Level 1 activation reduces LOS, mortality in geriatric trauma

Key clinical point: Consider treating Level 2 elderly trauma patients at Level 1 status.

Major finding: The 998 Level 2 elderly trauma patients treated as Level 1, after controlling for age, comorbidities, and injury severity scores, were more likely to leave the ED in less than 2 hours and were less likely to die, compared with patients treated in the previous 2 years.

Data source: More than 2,000 trauma patients aged 70 years or older.

Disclosures: The investigators had no disclosures.




SAN ANTONIO – Automatically bumping elderly Level 2 trauma patients to Level 1 status reduced mortality and emergency department lengths of stay at Indiana University Health Methodist Hospital, Indianapolis.

Like trauma services elsewhere, the Methodist team is trying to figure out how best to handle the coming increase in elderly patients as the Baby Boom generation ages. It’s known that older trauma patients tend to be undertriaged. To improve the situation, “we need to respond quickly with a lot of resources up front so we don’t delay diagnosis” and treatment, said investigator Dr. Peter Hammer, assistant professor of surgery at Indiana University, Indianapolis.

Dr. Peter Hammer

Dr. Peter Hammer

The solution Methodist has tried since October 2013 is a Level 1 response to any patient aged 70 years or older who meets Level 2 criteria, regardless of vital sign stability or injury mechanism. With Level 1, trauma attendings, residents, respiratory therapists, clinical pharmacists, and others are at the bedside within 15 minutes and CT services and operating rooms are on standby, among other measures. Compared with the 1,271 patients aged 70 years or older treated in the almost 2 years before the change, the 998 treated in the year and a half afterwards were, after controlling for age, comorbidities, and injury severity scores (ISS), more likely to leave the ED in less than 2 hours (odds ratio, 1.614; 95% confidence interval, 1.088-2.394) and less likely to die (OR, 0.689, 95% CI, 0.484-0.979).

The before and after groups were similar, with a mean age of 81 years, a mean ISS of 12.2, a high comorbidity burden, and, for most, a blunt injury: 8.3% died in the before group, versus 7.6% in the after group. The shorter ED stays occurred despite a nursing staff reduction in 2014. Patients who went into cardiac arrest before arrival or died in the ED were excluded from the analysis.

“A simple, focused intervention of a higher level of trauma activation can decrease ED length of stay and in-hospital mortality in elderly trauma patients,” Dr. Hammer said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Among many initiatives as many trauma centers gear up for aging baby boomers, others are trying age as a criteria for higher activation, too, and recent guidelines from EAST recommend a lower threshold for trauma activation for patients 65 years or older, among other steps.

With more expertise and resources to brought to bear, it’s not surprising that Level 1 patients left the ED sooner, but it’s unclear what role that played in reducing mortality. “I wouldn’t hazard [to say] that shorter lengths of stay necessarily” saved lives, Dr. Hammer said.

Before the intervention, just 4.8% of geriatric patients left the ED within 2 hours, versus 6.5% afterwards. The numbers are low because, “as in most hospitals, there are more trauma patients than beds. [Reducing ED] length or stay [remains] an ongoing project” at Methodist, and not just for the elderly. “The ED is always overcrowded come afternoon and into the evening,” Dr. Hammer said.

That’s one of the reasons management supported the project. “They like the concept of getting patients moved through quickly. We have a lot of resources in the ED, so there doesn’t seem to be much of a slowdown” with increased Level 1 activation. It probably costs more up front, “but the hope is we’ll save money on the back end with lower mortality and shorter ED stays,” he said.

The investigators had no disclosures.

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