Ohio State Board of Ohio State Board of Emergency Medical ServicesEmergency Medical Services

Trauma CommitteeTrauma Committee

Geriatric Trauma Triage Criteria: Geriatric Trauma Triage Criteria: How and WhyHow and Why

Required ReviewRequired Review

EMS Board is required by law to review EMS Board is required by law to review their trauma triage criteria every three their trauma triage criteria every three years to minimize overtriage and years to minimize overtriage and undertriageundertriage Solicitation of public input also requiredSolicitation of public input also required

11stst 3-year review in 2005 3-year review in 2005 A recommendation to treat geriatrics as a A recommendation to treat geriatrics as a

distinct, special needs population was distinct, special needs population was received.received.

Data: First BlushData: First BlushPatients by Age Group

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

<1 1-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85-94 95-105

Age

% o

f T

ota

l

EMSIRS OTR

Discussion ensuesDiscussion ensues

Evidence shows… Evidence shows… Elderly have worse outcomes than younger Elderly have worse outcomes than younger

trauma patients with similar injuriestrauma patients with similar injuries Trauma patients have better outcomes Trauma patients have better outcomes

when treated at trauma centerswhen treated at trauma centers But Ohio has no geriatric-specific triage But Ohio has no geriatric-specific triage

criteriacriteria Age is simply a “consideration”Age is simply a “consideration”

Action followsAction follows

Trauma Committee forms Geriatric Trauma Committee forms Geriatric Trauma Task ForceTrauma Task Force Howard Werman, MD – ChairHoward Werman, MD – Chair Charged with finding evidence of need Charged with finding evidence of need

for geriatric-specific triage criteriafor geriatric-specific triage criteria Utilizing current literature and data within Utilizing current literature and data within

the Ohio Trauma Registry and EMS Incident the Ohio Trauma Registry and EMS Incident Reporting SystemReporting System

Step 1Step 1

Define “old”Define “old” Literature unhelpfulLiterature unhelpful

Geriatric age groups begin anywhere Geriatric age groups begin anywhere from age 54 to 75from age 54 to 75

No basis for selectionNo basis for selection

Need to create evidence-based Need to create evidence-based definition using Ohio datadefinition using Ohio data

Gross MortalityGross Mortality

Gross Mortality: All patients

0%

1%

2%

3%

4%

5%

6%

7%

8%

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 89 91 93 95

Age

% m

ort

alit

y

Magic number: 72Magic number: 72

At age 72, gross mortality went above, At age 72, gross mortality went above, and stayed above, 4%and stayed above, 4% Overall mortality in OTR - 3.6%Overall mortality in OTR - 3.6%

72 years old was cut point for gross 72 years old was cut point for gross mortality formortality for All trauma patientsAll trauma patients Minor injuries (ISS 1-9)Minor injuries (ISS 1-9) Moderate injuries (ISS 10-15)Moderate injuries (ISS 10-15) Severe injuries (ISS >15)Severe injuries (ISS >15) Trauma patients with blunt injuriesTrauma patients with blunt injuries Trauma patients with penetrating injuriesTrauma patients with penetrating injuries

Statistical validationStatistical validation

Cut-point DeathsTotal Pop % fatal

Uncorrected Chi-Squares

OR CI RR CI

55 2874 66250 4.338 158.23 1.38 1.31,1.45 1.36 1.30,1.43

65 2359 51806 4.554 184.71 1.43 1.36,1.50 1.41 1.34,1.48

66 2315 50487 4.585 190.43 1.44 1.36,1.52 1.42 1.35,1.49

67 2250 49170 4.576 180.06 1.43 1.35,1.50 1.41 1.34,1.48

68 2203 47829 4.606 184.36 1.44 1.36,1.51 1.42 1.35,1.49

69 2160 46393 4.656 195.12 1.45 1.38,1.53 1.43 1.36,1.51

70 2114 44865 4.712 207.16 1.47 1.40,1.55 1.45 1.38,1.53

71 2058 43349 4.748 210.97 1.48 1.40,1.56 1.46 1.39,1.54

72 2000 41748 4.791 216.38 1.49 1.42,1.58 1.47 1.40,1.55

73 1914 40041 4.780 201.34 1.48 1.40,1.56 1.46 1.38,1.54

74 1836 38184 4.808 198.75 1.48 1.40,1.57 1.46 1.39,1.54

75 1734 36294 4.778 176.98 1.46 1.38,1.55 1.44 1.36,1.52

““Old” definedOld” defined

Geriatric trauma patients defined as Geriatric trauma patients defined as =>70 years of age=>70 years of age Rounded down to make it easier to Rounded down to make it easier to

rememberremember

Step 2Step 2

Find factors that indicate a need for Find factors that indicate a need for direct transport to a trauma center direct transport to a trauma center based on significantly higher based on significantly higher mortalitymortality AnatomicAnatomic PhysiologicPhysiologic MechanisticMechanistic

Step 2Step 2

MethodologyMethodology Compare outcomes for theoretical Compare outcomes for theoretical

indicators in the geriatric population indicators in the geriatric population versus the adult population (age 16-69)versus the adult population (age 16-69)

Step 2Step 2

Proposed indicatorsProposed indicators Falls (any height, including standing) Falls (any height, including standing)

associated with TBI, chest, abdominal or spinal associated with TBI, chest, abdominal or spinal injuryinjury

Pedestrian struckPedestrian struck MVC with single proximal long bone fractureMVC with single proximal long bone fracture Multiple body regions injuredMultiple body regions injured Hypotension (initial systolic B/P)Hypotension (initial systolic B/P) Altered LOC (initial GCS score)Altered LOC (initial GCS score)

