Our elderly population is growing rapidly, and the average age of the patients on the trauma service is escalating. These patients offer a number of challenges throughout their presentation to the hospital and the rest of their stay. Some trauma centers are now organizing special teams or response types to deal with the unique needs of this population. A few have adopted a separate response type when injured elderly patients present to the ED.

The group at Reading Hospital  implemented a separate trauma activation tier, “Tier 3”, driven by emergency physicians, to manage these patients. Tier 3 was designed to identify patients > 65 years of age with the potential for occult blunt injury to the head and torso. The normal activation criteria at this center would not have necessarily identified these patients. This study retrospectively looked at demographics and outcomes for two separate three year periods, one before and one after implementation of Tier 3.

Here are the factoids:

• Geriatric volume increased significantly from 1715 to 3688 patients (!!), and more received expedited workup as either a trauma activation or Tier 3
• There were statistically significant decreases in time to CT (102 vs 128 minutes) and ED length of stay (361 vs 432 minutes) (see my comments)
• Mortality decreased from 8% to 5% overall, and from 19% to 11% in patients with head AIS > 3, both of which were significant
• Regression analysis showed that implementation of the Tier 3 response was an independent predictor of improved survival

Bottom line: This poster shows results that suggest having a specific response for select elderly patients who don’t meet trauma activation criteria can be beneficial. However, the devil is in the details. Each center must develop criteria for the Tier 3 response that mesh with their own activation criteria. And the details of that response need to be clinically significantly better than the usual consult response.

Questions and comments for the authors/presenters:

1. Be careful not to confuse statistical significance with clinical significance. Decreasing mean time to CT from 2:08 to 1:42 is not that big of a deal. The same applies to 7 hours in the ED vs 6.
2. Please share the Tier 3 criteria and details of the ED response.
3. Have you modified your Tier 3 criteria and/or response since inception, and if so, how and why?

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

• Adding a hospitalist to your trauma service
• Impact of a geriatric trauma service
• Pan-scanning for elderly trauma

Reference: “Tier 3”: Long term experience with a novel addition to a two-tiered triage system to expedite care of geriatric trauma patients.. Poster #34, EAST 2017.