ABSTRACT
Background
Undertriage of women with trauma is associated with preventable deaths. This project was developed to determine whether older women with trauma were less likely to be admitted to a specialist trauma unit.
Methods
The study was undertaken at a specialist, level one trauma service and included all people aged 65 and older admitted following trauma over a twelve‐month period. Patients were included if they were admitted to general medicine, trauma or orthopaedics. The primary outcome was admission to general medicine versus trauma. Baseline data included age, sex, Charlson Comorbidity Index (CCI), mechanism of injury (low fall vs. other) and baseline function. Injury Severity Score (ISS) was calculated by trained assessors.
Results
A total of 648 (50.3%) were admitted to trauma, 286 (22.2%) to orthopaedics and 352 (27.4%) to General medicine (GM). 686 (53%) of patients were women. Low fall was the most common mechanism of injury (75.6% of women, 51.3% of men). In a multivariate model to look at admission to GM versus trauma, including age, sex, language other than English, CCI and ISS, women were more likely to be admitted to GM (1.67 (1.14, 2.44)). Low fall was the biggest predictor of general medical admission versus trauma (11.4 (6.7, 18.9)) Low fall was associated with mortality (2.0 (1.11, 3.67)).
Conclusions
Accounting for age and frailty women and people with low falls were more likely to be admitted to a general medical unit than a trauma unit compared to men. This supports the need for standard admission guidelines for trauma.
Keywords: frailty, gender equity, low energy trauma
While the trauma patient population is predominated by young men with a high energy mechanism of injury, in older trauma patients, this is reversed. In younger age groups, men make up around two thirds of older trauma patients, but in older cohorts, women make up a slightly higher proportion of trauma patients than men [1]. Elderly trauma patients have multiple well described challenges in trauma care including under triage [2] and the potential for severe injury from low energy mechanisms [3]. Pre‐existing comorbidity and frailty may be a greater determinant of outcome than injury severity [4, 5].
A centralised trauma model has been associated with a significant decrease in mortality for people with trauma in Victoria and is a remarkable achievement [6]. However, the impact of this centralisation is greater for younger adults than older adults [7], and there is inconclusive evidence on the effect on mortality of a major trauma service in low‐energy trauma in the elderly [8].
An ongoing challenge in care of the older trauma patient is to determine the optimal admitting unit for elderly patients with a traumatic mechanism of injury. When patients present with an injury, sometimes there are clear‐cut criteria for admitting unit, such as an isolated neck of femur for orthopaedics. However, for those elderly patients with more than one body system injured or substantial comorbidities, the pathways are less clear. In our institution, such persons are usually admitted to either Trauma Unit or General Medicine.
There is widespread recognition of under triage of women with traumatic mechanism of injury and that this is associated with preventable deaths [9, 10, 11] In a study utilising the American College of Surgeons (ACS) Trauma Quality Improvement Project (TQIP) databases with 28 332 aged 18 and over with an ISS of 15 or more, women were more likely to experience delays to triage and more likely to be discharged to a skilled nursing facility than men [12]. The accelerated loss of bone density and muscle mass following menopause contributes to higher fracture risk [13]. Compared to men, women do have a longer life expectancy but are more likely to have chronic conditions, age‐related disability and to be frail [14]. There are concerns about the choice of admission unit that this could be impacted by unconscious gender bias, which has important implications for access to care.
The aims of this study are two‐fold; firstly, to describe hospital level data for all elderly persons admitted with a traumatic mechanism of injury, inclusive of all admitting units and all injury severity, and secondly, for those persons > 64 years of age not admitted to an orthopaedic unit, to determine whether women are more or less likely to be admitted to a trauma unit compared to General Medicine (GM), after accounting for injury severity.
1. Methods
1.1. Study Design and Setting
The RMH, which is a level one adult Major Trauma Centre in Melbourne, Australia, and one of the two in the state of Victoria, manages over 4000 trauma patients per annum. Patients triggering a trauma team response, and/or those with major or multisystem trauma, are admitted to the RMH Trauma Unit. Generally, patients not triggering a team activation and sustaining a single speciality injury are admitted under the relevant speciality, for example, orthopaedics, neurosurgery, or a general medical unit, although clinician judgement may be applied. Those injured but not requiring a trauma resuscitation response, nor admission to a specialty surgical unit, are variably admitted to the Trauma Unit or General Medicine.
