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Comorbidities, anticoagulants, and geriatric-specific physiology for the field triage of injured older adults

Newgard, Craig D., MD, MPH; Lin, Amber, MS; Eckstrom, Elizabeth, MD; Caughey, Aaron, MD, PhD; Malveau, Susan, MS; Griffiths, Denise, BS; Zive, Dana, MPH; Bulger, Eileen, MD

Journal of Trauma and Acute Care Surgery: May 2019 - Volume 86 - Issue 5 - p 829–837
doi: 10.1097/TA.0000000000002195

BACKGROUND Comorbid conditions and anticoagulants have been considered as field triage criteria to raise the sensitivity for identifying seriously injured older adults, but research is sparse. We evaluated the utility of comorbidities, anticoagulant use, and geriatric-specific physiologic measures to improve the sensitivity of the field triage guidelines for high-risk older adults in the out-of-hospital setting.

METHODS This was a cohort study of injured adults 65 years or older transported by 44 emergency medical services agencies to 51 trauma and nontrauma hospitals in seven Oregon and Washington counties from January 1, 2011, to December 31, 2011. Out-of-hospital predictors included current field triage criteria, 13 comorbidities, preinjury anticoagulant use, and previously developed geriatric specific physiologic measures. The primary outcome (high-risk patients) was Injury Severity Score of 16 or greater or need for major nonorthopedic surgical intervention. We used binary recursive partitioning to develop a clinical decision rule with a target sensitivity of 95% or greater.

RESULTS There were 5,021 older adults, of which 320 (6.4%) had Injury Severity Score of 16 or greater or required major nonorthopedic surgery. Of the 2,639 patients with preinjury medication history available, 400 (15.2%) were taking an anticoagulant. Current field triage practices were 36.6% sensitive (95% confidence interval [CI], 31.2%–42.0%) and 90.1% specific (95% CI, 89.2%–91.0%) for high-risk patients. Recursive partitioning identified (in order): any current field triage criteria, Glasgow Coma Scale score of 14 or less, geriatric-specific vital signs, and comorbidity count of 2 or more. Anticoagulant use was not identified as a predictor variable. The new criteria were 90.3% sensitive (95% CI, 86.8%–93.7%) and 17.0% specific (95% CI, 15.8%–18.1%).

CONCLUSIONS The current field triage guidelines have poor sensitivity for high-risk older adults. Adding comorbidity information and geriatric-specific physiologic measures improved sensitivity, with a decrement in specificity.

LEVEL OF EVIDENCE Prognostic/Epidemiologic, level II.

From the Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine (C.D.N., A.L., S.M., D.G., D.Z.), Division of Geriatrics, Department of Internal Medicine (E.E.), and Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon (A.C.); and Department of Surgery, University of Washington, Seattle, WA (E.B.), Washington.

Submitted: September 24, 2018, Revised: December 11, 2018, Accepted: December 13, 2018, Published online: January 8, 2019.

Address for reprints: Craig D. Newgard, MD, MPH, Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code CR-114, Portland, OR 97239; email:

D.Z. died on September 30, 2018.

Findings from this study have not been presented at any national or regional meetings.

© 2019 Lippincott Williams & Wilkins, Inc.