to calculate Charlson index of comorbidity. Available from: URL: http://ideas.repec.org/c/boc/bocode/s456719.html#author. [2014 Nov 16].
- A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis. 1987; 40: 373
- Explaining the paradoxical age-based racial disparities in survival after trauma: the role of the treating facility.Ann Surg. 2015; 262: 179
- Association between race and age in survival after trauma.JAMA Surg. 2014; 149: 642
- Access to trauma centers in the United States.JAMA. 2005; 21: 2626
- The physician orders for life-sustaining treatment program: Oregon emergency medical technicians' practical experiences and attitudes.JAGS. 2004; 52: 1430
- Defining geriatric trauma: when does age make a difference?.Surgery. 2012; 152: 668
- Severely injured geriatric patients return to independent living: a study of factors influencing function and independence.J Trauma. 1991; 31: 1096
Article info
Publication history
Published online: May 18, 2015
Accepted:
May 12,
2015
Received in revised form:
March 1,
2015
Received:
January 2,
2015
Identification
Copyright
© 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
