New Horizons in Understanding Appropriate Prehospital Identification and Trauma Triage for Older Adults

Introduction

The population of older adults has increased worldwide over the last years. More people in the world currently live into or beyond 60 years of age.¹ The number of older adults aged 60 years and over has projected by 48% from 607 million in 2000 to 901 million in 2015.¹ The number of this population (60 years and over) is expected to reach a total of 2.1 billion by 2050.¹ This means the rates of older adults requiring health care including trauma care will increase. Therefore, high-quality trauma care for this population is needed including that of prehospital trauma care.

Prehospital care represents an essential and important part of the patient’s journey and plays a significant role in determining outcomes. One of the main principles of prehospital care is to get the right patient, to the right place, at the right time.² This means prehospital assessment should accurately identify complaint(s), nature, and severity enabling appropriate triage decisions. This article aims to highlight and investigate the issues around prehospital trauma triage of older patients, discuss the current evidence, and provide recommendations for future improvement of prehospital care for older people.

Scope of the Problem

Many triage tools have been developed to aid prehospital care providers to make appropriate and accurate triage decisions for patients. However, this is far from true when it comes to the prehospital triage of people aged ≥55 years, especially for trauma. The literature from the United States of America (USA) and Australia show increased rates of under-triage among this population.^3–15 Under-triage is simply defined as the transportation of severely injured patients to lower-level Trauma Centers (TCs) or other Acute Care (AC) facilitates, as opposed to Major Trauma Centers (MTCs) (equivalent to major trauma service or Level I or II TCs).¹⁶ A number of recent studies in the USA developed trauma triage tools specific for older adults in order to improve early identification and appropriate triage and transportation decisions.^8,12–14,17 Although most of these tools had better sensitivity than the current adult trauma triage tools, they had sub-optimal specificity.^12–14 Only one recently developed triage tool has a better sensitivity with an acceptable reduction in the specificity when compared to current triage tool for adult trauma patients in predicting the need of MTC care (sensitivity: 93% vs 61%, and specificity: 49% vs 61%).⁸ Furthermore, the performance of this tool among older trauma patients is similar to the performance of the current triage tool in younger trauma patients (sensitivity: 93% vs 87%, and specificity: 49% vs 44%, respectively).⁸ However, using the cut-off point of ≥70 years in this study represents a major limitation as a previous study from the USA has shown that the issue of under-triage can begin as early as the age of 50 years.⁴

Current triage tools predominantly assess injury severity or high-energy mechanism. However, older people usually have injuries compounded by multimorbidity and frailty. They also exhibit age-related anatomical and physiological changes,^18–24 which could adversely affect the accuracy of the triage tool. This in turn risks inappropriate prehospital identification and transportation decisions. Therefore, applying traditional trauma triage criteria only, for the assessment of older adults, may not be effective. However, integrating additional assessment tools such as frailty assessment into prehospital trauma tirage may improve early identification of older patients who are at high risk of adverse outcomes.

Frailty assessment has been embedded in routine care for patients requiring emergency care in the United Kingdom (UK). Applying simple frailty assessment tools using, for example, the Clinical Frailty Scale (CFS) was shown recently to independently predict 30-day mortality, inpatient delirium, and increased care level at discharge in trauma patients aged ≥65 years.²⁵ The application of the CFS in emergency care was determined to be feasible, reliable, and accurate.²⁶ However, compliance to frailty attuned scores in prehospital care may impact their effectiveness in such setting as previous evidence showed that paramedics’ compliance with trauma triage tools varied from a rate of 21% to 93%.²⁷

Whilst there is reasonable evidence that care in MTCs benefits younger patients with severe injuries, it is uncertain whether or not the same benefits will accrue to injured older adults. This could be partially due to the lack of trauma-specific outcome measures for older people,²⁸ thereby limiting the determination of benefits of MTC access. It also results from differences in aetiology - whereby high energy transfer (road traffic collisions, sport, assault) is usually required to injure a young adult. However, from the seventh decade of life onwards, major injury is most likely to result from fall from a standing height.²⁹ Older people are more likely to have low-level falls (ie, <2 meters) and when they occur, major injury is more likely to result compared to younger adults.²⁹ The less robust injured structures may not respond to aggressive treatments (organ surgery and critical care) employed in MTCs. Hence, there is a need to clarify the optimal level of care that should be provided to older people to support Emergency Medical Service (EMS) personnel decision-making.

