Undertriage of elderly trauma patients to state-designated trauma centers

Arch Surg. 2008 Aug;143(8):776-81; discussion 782. doi: 10.1001/archsurg.143.8.776.


Objective: To determine whether age bias is a factor in triage errors.

Design: Retrospective analysis of 10 years (1995-2004) 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.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Age Factors
  • Aged
  • Female
  • Humans
  • Male
  • Maryland / epidemiology
  • Medical Errors / statistics & numerical data*
  • Middle Aged
  • Prejudice*
  • Retrospective Studies
  • Trauma Centers / statistics & numerical data*
  • Triage / standards
  • Triage / statistics & numerical data*
  • Wounds and Injuries / therapy*