The impact of frailty on failure-to-rescue in geriatric trauma patients

Introduction The interaction of increasing age, Injury Severity Score (ISS), and complications is not well described in geriatric trauma patients. We hypothesized that failure to rescue rate from any complication worsens with age and injury severity. Methods The National Trauma Data Bank (NTDB) was queried for injured patients aged 65 years or older from January 1, 2013 through December 31, 2016. Demographics and injury characteristics were used to compare groups. Mortality rates were calculated across subgroups of age and ISS, and captured with heatmaps. Multivariable logistic regression was performed to identify independent predictors of mortality. Results 614,496 geriatric trauma patients were included; 151,880 (24.7%) experienced a complication. Those with complications tended to be older, female, non-white, have non-blunt mechanism, higher ISS, and hypotension on arrival. Overall mortality was highest (19%) in the oldest (≥86 years old) and most severely injured (ISS ≥ 25) patients, with constant age increasing across each ISS group was associated with a 157% increase in overall mortality ( P < .001, 95% CI: 148-167%). Holding ISS stable, increasing age group was associated with a 48% increase in overall mortality ( P < .001, 95% CI: 44-52%). After controlling for standard demographic variables at presentation, the existence of any complication was an independent predictor of overall mortality in geriatric patients (OR: 2.3; 95% CI: 2.2-2.4). Conclusions Any complication was an independent risk factor for mortality, and scaled with increasing age and ISS in geriatric patients. Differences in failure to rescue between populations may reflect critical differences in physiologic vulnerability that could represent targets for interventions.

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The Triage of Older Adults with Physiologic Markers of Serious Injury Using a State-Wide Prehospital Plan

Prehospital and Disaster Medicine ◽

10.1017/s1049023x19004825 ◽

2019 ◽

Vol 34 (05) ◽

pp. 497-505

Author(s):

Matthew H. Meyers ◽

Trent L. Wei ◽

Julianne M. Cyr ◽

Thomas M. Hunold ◽

Frances S. Shofer ◽

...

Keyword(s):

Older Adults ◽

Trauma Center ◽

Medical Information ◽

Geriatric Trauma ◽

Medical Information System ◽

Trauma Patients ◽

Glascow Coma Scale ◽

Serious Injury ◽

Gcs Score ◽

The Impact

AbstractIntroduction:In January of 2010, North Carolina (NC) USA implemented state-wide Trauma Triage Destination Plans (TTDPs) to provide standardized guidelines for Emergency Medical Services (EMS) decision making. No study exists to evaluate whether triage behavior has changed for geriatric trauma patients.Hypothesis/Problem:The impact of the NC TTDPs was investigated on EMS triage of geriatric trauma patients meeting physiologic criteria of serious injury, primarily based on whether these patients were transported to a trauma center.Methods:This is a retrospective cohort study of geriatric trauma patients transported by EMS from March 1, 2009 through September 30, 2009 (pre-TTDP) and March 1, 2010 through September 30, 2010 (post-TTDP) meeting the following inclusion criteria: (1) age 50 years or older; (2) transported to a hospital by NC EMS; (3) experienced an injury; and (4) meeting one or more of the NC TTDP’s physiologic criteria for trauma (n = 5,345). Data were obtained from the Prehospital Medical Information System (PreMIS). Data collected included proportions of patients transported to a trauma center categorized by specific physiologic criteria, age category, and distance from a trauma center.Results:The proportion of patients transported to a trauma center pre-TTDP (24.4% [95% CI 22.7%-26.1%]; n = 604) was similar to the proportion post-TTDP (24.4% [95% CI 22.9%-26.0%]; n = 700). For patients meeting specific physiologic triage criteria, the proportions of patients transported to a trauma center were also similar pre- and post-TTDP: systolic blood pressure <90 mmHg (22.5% versus 23.5%); respiratory rate <10 or >29 (23.2% versus 22.6%); and Glascow Coma Scale (GCS) score <13 (26.0% versus 26.4%). Patients aged 80 years or older were less likely to be transported to a trauma center than younger patients in both the pre- and post-TTDP periods.Conclusions:State-wide implementation of a TTDP had no discernible effect on the proportion of patients 50 years and older transported to a trauma center. Under-triage remained common and became increasingly prevalent among the oldest adults. Research to understand the uptake of guidelines and protocols into EMS practice is critical to improving care for older adults in the prehospital environment.