Little is known about factors other than triage criteria that could affect the triage decisions of older trauma patients including patient (or relative) choice, paramedics’ training and familiarity with protocols, and their impact on outcomes.

The aim of this article is to provide an overview on prehospital frailty assessment, appropriate outcome measures for older trauma patients, the benefits of MTC access for older patients, and factors other than triage criteria that could impact accurate triage decisions for older trauma patients, discuss the evidence base surrounding these issues, and recommend possible solutions that require further scrutiny from prehospital care providers and policymakers within the healthcare system.

Frailty Assessment in Prehospital Care

Frailty is known to be an independent predictor of mortality, morbidity, and hospitalizations among older adults from studies including older trauma patients.^30,31 The “frailty index” has been shown to be an independent predictor of poor health outcomes, in-hospital complications, and adverse discharge disposition among older trauma patients.^32–34 Hitherto, no frailty assessment tool has been used for older trauma patients as a method of prehospital triage.

With respect to applying frailty assessment in prehospital care, there is a limited evidence on the feasibility of assessing frailty and the validation of frailty assessment tools (Table 1).^35–37 Two studies from Canada investigated the feasibility of the Care Partner – Comprehensive Geriatric Assessment (CP-CGA) and validity of the Care Partner-derived Frailty Index based upon Comprehensive Geriatric Assessment (CP-FI-CGA) to measure frailty in the prehospital phase by paramedics and in busy clinical practice (Table 1).^35,36 One recent study from Australia assessed the perceptions of paramedic students about the application of the Edmonton Frail Scale (EFS) and the Groningen Frailty Index (GFI) for assessing and screening older adults in the prehospital phase (Table 1).³⁷ Overall, frailty assessment and screening in the prehospital phase was recognised to be important and feasible.

Table 1 The Use of Frailty Assessment Tools in Prehospital Care

Furthermore, two studies have investigated the application of clinical decision rules by paramedics to determine which older person should stay at home or be transported to the Emergency Department (ED).^38,39 Although neither of these studies explicitly assessed frailty among older adults, the outcomes of these studies were relevant to frail patients.^38,39 One study from Canada assessed the performance of the Paramedic assessing Elders at Risk of Independence Loss (PERIL) rule which is a checklist of 43 yes/no questions for all older patients and not specific to trauma or fall mechanisms³⁸ (Table 1). The study showed that the four-item PERIL prediction rule performed better than a proxy measure of paramedic clinical judgement and has more advantages over it as it has better prediction performance and has the ability to set different thresholds that meet the needs of the EMS service³⁸ (Table 1). The Identifying Seniors at Risk (ISAR) tool, which is a screening tool that was developed to identify high-risk older patients in the ED, was applied by trained paramedics and showed to be a good alternative to the four-item PERIL tool as it had similar performance (AUC 0.57 vs 0.61, respectively, p = 0.28), however, the four-item PERIL tool is simpler and had better adherence.³⁸ The other study from the UK evaluated the effectiveness, safety, and cost-effectiveness of the Computerized Clinical Decision Support (CCDS) for paramedics attending older people who fall.³⁹ The study showed that the use of CCDS is safe, effective in referring older people who fall to community falls services and potentially cost-effective³⁹ (Table 1).

Overall, frailty assessment in prehospital care was shown to be important, feasible, and maybe cost-effective. This suggests that Integrating frailty assessment in prehospital triage could improve the accuracy of appropriate triage decisions and be more beneficial in terms of outcomes.

