Geriatric Trauma Outcome Score Research Articles

Application of the Geriatric Trauma Outcome Score in a Rural Setting.

To retrospectively apply the Geriatric Trauma Outcome (GTO) score to the patient population of a rural South Central Appalachian level 1 trauma center and identify the potential utility of the GTO score in guiding goals of care discussions. Trauma registry data was extracted for 5,627 patients aged 65+ from 2017 to 2021. GTO score was calculated for each patient. Descriptive statistics were calculated for age, Injury Severity Score (ISS), GTO score, receipt of red blood cells, discharge status, and code status. A simple logistic regression model was used to determine the relationship between GTO score and discharge status. The probability of mortality was then calculated using GTO score, and the distribution of code status among patients with ≤50, 51-75%, and >75% probability of mortality was examined. For every 10-point increase in GTO score, odds of mortality increased by 79% (OR = 1.79; P < .001). Patients had an estimated 50% probability of mortality with a GTO score of 156, 75% with 174, and 99% with a score of 234, respectively. Seventeen patients had a GTO score associated with >75% probability of mortality. Of those 17 patients, four retained a full code status. Our analysis demonstrates that the GTO score is a validated measure in a rural setting and can be an easily calculated metric to help determine a geriatric patient's probability of mortality following a trauma. The results of our study also found that GTO score can be used to inform goals of care discussions with patients.

Performance of trauma scoring systems in predicting mortality in geriatric trauma patients: comparison of the ISS, TRISS, and GTOS based on a systemic review and meta-analysis.

This meta-analysis aimed to evaluate the performance of the Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), and the Geriatric Trauma Outcome Score (GTOS) in predicting mortality in geriatric trauma patients. The MEDLINE, Web of Science, and EMBASE databases were searched for studies published from January 2008 to October 2023. Studies assessing the performance of the ISS, TRISS, or GTOS in predicting mortality in geriatric trauma patients (over 60years old) and reporting data for the analysis of the pooled area under the receiver operating characteristic curve (AUROC) and the hierarchical summary receiver operating characteristic curve (HSROC) were included. Studies that were not conducted in a group of geriatric patients, did not consider mortality as the outcome variable, or had incomplete data were excluded. The Critical Appraisal Skills Programme (CASP) Clinical Prediction Rule Checklist was utilized to assess the risk of bias in included studies. STATA 16.0. was used for the AUROC analysis and HSROC analysis. Nineteen studies involving 118,761 geriatric trauma patients were included. The pooled AUROC of the TRISS (AUC = 0.82, 95% CI: 0.77-0.87) was higher than ISS (AUC = 0.74, 95% CI: 0.71-0.79) and GTOS (AUC = 0.80, 95%CI: 0.77-0.83). The diagnostic odds ratio (DOR) calculated from HSROC curves also suggested that the TRISS (DOR = 21.5) had a better performance in predicting mortality in geriatric trauma patients than the ISS (DOR = 6.27) and GTOS (DOR = 4.76). This meta-analysis suggested that the TRISS showed better accuracy and performance in predicting mortality in geriatric trauma patients than the ISS and GTOS.

Defining the Mortality Rate of Elderly Trauma Patients With Operative Feeding Tubes.

Placement of feeding tubes in elderly patients has not been studied in elderly trauma patients. The objectives of this study were to determine in-hospital mortality in elderly trauma patients receiving operative feeding tubes and to identify factors associated with in-hospital mortality. A retrospective study utilizing 2017 National Trauma Data Bank data was conducted. Trauma patients aged 65 and older with operative feeding tubes were included. Demographic, injury, comorbidity, and general hospital course data were analyzed. Two cohorts were constructed: survival and non-survival to hospital discharge. Bivariate analysis and logistic regression were performed to determine factors independently associated with in-hospital mortality. A total of 3,398 patients were analyzed with 331 (9.7%) dying during hospitalization. Patients had a median age of 75years and sustained severe injuries (median ISS 17). Patients who died were older (76 vs. 75years, p = .03), more severely injured (ISS 22 vs. 17, p < .001), had a higher geriatric trauma outcome score (134 vs. 121, p < .001), and had lower rates of dementia (8 vs. 13%, p = .01). Multivariate regression showed male sex, lower admission GCS, higher Charlson Comorbidity Index, and an Advance Directive Limiting Care (ADLC) were independently associated with in-hospital mortality. Dementia diagnosis was negatively associated with in-hospital mortality. The in-hospital mortality rate for elderly trauma patients with operative feeding tubes placed was notably high. Identifying factors associated with in-hospital mortality will serve to assist providers in counseling patients and caregivers about the outcomes of operative feeding tube placement in this patient population.