1.2. Ethics Approval
The project received full high risk ethics approval through the Melbourne Health High Risk Ethics committee (HREC/72410/MH‐2021). As this was based on routine clinical data, individual consent was not required.
1.3. Participants
This is a prospective cohort study of people 65 and older flagged for potential inclusion on the Royal Melbourne Hospital Trauma Registry from 16th February 2022 to 16th February 2023 [15]. This is all patients who present to the emergency with a traumatic mechanism of injury, (including low falls) and who have a length of stay 24 h from the time of admission or who died. While the trauma registry subsequently excludes those with an abbreviated injury score of less than or equal to one, this group were included in this cohort to look at mortality. Patients were excluded if the injury was known to have occurred more than 14 days prior to admission or an injury of indeterminate age.
1.4. Variables and Data Sources
All data was routine clinical data obtained from the electronic medical record. Data was stored in a password protected database on RedCap and was deidentified.
Variables included Medical Early Warning Score based on the first recorded observations at presentation to hospital, Clinical Frailty Scale, based on function 2 weeks prior to hospital admission, Katz activities of daily living, usual residence, low fall vs. other mechanism of injury, age, gender, whether English is usual language, Charlson Comorbidity Score, and mortality. Injury Severity Score was calculated by a trained assessor.
The initial admitting unit was obtained from the EMR.
Patients with an ISS of 0 were excluded from the multivariate analysis for first admission unit, but were included in the analysis for mortality.
1.5. Statistical Analysis
Statistical analysis was performed on STATA version 14.1. For categorical variables, Chi‐2 was used. For continuous variables with normal distribution, means were compared with t‐test. For ISS, Katz and length of stay median was calculated and ANOVA was used for comparison. Variables of interest were compared between genders and admitting unit (Orthopaedics, Trauma Unit or General Medicine). For those not admitted to Orthopaedics, a multivariable logistic regression model was constructed to test the null hypothesis that gender was not associated with admission unit after adjustment for relevant covariates (age, sex, mechanism of injury [low fall vs. other]), language other than English, CCI and ISS category (for patients with an ISS greater than 0).
2. Results
Over the study period, 1576 persons > 65years who met criteria for entry to the trauma registry were identified and of this group 113 (7.5%) died. Within this, a total of 648 were admitted to trauma, 286 to orthopaedics and 352 to a medical unit. Women made up 53% of all patients. Women had a higher mean Clinical Frailty scale than men (4.2 vs. 3.5) and a higher mean age (81.4 vs. 78.1) For both men and women, low fall was the most common mechanism of injury (75.6% of women, 51.3% of men). Men had a higher median ISS (10 vs. 9). While there was no difference in baseline Katz ADLs, women had a lower median ADL on discharge compared to men (3 vs. 4). (Table 1).
TABLE 1.
Characteristics of female and male patients with trauma admitted to trauma, general medicine or orthopaedics.
| Female (n = 686) | Male (n = 600) | ||
|---|---|---|---|
| Age (mean and range) | 81.4 (65, 103) | 78.1 (65, 101) | p < 0.00 |
| Low fall (%) | 539 (75.6) | 308 (51.3) | p < 0.00 |
| Language other than English (%) | 149 (21.7) | 104 (17.3) | p = 0.048 |
|
Charlson Comorbidity Score (mean (95% CI)) |
1.3 (1.2, 1.4) | 1.4 (1.4, 1.5) | p = 0.41 |
| Clinical Frailty Scale (mean) | 4.2 (n = 482) | 3.5 (n = 475) | p < 0.00 |