Determining Appropriate Outcome Measures

An outcome measure is referred to any measure that is chosen to assess the impact of interventions.⁴⁰ It is a supposition that is the end point of an intervention.⁴⁰ Therefore, it is important to measure the impact of interventions on outcomes. Mortality is an important Clinician Reported Outcome Measure (CROM) to improve trauma care for patients. It should be the primary focus when assessing trauma outcomes. For example, changing the trauma care system in the UK was shown to improve survival rates.⁴¹ However, reliance mostly on mortality as the primary outcome measure and not looking for other important secondary outcomes especially for older people seems to be inappropriate and could lead away from a focus on patient-centred care. A global health standard set of outcome measures in older persons which was relevant for people in the last 10 years of life was developed.⁴² It showed that older adults and their carers perceived survival to be less crucial than other outcome measures.⁴² In fact, they consider mortality as an inevitable and expected outcome.⁴² Outcomes that were considered important by older persons and their carers included:

1. independence and living at own home,
2. participation in social and community activities,
3. quality of life and wellbeing,
4. the avoidance of inappropriate discharge and readmission,
5. isolation,
6. loneliness and friendship,
7. physical disabilities,
8. hobbies and activities,
9. access to 24 hours healthcare and social services,
10. avoiding falls,
11. delaying frailty,
12. care and respite for the carer,
13. malnutrition,
14. physical symptom burden,
15. pain,
16. and sleep quality.⁴²

In terms of outcomes following major trauma, an expert panel, which determined research priorities for older trauma patients, highlighted the need to determine appropriate outcome measures specifically for older people.²⁸ They mentioned, for example, that the identification of polytrauma in older people living with frailty does not always change their outcomes, so in young trauma patients, we usually expect them to walk out of hospital and regain their full functional ability, while in these patients, we may rather look at their comfort and palliation.²⁸

Previous reviews showed that many outcome measurement tools are used in trauma registries to assess patient outcomes following trauma.^43–46 For example, a recent scoping review showed that more than 100 unique measurement tools were used to assess Patient-Reported Outcome Measures (PROMs) for hospitalized trauma patients.⁴⁵ However, no study, to date, has investigated and validated the use of already existing outcome measure or developed an outcome measure specifically for older trauma patients. In the UK, a consensus study made recommendations on appropriate outcome measures for adults in general and pediatrics following major trauma, but no consensus has been made specifically for older adults.⁴⁷

Therefore, it is important to assess CROMs and PROMs for older trauma patients as we need to look at both outcome measures in order to strike an ethical balance between paternalism (in healthcare provision) and autonomy (of the patient in what they expect and seek) when caring for this population.

Outcomes Beyond Mortality for Older Trauma Patients

For the assessment of outcomes beyond mortality for older trauma patients, outcomes including frailty, mental health, quality of life, overall health status, complications, use of healthcare services, in-hospital Length of Stay (LOS), readmission, functional status, and level of independence are all reported to be important (Table 2).

Table 2 Outcomes Beyond Mortality for Older Trauma Patients

Frailty and Overall Health Status

Only one study from the UK assessed frailty during follow-up period and showed that patients aged >75 years with major trauma (Injury Severity Score [ISS] >15) had significant worsening of frailty at one-year after injury compared to pre-injury (8% of the study group were frail at pre-injury phase compared to 46% at one-year post injury).⁴⁸ It also reported that 57% had positive comments on their mental health, quality of life, and functional status whereas 29% of the participants have negative comments on the same aspects at one-year following major trauma.⁴⁸ Inaba et al⁴⁹ showed a significant decline in seven of eight health domains using the 36-item Short Form survey (SF-36) at 2.8 years after trauma for trauma patients aged ≥65 years compared to non-injured residents of the same age (Table 2).

Complications

Few studies reported serious complications of older patients following trauma including pulmonary complications, cardiac complications, systematic sepsis, renal failure, delirium, and alcohol withdrawal (Table 2).^50,51 When compared to younger adults, older trauma patients who survived following trauma had significantly higher serious complication rates.⁵¹ Lower rates of complications related to injury were reported for older patients discharged from the ED including extremity infection and poorly healing wounds (Table 2).⁵²

