Ohio State Board of Ohio State Board of Emergency Medical ServicesEmergency Medical Services
Old People Break Easily:Old People Break Easily:Ohio’s Geriatric Trauma Triage CriteriaOhio’s Geriatric Trauma Triage Criteria
Ohio and the Ohio Trauma Ohio and the Ohio Trauma SystemSystem
OhioOhio 11.5 million 11.5 million
populationpopulation 77thth largest state by largest state by
populationpopulation 88thth in population in population
densitydensity
IndianaIndiana 6.3 million 6.3 million
populationpopulation 1515thth largest state by largest state by
population population 1515thth in population in population
densitydensity
Ohio and the Ohio Trauma Ohio and the Ohio Trauma SystemSystem
180 acute care hospitals180 acute care hospitals 45 ACS-verified trauma centers45 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 318 Level 3
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1 1 1 11 1 1 1
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Ft. Wayne, INFt. Wayne, IN
Huntington, WVHuntington, WV
Wheeling, WVWheeling, WV
Pittsburgh, PAPittsburgh, PA
Erie, PAErie, PA
Parkersburg, WVParkersburg, WV
44Weirton, WVWeirton, WV
44 New Martinsville, WVNew Martinsville, WV
44 Point Pleasant, WVPoint Pleasant, WV
44
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Ohio and the Ohio Trauma Ohio and the Ohio Trauma SystemSystem
Ohio Trauma System created in law – July Ohio Trauma System created in law – July 20002000 Trauma patient definedTrauma patient defined
Triage criteria for EMS set in administrative rule*Triage criteria for EMS set in administrative rule* Trauma centers must be ACS verifiedTrauma centers must be ACS verified EMS must transport trauma patients to a EMS must transport trauma patients to a
trauma centertrauma center Limited exceptionsLimited exceptions
Hospitals may not admit trauma patients that Hospitals may not admit trauma patients that exceed their capability to treatexceed their capability to treat
No exceptionsNo exceptions
Required ReviewRequired Review
EMS Board is required by law to review EMS Board is required by law to review their trauma triage criteria every three their trauma triage criteria every three years to minimize overtriage and years to minimize overtriage and undertriageundertriage Solicitation of public input also requiredSolicitation of public input also required
11stst 3-year review in 2005 3-year review in 2005 A recommendation to treat geriatrics as a A recommendation to treat geriatrics as a
distinct, special needs population was distinct, special needs population was received.received.
Data: First BlushData: First BlushPatients by Age Group
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
<1 1-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85-94 95-105
Age
% o
f T
ota
l
EMSIRS OTR
Discussion ensuesDiscussion ensues
Evidence shows… Evidence shows… Elderly have worse outcomes than younger Elderly have worse outcomes than younger
trauma patients with similar injuriestrauma patients with similar injuries Trauma patients have better outcomes Trauma patients have better outcomes
when treated at trauma centerswhen treated at trauma centers But Ohio has no geriatric-specific triage But Ohio has no geriatric-specific triage
criteriacriteria Age is simply a “consideration”Age is simply a “consideration”
Action followsAction follows
Trauma Committee forms Geriatric Trauma Committee forms Geriatric Trauma Task ForceTrauma Task Force Howard Werman, MD – ChairHoward Werman, MD – Chair Charged with finding evidence of need Charged with finding evidence of need
for geriatric-specific triage criteriafor geriatric-specific triage criteria Utilizing current literature and data within Utilizing current literature and data within
the Ohio Trauma Registry and EMS Incident the Ohio Trauma Registry and EMS Incident Reporting SystemReporting System
Step 1Step 1
Define “old”Define “old”
Step 1Step 1
