Ohio State Board of Emergency Medical Services

1. Ohio State Board of Emergency Medical Services Old People Break Easily: Ohio’s Geriatric Trauma Triage Criteria

2. Ohio 11.5 million population 7th largest state by population 8th in population density Indiana 6.3 million population 15th largest state by population 15th in population density Ohio and the Ohio Trauma System

3. Ohio and the Ohio Trauma System • 180 acute care hospitals • 45 ACS-verified trauma centers • 14 Level 1 (3 pediatric) • 13 Level 2 (3 pediatric) • 18 Level 3

4. 2 Erie, PA 3 1 3 1 1 2 2 1 3 3 1 2 3 3 3 3 3 2 3 2 1 1 Ft. Wayne, IN 1 3 3 2 2 2 2 2 1 1 1 1 4 Pittsburgh, PA Weirton, WV 3 2 2 3 Wheeling, WV 1 2 1 1 2 1 4 2 3 New Martinsville, WV 3 3 3 3 Parkersburg, WV 4 1 1 4 Point Pleasant, WV 2 2 Huntington, WV

5. Ohio and the Ohio Trauma System • Ohio Trauma System created in law – July 2000 • Trauma patient defined • Triage criteria for EMS set in administrative rule* • Trauma centers must be ACS verified • EMS must transport trauma patients to a trauma center • Limited exceptions • Hospitals may not admit trauma patients that exceed their capability to treat • No exceptions

6. Required Review • EMS Board is required by law to review their trauma triage criteria every three years to minimize overtriage and undertriage • Solicitation of public input also required • 1st 3-year review in 2005 • A recommendation to treat geriatrics as a distinct, special needs population was received.

7. Data: First Blush

8. Discussion ensues • Evidence shows… • Elderly have worse outcomes than younger trauma patients with similar injuries • Trauma patients have better outcomes when treated at trauma centers • But Ohio has no geriatric-specific triage criteria • Age is simply a “consideration”

9. Action follows • Trauma Committee forms Geriatric Trauma Task Force • Howard Werman, MD – Chair • Charged with finding evidence of need for geriatric-specific triage criteria • Utilizing current literature and data within the Ohio Trauma Registry and EMS Incident Reporting System

10. Step 1 Define “old”

11. Step 1 • Literature unhelpful • Geriatric age groups begin anywhere from age 54 to 75 • No basis for selection • Need to create evidence-based definition using Ohio data

12. Gross Mortality

13. Magic number: 72 • At age 72, gross mortality went above, and stayed above, 4% • Overall mortality in Ohio Trauma Registry: 3.6% • 72 years old was cut point for gross mortality for • All trauma patients • Minor injuries (ISS 1-9) • Moderate injuries (ISS 10-15) • Severe injuries (ISS >15) • Trauma patients with blunt injuries • Trauma patients with penetrating injuries

14. Statistical validation

15. Step 1 completed • “Old” defined • Geriatric trauma patients defined as =>70 years of age • Rounded down to make it easier to remember

16. Step 2 • Find factors that indicate a need for direct transport to a trauma center based on significantly higher mortality* • Anatomic • Physiologic • Mechanistic *Critical resource usage (ICU, vent, OR, etc.) was found to be inversely proportional to age.

17. Step 2 • Methodology • Compare outcomes for theoretical indicators in the geriatric population versus the adult population (age 16-69)

18. Step 2 • Proposed indicators • Falls (any height, including standing) associated with TBI, chest, abdominal or spinal injury • Pedestrian struck • MVC with single proximal long bone fracture • Multiple body regions injured • Hypotension (initial systolic B/P) • Altered LOC (initial GCS score)

19. Step 2 • Proposed indicators • Co-morbid conditions • Any • COPD • Coronary Artery Disease • Cardiac Disease (any) • Clotting disorder (including Coumadin therapy) • Diabetes (Type 1 or Type 2) • Dialysis • Immunocompromised • Liver Disease

20. Results

21. Results

22. Results

23. Results • Proposed indicators • Falls (any height, including standing) associated with • TBI  • Chest injury • Abdominal injury • Pedestrian struck • MVC with single proximal long bone fracture

24. Results • Proposed indicators • Multiple body regions injured  • TBI • Head/face/neck • Chest • Abdomen/pelvis • Spine • Extremities

25. Results • Co-morbid conditions • Any • COPD • Coronary Artery Disease • Cardiac Disease (any) • Clotting disorder (including Coumadin therapy) • Diabetes (Type 1 or Type 2) • Dialysis • Immunocompromised • Liver Disease

26. Recommendations to EMS Board Trauma patients =>70 years should be defined as geriatric trauma. They should be triaged for evaluation in a trauma center for: • GCS < 15 with evidence of traumatic brain injury • Systolic BP < 100 mmHg • Falls with evidence of traumatic brain injury (even from standing position) • Pedestrian struck by motor vehicle • Multiple body regions injured • Known or suspected proximal long bone fracture sustained in a motor vehicle crash

27. Impact • Estimated change in admissions to hospitals (based on applying new criteria to previous year’s trauma registry data): • Non-trauma hospitals estimated to admit an average of 11.4 fewer patients annually

28. Implementation • Trauma Committee recommended EMS Board make changes to triage criteria based on this research • EMS Board accepted changes in October 2008, promulgated in administrative rules • New triage rules implemented December 29, 2008

29. Full report to EMS Board and analysis of change in admission patterns available in Data Center section of EMS Division website ems.ohio.gov

30. Questions? Ohio Department of Public Safety, Division of EMS Office of Research and Analysis 800-233-0785 EMSdata@dps.state.oh.us