Failure to Rescue in Geriatric Trauma: The Impact of Any Complication Increases with Age and Injury Severity in Elderly 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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Geriatric Trauma Mortality: Does Trauma Center Level Matter?

The American Surgeon ◽

10.1177/0003134820983190 ◽

2020 ◽

pp. 000313482098319

Author(s):

Frederick B. Rogers ◽

Madison E. Morgan ◽

Catherine Ting Brown ◽

Tawnya M. Vernon ◽

Kellie E. Bresz ◽

...

Keyword(s):

Geriatric Patients ◽

Injury Severity ◽

Data Bank ◽

Absolute Number ◽

Geriatric Trauma ◽

Multivariate Logistic Regression Model ◽

Trauma Patients ◽

Adjusted Analysis ◽

Level Ii ◽

Level I

Background Given their mostly rural/suburban locations, level II trauma centers (TCs) may offer greater exposure to and experience in managing geriatric trauma patients. We hypothesized that geriatric patients would have improved outcomes at level II TCs compared to level I TCs. Methods The Pennsylvania Trauma Outcome Study (PTOS) database was retrospectively queried from 2003 to 2017 for geriatric (age ≥65 years) trauma patients admitted to level I and II TCs in Pennsylvania. Patient demographics, injury severity, and clinical outcomes were compared to assess differences in care between level I and II TCs. A multivariate logistic regression model assessed the adjusted impact of care at level I vs II TCs on mortality, complications, and functional status at discharge (FSD). The National Trauma Data Bank (NTDB) was retrospectively queried for geriatric (age ≥65 years) trauma admissions to state-accredited level I or level II TCs in 2013. Results 112 648 patients met inclusion criteria. The proportion of geriatric trauma patients across level I and level II TCs were determined to be 29.1% and 36.2% ( P <.001), respectively. In adjusted analysis, there was no difference in mortality (adjusted odds ratio [AOR]: 1.13; P = .375), complications (AOR: 1.25; P = .080) or FSD (AOR: 1.09; P = .493) when comparing level I to level II TCs. Adjusted analysis from the NTDB (n = 144 622) also found that mortality was not associated with TC level (AOR: 1.04; P = .182). Discussion Level I and level II TCs had similar rates of mortality, complications, and functional outcomes despite a higher proportion (but lower absolute number) of geriatric patients being admitted to level II TCs. Future consideration for location of centers of excellence in geriatric trauma should include both level I and II TCs.

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

Journal of Trauma and Acute Care Surgery ◽

10.1097/ta.0000000000001250 ◽

2016 ◽

Vol 81 (6) ◽

pp. 1150-1155 ◽

Cited By ~ 38

Author(s):

Bellal Joseph ◽

Herb Phelan ◽

Ahmed Hassan ◽

Tahereh Orouji Jokar ◽

Terence O’Keeffe ◽

...

Keyword(s):

Geriatric Trauma ◽

Trauma Patients ◽

Failure To Rescue ◽

The Impact

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Medication Errors in Injured Patients

The American Surgeon ◽

10.1177/000313481708300738 ◽

2017 ◽

Vol 83 (7) ◽

pp. 780-785 ◽

Cited By ~ 2

Author(s):

Scott C. Dolejs ◽

Christopher F. Janowak ◽

Ben L. Zarzaur

Keyword(s):

Medication Error ◽

Patient Outcomes ◽

Medication Errors ◽

Injury Severity ◽

Trauma Patients ◽

Lengths Of Stay ◽

Scale Scores ◽

Level I ◽

Injured Patients ◽

The Impact

Trauma patients are vulnerable to medication error given multiple handoffs throughout the hospital. The purpose of this study was to assess trends in medication errors in trauma patients and the role these errors play in patient outcomes. Injured adults admitted from 2009 to 2015 to a Level I trauma center were included. Medication errors were determined based on a nurse-driven, validated, and prospectively maintained database. Multivariable logistic regression modeling was used to control for differences between groups. Among 15,635 injured adults admitted during the study period, 132 patients experienced 243 errors. Patients who experienced errors had significantly worse injury severity, lower Glasgow Coma Scale scores and higher rates of hypotension on admission, and longer lengths of stay. Before adjustment, mortality was similar between groups but morbidity was higher in the medication error group. After risk adjustment, there were no significant differences in morbidity or mortality between the groups. Medication errors in trauma patients tend to occur in significantly injured patients with long hospital stays. Appropriate adjustment when studying the impact of medical errors on patient outcomes is important.

