Validation of Air Medical Prehospital Triage Score in Determining Resource Utilization at Level 1 Trauma Centers.

OBJECTIVE: Overtriage (ie, delivering less severely injured patients via helicopter) is costly, raises safety concerns, and reduces efficiency of the trauma system. The Air Medical Prehospital Triage (AMPT) scoring system was developed to determine which trauma patients would gain a survival benefit by air transport. The objective of this study was to evaluate the AMPT scoring system as a method of reducing trauma overtriage when helicopter emergency medical services were used. METHODS: A retrospective study of all scene trauma transports delivered by helicopter to 1 of 2 level 1 trauma centers was evaluated for 1) hospital stay less than 1 day and 2) failure to meet 1 of the following criteria for resource utilization: intensive care unit admission, an operative procedure within the first 24 hours, the need for blood products, Injury Severity Score ≥ 16, or death during hospitalization. Helicopter emergency medical services personnel recorded specific criteria from the Centers for Disease Control and Prevention (CDC) field trauma triage guidelines and AMPT that were met by transported trauma patients. RESULTS: There were 244 patients in the study population. Eighty-one (33.2%) patients were discharged within 24 hours; 11 (13.5%) of these patients were positive using AMPT scoring, whereas 44 (54.3%) patients met 1 of the CDC criteria. Similarly, 141 (57.8%) patients failed to meet 1 of the level 1 resource criteria; 19 (13.5%) met the AMPT criteria for air medical transport, whereas 84 (59.6%) met 1 of the CDC criteria. Undertriage was 63.5% for AMPT and 20.2% for CDC based on resource utilization criteria. CONCLUSION: The AMPT score reduced the number of patients who were inappropriately transported to a trauma center. However, this appeared to be at the expense of undertriage. Future studies should focus on developing a refined air medical-specific triage tool that has both low overtriage rates as well as lower undertriage rates.

Correlation of Preflight Risk Assessment Scores With First-Pass Intubation Success in a Critical Care Transport Environment.

OBJECTIVE: The purpose of this study was to examine the impact of crew fatigue on the performance of a high-risk clinical skill in a clinical setting. METHODS: This was a retrospective analysis of first-pass intubation success comparing critical care providers with self-reported fatigue and those without fatigue in a transport environment. RESULTS: No statistical difference was found in first-pass intubation between fatigued and nonfatigued practitioners. CONCLUSION: Future studies should determine the impact of fatigue on psychomotor and cognitive skills using validated methods of assessing the level of fatigue at the time of skill performance.

Botulism Outbreak in a Regional Community Hospital: Lessons Learned in Transfer and Transport Considerations.

Botulism is a potentially lethal disease caused by a toxin released by Clostridium botulinum. Outbreaks of botulism from food sources can lead to a Mass Casualty Incident (MCI) involving sometimes hundreds of individuals. We report on a recent outbreak of botulism treated at a regional community hospital with a focus on emergency medical services (EMS) response and transport considerations. Case Presentation: There were 53 patient evaluated for botulism at the sending facility. In total, 11 botulism exposures required intubation at the sending facility. Twenty-four patients were ultimately transported by critical care capable ALS crews with the majority (16) of these transports occurred in the first 24 hours. There was one fatality in the first days of the outbreak and a second death that occurred in a patient who died after long-term acute care (LTAC) placement several months after hospital discharge. Conclusion: Local EMS providers and public safety officers have a critical role in identifying and following up on potentially exposed botulism cases. The organization of transporting agencies and the logistics of transfer turned out to be 2 opportunities for improvement in response to this mass casualty incident.

Real-Time Fatigue Mitigation with Air-Medical Personnel: The SleepTrackTXT2 Randomized Trial.