Predictive Value of the Geriatric Trauma Outcome Score in Older Patients After Trauma: A Retrospective Cohort Study.

PurposeThe Geriatric Trauma Outcome Score (GTOS) has been developed and indicate to be a valid prognostic tool for the prediction of mortality in geriatric trauma patients (GTPs) during hospitalization. However, the predictive value of the GTOS for morbidity is still unclear. We aimed to evaluate the association between GTOS, morbidity and mortality in GTPs.Patients and MethodsWe performed a retrospective cohort study between June 1, 2016, and May 31, 2020, and collected data for patients aged 65 years or older. These patients were treated at the Trauma Center of Tongji Hospital, Wuhan, China. Clinical data were retrieved from the trauma registry. The GTOS was calculated with the following formula: age + ISS * 2.5 + 22 (if any packed red blood cells were transfused within 24 hours after admission). The outcomes were mortality, morbidity, length of hospital stay (LOS), and functional outcome at discharge.ResultsA total of 485 patients were enrolled: 214 (44.1%) were classified into the low-GTOS group, and 271 (55.9%) were classified into the high-GTOS group. The median (IQR) age was 68 (66–71) years; 361 (74.4%) were male. The most common mechanism of injury was vehicle collision (66.4%), followed by falls <2 m (19.6%). The median (IQR) ISS was 18 (14–22). The median (IQR) GCS was 13 (9–15). A high GTOS was associated with high rates of all-cause mortality (13.3% vs 0.9%, P < 0.001), complications (88.2% vs 31.8%, P < 0.001), unplanned intubation (19.2% vs 1.4%, P < 0.001), and unplanned admissions to the intensive care unit (8.5% vs 0.5%, P < 0.001). In multivariable logistic regression analysis, GTOS was associated with morbidity (OR 1.07, 95% CI, 1.05–1.09, p < 0.001) and mortality (OR 1.04, 95% CI, 1.02–1.06, p < 0.001).ConclusionThe GTOS is an independent predictor of morbidity and mortality in GTPs, and it will help us identify patients at high risk on admission.

Predicting mortality in elderly trauma patients: a review of the current literature.

Advances in medical care allow patients to live longer, translating into a larger geriatric patient population. Adverse outcomes increase with older age, regardless of injury severity. Age, comorbidities, and physiologic deterioration have been associated with the increased mortality seen in geriatric trauma patients. As such, outcome prediction models are critical to guide clinical decision making and goals of care discussions for this population. The purpose of this review was to evaluate the various outcome prediction models for geriatric trauma patients. There are several prediction models used for predicting mortality in elderly trauma patients. The Geriatric Trauma Outcome Score (GTOS) is a validated and accurate predictor of mortality in geriatric trauma patients and performs equally if not better to traditional scores such as the Trauma and Injury Severity Score. However, studies recommend medical comorbidities be included in outcome prediction models for geriatric patients to further improve performance. The ideal outcome prediction model for geriatric trauma patients has not been identified. The GTOS demonstrates accurate predictive ability in elderly trauma patients. The addition of medical comorbidities as a variable in outcome prediction tools may result in superior performance; however, additional research is warranted.

Predicting Mortality of Korean Geriatric Trauma Patients: A Comparison between Geriatric Trauma Outcome Score and Trauma and Injury Severity Score.

PurposeThe Geriatric Trauma Outcome Score (GTOS) is a new prognostic tool used to predict mortality of geriatric trauma patients. We aimed to apply this model to Korean geriatric trauma patients and compare it with the Trauma and Injury Severity Score (TRISS) method.Materials and MethodsPatients aged ≥65 years who were admitted to a level 1 trauma center from 2014 to 2018 were included in this study. Data on age, Injury Severity Score (ISS), packed red blood cell transfusion within 24 h, TRISS, admission disposition, mortality, and discharge disposition were collected. We analyzed the validity of GTOS and TRISS by comparing the area under the survival curve. Subgroup analysis for age, admission disposition, and ISS was performed.ResultsAmong 2586 participants, the median age was 75 years (interquartile range: 70–81). The median ISS was 9 (interquartile range: 4–12), with a transfusion rate (within 24 h) of 15.9% and mortality rate of 6.1%. The areas under the curve (AUCs) were 0.832 [95% confidence interval (CI), 0.817–0.846] and 0.800 (95% CI, 0.784–0.815) for GTOS and TRISS, respectively. On subgroup analysis, patients with ISS ≥9 showed a higher AUC of GTOS compared to the AUC of TRISS (p<0.05). Other subgroup analyses showed equally good power of discrimination for mortality.ConclusionGTOS can be used to predict mortality of severely injured Korean geriatric patients, and also be helpful in deciding whether invasive or aggressive treatments should be administered to them.

