- Email: [email protected]
34: Evaluation of the Revised Trauma and Injury Severity Scores in Elderly Trauma Patients
Research Forum Abstracts
33
Barriers to Depression Screening and Referral in Emergency Department Elders
Hogan TM/Emergency Medicine Residency Program, Resurrection Medical Center, Chicago, IL
Study Objectives: Emergency department (ED) screening has been used for many conditions undetected by usual evaluation. Although screening successfully identifies many conditions, compliance of positively screened subjects to referral is key to successful treatment. Barriers to mental health referral are especially strong. Identification and resolution of barriers are needed to ensure best patient outcomes. Our goals are to screen for depression among elder ED patients (65 and older), provide case management, and evaluate barriers faced by these subjects. Methods: After consent, all elders to be discharged from an ED visit were screened by a crisis counselor with the 15 item Geriatric Depression Screen (GDS15). Positive subjects (GDSⱖ5) were told of the findings and given mental health referral. Case manager contact occurred within 2 weeks. Barriers to compliance were documented by the case manager as determined by direct observation, patient, provider or family reporting or motivational questioning of subjects. Results: There were 923 patients screened between 2006 and 2008. Positive screens occurred in 21.8% (201/923). 43.8% (88/201) refused to participate with 31 patients initially agreeing to participate but not actually complying. After excluding 47 patients for unsuccessful contact or physical issues, 66 (32.8%) participants remained. The mean initial GDS score for participants was 7.67 (SD:2.56) versus 6.98 (SD:2.22) for refusals (P⫽.077). There were 48 barriers identified in 39/66 participants (59.1%) while 79 barriers were identified in 62/88 refusals (70.4%). For participants the most common barriers to follow-up were: motivation, follow-up care elsewhere, ageism, denial, stoicism, and stigma. For refusals, the most common barriers were: denial, ageism, motivation, stigma, provider attitude, and stoicism. There were significant differences between participants and refusals. More participants had follow-up care elsewhere (10.6% versus 0%, P⫽.006). Refusals experienced greater provider attitude barriers to care (9.1% versus 3.0%, P⫽.008). Conclusion: There is a 21.8% incidence of depression among elder patients discharged from our EDs. This study provides evidence that 65.6% of patients screened for depression experience barriers to care. Provider attitude was a significant barrier in refusal of screening recommendations for care.
34
Evaluation of the Revised Trauma and Injury Severity Scores in Elderly Trauma Patients
Watts H, Doherty J, Kulstad E/Advocate Christ Medical Center, Oak Lawn, IL
Study Objectives: Severity of illness scoring systems have primarily been developed for, and validated in, younger trauma patients. Although older trauma patients appear to have worse outcomes for a given severity of illness, few recent analyses of scoring systems in elderly trauma patients have been performed. We sought to determine the accuracy of the Injury Severity Score (ISS) and the Revised Trauma Score (RTS) in predicting mortality and hospital length of stay (LOS) in trauma patients over the age of 65 treated in our emergency department (ED), hypothesizing that neither score would successfully predict LOS or mortality in this age group. Methods: We performed a retrospective study utilizing our state trauma registry. All patients 65 years and older treated in our level I trauma facility from January 2004 to November 2007 were included. Using a closed-ended data abstraction instrument, we recorded the admission date, age, ISS, and RTS of all eligible patients in the registry. The primary outcome was death; the secondary outcome was overall hospital LOS. We measured the correlation between the ISS, the RTS, and the overall hospital LOS. We then determined each score’s accuracy in mortality prediction by calculating the area under receiver operating characteristic (ROC) curves. Results: A total of 347 patients 65 years of age and older were treated in our hospital during the study period. Median age was 76 years (IQR 69-82), with median ISS 13 (IQR 8 to 17) and median RTS 7.8 (IQR 7.1 to 7.8). Overall mortality was
S52 Annals of Emergency Medicine
24%. The total hospital length of stay correlated positively with ISS (Spearman’s rho⫽.13, p⫽.01) and RTS (Spearman’s rho⫽.18, p⫽.001), but correlation size was small. Both ISS and RTS had fair discriminatory power for mortality in our study population, with an area under the ROC curve for prediction of mortality with ISS of 0.78 (95% CI .71 to .84) and with RTS of .81 (95% CI .75 to .87). Conclusion: ISS and RTS correlated positively with hospital length of stay in our geriatric trauma population, but with a small correlation size. Both scores had a fair ability to predict the outcome of mortality. Because of its ease of calculation, the RTS may be more useful than the ISS for mortality prediction in elderly trauma patients.
