Elsevier

Annals of Emergency Medicine

Volume 60, Issue 3, September 2012, Pages 335-345
Annals of Emergency Medicine

Trauma/original research
Evaluating Age in the Field Triage of Injured Persons

https://doi.org/10.1016/j.annemergmed.2012.04.006Get rights and content

Study objective

We evaluate trauma undertriage by age group, the association between age and serious injury after accounting for other field triage criteria and confounders, and the potential effect of a mandatory age triage criterion for field triage.

Methods

This was a retrospective cohort study of injured children and adults transported by 48 emergency medical services (EMS) agencies to 105 hospitals in 6 regions of the western United States from 2006 through 2008. We used probabilistic linkage to match EMS records to hospital records, including trauma registries, state discharge databases, and emergency department databases. The primary outcome measure was serious injury, as measured by an Injury Severity Score greater than or equal to 16. We assessed undertriage (Injury Severity Score ≥16 and triage-negative or transport to a nontrauma center) by age decile and used multivariable logistic regression models to estimate the association (linear and nonlinear) between age and Injury Severity Score greater than or equal to 16, adjusted for important confounders. We also evaluated the potential influence of age on triage efficiency and trauma center volume.

Results

Injured patients (260,027) were evaluated and transported by EMS during the 3-year study period. Undertriage increased for patients older than 60 years, reaching approximately 60% for those older than 90 years. There was a strong nonlinear association between age and Injury Severity Score greater than or equal to 16. For patients not meeting other triage criteria, the probability of serious injury was most notable after 60 years. A mandatory age triage criterion would have decreased undertriage at the expense of overtriage, with 1 patient with Injury Severity Score greater than or equal to 16 identified for every 60 to 65 additional patients transported to major trauma centers.

Conclusion

Trauma undertriage increases in patients older than 60 years. Although the probability of serious injury increases among triage-negative patients with increasing age, the use of a mandatory age triage criterion appears inefficient for improving field triage.

Introduction

Field triage plays a critical role in directing seriously injured patients to major trauma centers, which improve survival and functional outcomes.1 The process of field triage is guided by a triage algorithm originally developed by the American College of Surgeons Committee on Trauma and revised under the auspices of the Centers for Disease Control and Prevention.2, 3 Starting in 1987, the Field Triage Decision Scheme included age (<5 or >55 years)4 as a “special consideration” criterion to identify vulnerable populations potentially benefitting from care in major trauma centers. However, there is little empiric evidence demonstrating the utility of age as a field triage criterion for identifying patients with serious injuries. Complicating this issue are several studies suggesting that undertriage (the proportion of patients with serious injuries not meeting field triage criteria and/or taken to nontrauma centers) is notably higher among elders5, 6, 7, 8 and possibly children.9

Several studies have demonstrated advanced age to be a risk factor for adverse outcomes in trauma.10, 11, 12, 13, 14, 15, 16, 17 The criterion specifying age younger than 5 years or older than 55 years as a reason to transport to a major trauma center was based on early studies demonstrating increased inhospital mortality among injured patients in these age ranges.10, 18, 19 However, evidence supporting the use of specific age cut points to guide appropriate field triage is sparse, especially for patients not already identified by other triage criteria. Adding importance to this topic is the suggestion that undertriage differs by age5, 6, 7, 8, 9 and the possibility that outcomes may be worse in seriously injured patients at the extremes of age because of lack of access to appropriate trauma care. Whether modifying the age criterion in the field triage guidelines would reduce age-specific undertriage practices, improve access to trauma care, and reduce morbidity and mortality without adversely affecting major trauma centers remains unknown.

We analyzed a large, multisite, population-based, out-of-hospital injury cohort to evaluate undertriage in multiple age groups, including children and elders. We also examined the association between age and serious injury (Injury Severity Score ≥16) after accounting for other triage criteria to potentially identify an appropriate field triage criterion for age. Finally, we evaluated the implications of different mandatory age triage criteria on trauma centers and trauma systems. Although we have previously evaluated the diagnostic value of the field triage criteria,8 this study represents a more detailed assessment of age in the field triage of injured persons.

Section snippets

Study Design

This was a multisite retrospective cohort study. Fourteen institutional review boards at 6 sites approved this protocol and waived the requirement for informed consent.

Setting

The study included injured children and adults who were evaluated and transported by 48 emergency medical services (EMS) agencies to 105 hospitals (12 Level I, 5 Level II, 3 Level III, 4 Level IV, 1 Level V, and 80 community/private/federal hospitals) in 6 regions across the western United States during a 3-year period (January

Results

There were 260,027 injured persons evaluated and transported by EMS during the study period, of whom 8,007 (3.1%) had an Injury Severity Score greater than or equal to 16 and 46,414 (17.9%) met field triage criteria for trauma center transport by EMS personnel. Of triage-positive patients, 6,026 (13.0%) were recorded as meeting the field triage age criterion of younger than 5 years or older than 55 years. Characteristics of the sample are listed in Table 1, by age group.

Use of field triage

Limitations

This study used a retrospective cohort design and is subject to the standard limitations that accompany such research, including the possibility of unmeasured confounding and bias. Unmeasured factors, such as comorbid conditions, patient preference about transport destination, and lack of uniformity in the application of trauma triage criteria, could have altered our findings. We attempted to minimize selection bias by using population-based data from multiple sites and EMS agencies, as well as

Discussion

In this study, we demonstrated that undertriage increases with age for patients older than 60 years and that among patients not meeting other triage criteria, there is no single age (or combination of ages) that could be used as a triage criterion to effectively reduce undertriage without large increases in overtriage and the volume of patients with minor injuries transported to major trauma centers. We also demonstrated that current use of the age-specific triage criterion is selective (ie,

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  • Cited by (0)

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. This project was supported by the Robert Wood Johnson Foundation Physician Faculty Scholars Program; the Oregon Clinical and Translational Research Institute (grant UL1 RR024140), UC Davis Clinical and Translational Science Center (grant UL1 RR024146), Stanford Center for Clinical and Translational Education and Research (grant 1UL1 RR025744), University of Utah Center for Clinical and Translational Science (grant UL1-RR025764 and C06-RR11234), and UCSF Clinical and Translational Science Institute (grant UL1 RR024131). All Clinical and Translational Science Awards are from the National Center for Research Resources, a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research.

    Supervising editor: Judd E. Hollander, MD

    Author contributions: YN and CDN conceived of and designed the study. EMB, RYH, NCM, JFH, KS, ML, and CDN assisted with acquisition of data. CDN performed all database management and statistical analyses. All authors helped interpret the data and results. MD and CDN provided oversight, guidance, and mentorship during the project. YN drafted the article, and all authors participated in its critical revision. YN and CDN take responsibility for the data and results. CDN takes responsibility for the paper as a whole.

    Publication date: Available online May 24, 2012.

    Please see page 336 for the Editor's Capsule Summary of this article.

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