Literature unhelpfulLiterature unhelpful Geriatric age groups begin anywhere Geriatric age groups begin anywhere
from age 54 to 75from age 54 to 75 No basis for selectionNo basis for selection
Need to create evidence-based Need to create evidence-based definition using Ohio datadefinition using Ohio data
Gross MortalityGross Mortality
Gross Mortality: All patients
0%
1%
2%
3%
4%
5%
6%
7%
8%
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 89 91 93 95
Age
% m
ort
alit
y
Magic number: 72Magic number: 72
At age 72, gross mortality went above, and At age 72, gross mortality went above, and stayed above, 4%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 72 years old was cut point for gross mortality formortality for All trauma patientsAll 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 injuriesTrauma patients with blunt injuries Trauma patients with penetrating injuriesTrauma patients with penetrating injuries
Statistical validationStatistical validation
Cut-point DeathsTotal Pop % fatal
Uncorrected Chi-Squares
OR CI RR CI
55 2874 66250 4.338 158.23 1.38 1.31,1.45 1.36 1.30,1.43
65 2359 51806 4.554 184.71 1.43 1.36,1.50 1.41 1.34,1.48
66 2315 50487 4.585 190.43 1.44 1.36,1.52 1.42 1.35,1.49
67 2250 49170 4.576 180.06 1.43 1.35,1.50 1.41 1.34,1.48
68 2203 47829 4.606 184.36 1.44 1.36,1.51 1.42 1.35,1.49
69 2160 46393 4.656 195.12 1.45 1.38,1.53 1.43 1.36,1.51
70 2114 44865 4.712 207.16 1.47 1.40,1.55 1.45 1.38,1.53
71 2058 43349 4.748 210.97 1.48 1.40,1.56 1.46 1.39,1.54
72 2000 41748 4.791 216.38 1.49 1.42,1.58 1.47 1.40,1.55
73 1914 40041 4.780 201.34 1.48 1.40,1.56 1.46 1.38,1.54
74 1836 38184 4.808 198.75 1.48 1.40,1.57 1.46 1.39,1.54
75 1734 36294 4.778 176.98 1.46 1.38,1.55 1.44 1.36,1.52
Step 1 completedStep 1 completed
““Old” definedOld” defined Geriatric trauma patients defined as Geriatric trauma patients defined as
=>70 years of age=>70 years of age Rounded down to make it easier to Rounded down to make it easier to
rememberremember
Step 2Step 2
Find factors that indicate a need for Find factors that indicate a need for direct transport to a trauma center direct transport to a trauma center based on significantly higher based on significantly higher mortality*mortality* AnatomicAnatomic PhysiologicPhysiologic MechanisticMechanistic
*Critical resource usage (ICU, vent, OR, etc.) was found to be inversely proportional to age.
Step 2Step 2
MethodologyMethodology Compare outcomes for theoretical Compare outcomes for theoretical
indicators in the geriatric population indicators in the geriatric population versus the adult population (age 16-69)versus the adult population (age 16-69)
Step 2Step 2
Proposed indicatorsProposed indicators Falls (any height, including standing) Falls (any height, including standing)
associated with TBI, chest, abdominal or spinal associated with TBI, chest, abdominal or spinal injuryinjury
Pedestrian struckPedestrian struck MVC with single proximal long bone fractureMVC with single proximal long bone fracture Multiple body regions injuredMultiple body regions injured Hypotension (initial systolic B/P)Hypotension (initial systolic B/P) Altered LOC (initial GCS score)Altered LOC (initial GCS score)
Step 2Step 2
Proposed indicatorsProposed indicators Co-morbid conditionsCo-morbid conditions
AnyAny COPDCOPD Coronary Artery DiseaseCoronary 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) DialysisDialysis ImmunocompromisedImmunocompromised Liver DiseaseLiver Disease
ResultsResultsInitial SBP and mortality
All injuries
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0-40 41-50 51-60 61-70 71-80 81-90 91-100 101-110
111-120
121-130
131-140
141-150
151-160
161-170
171-180
181-190
191-200
200-299
SBP
Mor
talit
y
Adult
Elderly
ResultsResultsGCS and mortality
Patients with diagnosed TBI
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
3 4 5 6 7 8 9 10 11 12 13 14 15
GCS
Mor
talit
y
Adult
Elderly
ResultsResults