35
Identification of Appropriate Glasgow Coma Score Trauma Criteria in Elderly Patients
Caterino JM, Cudnik MT/The Ohio State University, Columbus, OH
Study Objectives: An abnormal field Glasgow Coma Score (GCS) of ⱕ13 is used in our system to prompt transport to a trauma center, regardless of age. Elderly patients respond differently to trauma and may benefit from a different GCS threshold. We sought to determine if a field GCS of 14 in patients ⱖ70 years of age was associated with equivalent or worse mortality than younger patients with a GCS of 13. Methods: We performed a retrospective, observational, multi-center statewide analysis of injured patients transported to any trauma center and captured by the Ohio Trauma Registry. We included all patients 70 years of age and older (“elders”) with a GCS of 14 as well as those aged 18-69 years with a GCS of 13. Multiple imputation was used to take full advantage of the maximum numbers of subjects. We derived a non-parsimonius, multinomial logit propensity model to adjust for transport destination to a designated trauma center (Level I, II, or III) from patient characteristics, patient physiologic parameters, mechanism of injury, injury type, outof-hospital procedures, and other factors associated with mortality. We then performed a propensity-adjusted multivariable logistic regression analysis with the primary outcome of mortality. The final model compared those trauma patients 70 years of age and older (GCS ⫽14) to those aged 50-69 years of age (GCS⫽13). The final model also included the multi-level propensity score, year of injury, and trauma center type. Secondary outcomes included discharge to home and to extended care facility (ECF). Secondary analysis was performed comparing elders with GCS 14 to the entire population aged 18-69 with a GCS of 13. Results: 711 patients were included in the analysis, including 272 elders with GCS of 14 and 439 aged 18-69 with GCS 13 (92 were 50-69 years of age). Mortality was 10% among elders, 4.5% in the 18-69 group, and 6.5% in the 50-69 subset. When comparing elders with GCS 14 to those 50-69 with GCS 13, the older group demonstrated a trend towards increased mortality (odds ratio [OR] 2.63, 95% confidence interval [CI] 0.86-7.95). Elders were less likely to be discharged to home (OR 0.44, 95% CI 0.25-0.77) and more likely to be discharged to an ECF (OR 2.87, 95% CI 1.53-5.38). When compared to the entire group aged 18-69 with GCS 13, elders with GCS of 14 had greater mortality (OR 4.98, 95% CI 2.10-11.76), were less likely to be discharged home (OR 0.17, 95% CI 0.11-0.28), and were more likely to be discharged to an ECF (OR 6.37, 95% CI 3.85-10.50). Conclusion: Trauma patients aged 70 and over with a GCS of 14 have equivalent mortality to those aged 50-69 with GCS 13 and increased mortality than those aged 18-69 with GCS 13. In addition, they are more likely to be discharged to an ECF and less likely to be discharged home than the younger cohort. Consideration should be given to modify current trauma triage guidelines to use any GCS abnormality as criteria for transport of an elderly patient to a trauma center.
