Ohio State Board of Emergency Medical Services Old People Break Easily: Ohio’s Geriatric Trauma Triage Criteria

Ohio and the Ohio Trauma System Ohio Ohio 11.5 million population 11.5 million population 7 th largest state by population 7 th largest state by population 8 th in population density 8 th in population density Indiana Indiana 6.3 million population 15 th largest state by population 15 th in population density

Ohio and the Ohio Trauma System 180 acute care hospitals 180 acute care hospitals 45 ACS-verified trauma centers 45 ACS-verified trauma centers 14 Level 1 (3 pediatric) 14 Level 1 (3 pediatric) 13 Level 2 (3 pediatric) 13 Level 2 (3 pediatric) 18 Level 3 18 Level 3

Ft. Wayne, IN Huntington, WV Wheeling, WV Pittsburgh, PA Erie, PA Parkersburg, WV 4 Weirton, WV 4 New Martinsville, WV 4 Point Pleasant, WV

Ohio and the Ohio Trauma System Ohio Trauma System created in law – July 2000 Ohio Trauma System created in law – July 2000 Trauma patient defined Trauma patient defined Triage criteria for EMS set in administrative rule* Triage criteria for EMS set in administrative rule* Trauma centers must be ACS verified Trauma centers must be ACS verified EMS must transport trauma patients to a trauma center EMS must transport trauma patients to a trauma center Limited exceptions Limited exceptions Hospitals may not admit trauma patients that exceed their capability to treat Hospitals may not admit trauma patients that exceed their capability to treat No exceptions No exceptions

Required Review EMS Board is required by law to review their trauma triage criteria every three years to minimize overtriage and undertriage EMS Board is required by law to review their trauma triage criteria every three years to minimize overtriage and undertriage Solicitation of public input also required Solicitation of public input also required 1 st 3-year review in st 3-year review in 2005 A recommendation to treat geriatrics as a distinct, special needs population was received. A recommendation to treat geriatrics as a distinct, special needs population was received.

Data: First Blush

Discussion ensues Evidence shows… Evidence shows… Elderly have worse outcomes than younger trauma patients with similar injuries Elderly have worse outcomes than younger trauma patients with similar injuries Trauma patients have better outcomes when treated at trauma centers Trauma patients have better outcomes when treated at trauma centers But Ohio has no geriatric-specific triage criteria But Ohio has no geriatric-specific triage criteria Age is simply a “consideration” Age is simply a “consideration”

Action follows Trauma Committee forms Geriatric Trauma Task Force Trauma Committee forms Geriatric Trauma Task Force Howard Werman, MD – Chair Howard Werman, MD – Chair Charged with finding evidence of need for geriatric-specific triage criteria Charged with finding evidence of need for geriatric-specific triage criteria Utilizing current literature and data within the Ohio Trauma Registry and EMS Incident Reporting System Utilizing current literature and data within the Ohio Trauma Registry and EMS Incident Reporting System

Step 1 Define “old”

Step 1 Literature unhelpful Literature unhelpful Geriatric age groups begin anywhere from age 54 to 75 Geriatric age groups begin anywhere from age 54 to 75 No basis for selection No basis for selection Need to create evidence-based definition using Ohio data Need to create evidence-based definition using Ohio data

Gross Mortality

Magic number: 72 At age 72, gross mortality went above, and stayed above, 4% At age 72, gross mortality went above, and stayed above, 4% Overall mortality in Ohio Trauma Registry: 3.6% Overall mortality in Ohio Trauma Registry: 3.6% 72 years old was cut point for gross mortality for 72 years old was cut point for gross mortality for All trauma patients All trauma patients Minor injuries (ISS 1-9) Minor injuries (ISS 1-9) Moderate injuries (ISS 10-15) Moderate injuries (ISS 10-15) Severe injuries (ISS >15) Severe injuries (ISS >15) Trauma patients with blunt injuries Trauma patients with blunt injuries Trauma patients with penetrating injuries Trauma patients with penetrating injuries

Statistical validation Cut-pointDeathsTotal Pop% fatal Uncorrected Chi-Squares ORCIRRCI , , , , , , , , , , , , , , , , , , , , , , , ,1.52

Step 1 completed “Old” defined “Old” defined Geriatric trauma patients defined as =>70 years of age Geriatric trauma patients defined as =>70 years of age Rounded down to make it easier to remember Rounded down to make it easier to remember

Step 2 Find factors that indicate a need for direct transport to a trauma center based on significantly higher mortality* Find factors that indicate a need for direct transport to a trauma center based on significantly higher mortality* Anatomic Anatomic Physiologic Physiologic Mechanistic Mechanistic *Critical resource usage (ICU, vent, OR, etc.) was found to be inversely proportional to age.