Adult Mortality %Adult Mortality % Geriatric Mortality %Geriatric Mortality % OROR 95% CI95% CI P valueP value
Falls w/ TBIFalls w/ TBI 6.00%6.00% 11.89%11.89% 2.122.12 1.88 – 1.88 – 2.392.39 p <0.001p <0.001
Falls w/ chest injuryFalls w/ chest injury 4.18%4.18% 5.43%5.43% 1.221.22 0.99 – 0.99 – 1.521.52 p = 0.056p = 0.056
Falls w/ pelvis/abd injuryFalls w/ pelvis/abd injury 1.15%1.15% 2.47%2.47% 0.980.98 0.73 – 0.73 – 1.311.31 p = 0.865p = 0.865
Falls w/SCIFalls w/SCI 4.92%4.92% 20.13%20.13% 1.221.22 0.99 – 0.99 – 1.521.52 p = 0.056p = 0.056
Pedestrian struckPedestrian struck 7.45%7.45% 16.63%16.63% 2.392.39 1.77 – 1.77 – 3.213.21 p <0.001p <0.001
MVC w/ humerus/femur fxMVC w/ humerus/femur fx 9.22%9.22% 15.63%15.63% 2.412.41 1.81 – 1.81 – 3.213.21 p < 0.001p < 0.001
Multiple body regions injuredMultiple body regions injured 6.3%6.3% 8.0%8.0% 1.291.29 1.06-1.571.06-1.57 p = 0.01p = 0.01
ResultsResults
Proposed indicatorsProposed indicators Falls (any height, including standing) Falls (any height, including standing)
associated with associated with TBI TBI Chest injuryChest injury Abdominal injuryAbdominal injury
Pedestrian struckPedestrian struck MVC with single proximal long bone MVC with single proximal long bone
fracturefracture
ResultsResults
Proposed indicatorsProposed indicators Multiple body regions injured Multiple body regions injured
TBITBI Head/face/neckHead/face/neck ChestChest Abdomen/pelvisAbdomen/pelvis SpineSpine ExtremitiesExtremities
ResultsResults
Co-morbid conditionsCo-morbid conditions AnyAny 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 ImmunocompromisedImmunocompromised Liver DiseaseLiver Disease
Recommendations to EMS Recommendations to EMS BoardBoard
Trauma patients =>70 years should be Trauma patients =>70 years should be defined as geriatric trauma. They should be defined as geriatric trauma. They should be triaged for evaluation in a trauma center triaged for evaluation in a trauma center for:for:
GCS < 15 with evidence of traumatic brain injuryGCS < 15 with evidence of traumatic brain injury Systolic BP < 100 mmHgSystolic BP < 100 mmHg Falls with evidence of traumatic brain injury Falls with evidence of traumatic brain injury
(even from standing position)(even from standing position) Pedestrian struck by motor vehiclePedestrian struck by motor vehicle Multiple body regions injuredMultiple body regions injured Known or suspected proximal long bone fracture Known or suspected proximal long bone fracture
sustained in a motor vehicle crashsustained in a motor vehicle crash
ImpactImpact
Estimated change in admissions to Estimated change in admissions to hospitals (based on applying new hospitals (based on applying new criteria to previous year’s trauma criteria to previous year’s trauma registry data):registry data): Non-trauma hospitals estimated to Non-trauma hospitals estimated to
admit an average of 11.4 fewer patients admit an average of 11.4 fewer patients annually annually
ImplementationImplementation
Trauma Committee recommended Trauma Committee recommended EMS Board make changes to triage EMS Board make changes to triage criteria based on this researchcriteria based on this research
EMS Board accepted changes in EMS Board accepted changes in October 2008, promulgated in October 2008, promulgated in administrative rulesadministrative rules
New triage rules implemented New triage rules implemented December 29, 2008December 29, 2008
Full report to EMS Board and Full report to EMS Board and analysis of change in analysis of change in
admission patterns available admission patterns available in Data Center section of EMS in Data Center section of EMS
Division websiteDivision websiteems.ohio.govems.ohio.gov
Questions?Questions?
Ohio Department of Public Safety, Division of EMSOhio Department of Public Safety, Division of EMSOffice of Research and AnalysisOffice of Research and Analysis
[email protected]@dps.state.oh.us