| Usual residence (%) | p < 0.00 | ||
| Home alone | 246 (36.2) | 151 (25.3) | |
| Home with others | 329 (48.6) | 415 (69.5) | |
| Residential care | 88 (13.0) | 30 (5.0) | |
| Other | 16 (2.4) | 1 (0.17) | |
| MEWS (mean (95% CI)) | 1.5 (1.4, 1.6) | 1.6 (1.5, 1.7) | p = 0.11 |
| Injury Severity score (median, 25th,75th centiles) | 9 (5, 14) | 10 (8, 17) | p = 0.001 |
| ISS (number and %) | p < 0.00 | ||
| ≤ 1 | 217 (31.6) | 147 (24.5) | |
| 2–8 | 162 (23.6) | 116 (19.3) | |
| 9–15 | 227 (33.1) | 211 (35.2) | |
| 16–25 | 54 (7.9) | 83 (13.8) | |
| 26–100 | 26 (3.8) | 43 (7.2) | |
| Katz ADLs on admission (median (25th, 75th centiles)) | 6 (5, 6) | 6 (6, 6) | |
| Katz ADLs on discharge | 3 (1.5, 5) | 4 (2, 6) | |
| Acute LOS (median, 25th,75th centile) | 8 (4, 13) | 8 (4, 14) | |
| Died in‐hospital (%) | 33 (4.8) | 48 (8.0) | p = 0.018 |
People admitted to the trauma unit had a younger mean age (77.4) than those admitted to orthopaedics (83.6) or general medicine (81.2). A higher proportion of patients admitted to medicine were female than admitted to trauma (67.3% vs. 40.7%). There was a higher proportion of patients admitted following a low fall to orthopaedics (94.0%) and GM (90.3%) than to trauma (40.1%). Patients in the trauma unit had a higher median ISS (14, IQR 9, 19) than orthopaedics (5, IQR 4, 10) and GM (9, IQR 9, 10). Despite differences in ISS, in‐hospital mortality was similar across all groups (trauma: 5.72%, orthopaedics: 7.69%, GM: 6.25%) (Table 2). While median Katz ADL on admission was 6 for men and women, and decreased on discharge for both, women had a greater mean decline (2.0 vs. 1.6, p < 0.00).
TABLE 2.
Characteristics by first admitted unit for patients admitted to trauma/orthopaedics/general medicine.
| Trauma (n = 648) | Orthopaedics (n = 286) | General medicine (n = 352) | ||
|---|---|---|---|---|
| Age (mean and range) | 77.4 (65, 101) | 83.6 (65, 103) | 81.2 (65, 102) | p < 0.00 (ANOVA) |
| Female (%) | 264 (40.7) | 185 (64.7) | 237 (67.3) | p < 0.00 |
| Language other than English (%) | 91 (14.4) | 83 (29.0) | 79 (22.4) | p < 0.00 |
| Injury by Fall < 1 m (%) | 260 (40.1) | 269 (94.0) | 318 (90.3) | p < 0.00 |
|
Charlson Comorbidity Score (mean (95% CI)) |
1.09 (0.99, 1.19) | 1.66 (1.48, 1.85) | 1.52 (1.35, 1.70) | p < 0.00 (ANOVA) |
| Usual residence | ||||
| Home alone | 194 (30.1) | 103 (36.3) | 100 (28.8) | |
| Home with others | 421 (65.3) | 148 (52.1) | 175 (50.4) | |
| Residential care | 25 (3.9) | 29 (10.2) | 64 (18.4) | |
| Other | 5 5 (0.8) | 4 (1.4) | 8 (2.3) | |
| MEWS (mean (95% CI)) | 1.66 (1.55, 1.77) | 1.56 (1.42, 1.70) | 1.27 (1.19,1.36) | p < 0.00 (ANOVA) |
| ISS (median and IQR) | 14 (9, 19) | 5 (4, 10) | 9 (9, 10) | p < 0.00 (Kruskal–Wallis) |
| ISS (number and %) | ||||
| ≤ 1 | 162 (25) | 88 (30.8) | 114 (32.4) | |
| 2–8 | 98 (15.1) | 125 (43.7) | 55 (15.6) | |
| 9–15 | 204 (31.5) | 58 (20.3) | 176 (50.0) | |
| 16–25 | 117 (18.1) | 13 (4.6) | 7 (1.99) | |
| 26–100 | 67 (10.3) | 2 (0.7) | 0 | |
| Katz ADLs (median (25th, 75th centiles)) | 6 (6, 6) | 6 (4, 6) | 6 (5, 6) | p < 0.001 |
| Hb (mean, 95% CI) |
129 (128, 131) |
123 (121, 126) |
122 (120, 123) |
|
| Required surgery (%) | 422 (65.6) | 259 (90.6) | 26 (7.5) | p < 0.001 |
| Acute LOS (median, 25th,75th centile) | 7 (3, 12) | 9 (5, 16) | 8 (4, 14) | |
| Died in‐hospital | 37 (5.72) | 22 (7.69) | 22 (6.25) | p = 0.519 |
After exclusion of the those admitted to the orthopaedic unit, patients were more likely to be admitted to a general medical unit vs. trauma in multivariate analysis if they were female (OR 1.67 (1.14, 2.44)), had a low fall (OR 11.4 (6.7, 18.9)) or spoke a language other than English (OR 1.32 (1.04, 1.68)). Patients with a lower ISS were less likely to be admitted to general medicine (OR 0.46 (0.34, 0.62)) (Table 3).