Use of Healthcare Services

With regard to the use of healthcare services, more than 80% of the older trauma patients required rehabilitation (physiotherapy or occupational therapy) extending beyond discharge from the hospital.⁴⁹ An average of 3.4 operations were performed per patient for trauma patients aged ≥65 years.⁵³ Thirty-eight percent of trauma patients with ISS ≥10 required surgical treatment (Table 2).⁵⁴ The most common performed procedure for these patients was fracture management via open reduction and internal fixation (Table 2).⁵⁴

Sixty percent of trauma patients aged ≥65 years required Intensive Care Unit (ICU) admission.⁵³ Previous evidence showed no significant change in ICU admission between older and younger trauma patients^51,55 (Table 2). Older adults with major trauma (ie, ISS >15) stayed ventilated in the ICU for longer periods than younger patients and the duration of staying ventilated increased with age⁵⁵ (Table 2). For the use of surgical ICU, 37% of trauma patients aged ≥65 years with an ISS ≥10 were admitted for the following interventions: mechanical ventilation, antiarrhythmic drugs, and inotropic support.⁵⁴

An earlier study showed that 90% of hospitalization time for non-survivor older trauma patients aged >70 years was spent in the ICU.⁵⁶ This reflected on the cost of their treatment as the mean cost per patient was $23,003 compared to $13,158 for the survivors.⁵⁶

Length of Stay

Variation in hospital LOS for older trauma patients ranges from a mean of 10 days to 35 days (Table 2).^{49–51,54–57} Older trauma patients significantly stayed for longer period in-hospital than younger patients even after major trauma (ie, ISS >15) (Table 2).^49,51,55 Furthermore, older patients with an ISS >15 who survived had lengthier in-hospital stay than younger adults and also the same is true for those who did not survive⁵⁵ (Table 2). For patients aged >70 years, those who survived had a mean LOS of 23 days compared to 19 days for non-survivors.⁵⁶

Differences in ICU LOS were identified in the literature ranging from a mean of 2 days to 16 days^51,54–57 (Table 2). One study showed that patients aged ≥65 years with an ISS >15 had shorter LOS in ICU than younger patients aged 20–30 years old (P =0.70).⁵¹ However, another study showed significantly increased LOS in ICU for older patients who survived and who did not survive compared to younger patients after major trauma (ie, ISS >15) (P <0.05)⁵⁵ (Table 2). Older trauma patients aged >70 years who survived spent an average of two days in the ICU compared to 16 days for those who did not survive.⁵⁶

Readmission and Hospitalization

A previous study, which followed-up older trauma patients for a mean length of 5.4 (SD ± 1.1) years, found that 29% of trauma patients aged ≥75 years required hospitalization at least once in the year preceding the survey.⁵⁷ It also showed that 16% of the patients reported more than six physician visits in the previous year.⁵⁷ Of injured patients aged ≥65 years and discharged from the ED, 11% were admitted to the ED at the first 30 days following trauma, of which 55% had problems related to their initial injury or its management (Table 2).⁵²

Functional Status and Level of Independence

For the assessment of functional status, Oreskovich et al⁵⁶ showed that more than 90% of trauma patients aged >70 years with “severe” injuries (ISS mean =19) required nursing care at home or in a nursing care facility. The studies published after that, however, showed more promising results, with 70% or more of older patients with different ISS means returning to live independently at home (Table 2).^{50,51,55,58,59} Others also reported much higher rates of independence and living at home than the earlier study by Oreskovich et al⁵⁶ (Table 2).^{48,49,52–54,57,60,61} Although improvements in the level of independence and living at home were reported at different follow-up periods, it did not reach the pre-injury level (Table 2).^{49–51,54,60} Progressive deterioration in functional ability for older trauma patients at one-year follow-up was reported⁵⁹ (Table 2). However, comparing the results of functional status for older trauma patients is difficult due to the recruitment of different patient populations (age group, pattern of injury, and injury severity), applying different follow-up periods (ranging from a mean of 49 days up to 5 years), not using standardized measures, variable definitions of “independence”, and many studies were published more than a decade ago (Table 2).

Overall, the findings of these studies indicate the importance of measuring outcomes other than mortality for older trauma patients. These could include outcome measures looking into independence and living at own home, frailty, cognition and mood, social networking and support, complications, and use of healthcare services, LOS, and readmissions.