Best case/worst case for the trauma ICU: Development and pilot testing of a communication tool for older adults with traumatic injury.

"Best Case/Worst Case" (BC/WC) is a communication tool to support shared decision making in older adults with surgical illness. We aimed to adapt and test BC/WC for use with critically ill older adult trauma patients. We conducted focus groups with 48 trauma clinicians in Wisconsin, Texas, and Oregon. We used qualitative content analysis to characterize feedback and adapted the tool to fit this setting. Using rapid sequence iterative design, we developed an implementation tool kit. We pilot tested this intervention at two trauma centers using a pre-post study design with older trauma patients in the intensive care unit (ICU). Main outcome measures included study feasibility, intervention acceptability, quality of communication, and clinician moral distress. BC/WC for trauma patients uses a graphic aid to document major events over time, illustrate plausible scenarios, and convey uncertainty. We enrolled 86 of 116 eligible patients and their surrogates (48 pre/38 postintervention). The median patient age was 72 years (51-95 years) and mean Geriatric Trauma Outcome Score was 126.1 (±30.6). We trained 43 trauma attendings and trauma fellows to use the intervention. Ninety-four percent could perform essential tool elements after training. The median end-of-life communication score (scale 0-10) improved from 4.5 to 6.6 (p = 0.006) after intervention as reported by family and from 4.1 to 6.0 (p = 0.03) as reported by nurses. Moral distress did not change. However, there was improvement (less distress) reported by physicians regarding "witnessing providers giving false hope" from 7.34 to 5.03 (p = 0.022). Surgeons reported the tool put multiple clinicians on the same page and was useful for families, but tedious to incorporate into rounds. BC/WC trauma ICU is acceptable to clinicians and may support improved communication in the ICU. Future efficacy testing is threatened by enrollment challenges for severely injured older adults and their family members. Therapeutic, level III.

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

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.

Validation of the geriatric trauma outcome scores in predicting outcomes of elderly trauma patients

BackgroundUsing three patient characteristics, including age, Injury Severity Score (ISS) and transfusion within 24 h of admission (yes vs. no), the Geriatric Trauma Outcome Score (GTOS) and Geriatric Trauma Outcome Score II (GTOS II) have been developed to predict mortality and unfavourable discharge (to a nursing home or hospice facility), of those who were ≥65 years old, respectively. ObjectivesThis study aimed to validate the GTOS and GTOS II models. For the nested-cohort requiring intensive care, we compared the GTOS scores with two ICU prognostic scores – the Acute Physiology and Chronic Health Evaluation (APACHE) III and Australian and New Zealand Risk of Death (ANZROD). MethodsAll elderly trauma patients admitted to the State Trauma Unit between 2009 and 2019 were included. The discrimination ability and calibration of the GTOS and GTOS II scores were assessed by the area under the receiver-operating-characteristic (AUROC) curve and a calibration plot, respectively. ResultsOf the 57,473 trauma admissions during the study period, 15,034 (26.2%) were ≥65 years-old. The median age and ISS of the cohort were 80 (interquartile range [IQR] 72–87) and 6 (IQR 2–9), respectively; and the average observed mortality was 4.3%. The ability of the GTOS to predict mortality was good (AUROC 0.838, 95% confidence interval [CI] 0.821–0.855), and better than either age (AUROC 0.603, 95%CI 0.581–0.624) or ISS (AUROC 0.799, 95%CI 0.779–0.819) alone. The GTOS II's ability to predict unfavourable discharge was satisfactory (AUROC 0.707, 95%CI 0.696–0.719) but no better than age alone. Both GTOS and GTOS II scores over-estimated risks of the adverse outcome when the predicted risks were high. The GTOS score (AUROC 0.683, 95%CI 0.591–0.775) was also inferior to the APACHE III (AUROC 0.783, 95%CI 0.699–0.867) or ANZROD (AUROC 0.788, 95%CI 0.705–0.870) in predicting mortality for those requiring intensive care. ConclusionsThe GTOS scores had a good ability to discriminate between survivors and non-survivors in the elderly trauma patients, but GTOS II scores were no better than age alone in predicting unfavourable discharge. Both GTOS and GTOS II scores were not well-calibrated when the predicted risks of adverse outcome were high.