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Application of a Geriatric Injury Protocol Demonstrates High Survival Rates for Geriatric Trauma Patients with High Injury Acuity

The American Surgeon ◽

10.1177/000313481708301022 ◽

2017 ◽

Vol 83 (10) ◽

pp. 1122-1126

Author(s):

Tigran Karamanukyan ◽

Andrea Pakula ◽

Maureen Martin ◽

Ashwitha Francis ◽

Ruby Skinner

Keyword(s):

Injury Severity ◽

Survival Rates ◽

Geriatric Trauma ◽

Study Cohort ◽

High Survival ◽

Trauma Patients ◽

Advanced Directives ◽

Severity Scores ◽

The Mean ◽

The Impact

Geriatric trauma has historically been associated with poor outcomes, particularly in the setting of severe polytrauma. Although geriatric trauma protocols are common, there are limited data on their impact in patients with high injury severity. In this study, we sought to investigate the impact of a geriatric injury protocol on outcomes in patients with severe trauma acuity. Ninety-eight geriatric patients (age ≥65) admitted to our trauma center with injury severity scores (ISS) ≥15 comprised the study cohort. The mean age was 75 ± 7.7 yrs. The mean ISS was 25 ± 9.2, and the mean geriatric trauma outcome score was 150 ± 3. Mortality was 17 per cent and 70 per cent were due to central nervous system injury. When patients with nonsurvivable injuries or advanced directives resulting in early care withdrawal were excluded, the mortality was 6 per cent. Extremes of age did not impact mortality [(>80 years, 21%) vs (65–79, 16%, P = 0.5)]. Most patients (53%) were discharged home. The application of our geriatric trauma protocol led to favorable results despite high injury acuity. These data suggest that even at the extremes of age, a large percentage of patients can be expected to survive. A prospective validation of these findings is warranted.

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The impact of associated diseases on the etiology, course and mortality in geriatric trauma patients

European Journal of Emergency Medicine ◽

10.1097/00063110-200610000-00010 ◽

2006 ◽

Vol 13 (5) ◽

pp. 295-298 ◽

Cited By ~ 7

Author(s):

Serkan Yilmaz ◽

Ozgur Karcioglu ◽

Serkan Sener

Keyword(s):

Geriatric Trauma ◽

Trauma Patients ◽

Associated Diseases ◽

The Impact

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Understanding Preventable Deaths in the Geriatric Trauma Population: Analysis of 3,452,339 Patients From the Center of Medicare and Medicaid Services Database

The American Surgeon ◽

10.1177/00031348211056284 ◽

2021 ◽

pp. 000313482110562

Author(s):

Darwin Ang ◽

Kenny Nieto ◽

Mason Sutherland ◽

Megan O’Brien ◽

Huazhi Liu ◽

...

Keyword(s):

United States ◽

Geriatric Patients ◽

Blood Stream Infection ◽

The United States ◽

Geriatric Trauma ◽

Trauma Patients ◽

Failure To Rescue ◽

Patient Safety Indicators ◽

Trauma Population ◽

Preventable Mortality

Background Patient safety indicators (PSIs) are avoidable complications that can impact outcomes. Geriatric patients have a higher mortality than younger patients with similar injuries, and understanding the etiology may help reduce mortality. We aim to estimate preventable geriatric trauma mortality in the United States and identify PSIs associated with increased preventable mortality. Methods A retrospective cohort study of patients aged ≥65 years, in the CMS database, 2017-second quarter of 2020. Risk-adjusted multivariable regression was performed to calculate observed-to-expected (O/E) mortality ratios for failure-to-prevent and failure-to-rescue PSIs with significance defined as P < .05. Results 3,452,339 geriatric patients were analyzed. Patients aged 75-84 years had 33% higher odds of preventable mortality (adjusted odds ratio [aOR] = 1.33 and 95% confidence interval [CI] = 1.31, 1.36), whereas patients aged ≥85 years had 91% higher odds of preventable mortality (aOR = 1.91 and 95% CI = 1.87, 1.94) compared to patients aged 65-74 years. Failure-to-prevent O/E were >1 for all PSIs evaluated with central line–related blood stream infection having a high O/E (747.93). Failure-to-rescue O/E were >1 for 10/11 (91%) PSIs with physiologic and metabolic derangements having the highest O/E (5.98). United States’ states with higher quantities of geriatric trauma patients experienced reduced preventable mortality. Conclusion Odds of preventable mortality increases with age. Perioperative venous thrombotic events, hemorrhage or hematoma, and postoperative physiologic/metabolic derangements produce significant preventable mortalities. United States’ states differ in their failure-to-prevent and failure-to-rescue PSIs. Utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy especially anticoagulation, ensuring operative and procedure-based competencies, and greater incorporation of inpatient geriatricians may serve to reduce preventable mortality in elderly trauma patients.

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The impact of preexisting comorbidities on failure to rescue outcomes in nonelderly trauma patients

Journal of Trauma and Acute Care Surgery ◽

10.1097/ta.0000000000000467 ◽

2015 ◽

Vol 78 (2) ◽

pp. 312-317 ◽

Cited By ~ 10

Author(s):

Teresa M. Bell ◽

Ben L. Zarzaur

Keyword(s):

Trauma Patients ◽

Failure To Rescue ◽

The Impact

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The Impact of Age and Receipt Antihypertensives to Systolic Blood Pressure and Shock Index at Injury Scene and in the Emergency Department to Predict Massive Transfusion in Trauma Patients

10.21203/rs.3.rs-33779/v1 ◽

2020 ◽

Author(s):

Se Jin Park ◽

Mi Jin Lee ◽

Changho Kim ◽

Haewon Jung ◽

Seong Hun Kim ◽

...