Prehospital Triage and Outcomes

The impact of prehospital triage decisions on outcomes of older trauma patients is still uncertain.^3,5,10,15 Most of current prehospital triage tools were assessed for their accuracy in identifying major trauma among older people^{4,6,8,9,11,12,14,17,62} and only few were assessed for their effects on the outcomes, with mortality used as the main outcome measure.^{3,5,7,10,13,15,63,64} Other outcomes including disability, complications, costs, LOS, and discharge to home were rarely captured in the assessment of triage tools.^7,10,15,63 No standardized patient outcome measures regarding functional status, quality of life, and well-being for older trauma patients were reported in these studies.

Determining the Benefits of Major Trauma Centres Access

There is still no strong consensus if triaging older trauma patients to MTCs is beneficial (Table 3). In terms of mortality, a recent evidence showed that older trauma patients were under-triaged, ie, had lower odds of MTC transport (adjusted OR 0.52, 95% CI 0.35–0.78) than younger adults and this was associated with 1.7 times increase in their in-hospital mortality (95% CI 1.04–2.7).³ Furthermore, a previous study showed that under-triaged older trauma patients had higher mortality than under-triaged younger patients (21% vs 6.0%, respectively).¹⁰ However, Staudenmayer et al¹⁵ investigated the unadjusted 60-day mortality rate for older trauma patients with an ISS >15 and found no significant difference between patients who were transported to non-MTCs compared to those transported to MTCs (16% vs 17%, p=0.87). They also showed that the transportation of this population to MTCs is associated with higher costs [Total costs, $, median (Interquartile Range [IQR]): 35,069 (19,321–88,357) vs 14,332 (5112–29,321)] and prolonged in-hospital LOS [LOS, days, median (IQR): 6.0 (3.0–14.0) vs 5.0 (1.5–8.0)].¹⁵ The study, however, did not adjust for comorbidities and there was no consideration of specific patterns of injury such as head injury.¹⁵ The study also performed mortality analysis based on only 41 deaths which may have impacted the precision of the estimated effect.¹⁵

Table 3 Benefits of MTC Access for Older Trauma Patients

A recent study, which assessed the impact of specific geriatric trauma triage criteria on outcomes found no significant difference in mortality rate before its application (7.1%) (95% CI, 6.6–7.4%) compared to post application (6.6%) (95% CI, 5.9–6.6%) despite identifying more older trauma patients who required MTC transport (improved sensitivity from 61% to 93% after applying the criteria).⁶³ It also showed minimal increase in the rate of older trauma patients discharged home from 34% (95% CI 33–35%) to 35% (95% CI, 35–35%) (difference 1.2%, 95% CI of the difference 0.2–2.2%).⁶³ However, the results of this study may have been influenced by destination compliance as initial transportation to MTCs improved by only 1% after the application of the developed triage tool (45% vs 44%).⁶³ “Destination compliance” is simply defined as access to the highest level of trauma services for patients who meet the prehospital trauma triage criteria. Another study showed higher disability rates (22% vs 6.0%) and complication rates (39% vs 23%) in older trauma patients triaged to lower MTCs in comparison with their younger counterparts.¹⁰

As previous literature looking into the benefits of prehospital triage of older trauma patients to MTCs showed conflicting findings, these findings echo the broader literature, which showed no strong consensus about the impact of conveyance to MTCs for older people with trauma (Table 3). The literature review showed that most of the previous evidence investigated the benefits of older trauma patients’ access to MTCs with regards to their survival or mortality. Other outcomes that were rarely measured regarding the benefits of MTC access for older trauma patients included LOS, complications, and discharge to home. No patient outcomes were measured in the previous literature to assess the benefits of MTC access including outcomes related to mental health, functional ability, and quality of life. Such outcomes were shown in the previous section to be important to measure when caring for older trauma patients.