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Change in Age Distribution of the Injuries and Comparison of Different Scoring Tools in Predicting Mortality Among Geriatric Trauma Patients

10.21203/rs.3.rs-52207/v1 ◽

2020 ◽

Author(s):

Libing Jiang ◽

Zhongjun Zheng ◽

Mao Zhang

Keyword(s):

Hospital Mortality ◽

Injury Severity Score ◽

Severity Score ◽

Injury Severity ◽

Geriatric Trauma ◽

Trauma Patients ◽

Survival Group ◽

Elderly Trauma Patients ◽

Scoring Tools ◽

Death Group

Abstract Purpose: The aim of this study was to describe the age trend of trauma patients and to compare different scoring tools to predict in-hospital mortality in elderly trauma patients.Methods: National Trauma Database (NTDB) in the United States from 2005 to 2015 and the Trauma Register DGU® in German from 1994 to 2012 was searched to describe age change of trauma patients. Then we secondly analyzed the data published in http://datadryad.org/. According to the in-hospital survival status, patients were divided into survival group and non-survival group. Receiver Operating Characteristic Curve (ROC) analysis was used to evaluated the value of ISS (injury severity score); NISS (new injury severity score), APACHE Ⅱ (Acute Physiology and Chronic Health Evaluation Ⅱ), SPAS Ⅱ (simplified acute physiology score Ⅱ) and TRISS (Trauma and Injury Severity Score) in predicting in-hospital mortality among geriatric trauma patients.Results:The analysis of NTDB showed the percentage of geriatric trauma has increased from 0.18 to 0.30, 2005-2015. The analysis of DGU showed the mean age rose from 39.11 in 1993 to 51.10 in 2013, and the percentage of patients aged ≥60 rose from 16.5% to 37.5%. A total of 311 patients aged more than 65 years were secondly analyzed. One hundred and sixty-four (52.73%) patients died in the hospital. ISS, NISS, APACHE, and SAPS in the death group were significantly higher than those in the survival group, but TRISS in the death group was significantly lower than those in the survival group. The AUC of APACHE Ⅱ was 0.715, ISS was 0.807, NISS was 0.850, SPAS Ⅱ was 0.725, and TRISS was 0.828.Conclusion:The increasing number of trauma in the elderly is a challenge for current and future trauma management. Compared with APACHE and SAPS, ISS, NISS and TRISS are more suitable for predicting in-hospital mortality in elderly trauma patients.

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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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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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Restrictive Transfusion in Geriatric Trauma Patients

The American Surgeon ◽

10.1177/000313481608200129 ◽

2016 ◽

Vol 82 (1) ◽

pp. 85-88

Author(s):

Ashley N. Deleon ◽

John M. Uecker ◽

Susan V. Stafford ◽

Sadia Ali ◽

Adam Clark ◽

...