Step 2 Methodology Methodology Compare outcomes for theoretical indicators in the geriatric population versus the adult population (age 16-69) Compare outcomes for theoretical indicators in the geriatric population versus the adult population (age 16-69)

Step 2 Proposed indicators Proposed indicators Falls (any height, including standing) associated with TBI, chest, abdominal or spinal injury Falls (any height, including standing) associated with TBI, chest, abdominal or spinal injury Pedestrian struck Pedestrian struck MVC with single proximal long bone fracture MVC with single proximal long bone fracture Multiple body regions injured Multiple body regions injured Hypotension (initial systolic B/P) Hypotension (initial systolic B/P) Altered LOC (initial GCS score) Altered LOC (initial GCS score)

Step 2 Proposed indicators Proposed indicators Co-morbid conditions Co-morbid conditions Any Any COPD COPD Coronary Artery Disease Coronary Artery Disease Cardiac Disease (any) Cardiac Disease (any) Clotting disorder (including Coumadin therapy) Clotting disorder (including Coumadin therapy) Diabetes (Type 1 or Type 2) Diabetes (Type 1 or Type 2) Dialysis Dialysis Immunocompromised Immunocompromised Liver Disease Liver Disease

Results

Results

Results Adult Mortality % Geriatric Mortality % OR 95% CI P value Falls w/ TBI 6.00%11.89% – 2.39 p <0.001 Falls w/ chest injury 4.18%5.43% – 1.52 p = Falls w/ pelvis/abd injury 1.15%2.47% – 1.31 p = Falls w/SCI 4.92%20.13% – 1.52 p = Pedestrian struck 7.45%16.63% – 3.21 p <0.001 MVC w/ humerus/femur fx 9.22%15.63% – 3.21 p < Multiple body regions injured 6.3%8.0% p = 0.01

Results Proposed indicators Proposed indicators Falls (any height, including standing) associated with Falls (any height, including standing) associated with TBI TBI Chest injury Chest injury Abdominal injury Abdominal injury Pedestrian struck Pedestrian struck MVC with single proximal long bone fracture MVC with single proximal long bone fracture

Results Proposed indicators Proposed indicators Multiple body regions injured Multiple body regions injured TBI TBI Head/face/neck Head/face/neck Chest Chest Abdomen/pelvis Abdomen/pelvis Spine Spine Extremities Extremities

Results Co-morbid conditions Co-morbid conditions Any Any COPD COPD Coronary Artery Disease Coronary Artery Disease Cardiac Disease (any) Cardiac Disease (any) Clotting disorder (including Coumadin therapy) Clotting disorder (including Coumadin therapy) Diabetes (Type 1 or Type 2) Diabetes (Type 1 or Type 2) Dialysis Dialysis Immunocompromised Immunocompromised Liver Disease Liver Disease

Recommendations to EMS Board Trauma patients =>70 years should be defined as geriatric trauma. They should be triaged for evaluation in a trauma center for: GCS < 15 with evidence of traumatic brain injury GCS < 15 with evidence of traumatic brain injury Systolic BP < 100 mmHg Systolic BP < 100 mmHg Falls with evidence of traumatic brain injury (even from standing position) Falls with evidence of traumatic brain injury (even from standing position) Pedestrian struck by motor vehicle Pedestrian struck by motor vehicle Multiple body regions injured Multiple body regions injured Known or suspected proximal long bone fracture sustained in a motor vehicle crash Known or suspected proximal long bone fracture sustained in a motor vehicle crash

Impact Estimated change in admissions to hospitals (based on applying new criteria to previous year’s trauma registry data): Estimated change in admissions to hospitals (based on applying new criteria to previous year’s trauma registry data): Non-trauma hospitals estimated to admit an average of 11.4 fewer patients annually Non-trauma hospitals estimated to admit an average of 11.4 fewer patients annually

Implementation Trauma Committee recommended EMS Board make changes to triage criteria based on this research Trauma Committee recommended EMS Board make changes to triage criteria based on this research EMS Board accepted changes in October 2008, promulgated in administrative rules EMS Board accepted changes in October 2008, promulgated in administrative rules New triage rules implemented December 29, 2008 New triage rules implemented December 29, 2008

Full report to EMS Board and analysis of change in admission patterns available in Data Center section of EMS Division website ems.ohio.gov

Questions? Ohio Department of Public Safety, Division of EMS Office of Research and Analysis