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Invited Critique |

Undertriage of Elderly Trauma Patients to State-Designated Trauma Centers—Invited Critique

Richard J. Mullins, MD
Arch Surg. 2008;143(8):782. doi:10.1001/archsurg.143.8.782.
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Statewide trauma systems require 3 components: trauma centers (TCs), committed trauma care providers, and rational, effective triage mechanisms. Chang and coinvestigators observed that only 50% of elderly patients who met triage criteria were transported to 1 of Maryland's 8 TCs. One cause for this was a potential age bias among EMS providers. The authors dismissed 3 pertinent issues:

  • There is no evidence that elderly injured patients would benefit from transport to TCs. In the authoritative National Study on the Costs and Outcomes of Trauma, patients older than 55 years treated in TCs did not have superior odds of survival.1 That elderly patients would benefit from transport to TCs is a hypothesis.

  • Maryland's trauma system designates only 20% of acute care hospitals as TCs. Trauma systems improved survival in states in which more than 50% of hospitals are categorized as TCs.2 Elderly patients are undertriaged in Maryland because rural hospitals are excluded from the state's trauma system.

  • Mandatory admission to TCs for patients meeting ACS criteria defies the wishes of elderly patients, for whom control over end-of-life medical decisions is a priority. Many elderly patients in Oregon favor a mechanism implemented in this state, the Physician Orders for Life-Sustaining Treatment form, which enables them to document, in the event of an emergency, their preferences for comfort care, not aggressive life-extending treatments.3 Most Oregon EMS providers reported that the Physician Orders for Life-Sustaining Treatment form was useful.

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