Step 2Step 2

Proposed indicatorsProposed indicators Co-morbid conditionsCo-morbid conditions

AnyAny COPDCOPD Coronary Artery DiseaseCoronary Artery Disease Cardiac Disease (any)Cardiac Disease (any) Clotting disorder (including Coumadin therapy)Clotting disorder (including Coumadin therapy) Diabetes (Type 1 or Type 2)Diabetes (Type 1 or Type 2) DialysisDialysis ImmunocompromisedImmunocompromised Liver DiseaseLiver Disease

ResultsResultsInitial SBP and mortality

All injuries

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0-40 41-50 51-60 61-70 71-80 81-90 91-100 101-110

111-120

121-130

131-140

141-150

151-160

161-170

171-180

181-190

191-200

200-299

SBP

Mor

talit

y

Adult

Elderly

ResultsResultsGCS and mortality

Patients with diagnosed TBI

0

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3 4 5 6 7 8 9 10 11 12 13 14 15

GCS

Mor

talit

y

Adult

Elderly

ResultsResults

Adult Mortality %Adult Mortality % Geriatric Mortality %Geriatric Mortality % OROR 95% CI95% CI P valueP value

Falls w/ TBIFalls w/ TBI 6.00%6.00% 11.89%11.89% 2.122.12 1.88 – 1.88 – 2.392.39 p <0.001p <0.001

Falls w/ chest injuryFalls w/ chest injury 4.18%4.18% 5.43%5.43% 1.221.22 0.99 – 0.99 – 1.521.52 p = 0.056p = 0.056

Falls w/ pelvis/abd injuryFalls w/ pelvis/abd injury 1.15%1.15% 2.47%2.47% 0.980.98 0.73 – 0.73 – 1.311.31 p = 0.865p = 0.865

Falls w/SCIFalls w/SCI 4.92%4.92% 20.13%20.13% 1.221.22 0.99 – 0.99 – 1.521.52 p = 0.056p = 0.056

Pedestrian struckPedestrian struck 7.45%7.45% 16.63%16.63% 2.392.39 1.77 – 1.77 – 3.213.21 p <0.001p <0.001

MVC w/ humerus/femur fxMVC w/ humerus/femur fx 9.22%9.22% 15.63%15.63% 2.412.41 1.81 – 1.81 – 3.213.21 p < 0.001p < 0.001

Multiple body regions injuredMultiple body regions injured 6.3%6.3% 8.0%8.0% 1.291.29 1.06-1.571.06-1.57 p = 0.01p = 0.01

ResultsResults Proposed indicatorsProposed indicators

Falls (any height, including standing) associated with Falls (any height, including standing) associated with TBI TBI Chest injuryChest injury Abdominal injuryAbdominal injury

Pedestrian struckPedestrian struck MVC with single proximal long bone fractureMVC with single proximal long bone fracture Multiple body regions injured Multiple body regions injured

TBITBI Head/face/neckHead/face/neck ChestChest Abdomen/pelvisAbdomen/pelvis SpineSpine ExtremitiesExtremities

ResultsResults

Co-morbid conditionsCo-morbid conditions AnyAny COPD COPD Coronary Artery Disease Coronary Artery Disease Cardiac Disease (any)Cardiac Disease (any) Clotting disorder (including Coumadin therapy) Clotting disorder (including Coumadin therapy) Diabetes (Type 1 or Type 2) Diabetes (Type 1 or Type 2) Dialysis Dialysis ImmunocompromisedImmunocompromised Liver DiseaseLiver Disease

Recommendations to EMS Recommendations to EMS BoardBoard

Trauma patients =>70 years should be Trauma patients =>70 years should be defined as geriatric trauma. They should be defined as geriatric trauma. They should be triaged for evaluation in a trauma center triaged for evaluation in a trauma center for:for:

GCS < 15 with evidence of traumatic brain injuryGCS < 15 with evidence of traumatic brain injury Systolic BP < 100 mmHgSystolic BP < 100 mmHg Falls with evidence of traumatic brain injury Falls with evidence of traumatic brain injury

(even from standing position)(even from standing position) Pedestrian struck by motor vehiclePedestrian struck by motor vehicle Multiple body regions injuredMultiple body regions injured Known or suspected proximal long bone fracture Known or suspected proximal long bone fracture

sustained in a motor vehicle crashsustained in a motor vehicle crash

ImpactImpact

Estimated change in admissions to Estimated change in admissions to hospitals (based on applying new hospitals (based on applying new criteria to previous year’s trauma criteria to previous year’s trauma registry data):registry data): Non-trauma hospitals estimated to Non-trauma hospitals estimated to

admit an average of 11.4 fewer patients admit an average of 11.4 fewer patients annually annually

ImplementationImplementation

Trauma Committee recommended EMS Board Trauma Committee recommended EMS Board make changes to triage criteria based on this make changes to triage criteria based on this researchresearch Triage criteria set in rule (Ohio Administrative Triage criteria set in rule (Ohio Administrative

Code)Code) Rule revision process takes 3-6 monthsRule revision process takes 3-6 months

EMS Board accepted changes in October EMS Board accepted changes in October 20082008

New triage rules implemented December 29, New triage rules implemented December 29, 20082008

Full report to EMS Board and Full report to EMS Board and analysis of change in analysis of change in

admission patterns available admission patterns available in Data Center section of EMS in Data Center section of EMS

Division websiteDivision websiteems.ohio.govems.ohio.gov