Seniors Much Less Likely Than Younger Patients to Be
Rushed to Trauma Centers
Unconscious age bias in EMS and receiving trauma
center personnel identified as a possible cause
Aug. 18, 2008 If you are a senior citizen age
65 or older and suffer a trauma, your chances of getting emergency
services to transport you to a trauma center are 52 percent less than
for younger people. But, if you are 70 or older it gets even worse,
according to a report in the August issue of Archives of Surgery, one of
the JAMA/Archives journals.
There seems to be an unconscious age bias among
emergency medical services personnel, the study finds.
This is particularly bad news when projections are
that an estimated 39 percent of all trauma patients will be age 65 years
or older by the year 2050.
Evidence-based clinical practice guidelines
strongly recommend that elderly trauma patients be treated as
aggressively as non-elderly patients, the authors write. However, some
studies have suggested that age bias may still exist in trauma care,
even in the prehospital phase of that care.
David C. Chang, Ph.D., M.P.H., M.B.A., of Johns
Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public
Health, Baltimore, and colleagues analyzed 10 years of data from the
statewide Maryland Ambulance Information System.
They also surveyed emergency medical services (EMS)
and trauma center personnel after presenting them with the registry
findings at EMS conferences and grand rounds between 2004 and 2006.
The registry identified 26,565 trauma patients,
defined as those who met criteria set by the American College of
Surgeons (ACS) and were declared level I status (critically ill or
injured and requiring immediate attention) by EMS personnel.
Conclusions:
Even when trauma is recognized and
acknowledged by EMS, providers are consistently less likely to consider
transporting elderly patients to a trauma center. Unconscious age bias,
in both EMS in the field and receiving trauma center personnel, was
identified as a possible cause.
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.
More patients older than 65 were undertriaged, or
not taken to a state-designated trauma center, than were younger
patients (49.9 percent vs. 17.8 percent).
After adjusting for other related factors, the
researchers found that being 65 years or older was associated with a 52
percent reduction in likelihood of being transported to a trauma center.
This decrease in transports was found to start at age 50 years, with
another decrease at age 70.
A total of 166 individuals, including 127 EMS
personnel and 32 medical personnel (14 attending physicians, four
residents, six medical students and eight nurses), responded to the
follow-up surveys.
When asked about the most likely reasons for not
transporting elderly patients to trauma centers, participants cited
● inadequate training for managing elderly patients (25.3 percent),
● unfamiliarity with protocol (12 percent) and
● possible age bias (13.4 percent) as the top three factors.
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.
However, it may be difficult to change attitudes
of age bias and may require a broad societal campaign. Nevertheless, it
may be possible to address this problem without directly addressing age
bias. A focus on retraining the providers about triage protocols may be
sufficient, the authors conclude.
Additionally, 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.
Editor's Note: Dr. Chang was supported by an
Individual National Research Service Award from the National Institute
of General Medical Sciences for a portion of this study and was awarded
the Maryland EMS-Geriatrics Award by the governor of Maryland in 2005.
About Trauma
Centers
Trauma centers
are selected hospitals that provide a full range of care for
severely injured patients 24 hours a day, seven days a week.
This trauma care includes ready-to-go-teams that perform
immediate surgery and other necessary procedures for people with
serious or life-threatening injuries, for example, due to a car
accident, burn, bad fall, or gunshot.
In the
United States, a Level I trauma center provides the highest
level of surgical care to
trauma patients.
A Level I
trauma center is required to have a certain number of
surgeons and
anesthesiologists on duty 24 hours a day at the hospital, an
education program, preventive and outreach programs. Key
elements include 24-hour in-house coverage by general surgeons
and prompt availability of care in varying specialties such as
orthopedic surgery,
neurosurgery,
anesthesiology,
emergency medicine,
radiology,
internal medicine, oral and maxillofacial surgery, and
critical care, which are needed to adequately respond and care
for various forms of trauma that a patient may suffer.
Level I trauma-center hospitals in most states in
the U.S. (New
York,
Pennsylvania and
Florida among others are notable exceptions) are designated
by the
American College of Surgeons (ACS) for a period of three
years. Pennsylvania has its own rankings system, based on the
criteria of the Commonwealth's Trauma Foundation.
The ACS does not officially designate hospitals
as regional trauma centers, however. Numerous U.S. hospitals
that are not listed on the organization's trauma roster
nevertheless refer to their emergency or trauma units as "Level
I trauma centers."
The ACS describes that responsibility as a
geopolitical process by which empowered entities, government or
otherwise, are authorized to designate. The ACSs
self-appointed mission is limited to confirming and reporting on
any given hospitals ability to comply with the ACS standard of
care known as Resources for Optimal Care of the Injured Patient.
Aug. 18, 2008 If you are a senior citizen age
65 or older and suffer a trauma, your chances of getting emergency
services to transport you to a trauma center are 52 percent less than
for younger people. But, if you are 70 or older it gets even worse,
according to a report in the August issue of Archives of Surgery, one of
the JAMA/Archives journals.