165 Identifying Predictors of Undertriage in Injured Older Adults After Adoption of State Geriatric Triage Criteria

Abstract

Older trauma patients continue to be under-triaged to Level I and II trauma centers, even after the 2009 implementation of specific geriatric triage criteria for out-of-hospital providers. Although the 2009 criteria have been shown to improve prediction of serious injury, this has not resulted in improved transport rates to the appropriate level of care. To improve outcomes, we identified patient and geographical factors associated with failure to appropriately transfer injured older adults to a trauma enter. We hypothesized that being injured in a rural location and increasing age were both associated with under-triage. We conducted a retrospective cohort study of 10,411 patients ≥ 70 years of age transported by emergency medical sevices and meeting geriatric trauma triage criteria for transport to a Level I or II trauma centers contained within the Ohio Trauma Registry. Demographics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), and rural-urban commuting area code (RUCA) of residence as proxy for rural-urban location of trauma were assessed using multivariable logistic regression as factors impacting either initial or ultimate transport to Level I or II trauma centers. Of patients who met criteria to be transported to a Level I or II trauma center, only 47% were initially transported (95% CI 46-48%) and 59% were ultimately transported (95% CI 58-60%). Compared to the most rural areas, patients transported from metropolitan areas were most likely to be triaged to the appropriate Level I and II trauma centers (OR 2.26, p<0.001). Those from micropolitan and metropolitan-commuting areas which often had Level III trauma centers were found to be less likely to go to Level I or II trauma centers both initially (OR 0.25, p<0.001; OR 0.69, p=0.007) and ultimately (OR 0.36, p<0.001; OR 0.57, p<0.00). Patients from small rural areas without trauma centers were, therefore, more likely to be triaged appropriately than micropolitan and metropolitan-commuting areas. Women were significantly less likely to be appropriately transported while African Americans were more likely to be triaged to the appropriate Level I and II trauma centers. Those aged ≥ 90 years were less likely to be transported appropriately when compared to patients who were 70-79 years of age (initial transport OR 0.76, p<0.001; ultimate transport OR 0.65, p<0.001). Implementation of Ohio-wide emergency medical services protocol for geriatric trauma triage has not been sufficient to improve transport rates to the appropriate Level I and II trauma centers. Patients injured in micropolitan or metropolitan commuting areas are less likely to be transported appropriately than those in rural or metropolitan areas, possibly due to the presence of Level III trauma centers which may feel equipped to manage patients despite recommendations for higher levels of care. Racial differences in transport may be a result of geographic clustering of communities. Further studies specific to the emergency medical services system and provider level should be conducted with a focus on micropolitan and metropolitan commuting areas to better understand how practices can be improved.