Keyword(s):

Injury Severity ◽

Geriatric Trauma ◽

Trauma Patients ◽

Elderly Age ◽

Restrictive Transfusion ◽

Liberal Group ◽

Strategy Versus ◽

Level I ◽

Red Cell Transfusion ◽

Elderly Trauma Patients

To determine whether a restrictive strategy of red cell transfusion was safe in elderly trauma patients, we compared those treated with a restrictive transfusion strategy versus those who were liberally transfused. We performed a retrospective study of elderly (age ≥ 70 years) trauma patients admitted to our Level I trauma center from 2005 to 2013. Patients with a hemoglobin (Hg) < 10 g/dL after 48 hours were included. We excluded patients with an Injury Severity Score > 25 or active cardiac ischemia. Patients who were transfused for an Hg < 10 g/dL (liberal group) were compared to those who were transfused for an Hg< 7 g/dL (restrictive group). There were 382 patients included, 229 and 153 in the liberal and restrictive transfusion groups, respectively. All patients in the liberal group and 20 per cent of patients in the restrictive group received a transfusion ( P < 0.0001). Patients in the liberal group had more overall complications (52 vs 32%, P = 0.0001). On multivariate analysis, receiving a transfusion was an independent risk factor to develop a complication [odds ratio = 2.3 (1.5–3.6), P < 0.0001]. For survivors, patients in the liberal group spent more days in the hospital (nine versus seven days, P = 0.007) and intensive care unit (two versus one day, P = 0.01). There was no difference in mortality (3 vs 4%, P = 0.82). In conclusion, restrictive transfusion appears to be safe in elderly trauma patients and may be associated with decreased complications and shortened length of stay.

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A Comprehensive Investigation of Comorbidities, Mechanisms, Injury Patterns, and Outcomes in Geriatric Blunt Trauma Patients

The American Surgeon ◽

10.1177/000313481608201119 ◽

2016 ◽

Vol 82 (11) ◽

pp. 1055-1062 ◽

Cited By ~ 22

Author(s):

Carlos V. R. Brown ◽

Kevin Rix ◽

Amanda L. Klein ◽

Brent Ford ◽

Pedro G. R. Teixeira ◽

...

Keyword(s):

Injury Severity Score ◽

Blunt Trauma ◽

Severity Score ◽

Geriatric Patients ◽

Injury Severity ◽

Older Age ◽

Geriatric Trauma ◽

Trauma Patients ◽

Injury Patterns ◽

Abbreviated Injury Scale

The geriatric population is growing and trauma providers are often tasked with caring for injuries in the elderly. There is limited information regarding injury patterns in geriatric trauma patients stratified by mechanism of injury. This study intends to investigate the comorbidities, mechanisms, injury patterns, and outcomes in geriatric blunt trauma patients. A retrospective study of the 2012 National Trauma Databank was performed. Adult blunt trauma patients were identified; geriatric (>/=65) patients were compared with younger (<65) patients regarding admission demographics and vital signs, mechanism and severity of injury, and comorbidities. The primary outcome was injuries sustained and secondary outcomes included mortality, length of stay in the intensive care unit and hospital, and ventilator days. There were 589,830 blunt trauma patients who met the inclusion criteria, including 183,209 (31%) geriatric and 406,621 (69%) nongeriatric patients. Falls were more common in geriatric patients (79 vs 29%, P < 0.0001). Geriatric patients less often had an Injury Severity Score >/=16 (18 vs 20%, P < 0.0001) but more often a head Abbreviated Injury Scale >/=3 (24 vs 18%, P < 0.0001) and lower extremity Abbreviated Injury Scale >/=3 (24% vs 8%, P < 0.0001). After logistic regression older age was an independent risk factor for mortality for the overall population and across all mechanisms. Falls are the most common mechanism for geriatric trauma patients. Geriatric patients overall present with a lower Injury Severity Score, but more often sustain severe injuries to the head and lower extremities. Injury patterns vary significantly between older and younger patients when stratified by mechanism. Mortality is significantly higher for geriatric trauma patients and older age is independently associated with mortality across all mechanisms.

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The GERtality Score: The Development of a Simple Tool to Help Predict in-Hospital Mortality in Geriatric Trauma Patients

Journal of Clinical Medicine ◽

10.3390/jcm10071362 ◽

2021 ◽

Vol 10 (7) ◽

pp. 1362

Author(s):

Julian Scherer ◽

Yannik Kalbas ◽

Franziska Ziegenhain ◽

Valentin Neuhaus ◽

Rolf Lefering ◽

...

