Ohio Trauma Registry Research Articles

Identifying Predictors of Undertriage in Injured Older Adults After Implementation of Statewide Geriatric Trauma Triage Criteria.

The objective was to identify factors associated with transport of injured older adults meeting statewide geriatric trauma triage criteria to a trauma center. An observational retrospective cohort study using the 2009 to 2011 Ohio Trauma Registry. Subjects were adults ≥ 70 years old who met Ohio's geriatric triage criteria for trauma center transport by emergency medical services. We created multivariable logistic regression models to identify predictors of initial and ultimate (e.g., interfacility transfer) transport to a Level I or II trauma center and to a Level I, II, or III center. Of 10,411 subjects, 47% were initially and 59% were ultimately transported to a Level I or II trauma center with rates of 66 and 74%, respectively, for transport to a Level I, II, or III center. For initial transport to a Level I or II center, age 80 to 89 (odds ratio [OR]= 0.89), age ≥90 (OR= 0.76), and either only a Level 3 (OR= 0.3) or no trauma center (OR= 0.11) in county of residence had decreased odds of transport, while male sex (OR= 1.38), black race (OR= 2.07), Injury Severity Score (ISS) 10-15 (OR= 1.99), ISS>15 (OR= 2.85), and Glasgow Coma Scalescore <9 (OR= 2.11) had increased odds. Results were similar for ultimate transport to a Level I or II center. Analyzing transport to a Level I, II, or III center demonstrated similar results except a Level III trauma center in county of residence was associated with increased odds (OR= 2.00 for initial and 2.21 for ultimate) of transport to a Level I, II, or III center. We identified factors independently associated with failure to transport injured older adults to trauma centers in statewide data collected after adoption of geriatric triage criteria. Lack of a trauma center in the county of residence remained a factor even in analyses that included ultimate transport.

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

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.

Level I Trauma Centers: More Is Not Necessarily Better

The optimal number of level I trauma centers (L1TCs) in a region has not been elucidated. To begin addressing this, we compared mortalities for patients treated in counties or regions with 1 L1TC to those with >1 L1TC across Ohio. Ohio Trauma Registry data from 2010 to 2012 were analyzed. Patients with age ≥15 from counties/regions with L1TC were included. Region was defined as a L1TC containing county and its neighboring counties. Two analyses were performed. In the county analysis, counties containing 1 L1TC were compared with counties with multiple L1TCs. This comparison is repeated on a regional level for the regional analysis. Subgroup analyses were performed. 38,661 and 55,064 patients were in the county and regional analysis, respectively. Patients treated in counties or regions with multiple L1TCs were significantly younger (P < 0.001). Despite this, the mortality was similar for the two groups in the county analysis and significantly higher for regions with multiple L1TCs (P < 0.001). Multivariate logistic regression demonstrated that having multiple L1TC coverage in a region was an independent predictor for death (odds ratios: 1.17; 1.07-1.28; P = 0.001). Subgroup analyses showed that mortality in counties and regions with multiple L1TCs was not lower in any subgroups but was higher in patients with age ≥65 and patients with blunt injuries (P < 0.05). Having multiple L1TCs in a county was associated with increased mortality in certain patient subgroups. Having multiple L1TCs in a region was an independent predictor for death. These results should be considered carefully when designing future regionalized trauma networks. More L1TCs is not necessarily better.

The spatial epidemiology of pediatric trauma

Despite significant advances in the prevention and treatment of pediatric trauma, preventable injuries continue to burden the lives of millions of children. To target prevention strategies, it is critical to identify areas with high burdens of pediatric trauma. Therefore, this study analyzed statewide data from the Ohio Trauma Registry from 2007 to 2012 to identify geographical patterns in pediatric injury. Data from the first hospital of care for 16,330 pediatric trauma patients younger than 16 years were analyzed using the disease mapping method adaptive spatial filtering to estimate a series of maps that display age- and sex-adjusted rates of pediatric trauma, severe trauma, and standardized mortality ratios while controlling for population size to create stable estimates throughout the study area. The locations of all trauma centers were mapped to highlight access to trauma care. Areas with significantly higher than expected rates of severe injury were identified in nonurban areas, where children lacked timely access to a pediatric trauma center or Level I adult trauma center. Although highest standardized mortality ratios were in urban areas, nonurban areas experienced elevated mortality with rates over four times higher than expected. Areas with higher than expected age- and sex-adjusted rates of severe injury and mortality should be further explored to identify opportunities for injury prevention and appropriate access to timely care. Epidemiologic study, level III.

