T. Uribe Leitz1, D. J. Sturgeon1, A. F. Harlow1, M. P. Jarman1, S. Lipsitz1, Z. Cooper1, A. Salim1, A. H. Haider1 1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA
Introduction: Trauma is the fastest growing cause of death and disability among individuals ≥65 years in the United States (US) leading to nearly 1 million hospitalizations and 54,000 deaths in 2013. Regional studies suggest older patients may not be fully benefitting from the US’s advanced trauma care system and Trauma Centers (TC) as many older trauma patients are under-triaged to Non-Trauma Centers (NTC). Our objective was to determine if older patients are under-triaged to NTCs at a national level and identify any regions where this is more likely to occur.
Methods: We identified trauma patients that were transported by ambulance from a residential address, skilled nurse facility, or accident site to a hospital in Medicare 2008-2014 data (patients aged ≥65 years). We merged this with data from the American Trauma Society and the American Hospital Association to identify level of TC that these patients were transported to. TC care was defined as care received at a Level I or Level II TC and the rest were classified as NTC. Under-triage was defined as patients with an injury severity score (ISS) ≥16 treated at a NTC, per the ACS Committee on Trauma recommendations. We performed multivariable logistic regression with TC status as the outcome variable adjusting for sex, race, age, ISS, functional status and miles traveled.
Results:A total of 1,162,960 patients ≥65 years of age were transported and admitted to a hospital during our study period. Thirty four percent (399,933/1,162,960) were treated at a TC. Mean age was 83.3 (SD 7.9), more than 69% were female, and the majority were white (>90%). Patients traveled a median of 5 miles to receive care. Seventy two percent of the injuries were due to falls. Of the patients that received care at a TC 31.1% (124,419/399,933) were from the Midwest. Of the patients that received care at a NTC 44.0% (335,504/763,027) were form the South. Multivariable analysis showed that patients in the Midwest, West, and South had 1.1 (95% CI, 1.0- 1.1), 1.6 (95% CI, 1.5 – 1.7), and 2.2 (95% CI ,2.1- 2.2) higher odds of being under-triaged, respectively, when compared to the Northeast after adjusting for potential confounders. Fifty-nine percent (55,778/93,878) of patients with an ISS of ≥16 were treated at a TC and 41% (38,100/93,878) at a non-TC.
Conclusion: At at a national level, nearly 40% of severely injured trauma patients ≥65 are under triaged to a NTC. This problem appears to be particularly worse in the Southern US, despite the fact that most field triage guidelines currently call for expedited transport of older trauma patients to TC. Tools to improve field triage and enhance trauma center access for older patients are urgently needed.
