1. Ohio State Board of Emergency Medical Services Trauma Committee Geriatric Trauma Triage Criteria: How and Why

2. 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 2005 1 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.

3. Data: First Blush

4. 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”

5. 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

6. Step 1 Define “old” Define “old” 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

7. Gross Mortality

8. 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 OTR - 3.6% Overall mortality in OTR - 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

9. Statistical validation Cut-pointDeathsTotal Pop% fatal Uncorrected Chi-Squares ORCIRRCI 552874662504.338158.231.381.31,1.451.361.30,1.43 652359518064.554184.711.431.36,1.501.411.34,1.48 662315504874.585190.431.441.36,1.521.421.35,1.49 672250491704.576180.061.431.35,1.501.411.34,1.48 682203478294.606184.361.441.36,1.511.421.35,1.49 692160463934.656195.121.451.38,1.531.431.36,1.51 702114448654.712207.161.471.40,1.551.451.38,1.53 712058433494.748210.971.481.40,1.561.461.39,1.54 722000417484.791216.381.491.42,1.581.471.40,1.55 731914400414.780201.341.481.40,1.561.461.38,1.54 741836381844.808198.751.481.40,1.571.461.39,1.54 751734362944.778176.981.461.38,1.551.441.36,1.52

10. “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

11. 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

12. 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)

13. 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)

14. 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

15. Results

16. Results

17. Results Adult Mortality % Geriatric Mortality % OR 95% CI P value Falls w/ TBI 6.00%11.89%2.12 1.88 – 2.39 p <0.001 Falls w/ chest injury 4.18%5.43%1.22 0.99 – 1.52 p = 0.056 Falls w/ pelvis/abd injury 1.15%2.47%0.98 0.73 – 1.31 p = 0.865 Falls w/SCI 4.92%20.13%1.22 0.99 – 1.52 p = 0.056 Pedestrian struck 7.45%16.63%2.39 1.77 – 3.21 p <0.001 MVC w/ humerus/femur fx 9.22%15.63%2.41 1.81 – 3.21 p < 0.001 Multiple body regions injured 6.3%8.0%1.291.06-1.57 p = 0.01

18. 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 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

19. 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

20. 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

21. 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

22. 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 Triage criteria set in rule (Ohio Administrative Code) Triage criteria set in rule (Ohio Administrative Code) Rule revision process takes 3-6 months Rule revision process takes 3-6 months EMS Board accepted changes in October 2008 EMS Board accepted changes in October 2008 New triage rules implemented December 29, 2008 New triage rules implemented December 29, 2008

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