Pediatric trauma undertriage in Ohio.

Appropriate and timely triage is an essential component of a trauma system. In the state of Ohio, there are 6 verified pediatric trauma centers (PTCs) across 8 state regions. The purpose of this study was to better understand the pediatric undertriage rates in the state. We used the Ohio Trauma Registry from 2007 to 2012, consisting of 14,045 records of children younger than 16 years admitted to a hospital for more than 48 hours or who sustained a traumatic death. Pediatric undertriage was defined as not being directly transported to a PTC when one was available within 30 minutes or not being transferred to a PTC within 2 hours of injury. The state pediatric undertriage rate was 52%, only decreasing to 35% when up to a 4-hour transfer time was allowed. Across state trauma regions, undertriage rates varied from 94% to 40%. More than 28% of injured children had access to a PTC within 30 minutes of their home. A trauma center (adult or pediatric) was within 30 minutes for 66% of the children, yet 32% of the children went to a nontrauma center first. Overall, 29% of children never made it to a PTC, and 4% of children remained at a nontrauma center, with regional variation from 5% to 0.5%. Statewide mortality was nearly 3%, with regional variations between 5% and 0.4%. Mortality rate within the appropriately triaged group was 5.3%, while mortality rate in the undertriage group was only 0.7%. Overall, 53% of transferred patients had a more than 2-hour transfer time. Despite the significant number of PTCs in Ohio, there remains a high undertriage rate with significant regional variations and long transfer times. Continued analysis will be useful in furthering trauma system development for the injured child. Therapeutic/care management study, level IV; epidemiological, level IV.

Effect of Geriatric-Specific Trauma Triage Criteria on Outcomes in Injured Older Adults: A Statewide Retrospective Cohort Study.

To evaluate the effect on outcomes of the Ohio Department of Public Safety statewide geriatric triage criteria, established in 2009 for emergency medical services (EMS) to use for injured individuals aged 70 and older. Retrospective cohort study of the Ohio Trauma Registry. All hospitals in Ohio. Individuals aged 70 and older in the Ohio Trauma Registry from January 2006 through December 2011, 3 years before and 3 years after criteria adoption (N = 34,499). Primary outcomes were in-hospital mortality and discharge to home. Criteria effects were assessed using chi-square tests, multivariable logistic regression, interrupted time series plots, and multivariable segmented regression models. After geriatric criteria were adopted, the proportion of older adults qualifying for trauma center transport increased from 44% to 58%, but EMS transport rates did not change (44% vs 45%). There was no difference in unadjusted mortality (7.1% vs 6.6%) (P = .10). In adjusted analyses, subjects with an injury severity score (ISS) less than 10 had lower mortality after adoption (3.0% vs 2.5%) (odds ratio (OR) = 0.81, 95% confidence interval (CI) = 0.70-0.95, P = .01). Discharge to home increased after adoption in the adjusted analysis (OR = 1.06, 95% CI = 1.01-1.11, P = .02). There were no time-dependent changes for either outcome. Although the proportion of older adults meeting criteria for trauma center transport substantially increased with geriatric triage criteria, there were no increases in trauma center transports. Adoption of statewide geriatric triage guidelines did not decrease mortality in more severely injured older adults but was associated with slightly lower mortality in individuals with mild injuries (ISS <10) and with more individuals discharged to home. Improving outcomes in injured older adults will require further attention to implementation and use of geriatric-specific criteria.

Geriatric-Specific Triage Criteria Are More Sensitive Than Standard Adult Criteria in Identifying Need for Trauma Center Care in Injured Older Adults