TABLE 3.
Results of multivariate analysis for admission to general medicine versus admission to trauma OR (95% CI). Admissions to orthopaedics excluded.
| Female gender | 1.67 (1.14, 2.44) | p = 0.00 |
|---|---|---|
| ISS category | 0.46 (0.34, 0.62) | p = 0.00 |
| Age | 1.01 (0.99, 1.03) | p = 0.414 |
| Low fall vs. other mechanism of injury | 11.4 (6.7, 18.9) | p = 0.00 |
| CCI | 1.13 (1.00, 1.30) | p = 0.057 |
| Language other than English | 1.32 (1.04, 1.68) | p = 0.022 |
| MEWS | 0.69 (0.56, 0.84) | p = < 0.00 |
Abbreviations: CCI, Charlson Comorbidity Index; MEWS, medical early warning score.
For the entire cohort, a higher proportion of men died than women 8.0% vs. 4.8%, p = 0.018 including when stratified by injury severity score (Table S1). In a multivariate analysis for all patients with an injury severity score greater than 1, which adjusted for age, Charlson comorbidity score, low fall versus other mechanism of injury, men were more likely to die (OR 2.6 (1.56–4.45), p < 0.00) (Table 4). Being admitted to medicine or trauma was not associated with an (unadjusted) difference in the odds of mortality (p = 0.73).
TABLE 4.
Multivariate analysis for mortality for all people with an ISS greater than 1 OR, 95% CI, p value.
| Age | 1.07 (1.04, 1.10) p < 0.00 |
|---|---|
| Male sex | 2.63 (1.56, 4.45) p < 0.00 |
| Low fall vs. other mechanism of injury | 2.50 (1.30, 4.80) p = 0.004 |
| Charlson Comorbidity Index | 1.23 (1.07, 1.43) p = 0.004 |
| Injury severity score | 1.12 (1.10, 1.158) p < 0.00 |
Mortality for people with an injury severity score of zero or one, was 5.1% for women and 1.1% for men. All patients who died with an ISS ≤ 1 were admitted after a low fall.
3. Discussion
This study of all persons > 65years admitted to a large tertiary hospital with a traumatic mechanism of injury (but not necessarily a codable injury) has shown several insights into the presentation, management and outcomes of this cohort. Whilst it is acknowledged that there is a lack of evidence to base the preferred model of care for elderly trauma, in our institution, different admitting wards can offer differing levels of care.
Firstly, we hypothesised that there may be potential gender bias in the undifferentiated elderly trauma patient, that is, those not admitted to a specialty unit such as orthopaedics, with respect to choice of admitting unit. After adjusting for age, comorbidity, injury severity, English as a second language and mechanism of injury, women were 36.7% less likely to be admitted to the trauma unit than men. While it is possible that this was due to unmeasured clinical factors, it raises concerns for unconscious gender bias. At our health service, medical wards have less ability to provide specialised pain management such as patient controlled analgesia and erector spinae block. This means that potentially, women with similar injuries, particularly fractured ribs, may be receiving inferior pain management to men. Gender differences in pain and analgesia are described in elderly persons. In a systematic review of post‐operative pain, women experience higher levels of pain but receive less analgesia [16]. Conversely, underestimation of women's pain by clinicians may also impact decision making regarding admitting unit. While it is reassuring that this did not appear to have a significant impact on mortality, it is possible that this still represents a disparity in care. Patients admitted to trauma receive shared care between a trauma surgical specialist and geriatrician, meaning that there is concurrent management of injuries and medical conditions. Patients admitted to a medical unit may experience delays to injury management, noting how poorly trauma triage criteria perform for elderly persons, and lose specialised nursing and allied health input. The latter may be reflected in the lower median Katz score for women vs. men on discharge (3 vs. 4).