Previous evidence showed survival benefit for the treatment of older trauma patients of different age groups at MTCs compared to non-MTCs (Table 3).^65–67 However, some other studies showed no significant advantage of such access for older trauma patients⁶⁸ and that the treatment at non-MTC was associated with more than 4-fold increase in the likelihood of survival (Table 3).⁶⁹ It was shown that the admission of older trauma patients to MTCs was associated with lengthier in-hospital stay than non-MTCs (Table 3).⁶⁹ Smith et al⁷⁰ showed that the treatment of patients aged >55 years at MTCs was associated with lower rates of complications than those treated at non-MTCs (Table 3). The level of care, however, was not associated with discharge to home rates (Table 3).⁶⁹

Although most of these studies showed some benefit of MTC access for older adults, generalizing these results may not be appropriate as these studies had variations in the datasets that were used for analysis, included different patient populations in different trauma systems, and assessed different outcome measures. Furthermore, some of these studies did not adjust for some important confounders such as physiological factors, comorbidities, and mechanism of injury,^66,67,69,70 included small number of patients,⁶⁸ excluded transfers,⁶⁷ focused on single pattern of injury,⁷⁰ and did not track deaths post hospital discharge within a defined period⁶⁵ - all of which make comparisons difficult.

Factors Affecting Appropriate Triage Decisions

There are several unique factors that could adversely affect accurate prehospital trauma triage decisions for older patients. Some of which could directly affect meeting the thresholds of the existing triage criteria for direct transportation to an MTC including anatomical and physiological changes with age, comorbidities, and medication use.⁷¹ The efforts in recent research tried to overcome these challenges by developing geriatric-specific trauma triage criteria that are accurate enough to capture severely injured older patients.⁷¹ However, no geriatric-specific trauma triage criteria have achieved acceptable sensitivity and/or specificity⁷¹ and some were not applied to all older trauma patients.⁸

Despite these factors, there are other important factors that are not related to triage criteria and could significantly affect prehospital trauma triage decisions for older patients. Previous studies have consistently shown decreased rates of destination compliance among injured patients with increasing age.^5,12,62 For instance, a study from Australia showed that nearly 67% of the older trauma patients who met the triage criteria were transported to MTCs in contrast to almost 88% of the injured younger patients.⁵ This finding is consistent with other studies from the USA even when a specific triage tool for older adults was developed.^4,14,62,63 In this regard, there is limited evidence that factors other than the triage criteria have been assessed in relation to their effect on prehospital triage decisions for older trauma patients (Table 4). No study has assessed the impact of such factors on outcomes. These initial findings showed that such factors could impact prehospital triage decisions for these patients and may, consequently, affect their outcomes.

Table 4 Assessment of Other Factors Not Related to Prehospital Trauma Triage Criteria

The Future

• There is a paucity of information, worldwide, on the use of frailty assessment tools by paramedics and trauma outcomes in older people. Therefore, further efforts in future research are required to assess the feasibility and validity of frailty assessment for use in the prehospital environment.
• More studies are also required to assess the benefits of access to MTCs for older trauma patients.
• Appropriate patient- and clinician-reported, short-term and long-term outcome measures would also need to be determined for older trauma patients.
• It seems that there are other factors such as distance to MTCs, patient or relative choice, training, unfamiliarity with protocols, and possible ageism that affect prehospital triage of older trauma patients which require further investigation and assessment.
• More focus is also needed to ensure that EMS personnel have adequate education and training to assess and treat older trauma patients and be more familiar with their protocols.
• Overall, future research in this field could significantly improve prehospital triage decisions and the transition of care from prehospital to in-hospital setting which could, consequently, reduce patients’ complications and improve their quality of life and healthcare use and experience.

Conclusion

Prehospital care of older trauma patients represents a major part of the EMS service. This includes accurate identification and triage of this population followed by appropriate transportation to a designated facility. Prehospital triage criteria were found to be inaccurate in identifying high-risk older trauma patients. Applying other assessment tools, such as frailty identification, could be helpful. Furthermore, determining the appropriate outcome measures for older trauma patients and the benefits that they can get from their access to MTCs could improve triage and appropriate prehospital transportation which, consequently, could be positively reflected on their outcomes. Moreover, investigating factors other than triage criteria that could impact prehospital destination compliance will enhance high-quality prehospital care for this population.