Trauma triage: the effect of age on EMS provider clinical judgment and prehospital guidelines for transportation of injured patients

Thesis (Ph.D.)--University of Rochester. School of Medicine & Dentistry. Dept. of Epidemiology, 2014.Purpose Injury is among the leading causes of death and disability for older adults. Treatment at advanced care hospitals specializing in injury, also known as trauma centers, significantly improves patient outcomes. However, the selection of a receiving hospital is dependent upon emergency medical services (EMS) providers making appropriate clinical judgment in the prehospital setting – a process referred to as trauma triage. The American College of Surgeons Committee on Trauma developed the Field Triage Decision Scheme (FTDS) to guide EMS providers in their trauma triage decisions. Studies have demonstrated after controlling for injury severity older adults are less likely to receive trauma center care than younger adults, but reasons for this age-based disparity are not well understood. We proposed two mechanisms may lead to this under-triage of older adults to trauma centers: 1) EMS providers’ trauma triage decision-making process differs by patient age; and 2) the current guidelines are inadequate to identify older adults who require trauma center care. This purpose of this dissertation was to assess both of these potential reasons for the under-triage of older adults to trauma centers. Briefly, we made the following hypotheses: 1) patient age influences EMS providers’ decision to transport to a trauma center; 2) patient age is an independent predictor of trauma center need; 3) the 2006 FDTS has lower sensitivity and higher specificity among older adults compared to younger adults; and 4) age-specific trauma triage criteria result in differences in classification accuracy compared to the 2006 FTDS. Methods A multifactorial approach was used to address both potential mechanisms for the higher rate of under-triage of older adults. First, a survey was distributed to EMS providers in the Greater Rochester, NY area. The survey consisted of questions regarding self-reported factors that influence trauma triage decisions, as well as potential reasons for the under-triage of injured older adults to trauma centers. Additionally, the survey consisted of three factorial survey vignettes to assess EMS provider decision-making. Analysis consisted of descriptive statistics and generalized estimating equations to evaluate EMS provider decision-making processes. Second, preexisting data from a multi-center cohort study of injured EMS patients was used to assess the relationship between increasing age, the FTDS, and need for trauma center care. To test the association between increasing age and need for trauma center care, a multivariable logistic regression model was developed. The ability of the 2006 FTDS to identify older adults who do and do not require trauma center care was determined by calculating measures of classification accuracy within three age strata ( Results Results from the study indicated that EMS providers report comfort in making trauma triage decisions, regardless of patient age. The three most commonly EMS provider-cited reasons for under-triage of older adults were: 1) “patient/caregiver requested transportation to another hospital” (71.7%); 2) “lack of sufficient training on geriatric trauma management” (65.4%); and 3) “injuries among older adults are an expected part of the aging process” (53.9%). In our sample of EMS providers, there was not a statistically significant association with older age older age (≥ 55 years) and decision to transport to a trauma center (AOR: 1.09; 95% CI: 0.88, 1.34) or perceived importance of trauma center care to a patient’s clinical care (Aβ: 0.12; 95% CI: -0.04, 0.29). In our analysis of injured EMS patients, compared to adults aged less than 55, subjects aged 55-69 and ≥70 were statistically significantly more likely to require trauma center care (AOR 1.29; 95% CI: 1.03, 1.60 for 55-69 and AOR 2.06; 95% CI: 1.66, 2.55 for ≥70). There was a statistically significant linear trend in measures of classification accuracy (p Conclusion In conclusion, trauma triage is a complex process that has the potential to significantly influence patient outcomes. Two potential reasons for the higher rate of under-triage among the older adult population were evaluated: EMS provider clinical judgment and the classification accuracy of the 2006 FTDS. Despite older adults having an increased need for trauma center care, we failed to detect a statistically significant association between older age and EMS provider decision to transport to a trauma center. The 2006 FTDS inadequately identifies older adults who require trauma center care. Its sensitivity can be improved through the creation of age-specific criteria, but with an expected tradeoff of decreased specificity. Future studies should further explore the relationship between age, trauma triage, and EMS provider decision-making as well as population-based studies to identify additional criteria that can further improve prediction of trauma center need in the older adult population