Objective: The aims of this study were: 1) to determine the short-term impact of the SleepTrackTXT2 intervention on air-medical clinician fatigue during work shifts and 2) determine the longer-term impact on sleep quality over 120 days. Methods: We used a multi-site randomized controlled trial study design with a targeted enrollment of 100 (ClinicalTrials.gov NCT02783027). The intervention was behavioral (non-pharmacological) and participation was scheduled for 120 days. Participation was voluntary. All consented participants answered baseline as well as follow-up surveys. All participants answered text message queries, which assessed self-rated fatigue, sleepiness, concentration, recovery, and hours of sleep. Intervention participants received additional text messages with recommendations for behaviors that can mitigate fatigue. Intervention participants received weekly text messages that promoted sleep. Our analysis was guided by the intent-to-treat principle. For the long-term outcome of interest (sleep quality at 120 days), we used a two-sample t-test on the change in sleep quality to determine the intervention effect. Results: Eighty-three individuals were randomized and 2,828 shifts documented (median shifts per participant =37, IQR 23-49). Seventy-one percent of individuals randomized (n = 59) participated up to the 120-day study period and 52% (n = 43) completed the follow-up survey. Of the 69,530 text messages distributed, participants responded to 61,571 (88.6%). Mean sleep quality at 120 days did not differ from baseline for intervention (p > 0.05) or control group participants (p > 0.05), and did not differ between groups (p > 0.05). There was no change from baseline to 120 days in the proportion with poor sleep quality in either group. Intra-shift fatigue increased (worsened) over the course of 12-hour shifts for participants in both study arms. Fatigue at the end of 12-hour shifts was higher among control group participants than participants in the intervention group (p < 0.05). Pre-shift hours of sleep were often less than 7 hours and did not differ between the groups over time. Conclusions: The SleepTrackTXT2 behavioral intervention showed a positive short-term impact on self-rated fatigue during 12-hour shifts, but did not impact longer duration shifts or have a longer-term impact on sleep quality among air-medical EMS clinicians.

Impact of shift duration on alertness among air-medical emergency care clinician shift workers.

BACKGROUND: Greater than half of Emergency Medical Services (EMS) shift workers report fatigue at work and most work long duration shifts. We sought to compare the alertness level of EMS shift workers by shift duration. METHODS: We used a multi-site, 14-day prospective observational cohort study design of EMS clinician shift workers at four air-medical EMS organizations. The primary outcome was behavioral alertness as measured by psychomotor vigilance tests (PVT) at the start and end of shifts. We stratified shifts by duration (< 24 h and 24 h), night versus day, and examined the impact of intra-shift napping on PVT performance. RESULTS: One hundred and twelve individuals participated. The distribution of shifts <24 h and 24 h with complete data were 54% and 46%, respectively. We detected no differences in PVT performance measures stratified by shift duration (P > 0.05). Performance for selected PVT measures (lapses and false starts) was worse on night shifts compared to day shifts (P < 0.05). Performance also worsened with decreasing time between waking from a nap and the end of shift PVT assessment. CONCLUSIONS: Deficits in performance in the air-medical setting may be greatest during night shifts and proximal to waking from an intra-shift nap. Future research should examine alertness and performance throughout air-medical shifts, as well as investigate the timing and duration of intra-shift naps on outcomes.

Do Trauma Patients Aged 55 and Older Benefit from Air Medical Transport?

INTRODUCTION: A recent analysis of the National Sample Project demonstrated that the mortality benefits of air medical transport do not extend to patients age 55 or older. The purpose of the current investigation was to evaluate mortality benefits of air transport in adult trauma patients ≥ 55 years of age. METHODS: A retrospective analysis of all adult patients greater than age 55 years directly transported from a trauma scene to a Level I or II facility was conducted. The primary outcome variable was in-hospital mortality. Using the imputed dataset we then performed multivariable logistic regression with mortality as the dependent variable to determine if mode of transport had a significant impact on mortality for patients older than 55 years of age. RESULTS: There were 7,739 (90.9%) patients transported by ground and 682 (9.1%) transported by air in our dataset. There were 3,556 between the ages of 55 to 69 years and an additional 4865 over the age of 69 years. In the multivariable model of all patients ≥ 55, air transport was associated with lower mortality (adjusted odds ratio [aOR] = 0.60; 95% confidence interval [CI] = 0.39--0.91; p = 0.017) when compared to those transported by ground. CONCLUSION: Our study was able to demonstrate a survival benefit for the cohort of patients age greater than 55 years of age. Key words: air medical transport; trauma; geriatric.

Limb Replantation in Air-Transported Patients: A 4-Year Study.