36
“Am I Doing the Right Thing?” Provider Perspectives on Improving Palliative Care in the Emergency Department
Smith AK, Fisher J, Schonberg MA, Pallin DJ, Block SD, Forrow L, Phillips RS, McCarthy EP/Beth Israel Deaconess Medical Center, Boston, MA; Brigham and Women’s Hospital, Boston, MA
Study Objectives: Though the primary focus of emergency care is to cure disease or stabilize the patient for ongoing treatment, some patients may benefit from a palliative approach. Little is known about delivering palliative care in the emergency department (ED). We sought to explore the attitudes, experiences, and beliefs of emergency providers about palliative care in the ED. Methods: Three focus groups with 26 physicians, nurses, social workers, and emergency technicians working in 2 academic EDs in Boston. Transcripts were coded by three physician co-authors experienced in palliative, emergency, and general
Volume , . : October
33
Barriers to Depression Screening and Referral in Emergency Department Elders
Hogan TM/Emergency Medicine Residency Program, Resurrection Medical Center, Chicago, IL
Study Objectives: Emergency department (ED) screening has been used for many conditions undetected by usual evaluation. Although screening successfully identifies many conditions, compliance of positively screened subjects to referral is key to successful treatment. Barriers to mental health referral are especially strong. Identification and resolution of barriers are needed to ensure best patient outcomes. Our goals are to screen for depression among elder ED patients (65 and older), provide case management, and evaluate barriers faced by these subjects. Methods: After consent, all elders to be discharged from an ED visit were screened by a crisis counselor with the 15 item Geriatric Depression Screen (GDS15). Positive subjects (GDSⱖ5) were told of the findings and given mental health referral. Case manager contact occurred within 2 weeks. Barriers to compliance were documented by the case manager as determined by direct observation, patient, provider or family reporting or motivational questioning of subjects. Results: There were 923 patients screened between 2006 and 2008. Positive screens occurred in 21.8% (201/923). 43.8% (88/201) refused to participate with 31 patients initially agreeing to participate but not actually complying. After excluding 47 patients for unsuccessful contact or physical issues, 66 (32.8%) participants remained. The mean initial GDS score for participants was 7.67 (SD:2.56) versus 6.98 (SD:2.22) for refusals (P⫽.077). There were 48 barriers identified in 39/66 participants (59.1%) while 79 barriers were identified in 62/88 refusals (70.4%). For participants the most common barriers to follow-up were: motivation, follow-up care elsewhere, ageism, denial, stoicism, and stigma. For refusals, the most common barriers were: denial, ageism, motivation, stigma, provider attitude, and stoicism. There were significant differences between participants and refusals. More participants had follow-up care elsewhere (10.6% versus 0%, P⫽.006). Refusals experienced greater provider attitude barriers to care (9.1% versus 3.0%, P⫽.008). Conclusion: There is a 21.8% incidence of depression among elder patients discharged from our EDs. This study provides evidence that 65.6% of patients screened for depression experience barriers to care. Provider attitude was a significant barrier in refusal of screening recommendations for care.
34
Evaluation of the Revised Trauma and Injury Severity Scores in Elderly Trauma Patients
Watts H, Doherty J, Kulstad E/Advocate Christ Medical Center, Oak Lawn, IL
Study Objectives: Severity of illness scoring systems have primarily been developed for, and validated in, younger trauma patients. Although older trauma patients appear to have worse outcomes for a given severity of illness, few recent analyses of scoring systems in elderly trauma patients have been performed. We sought to determine the accuracy of the Injury Severity Score (ISS) and the Revised Trauma Score (RTS) in predicting mortality and hospital length of stay (LOS) in trauma patients over the age of 65 treated in our emergency department (ED), hypothesizing that neither score would successfully predict LOS or mortality in this age group. Methods: We performed a retrospective study utilizing our state trauma registry. All patients 65 years and older treated in our level I trauma facility from January 2004 to November 2007 were included. Using a closed-ended data abstraction instrument, we recorded the admission date, age, ISS, and RTS of all eligible patients in the registry. The primary outcome was death; the secondary outcome was overall hospital LOS. We measured the correlation between the ISS, the RTS, and the overall hospital LOS. We then determined each score’s accuracy in mortality prediction by calculating the area under receiver operating characteristic (ROC) curves. Results: A total of 347 patients 65 years of age and older were treated in our hospital during the study period. Median age was 76 years (IQR 69-82), with median ISS 13 (IQR 8 to 17) and median RTS 7.8 (IQR 7.1 to 7.8). Overall mortality was
S52 Annals of Emergency Medicine
24%. The total hospital length of stay correlated positively with ISS (Spearman’s rho⫽.13, p⫽.01) and RTS (Spearman’s rho⫽.18, p⫽.001), but correlation size was small. Both ISS and RTS had fair discriminatory power for mortality in our study population, with an area under the ROC curve for prediction of mortality with ISS of 0.78 (95% CI .71 to .84) and with RTS of .81 (95% CI .75 to .87). Conclusion: ISS and RTS correlated positively with hospital length of stay in our geriatric trauma population, but with a small correlation size. Both scores had a fair ability to predict the outcome of mortality. Because of its ease of calculation, the RTS may be more useful than the ISS for mortality prediction in elderly trauma patients.