Prediction of mortality in critically-ill elderly trauma patients: a single centre retrospective observational study and comparison of the performance of trauma scores

BackgroundTrauma in the elderly (≥ 65 years) population is increasing. This study compares the performance of trauma scoring systems in predicting 30-day mortality among the traumatised elderly patients admitted to the intensive care unit in a major trauma centre.MethodsWe collected retrospective data for all elderly trauma patients admitted to our intensive care units between January 2012 and December 2017. We assessed Injury Severity Score (ISS), Geriatric Trauma Outcome Score (GTOS) and the Trauma Audit and Research Network’s (TARN) Probability of Survival (Ps17) between survivors and non-survivors. Receiver operator characteristic (ROC) curves were used to assess the performance of these scoring systems.ResultsThere were 255 elderly trauma patients with overall 30-day survival of 76%. There was a statistically significant difference in ISS, GTOS and Ps17 scores between survivors and non-survivors (p < 0.001). The area under the ROC curve (AUROC) was statistically significant for all 3, with AUROC of 0.66 (95% CI 0.59–0.74) for the ISS, 0.68 (95% CI 0.61–0.76) for the GTOS and 0.79 (95% CI 0.72–0.85) for the Ps17. The optimal cut-off points were ≥ 28, ≥ 142, ≤ 76.73 for ISS, GTOS and Ps17, respectively.ConclusionBoth ISS and GTOS scoring systems preformed equally in predicting 30-day mortality in traumatised elderly patients admitted to the intensive care unit, however neither were robust enough to utilise in clinical practise. The Ps17 performed more robustly, although was not developed for prognosticating on individual patients. Larger prospective studies are needed to validate these scoring systems in critically-ill elderly traumatised patients, which may help to facilitate early prognostication.

Predictors of elderly mortality after trauma: A novel outcome score.

Elderly trauma patients are at high risk for mortality, even when presenting with minor injuries. Previous prognostic models are poorly used because of their reliance on elements unavailable during the index hospitalization. The purpose of this study was to develop a predictive algorithm to accurately estimate in-hospital mortality using easily available metrics. The National Trauma Databank was used to identify patients 65 years and older. Data were split into derivation (2007-2013) and validation (2014-2015) data sets. There was no overlap between data sets. Factors included age, comorbidities, physiologic parameters, and injury types. A two-tiered scoring system to predict in-hospital mortality was developed: a quick elderly mortality after trauma (qEMAT) score for use at initial patient presentation and a full EMAT (fEMAT) score for use after radiologic evaluation. The final model (stepwise forward selection, p < 0.05) was chosen based on calibration and discrimination analysis. Calibration (Brier score) and discrimination (area under the receiving operating characteristic curve [AuROC]) were evaluated. Because National Trauma Databank did not include blood product transfusion, an element of the Geriatric Trauma Outcome Score (GTOS), a regional trauma registry was used to compare qEMAT versus GTOS. A mobile-based application is currently available for cost-free utilization. A total of 840,294 patients were included in the derivation data set and 427,358 patients in the validation data set. The fEMAT score (median, 91; S.D., 82-102) included 26 factors, and the qEMAT score included eight factors. The AuROC was 0.86 for fEMAT (Brier, 0.04) and 0.84 for qEMAT. The fEMAT outperformed other trauma mortality prediction models (e.g., Trauma and Injury Severity Score-Penetrating and Trauma and Injury Severity Score-Blunt, age + Injury Severity Score). The qEMAT outperformed the GTOS (AuROC, 0.87 vs. 0.83). The qEMAT and fEMAT accurately estimate the probability of in-hospital mortality and can be easily calculated on admission. This information could aid in deciding transfer to tertiary referral center, patient/family counseling, and palliative care utilization. Epidemiological Study, level IV.

Predictors of mortality in patients with rib fractures.