Keyword(s):

Hospital Mortality ◽

Geriatric Patients ◽

Injury Severity ◽

Scoring Systems ◽

Geriatric Trauma ◽

Body Region ◽

Trauma Patients ◽

Severely Injured ◽

The Novel ◽

Packed Red Blood Cells

Feasible and predictive scoring systems for severely injured geriatric patients are lacking. Therefore, the aim of this study was to develop a scoring system for the prediction of in-hospital mortality in severely injured geriatric trauma patients. The TraumaRegister DGU® (TR-DGU) was utilized. European geriatric patients (≥65 years) admitted between 2008 and 2017 were included. Relevant patient variables were implemented in the GERtality score. By conducting a receiver operating characteristic (ROC) analysis, a comparison with the Geriatric Trauma Outcome Score (GTOS) and the Revised Injury Severity Classification II (RISC-II) Score was performed. A total of 58,055 geriatric trauma patients (mean age: 77 years) were included. Univariable analysis led to the following variables: age ≥ 80 years, need for packed red blood cells (PRBC) transfusion prior to intensive care unit (ICU), American Society of Anesthesiologists (ASA) score ≥ 3, Glasgow Coma Scale (GCS) ≤ 13, Abbreviated Injury Scale (AIS) in any body region ≥ 4. The maximum GERtality score was 5 points. A mortality rate of 72.4% was calculated in patients with the maximum GERtality score. Mortality rates of 65.1 and 47.5% were encountered in patients with GERtality scores of 4 and 3 points, respectively. The area under the curve (AUC) of the novel GERtality score was 0.803 (GTOS: 0.784; RISC-II: 0.879). The novel GERtality score is a simple and feasible score that enables an adequate prediction of the probability of mortality in polytraumatized geriatric patients by using only five specific parameters.

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Registry-Based Mortality Analysis Reveals a High Proportion of Patient Decrees and Presumed Limitation of Therapy in Severe Geriatric Trauma

Journal of Clinical Medicine ◽

10.3390/jcm9092686 ◽

2020 ◽

Vol 9 (9) ◽

pp. 2686 ◽

Cited By ~ 1

Author(s):

Cora Rebecca Schindler ◽

Mathias Woschek ◽

René Danilo Verboket ◽

Ramona Sturm ◽

Nicolas Söhling ◽

...

Keyword(s):

Brain Injuries ◽

Injury Severity ◽

Geriatric Trauma ◽

Hospital Treatment ◽

Trauma Patients ◽

Severely Injured ◽

Severely Injured Patients ◽

Initial Care ◽

Limitation Of Therapy ◽

Injured Patients

Background: The treatment of severely injured patients, especially in older age, is complex, and based on strict guidelines. Methods: We conducted a retrospective study by analyzing our internal registry for mortality risk factors in deceased trauma patients. All patients that were admitted to the trauma bay of our level-1-trauma center from 2014 to 2018, and that died during the in-hospital treatment, were included. The aim of this study was to carry out a quality assurance concerning the initial care of severely injured patients. Results: In the 5-year period, 135 trauma patients died. The median (IQR) age was 69 (38–83) years, 71% were male, and the median (IQR) Injury Severity Score (ISS) was 25 (17–34) points. Overall, 41% of the patients suffered from severe traumatic brain injuries (TBI) (AIShead ≥ 4 points). For 12.7%, therapy was finally limited owing to an existing patient’s decree; in 64.9% with an uncertain prognosis, a ‘therapia minima’ was established in consensus with the relatives. Conclusion: Although the mortality rate was primarily related to the severity of the injury, a significant number of deaths were not exclusively due to medical reasons, but also to a self-determined limitation of therapy for severely injured geriatric patients. The conscientious documentation concerning the will of the patient is increasingly important in supporting medical decisions.

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