We evaluate the sensitivity of Ohio's 2009 emergency medical services (EMS) geriatric trauma triage criteria compared with the previous adult triage criteria in identifying need for trauma center care among older adults. We studied a retrospective cohort of injured patients aged 16 years or older in the 2006 to 2011 Ohio Trauma Registry. Patients aged 70 years or older were considered geriatric. We identified whether each patient met the geriatric and the adult triage criteria. The outcome measure was need for trauma center care, defined by surrogate markers: Injury Severity Score greater than 15, operating room in fewer than 48 hours, any ICU stay, and inhospital mortality. We calculated sensitivity and specificity of both triage criteria for both age groups. We included 101,577 patients; 33,379 (33%) were geriatric. Overall, 57% of patients met adult criteria and 68% met geriatric criteria. Using Injury Severity Score, for older adults geriatric criteria were more sensitive for need for trauma center care (93%; 95% confidence interval [CI] 92% to 93%) than adult criteria (61%; 95% CI 60% to 62%). Geriatric criteria decreased specificity in older adults from 61% (95% CI 61% to 62%) to 49% (95% CI 48% to 49%). Geriatric criteria in older adults (93% sensitivity, 49% specificity) performed similarly to the adult criteria in younger adults (sensitivity 87% and specificity 44%). Similar patterns were observed for other outcomes. Standard adult EMS triage guidelines provide poor sensitivity in older adults. Ohio's geriatric trauma triage guidelines significantly improve sensitivity in identifying Injury Severity Score and other surrogate markers of the need for trauma center care, with modest decreases in specificity for older adults.

Substance Use and Type and Severity of Injury Among Hospitalized Trauma Cases: Ohio, 2004–2007

The purpose of this study was to determine whether persons who were injured severely enough to require hospitalization suffered more severe injury when substance use was involved. This was accomplished by evaluating four proxy outcome measures with Ohio Trauma Registry data from January 2004 through December 2007. Four injury outcomes were identified: injury severity score, admission to an intensive care unit, presence of at least one medical complication, and hospital length of stay. We examined their association with substance (alcohol and/or other drug) use stratified by the likelihood of being tested for substance use, mechanism of injury, sex, age, race, and insurance status. Relative risks and t test scores were calculated. Among 89,129 trauma cases reported to the Ohio Trauma Registry during 2004-2007, more than 21% were substance users. Those younger than 45 years of age were 65% more likely to use substances than those 45 or older, men were 110% more likely than women, Blacks were 86% more likely than non-Blacks, and uninsured persons were 127% more likely than insured persons. Stratified analyses yielded 16 comparisons (4 Injury Outcomes × 4 Age-Insurance Subgroups). For 13 of these 16 comparisons, injury severity was significantly worse (p < .0001) among substance users than nonusers. The evidence is strong enough to conclude that, among hospitalized trauma patients, use of substances (alcohol and/or drug) was associated with increased injury severity. These findings appear to be true for the young and old, regardless of insurance status.

Modification of Glasgow Coma Scale Criteria for Injured Elders

An abnormal field Glasgow Coma Scale (GCS) score of ≤13 has been used in our emergency medical services (EMS) system to prompt transport to a trauma center. For elders, Ohio has recently adopted a GCS of ≤14 to prompt EMS transport to a trauma center, as older patients respond differently to trauma and may benefit from a different GCS threshold. This study sought to determine if a field GCS of 14 is an appropriate cutoff to initiate transport to a trauma center among injured elders. This was a retrospective, observational statewide analysis of injured patients ≥16 years old captured by the Ohio Trauma Registry from 2002 to 2007. Outcomes studied included mortality, traumatic brain injury (TBI), neurosurgical intervention, and endotracheal intubation (ETI). Multiple imputation was performed to account for missing data. Age-stratified sensitivity and specificity for proposed GCS cutoffs of 13 and 14 were calculated. A series of multivariate logistic regression models was then constructed using each outcome as a dependent variable. Independent variables included age, GCS score, sex, blood pressure, injury type, nontrauma center, race, ethnicity, and Injury Severity Score (ISS). Two separate analyses were performed. For each age group, odds ratios (ORs) of each outcome were calculated both for the decrease in GCS from 15 to 14 and for the decrease from 14 to 13. The group of elders with GCS 14 was then compared to adults with GCS 13. A total of 52,412 study patients were identified. For a GCS cutoff of 13, sensitivity among elders for each outcome was >20% less than sensitivity for adults, and specificity was 5% to 10% greater. Increasing the GCS cutoff for elders to 14 resulted in improved sensitivity for all outcomes (approximately 10%), with a decline in specificity to values near that of adults with GCS 13. In the multivariate models for elders, mortality increased with a decrease in GCS both from 15 to 14 (OR = 1.40, 95% confidence interval [CI] = 1.07 to 1.83) and from GCS 14 to 13 (OR = 2.34, 95% CI = 1.57 to 3.52). In adults, mortality did not increase with the drop from GCS 15 to 14 (OR = 1.22, 95% CI = 0.88 to 1.71) or from GCS 14 to 13 (OR = 1.45, 95% CI = 0.91 to 2.30). When comparing elders with GCS 14 to adults with GCS 13, elders had greater odds of mortality (OR = 4.68, 95% CI = 2.90 to 7.54) and TBI (OR = 1.84, 95% CI = 1.45 to 2.34). Changing the EMS trauma triage cutoff for elders from GCS 13 to GCS 14 results in improved sensitivity for clinically relevant outcomes. In injured elders, the decline in GCS from 15 to 14 is associated with increased mortality, a finding not observed in younger adults. Elders with GCS 14 have greater odds of mortality and TBI than adults with GCS 13. These results support recent changes in EMS trauma triage guidelines for elders adopted in Ohio.