The aim of this study was to identify risk factors for morbidity and mortality in patients with rib fractures with focus on identifying a more exact age-dependent cut-off for increased morbidity and mortality. Retrospective study of patients 16years or older with rib fractures from blunt trauma. patients undergoing rib plating. Initial chest X-ray and Computed Tomography (CT) scans were re-read for the number of rib fractures (NRF) and presence of pulmonary contusion (PC). Data included demographics, mechanism of injury (MOI), NRF, associated injuries, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), Geriatric Trauma Outcome Score (GTOS), presence of pneumothorax, hemothorax, hemo-pneumothorax, PC, Adult Respiratory Distress Syndrome (ARDS), pulmonary complications (ventilator-associated pneumonia, nosocomial pneumonia), and mortality. PC was quantified from CT scans with Mimics. Continuous data were analyzed using Student's t test. Variables significantly different by univariate analysis were analyzed by logistic regression analysis. The study group consisted of 1188 adult trauma patients admitted during a 2-year period; 800 males and 388 females, with a mean age of 54 ± 21. MOI: MVC, 735 (61.8%); falls, 364 (30.6%); other: 89. Mean NRF, 4 ± 2; GCS, GTOS, and ISS, 15 (15-15), 101 (82-124), and 19 ± 9, respectively. Incidence of PC was 329 (27.7%); PTX, HTX, and HTX/PTX, 264 (20.2%), 57 (4.8%), and 147 (12.4%). Flail chest, in 17 (1.4%); 321 required mechanical ventilation. Age, GCS, male gender, and ISS but not NRF and/or PC were predictive of mortality. Increased mortality in patients with rib fractures starts at 65years of age without a further increase until age ≥ 80. NRF does not predict increased mortality independent of age. Severe TBI is the most common cause of death in patients 16-75years, as opposed to respiratory complications in patients 80years-old or greater.

A Comparison of Scoring Systems for Predicting Short- and Long-term Survival After Trauma in Older Adults.

Early identification of geriatric patients at high risk for mortality is important to guide clinical care, medical decision making, palliative discussions, quality assurance, and research. We sought to identify injured older adults at highest risk for 30-day mortality using an empirically derived scoring system from available data and to compare it with current prognostic scoring systems. This was a retrospective cohort study of injured adults ≥ 65 years transported by 44 emergency medical services (EMS) agencies to 49 emergency departments in Oregon and Washington from January 1, 2011, through December 31, 2011, with follow-up through December 31, 2012. We matched data from EMS to Medicare, inpatient, trauma registries, and vital statistics. Using a primary outcome of 30-day mortality, we empirically derived a new risk score using binary recursive partitioning and compared it to the Charlson Comorbidity Index (CCI), modified frailty index, geriatric trauma outcome score (GTOS), GTOS II, and Injury Severity Score (ISS). There were 4,849 patients, of whom 234 (4.8%) died within 30 days and 1,040 (21.5%) died within 1 year. The derived score, the geriatric trauma risk indicator (GTRI; emergent airway or CCI ≥ 2), had 87.2% sensitivity (95% confidence interval [CI]= 83.0% to 91.5%) and 30.6% specificity (95% CI= 29.3% to 31.9%) for 30-day mortality (area under the receiving operating characteristic curve [AUROC]= 0.589, 95% CI= 0.566 to 0.611). AUROC values for other scoring systems ranged from 0.592 to 0.678. When the sensitivity for each existing score was held at 90%, specificity values ranged from 7.5% (ISS) to 30.6% (GTRI). Older, injured adults transported by EMS to a large variety of trauma and nontrauma hospitals were more likely to die within 30 days if they required emergent airway management or had a higher comorbidity burden. When compared to other risk measures and holding sensitivity constant near 90%, the GTRI had higher specificity, despite a lower AUROC. Using GTOS II or the GTRI may better identify high-risk older adults than traditional scores, such as ISS, but identification of an ideal prognostic tool remains elusive.

Significance of Blood Transfusion Units in Determining the Probability of Mortality among Elderly Trauma Patients Based on the Geriatric Trauma Outcome Scoring System: A Cross-Sectional Analysis Based on Trauma Registered Data.