35
Identification of Appropriate Glasgow Coma Score Trauma Criteria in Elderly Patients
Caterino JM, Cudnik MT/The Ohio State University, Columbus, OH
Study Objectives: An abnormal field Glasgow Coma Score (GCS) of ⱕ13 is used in our system to prompt transport to a trauma center, regardless of age. Elderly patients respond differently to trauma and may benefit from a different GCS threshold. We sought to determine if a field GCS of 14 in patients ⱖ70 years of age was associated with equivalent or worse mortality than younger patients with a GCS of 13. Methods: We performed a retrospective, observational, multi-center statewide analysis of injured patients transported to any trauma center and captured by the Ohio Trauma Registry. We included all patients 70 years of age and older (“elders”) with a GCS of 14 as well as those aged 18-69 years with a GCS of 13. Multiple imputation was used to take full advantage of the maximum numbers of subjects. We derived a non-parsimonius, multinomial logit propensity model to adjust for transport destination to a designated trauma center (Level I, II, or III) from patient characteristics, patient physiologic parameters, mechanism of injury, injury type, outof-hospital procedures, and other factors associated with mortality. We then performed a propensity-adjusted multivariable logistic regression analysis with the primary outcome of mortality. The final model compared those trauma patients 70 years of age and older (GCS ⫽14) to those aged 50-69 years of age (GCS⫽13). The final model also included the multi-level propensity score, year of injury, and trauma center type. Secondary outcomes included discharge to home and to extended care facility (ECF). Secondary analysis was performed comparing elders with GCS 14 to the entire population aged 18-69 with a GCS of 13. Results: 711 patients were included in the analysis, including 272 elders with GCS of 14 and 439 aged 18-69 with GCS 13 (92 were 50-69 years of age). Mortality was 10% among elders, 4.5% in the 18-69 group, and 6.5% in the 50-69 subset. When comparing elders with GCS 14 to those 50-69 with GCS 13, the older group demonstrated a trend towards increased mortality (odds ratio [OR] 2.63, 95% confidence interval [CI] 0.86-7.95). Elders were less likely to be discharged to home (OR 0.44, 95% CI 0.25-0.77) and more likely to be discharged to an ECF (OR 2.87, 95% CI 1.53-5.38). When compared to the entire group aged 18-69 with GCS 13, elders with GCS of 14 had greater mortality (OR 4.98, 95% CI 2.10-11.76), were less likely to be discharged home (OR 0.17, 95% CI 0.11-0.28), and were more likely to be discharged to an ECF (OR 6.37, 95% CI 3.85-10.50). Conclusion: Trauma patients aged 70 and over with a GCS of 14 have equivalent mortality to those aged 50-69 with GCS 13 and increased mortality than those aged 18-69 with GCS 13. In addition, they are more likely to be discharged to an ECF and less likely to be discharged home than the younger cohort. Consideration should be given to modify current trauma triage guidelines to use any GCS abnormality as criteria for transport of an elderly patient to a trauma center.
36
“Am I Doing the Right Thing?” Provider Perspectives on Improving Palliative Care in the Emergency Department
Smith AK, Fisher J, Schonberg MA, Pallin DJ, Block SD, Forrow L, Phillips RS, McCarthy EP/Beth Israel Deaconess Medical Center, Boston, MA; Brigham and Women’s Hospital, Boston, MA
Study Objectives: Though the primary focus of emergency care is to cure disease or stabilize the patient for ongoing treatment, some patients may benefit from a palliative approach. Little is known about delivering palliative care in the emergency department (ED). We sought to explore the attitudes, experiences, and beliefs of emergency providers about palliative care in the ED. Methods: Three focus groups with 26 physicians, nurses, social workers, and emergency technicians working in 2 academic EDs in Boston. Transcripts were coded by three physician co-authors experienced in palliative, emergency, and general
Volume , . : October