L. M. Kodadek1, S. Selvarajah1, C. G. Velopulos1, A. H. Haider1 1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA
Introduction:
Older age is associated with higher morbidity and mortality after injury. National guidelines recommend that patients age ≥55 years be considered for triage to trauma centers (TCs) to ensure optimal care. However, recent statewide studies suggest that significantly injured patients ≥55 years are actually more likely to be undertriaged to nontrauma centers (NTCs). Our objective was to determine if older adult undertriage is a national phenomenon and to determine associated patient and injury factors.
Methods:
The 2011 Nationwide Emergency Department Sample was used to perform a national analysis. All adults age ≥55 years presenting to an emergency department (ED) with an injury diagnosis were identified using ICD-9 diagnosis codes (800.*-959.*). Patients transferred to another short-term facility and patients with ICD-9 codes indicating superficial injury, foreign body injury and late effects were excluded. To determine injury severity, Stata program for Injury Classification (ICDPIC) was used to assign a new injury severity score (NISS). We performed weighted descriptive analysis comparing characteristics of patients by trauma center status. As patients in rural areas may be transported to a NTC because of proximity, a subset analysis was performed examining patients in urban/suburban areas only where this would occur less commonly. Logistic regression was performed to determine association between patient demographics and injury characteristics, controlling for hospital characteristics, injury severity and Charlson Comorbidity Index.
Results:
Of 4,135,782 ED visits meeting inclusion criteria, 74.0% were treated at NTCs, and 70.4% of all ED visits were in urban/suburban areas. Although the majority of ED visits were associated with NISS<9 (85.1%), proportionally more ED visits at TCs had NISS≥9 compared to NTCs (22.2% vs. 12.3%, P<.001). We found that 58.1% of patients with NISS≥9 were managed at a NTC. On multivariate analysis it was noted that patients at NTCs were more likely to be ≥75 years, female, insured by the government and injured by falls. Patients with moderate injuries (NISS 9 to 15) were more commonly treated at NTCs (62.7%) and patients with the most severe injuries (NISS > 25) were seen at similar rates in TCs and NTCs (49.1% vs. 50.9%).
Conclusion:
There is substantial undertriage of patients age ≥55 years at the national level. Nearly half of significantly injured older patients are being treated at NTCs. The impact of undertriage needs to be determined and interventions are needed to ensure that older patients receive trauma care at the optimal site.
