Undertriage of elderly trauma patients to state-designated trauma centers

Objective: To determine whether age bias is a factor in triage errors. Design: Retrospective analysis of 10 years (19952004) of prospectively collected data in the statewide Maryland Ambulance Information System followed by surveys of emergency medical services (EMS) and trauma center personnel at regional EMS conferences and level I trauma centers, respectively. Patients: Trauma patients were defined as those who met American College of Surgeons physiology, injury, and/or mechanism criteria and were subjectively declared priority I status by EMS personnel. Main Outcome Measure: Undertriage, defined as when trauma patients were not transported to a state-designated trauma center. Results: The registry analysis identified 26 565 trauma patients. The undertriage rate was significantly higher in patients aged 65 years or older than in younger patients (49.9% vs 17.8%, P < .001). On multivariate analysis, this decrease in trauma center transports was found to start at age 50 years (odds ratio, 0.67; 95% confidence interval, 0.57-0.77), with another decrease at age 70 years (odds ratio, 0.45; 95% confidence interval, 0.39-0.53) compared with patients younger than 50 years. A total of 166 respondents participated in the follow-up surveys and ranked the top 3 causal factors for this undertriage as inadequate training, unfamiliarity with protocol, and possible age bias. 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.