The prehospital simplified motor score is as accurate as the prehospital Glasgow coma scale: analysis of a statewide trauma registry

ObjectivesThe simplified motor score (SMS) is a three-point measure of traumatic brain injury (TBI) severity, which is easier to calculate than the 15-point Glasgow coma scale (GCS). Using a state...

Development of Statewide Geriatric Patients Trauma Triage Criteria

The geriatric population is unique in the type of traumatic injuries sustained, physiological responses to those injuries, and an overall higher mortality when compared to younger adults. No published, evidence-based, geriatric-specific field destination criteria exist as part of a statewide trauma system. The Trauma Committee of the Ohio Emergency Medical Services (EMS) Board sought to develop specific criteria for geriatric trauma victims. A literature search was conducted for all relevant literature to determine potential, geriatric-specific, field-destination criteria. Data from the Ohio Trauma Registry were used to compare elderly patients, defined as age >70 years, to all patients between the ages of 16 to 69 years with regards to mortality risk in the following areas: (1) Glasgow Coma Scale (GCS) score; (2) systolic blood pressure (SBP); (3) falls associated with head, chest, abdominal or spinal injury; (4) mechanism of injury; (5) involvement of more than one body system as defined in the Barell matrix; and (6) co-morbidities and motor vehicle collision with one or more long bone fracture. For GCS score and SBP, those cut-off points with equal or greater risk of mortality as compared to current values were chosen as proposed triage criteria. For other measures, any criterion demonstrating a statistically significant increase in mortality risk was included in the proposed criteria. The following criteria were identified as geriatric-specific criteria: (1) GCS score <14 in the presence of known or suspected traumatic brain trauma; (2) SBP <100 mmHg; (3) fall from any height with evidence of traumatic brain injury: (4) multiple body-system injuries; (5) struck by a moving vehicle; and (6) the presence of any proximal long bone fracture following motor vehicle trauma. In addition, these data suggested that elderly patients with specific co-morbidities be given strong consideration for evaluation in a trauma center. The state of Ohio is the first state to develop evidence-based geriatric-specific field-destination criteria using data from its state-mandated trauma registry. Further analysis of these criteria will help determine their effects on over-triage and under-triage of geriatric victims of traumatic injuries and the impact on the overall mortality in the elderly.

Identification of an age cutoff for increased mortality in patients with elderly trauma

Objectives The chosen age cutoff for considering patients with trauma to be “elderly” has ranged from 55 to 80 years in trauma guidelines and studies. The goal of this study was to identify at what age mortality truly increases for older victims of trauma. Methods We performed a cross-sectional study of the Ohio Trauma Registry, a statewide database of all injured patients who died or were admitted for more than 48 hours to both trauma and nontrauma centers. Patients 16 years or older entered into the registry between January 1, 2003, and December 31, 2006, were included. Inhospital mortality rates were obtained and stratified by 5-year age intervals and by injury severity score (ISS). Rates between age groups were compared using logistic regression to identify significant differences in mortality. Results Included were 75 658 patients. In logistic regression, patients 70 to 74 years of age had significantly greater mortality than all younger age groups when stratified by ISS ( P ≤ .001-.004). When considering other 5-year age groups as referent (40-44, 45-49, 50-54, 55-59, 60-64, 65-69 years old), no other group was associated with significantly increased mortality, as compared to younger groups ( P > .05 for all). Conclusion Patients 70 to 74 years of age have significantly greater mortality than all younger age groups when stratified by ISS. Age cutoffs based on younger ages are not associated with significant increases in mortality. An age of 70 years should be considered as an appropriate cutoff for considering a patient to be elderly in future studies of trauma and development of geriatric trauma triage criteria.