Elderly Patients May Be Less Likely to be Taken to a Trauma Center by EMS Personnel

Emergency medical services (EMS) providers may be less likely to transport elderly patients to a trauma center, according to the results of a retrospective analysis reported in the August issue of Archives of Surgery.
"Evidence-based clinical practice guidelines strongly recommend that elderly trauma patients be treated as aggressively as non-elderly patients," write David C. Chang, PhD, MPH, MBA, from the Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and colleagues. "However, some studies have suggested that age bias may still exist in trauma care, even in the prehospital phase of that care."

The goal of this study was to assess whether age bias is a factor in triage errors. A retrospective analysis of 10 years of prospectively collected data (from 1995 to 2004) in the statewide Maryland Ambulance Information System was performed, followed by surveys of EMS personnel at regional EMS conferences and of trauma center personnel at level 1 trauma centers.

Trauma patients were defined as those who met criteria of the American College of Surgeons for physiology, injury, and/or mechanism and who were subjectively declared by EMS personnel to be priority 1 status (requiring immediate attention). The primary endpoint was undertriage, defined as failure to transport trauma patients to a state-designated trauma center.

Among 26,565 trauma patients identified by registry analysis, the undertriage rate was higher in patients aged 65 years or older than in younger patients (49.9% vs 17.8%; P < .001). Multivariate analysis revealed that being age 50 years was also associated with a decrease in trauma center transports (odds ratio [OR], 0.67; 95% confidence interval [CI], 0.57 – 0.77), with an even more marked decrease at age 70 years (OR, 0.45; 95% CI, 0.39 – 0.53) in comparison with patients aged younger than 50 years.

Among 166 respondents (127 EMS personnel and 32 medical personnel, with 7 respondents refusing to identify their training background) who completed the follow-up surveys, the leading 3 factors responsible for this undertriage were given as insufficient training for managing elderly patients (25.3%), lack of familiarity with the protocol (12%), and possible age bias (13.4%).

"Even when trauma is recognized and acknowledged by EMS, providers are consistently less likely to consider transporting elderly patients to a trauma center," the study authors write. "Unconscious age bias, in both EMS in the field and receiving trauma center personnel, was identified as a possible cause."

Limitations of this study include unknown effect of this undertriage on patient outcomes and unsuccessful attempt to link the EMS data to Maryland hospital discharge data.

"The problem of age bias raised in this study may negate efforts to improve clinical care for elderly trauma patients within trauma centers if the system as a whole does not function properly and deliver patients appropriately to needed resources," the authors write. "It may be helpful to highlight the literature that now suggests that elderly trauma patients do, in fact, return to productive lives after their injury, which can eliminate the perception of futility of care that may be used consciously or subconsciously to justify age bias."

Dr. Chang was supported by an Individual National Research Service Award from the National Institute of General Medical Sciences for part of this study and was awarded the Maryland EMS-Geriatrics Award by the governor of Maryland in 2005. The authors have disclosed no relevant financial relationships.

Arch Surg. 2008;143(8):776–781.

Reviewed by Ramaz Mitaishvili, MD

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