Background: For elderly trauma patients, a prognostic tool called the Geriatric Trauma Outcome Score (GTOS), where GTOS = (age) + (ISS × 2.5) + (22 if any packed red blood cells (pRBCs) were transfused within 24 h after admission), was developed for predicting mortality. In such calculation, a score of 22 was added in the calculation of GTOS regardless of the transfused units of blood. This study aimed to assess the effect of transfused blood units on the mortality outcomes of the elderly trauma patients who received blood transfusion (BT). Methods: Detailed data of 687 elderly trauma patients aged ≥65 years who were transfused with pRBCs within 24 h after admission into a level I trauma center between 1 January 2009 and 31 December 2016 were retrieved from the Trauma Registry System database. Based on the units of pRBCs transfused, the study population was divided into two groups to compare the mortality outcomes between these groups. Adjusted odds ratios (AORs) with its 95% confidence intervals (CIs) for mortality were calculated by adjusting sex, pre-existing comorbidities, and GTOS. Results: When the cut-off value of BT was set as 3 U of pRBCs, patients who received BT ≥ 3 U had higher odds of mortality than those who received BT < 3 U (OR, 3.0; 95% CI, 1.94–4.56; p < 0.001). Patients who received more units of pRBCs still showed higher odds of mortality than their counterparts. After adjusting for sex, pre-existing comorbidities, and GTOS, comparison revealed that the patients who received BT of 3 U to 6 U had a 1.7-fold adjusted odds of mortality than their counterparts. The patients who received BT ≥ 8 U and 10 U had a 2.1-fold (AOR, 2.1; 95% CI, 1.09–3.96; p < 0.001) and 4.4-fold (AOR, 4.4; 95% CI, 2.04–9.48; p < 0.001) adjusted odds of mortality than those who received BT < 8 U and <10 U, respectively. Conclusions: This study revealed that the units of BT did matter in determining the probability of mortality. For those who received more units of blood, the mortality may be underestimated according to the GTOS.

Predicting Survival in Geriatric Trauma Patients: A Comparison Between the TRISS Methodology and the Geriatric Trauma Outcome Score

IntroductionWe compared the Geriatric Trauma Outcome Score (GTOS) with the probability of survival using the TRISS methodology (PS-TRISS) in geriatric severe trauma patients admitted to Intensive Care Units (ICU) participating in the Spanish trauma ICU registry (RETRAUCI). MethodsRetrospective analysis from the RETRAUCI. Quantitative data were reported as median (Interquartile Range (IQR)), and categorical data as number (percentage). We analyzed the validity of the GTOS and PS-TRISS to predict survival. Discrimination was analyzed using receiver operating characteristics curves. Calibration was analyzed using the Hosmer–Lemeshow goodness-of-fit test. A P value <.05 was considered statistically significant. ResultsThe cohort included 1417 patients aged ≥65 years. Median age was 75.5 (70.5–80.5), 1003 patients were male (68.2%) and median Injury Severity Score was 18 (13–25). Mechanical ventilation was required in 61%. Falls were the mechanism of injury in 659 patients (44.8%). In-hospital mortality rate was 18.2%. The areas under the curve were: PS-TRISS 0.69 (95% CI 0.66–0.73), and GTOS 0.66 (95% CI 0.62–0.70); P<.05. Both scores overestimated mortality in the upper range of predicted mortality. ConclusionsIn our sample of geriatric severe trauma patients, the accuracy of GTOS was lower than the accuracy of the PS-TRISS to predict in-hospital survival. The calibration of both scores for the geriatric population was deficient.

Predicción de la supervivencia en pacientes traumáticos ancianos: comparación entre la metodología TRISS y el Geriatric Trauma Outcome Score

IntroductionWe compared the Geriatric Trauma Outcome Score (GTOS) with the probability of survival using the TRISS methodology (PS-TRISS) in geriatric severe trauma patients admitted to Intensive Care Units (ICU) participating in the Spanish trauma ICU registry (RETRAUCI). MethodsRetrospective analysis from the RETRAUCI. Quantitative data were reported as median (Interquartile Range (IQR)), and categorical data as number (percentage). We analyzed the validity of the GTOS and PS-TRISS to predict survival. Discrimination was analyzed using receiver operating characteristics curves. Calibration was analyzed using the Hosmer-Lemeshow goodness-of-fit test. A P value <.05 was considered statistically significant. ResultsThe cohort included 1417 patients aged ≥ 65 years. Median age was 75.5 (70.5-80.5), 1003 patients were male (68.2%) and median Injury Severity Score was 18 (13-25). Mechanical ventilation was required in 61%. Falls were the mechanism of injury in 659 patients (44.8%). In-hospital mortality rate was 18.2%. The areas under the curve were: PS-TRISS 0.69 (95%CI 0.66-0.73), and GTOS 0.66 (95%CI 0.62-0.70); P<.05. Both scores overestimated mortality in the upper range of predicted mortality. ConclusionsIn our sample of geriatric severe trauma patients, the accuracy of GTOS was lower than the accuracy of the PS-TRISS to predict in-hospital survival. The calibration of both scores for the geriatric population was deficient.

