Comorbidities, Anticoagulants, and Geriatric-Specific Physiology For the Field Triage of Injured Older Adults

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 transported by 44 EMS agencies to 51 trauma and non-trauma hospitals in 7 Oregon and Washington counties from 1/1/2011 to 12/31/2011. Out-of-hospital predictors included: current field triage criteria, 13 comorbidities, pre-injury anticoagulant use, and previously developed geriatric specific physiologic measures. The primary outcome (high-risk patients) was: Injury Severity Score (ISS) ≥ 16 or need for major non-orthopedic surgical intervention. We used binary recursive partitioning to develop a clinical decision rule with a target sensitivity of ≥ 95%. Results There were 5,021 older adults, of which 320 (6.4%) had ISS ≥ 16 or required major non-orthopedic surgery. Of the 2,639 patients with pre-injury medication history available, 400 (15.2%) were taking an anticoagulant. Current field triage practices were 36.6% sensitive (95% 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; GCS ≤ 14; geriatric-specific vital signs; and comorbidity count ≥ 2. 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 Level II evidence. Retrospective cohort study with consecutive patients, compared to a criterion gold standard – diagnostic test/criteria. Dana Zive assisted with acquisition of data for the project (electronic EMS data from 3 counties, trauma registry data, and POLST records), interpretation of data and the study results, and critical revision of the submitted manuscript. She died on September 30, 2018. Meetings: Findings from this study have not been presented at any national or regional meetings. Source of Funding: This project was supported by grant number R01HS023796 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Conflicts of Interest: No author had conflicts of interest related to this study. Address for Correspondence: Craig D. Newgard, MD, MPH, Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, mail code CR-114, Portland, Oregon 97239-3098, Phone (503) 494-1668, Fax (503) 494-4640, newgardc@ohsu.edu © 2019 Lippincott Williams & Wilkins, Inc.

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