Journal
PREHOSPITAL EMERGENCY CARE
Volume 18, Issue 4, Pages 461-470Publisher
TAYLOR & FRANCIS INC
DOI: 10.3109/10903127.2014.912707
Keywords
EMS; trauma; triage
Funding
- Robert Wood Johnson Foundation Physician Faculty Scholars Program
- Oregon Clinical and Translational Research Institute [UL1 RR024140]
- UC Davis Clinical and Translational Science Center [UL1 RR024146]
- Stanford Center for Clinical and Translational Education and Research [1UL1 RR025744]
- University of Utah Center for Clinical and Translational Science [UL1-RR025764, C06-RR11234]
- UCSF Clinical and Translational Science Institute [UL1 RR024131]
- National Center for Research Resources, a component of the National Institutes of Health (NIH)
- NIH Roadmap for Medical Research
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Objective. To evaluate the ability of out-of-hospital physiologic measures to predict serious injury for field triage purposes among older adults and potentially reduce the under-triage of seriously injured elders to non-trauma hospitals. Methods. This was a retrospective cohort study involving injured adults 55 years and older transported by 94 emergency medical services (EMS) agencies to 122 hospitals (trauma and non-trauma) in 7 regions of the western United States from January 1, 2006 to December 31, 2008. We evaluated initial out-of-hospital Glasgow Coma Scale (GCS) score, systolic blood pressure (SBP), respiratory rate, heart rate, shock index (SBP divided by heart rate), out-of-hospital procedures, mechanism of injury, and patient demographics. The primary outcome was serious injury, defined as Injury Severity Score (ISS) >= 16, as a measure of trauma center need. We used multivariable regression models, fractional polynomials and binary recursive partitioning to evaluate appropriate physiologic cut-points and the value of different physiologic triage criteria. Results. A total of 44,890 injured older adults were evaluated and transported by EMS, of whom 2,328 (5.2%) had ISS >= 16. Nonlinear associations existed between all physiologic measures and ISS >= 16 (unadjusted and adjusted p <= 0.001 for all,), except for heart rate (adjusted p = 0.48). Revised physiologic triage criteria included GCS score = 14; respiratory rate < 10 or > 24 breaths per minute or assisted ventilation; and SBP < 110 or > 200 mmHg. Compared to current triage practices, the revised criteria would increase triage sensitivity from 78.6 to 86.3% (difference 7.7%, 95% CI 6.1-9.6%), reduce specificity from 75.5 to 60.7% (difference 14.8%, 95% CI 14.3-15.3%), and increase the proportion of patients without serious injuries transported to major trauma centers by 60%. Conclusions. Existing out-of-hospital physiologic triage criteria could be revised to better identify seriously injured older adults at the expense of increasing overtriage to major trauma centers.
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