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

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.

Validation of a Geriatric Trauma Prognosis Calculator: A P.A.L.Li.A.T.E. Consortium Study.

The P.A.L.Li.A.T.E. (prognostic assessment of life and limitations after trauma in the elderly) consortium has previously created a prognosis calculator for mortality after geriatric injury based on age, injury severity, and transfusion requirement called the geriatric trauma outcome score (GTOS). Here, we sought to create and validate a prognosis calculator called the geriatric trauma outcome score ii (GTOS II) estimating probability of unfavorable discharge. Retrospective cohort. Four geographically diverse Level 1 trauma centers. Trauma admissions aged 65 to 102 years surviving to discharge from 2000 to 2013. None. Age, injury severity score (ISS), transfusion at 24 hours post-admission, discharge dichotomized as favorable (home/rehabilitation) or unfavorable (skilled nursing/long term acute care/hospice). Training and testing samples were created using the holdout method. A multiple logistic mixed model (GTOS II) was created to estimate the odds of unfavorable disposition then re-specified using the GTOS II as the sole predictor in a logistic mixed model using the testing sample. The final dataset was 16,114 subjects (unfavorable discharge status = 15.4%). Training (n = 8,057) and testing (n = 8,057) samples had similar demographics. The formula based on the training sample was (GTOS II = Age + [0.71 × ISS] + 8.79 [if transfused by 24 hours]). Misclassification rate and AUC were 15.63% and 0.67 for the training sample, respectively, and 15.85% and 0.67 for the testing sample. GTOS II estimates the probability of unfavorable discharge in injured elders with moderate accuracy. With the GTOS mortality calculator, it can help in goal setting conversations after geriatric injury.

Palliative Care in the Elderly Injured Patient

The purpose of this review is to provide up-to-date insight into the current practices of palliative care in elderly trauma patients. The use and need of palliative care programs have grown substantially throughout the USA in both public and not-for-profit hospitals. The geriatric trauma outcome score has been proposed as a tool to help better explain to patients and their stakeholders the likelihood of mortality in injured geriatric trauma patients. The study of frailty and the differences between patients of similar age has become a focus of many surgical societies. Recent studies also address how to improve end-of-life communication through training programs for health-care professionals. Palliative care in trauma and other populations is evolving. Adequately trained staff are needed for facilitating care in this vulnerable patient population, while also providing education on best practices for appropriate discussion of palliation and end-of-life care in the trauma population.

Predicting In-Hospital and 1-Year Mortality in Geriatric Trauma Patients Using Geriatric Trauma Outcome Score

The Geriatric Trauma Outcome Score (GTOS; [age]+ [2.5 × Injury Severity Score]+ 22 [if packed RBC transfused within ≤24 hours of admission]), was developed and validated as a prognostic indicator for in-hospital mortality in elderly trauma patients. However, GTOS neither provides information about post-discharge outcomes nor discriminates between patients dying with and without care restrictions. Isolating the latter, GTOS prediction performance was examined during admission and 1-year post discharge in a mature European trauma registry. All trauma admissions 65 years of age and older in a university hospital during 2007 to 2011 were considered. Data on age, Injury Severity Score, packed RBC transfusion within ≤24 hours, therapy restrictions, discharge disposition, and mortality were collected. In-hospital deaths with therapy restrictions and patients discharged to hospice were excluded. The GTOS was the sole predictor in a logistic regression model estimating mortality probabilities. Performance of the model was assessed by misclassification rate, Brier score, Tjur R2, and area under the curve. The study population was 1,080 patients with a median age of 75 years, mean Injury Severity Score of 10, and packed RBCs transfused in 8.2%. In-hospital mortality was 14.9% and 7.7% after exclusions. Misclassification rate fell from 14% to 6.5% and Brier score from 0.09 to 0.05, and area under the curve increased from 0.87 to 0.88. Equivalent values for the original GTOS sample were 9.8%, 0.07, and 0.82, respectively. One-year mortality follow-up showed a misclassification rate of 17.6% and Brier score of 0.13. Excluding patients with care restrictions and discharged to hospice improved GTOS performance for in-hospital mortality prediction. The GTOS is not adept at predicting 1-year mortality.