The Impact of Under-triage on Trauma Outcomes in Older Populations ≥65 Years

Undertriage of older trauma patients is implicated as a cause for outcome disparities. Undertriage is defined by an Injury Severity Score (ISS) ≥16 without full trauma activation. We hypothesized that in patients ≥65 years, undertriage is associated with unfavorable discharge.

This is a retrospective study of patients ≥65 years admitted at a Level 1 Trauma Center between July 2016 and June 2018 with blunt trauma. The Matrix method was used to determine the undertriage rate, and outcomes were compared between undertriaged and fully activated patients with ISS ≥16. Favorable outcomes in undertriaged patients instigated further analyses to determine factors that predicted unfavorable discharge condition, defined by discharge from the hospital with severe disability, persistent vegetative state, and in-hospital death.

The undertriage rate was 7.9%. When compared to fully activated patients with ISS ≥16, a lower percentage of undertriaged patients were discharged in an unfavorable condition (16.6% vs 64.7%, P < .001). On the multivariate analysis, male sex (OR = 1.52), preexisting coronary artery disease (OR = 1.86), age >90 years (OR = 2.31), ISS 16-25 (OR = 3.50), Glasgow Coma Score (GCS) ≤14 (OR = 6.34), and ISS >25 (OR = 9.64) were significant independent risk factors for unfavorable discharge.

The undertriage rate in patients ≥65 years was higher than the accepted standard (5%). However, undertriaged patients had better outcomes than those fully activated with ISS ≥16. Factors more predictive of unfavorable discharge condition were GCS ≤14 and ISS >25. These data suggest that ISS alone is a poor marker for assessing undertriage in older patients. Additional parameters established in this study should be considered as potential markers for better predicting outcomes in older trauma patients.