Keyword(s):

Blood Pressure ◽

Emergency Department ◽

Systolic Blood Pressure ◽

Massive Transfusion ◽

Geriatric Trauma ◽

Red Blood Cell Transfusion ◽

Trauma Patients ◽

Shock Index ◽

Cutoff Value ◽

The Impact

Abstract Background : Systolic blood pressure (SBP) and shock index (SI) are accurate indicators of hemodynamic instability and the need for transfusion in trauma patients. We aimed to determine whether the utility and cutoff point for SBP and SI are affected by age or antihypertensives. Methods : This was a retrospective observational study of a level 1 trauma center between January 2017 and December 2018. We analyzed the utility and cutoff points of SBP and SI for predicting massive transfusion (MT) and 30-day mortality according to patients’ age and whether they were taking antihypertensives. Results : We analyzed 4681 trauma cases. There were 1949 patients aged 65 years or older (41.6%), and 1375 (29.4%) hypertensive patients. MT was given to 137 patients (2.9%). The 30-day mortality rate was 6.3% (n = 294). In geriatric trauma patients taking antihypertensives, prehospital SBP less than 110 mmHg was the cutoff value for predicting MT in multivariate logistic regression analyses; packed red blood cell transfusion volume decreased abruptly based on prehospital SBP of 110 mmHg. Emergency Department SI greater than 1.0 was the cutoff value for the prediction of MT in patients who were older than 65 years who were not taking antihypertensives. Conclusions : The triage of trauma patients is based on the identification of clinical features that are readily identifiable by first responders. However, age and medications may also affect accurate evaluation. In initial trauma management, we must apply SBP and SI differently depending on age, whether a patient is taking antihypertensives, and the time at which the indicators are measured.

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The effect of geriatric comanagement (GC) in geriatric trauma patients treated in a level 1 trauma setting: A comparison of data before and after the implementation of a certified geriatric trauma center

PLoS ONE ◽

10.1371/journal.pone.0244554 ◽

2021 ◽

Vol 16 (1) ◽

pp. e0244554

Author(s):

Sascha Halvachizadeh ◽

Lea Gröbli ◽

Till Berk ◽

Kai Oliver Jensen ◽

Christian Hierholzer ◽

...

Keyword(s):

Clinical Outcome ◽

Trauma Center ◽

Geriatric Trauma ◽

Trauma Patients ◽

Complication Rates ◽

Geriatric Trauma Center ◽

Number Of Patients ◽

Before And After ◽

The Impact ◽

Group Post

Introduction Improvements in life expectancy imply that an increase of geriatric trauma patients occurs. These patients require special attention due to their multiple comorbidity issues. The aim of this study was to assess the impact of the implementation of geriatric comanagement (GC) on the allocation and clinical outcome of geriatric trauma patients. Methods This observational cohort study aims to compare the demographic development and the clinical outcome in geriatric trauma patients (aged 70 years and older) before and after implementation of a certified geriatric trauma center (GC). Geriatric trauma patients admitted between January 1, 2010 and December 31, 2010 were stratified to group pre-GC and admissions between January 1, 2018 and December 31, 2018 to Group post-GC. We excluded patients requiring end-of-life treatment and those who died within 24 h or due to severe traumatic brain injury. Outcome parameters included demographic changes, medical complexity (measured by American Society of Anaesthesiology Score (ASA) and Charlson Comorbidity Index (CCI)), in-hospital mortality and length of hospitalization. Results This study includes 626 patients in Group pre-GC (mean age 80.3 ± 6.7 years) and 841 patients in Group post-GC (mean age 81.1 ± 7.3 years). Group pre-GC included 244 (39.0%) males, group post-GC included 361 (42.9%) males. The mean CCI was 4.7 (± 1.8) points in pre-GC and 5.1 (± 2.0) points in post-GC (p <0.001). In Group pre-GC, 100 patients (16.0%) were stratified as ASA 1 compared with 47 patients (5.6%) in Group post-GC (p <0.001). Group pre-GC had significantly less patients stratified as ASA 3 or higher (n = 235, 37.5%) compared with Group post-GC (n = 389, 46.3%, p <0.001). Length of stay (LOS) decreased significantly from 10.4 (± 20.3) days in Group pre-GC to 7.9 (±22.9) days in Group post-GC (p = 0.011). The 30-day mortality rate was comparable amongst these groups (pre-GC 8.8% vs. post-GC 8.9%). Conclusion This study appears to support the implementation of a geriatric trauma center, as certain improvements in the patient care were found: Despite a higher CCI and a higher number of patients with higher ASA classifications, Hospital LOS, complication rates and mortality did were not increased after implementation of the CG. The increase in the case numbers supports the fact that a higher degree of specialization leads to a response by admitting physicians, as it exceeded the expectable trend of demographic ageing. We feel that a larger data base, hopefully in a multi center set up should be undertaken to verify these results.

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