The strongest association for admission to a general medical unit was mechanism low fall (OR 11.4). This likely reflects the complexity of this group, who may have an element of pre‐existing medical problem contributing to the fall, life threatening injuries from the low fall, or a combination of both, often all on the background of frailty. It is noted that those without a codable injury, or an ISS = 1, that is, a very minor injury, still had mortaltity of 1.09% for men and 5.09% for women. Of note, some people with an ISS of less than or equal to 1 were admitted to the trauma service, which includes some people who had no injuries. The authors' consider the patient who suffers an ‘elderly low fall’ to not quite fit into either a surgical or medical management paradigm, and that multidisciplinary care between surgeons and geriatricians is essential.
Secondly we explored mortality by admitting unit and gender. The unadjusted mortality was similar across patients admitted to trauma, orthopaedics, and general medicine, despite different median ISS across the groups. Patients admitted to the orthopaedic unit had the highest mortality rate at 7.69%, despite the lowest median ISS (5 (4, 10)). This highlights the limitations of ISS in older adults as there are likely to be other factors including frailty and comorbidity that contribute to mortality risk. While the median ISS for men was higher than for women (10 vs. 9), this is not likely to be a clinically significant difference.
In our cohort, men had a higher rate of mortality from trauma than women in a multivariate analysis that adjusted for age, comorbidity, and injury severity. This is consistent with a 2016 meta‐analysis, which showed a one and a half times increase in the odds of mortality for men [17].
It is challenging to elucidate reasons women were less likely to be admitted to trauma. It may be a continuation of trauma triage, which has limitations in the elderly, or it could be due to clinician concern regarding frailty or co‐morbidity and the impression that a medical unit is more suitable. Alternatively, there could be differences in injuries not detected by our methodology, which is based upon categories of ISS. There is broad evidence of gender bias in healthcare across many areas. Women are less likely to receive cardiopulmonary bypass in an out of hospital cardiac arrest [18]. Women with STEMI are also more likely to experience delays in care [19].
With population ageing and growing recognition of the importance of geriatric trauma, it is key to understand an effective model of care, particularly for those who are also frail. The number of people presenting with low falls creates a key challenge in appropriate resourcing and prioritisation, but this group is at high risk of mortality. That people still died with minor injuries indicates that this group has a high level of physiological burden and comorbidity.
There are lessons to be learnt from organisational factors in care of patients with hip fractures that are likely to be relevant to trauma geriatrics, including early mobilisation, proactive pain management and feedback from patients about their hospital experience at clinical governance meetings, which are both associated with lower mortality. Timely geriatrician review is also associated with a decreased length of stay [20]. It is possible that without an explicit gender lens, women will miss out on improvements in care for older people with trauma.
4. Lessons and Limitations
A key strength of this project is that it includes all older adults admitted with any traumatic mechanism, including those with minor or no injuries. Many studies of trauma in older adults only include those admitted to trauma units or reaching an ISS > 12, but our study included all older adults with a traumatic mechanism of injury, regardless of admitting unit or trauma severity. A limitation of this study is that it relies on initial admitting unit, and it is possible that patients were subsequently transferred to a more appropriate unit once clinical assessment was complete.
This study was also limited to clinical data that was routinely collected, which means there was no measure of frailty for patients admitted to units other than trauma. This is relevant as it is also likely there were unmeasured differences between groups. It is possible there were relevant clinical measures that accounted for differences between admitting groups that were not measured.
This database only includes patients who were admitted to hospital. Those who were deceased prior to admission were not included.
Another important limitation of this work is that there was no patient reported measure. This will be important to look at in future research as it can provide critical information to improve the service.
5. Conclusions
After excluding those admitted to the orthopaedic surgical unit, women requiring hospital admission for trauma are less likely to be admitted to a specialised trauma unit. Men had a higher inpatient mortality than women, even after adjustment for age, comorbidity, mechanism of injury, and injury severity, consistent with previous studies. It is possible that the differing admission pathways could be due to unconscious gender bias, or other factors unmeasured in this study.
Author Contributions
Katherine Gregorevic: conceptualization, funding acquisition, methodology, writing – original draft, writing – review and editing. Kwang Lim: conceptualization, formal analysis, investigation, methodology. Rachel Aitken: conceptualization, methodology. Alyssa Griffiths: data curation. David Read: conceptualization, formal analysis, methodology, writing – original draft, writing – review and editing.
Funding
This work was supported by RMH Health Service Improvement Grants.
Supporting information
Table S1: Mortality for men vs. women by injury severity score (n (%)).
Acknowledgements
The authors have nothing to report.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1: Mortality for men vs. women by injury severity score (n (%)).