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Creation of a decision aid for goal setting after geriatric burns: a study from the prognostic assessment of life and limitations after trauma in the elderly [PALLIATE] consortium

Hodgman, Erica I. MD; Joseph, Bellal MD; Mohler, Jane MSN, MPH, PhD; Wolf, Steven E. MD; Paulk, Mary Elizabeth MD; Rhodes, Ramona L. MD, MSCS; Nakonezny, Paul A. PhD; Phelan, Herb A. MD, MSCS

Journal of Trauma and Acute Care Surgery: July 2016 - Volume 81 - Issue 1 - p 168–172
doi: 10.1097/TA.0000000000000998
EAST 2016 Plenary Papers

OBJECTIVES We hypothesized that a decision-support aid to predict index admission mortality and discharge disposition for geriatric burns could be constructed using the well-accepted Baux score (age +total body surface area burned) in a geriatric-specific cohort.

METHODS National Burn Repository version 8.0 (2002–2011) was queried for all subjects aged 65 years or older. Baux scores were calculated and patients grouped into deciles. Three discharge outcomes (death,home, discharge to nonhome setting) were measured per decile. A receiver operating characteristic analysis was used to determine optimal Baux score cutpoints based on the Youden Index. The odds of mortality at various Baux score cutoffs were estimated using logistic regression.

RESULTS The sample was composed of 8,001 subjects. Withdrawal of care was documented in 264 deaths; median time to withdrawal was three days. As Baux score increased, three peaks in disposition were seen. Less than 50% of patients with a Baux score of 80 or greater were discharged home. Patients with a moderate Baux score (80–130) had an increased likelihood of discharge to a nonhome setting. Baux scores of 130 or greater were nearly uniformly fatal (mortality, 94–100%). Baux score of 86.15 or less was predictive of discharge home (area under the curve, 0.698; sensitivity, 75.28%; specificity, 54.64%), and a score greater than 93.3 was predictive of mortality (area under the curve, 0.779; sensitivity, 57.46%; specificity, 87.08%).

CONCLUSION For geriatric patients whose Baux scores exceed 86, return-to-home rates drop drastically; mortality increases at a score greater than 93, and mortality is nearly universal at a score ≥130 or greater. We are piloting a display of these findings as a decision-making aid when setting goals of care with stakeholders after geriatric burns.

LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III; therapeutic/care management, level IV.

From the Department of Surgery (E.H.), UT Southwestern Medical Center, Dallas, TX; Division of Trauma, Critical Care, Burn, and Emergency Surgery (B.J.), University of Arizona, Tucson, AZ; Arizona Center on Aging (J.M.), College of Medicine-Tucson, University of Arizona Tucson, AZ; Division of Burns/Trauma/Critical Care (S.E.W., H.A.P.), UT Southwestern Medical Center, Dallas, TX; Department of Internal Medicine (M.E.P.), Palliative Medicine, UT Southwestern Medical Center, Dallas, TX; Division of Geriatrics (R.L.R.), Palliative Medicine, UT Southwestern Medical Center, Dallas, TX; and Division of Biostatistics, Department of Clinical Sciences (P.A.N.), UT Southwestern Medical Center, Dallas, TX.

Submitted: October 27, 2015, Revised: January 17, 2016, Accepted: January 26, 2016, Published online: February 18, 2016.

This study was presented at the 29th annual meeting of the Eastern Association for the Surgery of Trauma, January 12–16, 2016, in San Antonio, Texas.

Erica Hodgman is currently receiving funding support from Sons of the Flag and the Pettis Family. The rest of the authors declare no conflicts of interest.

Address for reprints: Herb A. Phelan, MD, MSCS, University of Texas-Southwestern Medical Center, Parkland Memorial Hospital, Division of Burns/Trauma/Critical Care, 5323 Harry Hines Blvd, E5.508A, Dallas, TX; email: herb.phelan@utsouthwestern.edu.

© 2016 Lippincott Williams & Wilkins, Inc.