title: Improving early identification of the high-risk elderly trauma patient by emergency medical services.
abstract: OBJECTIVE
  We sought to (1) define the high-risk elderly trauma patient based on prognostic differences associated with different injury patterns and (2) derive alternative field trauma triage guidelines that mesh with national field triage guidelines to improve identification of high-risk elderly patients.
  
  
  METHODS
  This was a retrospective cohort study of injured adults ≥65 years transported by 94 EMS agencies to 122 hospitals in 7 regions from 1/1/2006 through 12/31/2008. We tracked current field triage practices by EMS, patient demographics, out-of-hospital physiology, procedures and mechanism of injury. Outcomes included Injury Severity Score≥16 and specific anatomic patterns of serious injury using abbreviated injury scale score ≥3 and surgical interventions. In-hospital mortality was used as a measure of prognosis for different injury patterns.
  
  
  RESULTS
  33,298 injured elderly patients were transported by EMS, including 4.5% with ISS≥16, 4.8% with serious brain injury, 3.4% with serious chest injury, 1.6% with serious abdominal-pelvic injury and 29.2% with serious extremity injury. In-hospital mortality ranged from 18.7% (95% CI 16.7-20.7) for ISS≥16 to 2.9% (95% CI 2.6-3.3) for serious extremity injury. The alternative triage guidelines (any positive criterion from the current guidelines, GCS≤14 or abnormal vital signs) outperformed current field triage practices for identifying patients with ISS≥16: sensitivity (92.1% [95% CI 89.6-94.1%] vs. 75.9% [95% CI 72.3-79.2%]), specificity (41.5% [95% CI 40.6-42.4%] vs. 77.8% [95% CI 77.1-78.5%]). Sensitivity decreased for individual injury patterns, but was higher than current triage practices.
  
  
  CONCLUSIONS
  High-risk elderly trauma patients can be defined by ISS≥16 or specific non-extremity injury patterns. The field triage guidelines could be improved to better identify high-risk elderly trauma patients by EMS, with a reduction in triage specificity.
authors.affiliation: Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, United States. Electronic address: newgardc@ohsu.edu.
authors.forename: Craig D
authors.initials: CD
authors.lastname: Newgard
authors.affiliation: Department of Emergency Medicine, University of California at Davis, Sacramento, CA, United States.
authors.forename: James F
authors.initials: JF
authors.lastname: Holmes
authors.affiliation: Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, United States; Department of Epidemiology, Colorado School of Public Health, University of Colorado School of Medicine, Aurora, CO, United States.
authors.forename: Jason S
authors.initials: JS
authors.lastname: Haukoos
authors.affiliation: Department of Surgery, University of Washington, Seattle, WA, United States.
authors.forename: Eileen M
authors.initials: EM
authors.lastname: Bulger
authors.affiliation: Department of Surgery, Stanford University, Palo Alto, CA, United States.
authors.forename: Kristan
authors.initials: K
authors.lastname: Staudenmayer
authors.affiliation: Clark Regional Emergency Services Agency, Vancouver, WA, United States.
authors.forename: Lynn
authors.initials: L
authors.lastname: Wittwer
authors.affiliation: Division of Cardiology, Department of Internal Medicine, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, United States.
authors.forename: Eric
authors.initials: E
authors.lastname: Stecker
authors.affiliation: Intermountain Injury Control Research Center, University of Utah, Salt Lake City, UT, United States.
authors.forename: Mengtao
authors.initials: M
authors.lastname: Dai
authors.affiliation: Department of Emergency Medicine, University of California, San Francisco, United States; San Francisco General Hospital, San Francisco, CA, United States.
authors.forename: Renee Y
authors.initials: RY
authors.lastname: Hsia
mesh_terms: D015998:Abbreviated Injury Scale; D000368:Aged; D000369:Aged, 80 and over; D004632:Emergency Medical Services / Q000592:standards; D005260:Female; D015577:Geriatric Assessment; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D058996:Quality Improvement; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology; D014947:Wounds and Injuries / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy
keywords: Elderly; Emergency medical services; Trauma; Trauma systems; Triage