OBJECTIVE: Patients who require extremity reimplantation represent a population in whom rapid transport could provide potential benefit. Only 1 previous report has described the use of air transport in patients with these injuries. We describe our experience in air medical transport of limb reimplantation candidates. METHODS: A retrospective chart review for all patients with amputation or near-amputation extremity injuries who were transported by helicopter to a regional reimplantation center over a 4-year period was conducted. The primary outcome measure was patients who were taken to the operating room (OR) for a definitive repair attempt by the surgical team. RESULTS: Of the 115 patients, 104 were taken to the OR (90%), and 84 (80%) had a repair attempted. Similar results were found between those patients who were transported from the scene or another hospital with regard to the number of candidates taken to the OR and the number of patients in who definitive repair was attempted. CONCLUSION: Air medical transport can play an important role in a regional reimplantation program.

Survivors Perceptions of Recovery following Air Medical Transport Accidents.

Abstract Objective: Air medical transport (AMT) teams play an essential role in the care of the critically ill and injured. Their work, however, is not without risk. Since the inception of the industry numerous AMT accidents have been reported. The objective of this research is to gain a better understanding of the post-accident sequelae for professionals who have survived AMT accidents. The hope is that this understanding will empower the industry to better support survivors and plan for the contingencies of post-accident recovery. Methods: Qualitative methods were used to explore the experience of flight crew members who have survived an AMT accident. "Accident" was defined using criteria established by the National Transportation Safety Board. Traditional focus group methodology explored the survivors' experiences following the accident. Results: Seven survivors participated in the focus group. Content analysis revealed themes in four major domains that described the experience of survivors: Physical, Psychological, Relational and Financial. Across the themes survivors reported that industry and company response varied greatly, ranging from generous support, understanding and action to make safety improvements, to little response or action and lack of attention to survivor needs. Conclusion: Planning for AMT post-accident response was identified to be lacking in scope and quality. More focused efforts are needed to assist and support the survivors as they regain both their personal and professional lives following the accident. This planning should include all stakeholders in safe transport; the individual crewmember, air medical transport companies, and the industry at large.

Ambulance Diversion: Ethical Dilema and Necessary Evil.

Ambulance diversion presents a dilemma pitting the ethical principles of patient autonomy and beneficence against the principles of justice and nonmaleficence. The guiding priority in requesting ambulance diversion is to maintain the safety of all patients in the emergency department as well as those waiting to be seen. Policies and procedures can be developed that maintain the best possible outcome for patients transported by ambulance during periods of diversion. More importantly, the discussion must focus on addressing the operational inefficiencies within our health systems that lead to conditions such as patient boarding, high waiting room congestion, and ambulance diversion. Addressing these inefficiencies has a greater potential impact on ambulance diversion than simply banning or restricting the practice for practical or ethical considerations.

A blueprint for critical care transport research.

INTRODUCTION: An estimated 500,000 critical care patient transports occur annually in the United States. Little research exists to inform optimal practices, promote safety, or encourage responsible, cost-effective use of this resource. Previous efforts to develop a research agenda have not yielded significant progress in producing much-needed scientific study. PURPOSE: Identify and characterize areas of research needed to direct the development of evidence-based guidelines METHODS: The study used a modified Delphi technique to develop a concept map of the research domains in critical care transport. Proprietary, internet-based software was used for both data collection and analysis. The study was conducted in 3 phases: brainstorming, categorizing, and prioritizing, using experts from all aspects of critical care transport. RESULTS: A total of 101 research questions were developed and ranked by 27 participants representing the transport community and stakeholders. An 8-cluster solution was developed with multidimensional scaling and hierarchical cluster analysis to identify the following research areas: clinical care, education/training, finance, human factors, patient outcomes, safety, team configuration, and utilization. A plot characterized each domain by urgency and feasibility. CONCLUSION: The content and concepts represented by the cluster map can help direct research planning in the critical care transport industry and prioritize funding decisions.

Assessing satisfaction and quality in the EMS/HEMS working relationship.

BACKGROUND/OBJECTIVE: Treatment provided to critically ill and injured patients during air medical transport bridges initial local emergency medical service (EMS) treatment and the care provided upon arrival to the emergency department. Transition of care from EMS to air medical service includes multiple elements, many of which have been previously undefined. These include operational details surrounding the handoff and attention to issues of continuity in patient care. The purpose of this study is to pilot the development of survey instrumentation to measure key elements of quality in the interaction between EMS and air medical crews. METHODS: A focus group of 12 individuals, including rural and urban EMS providers, medical directors, administrators, and air medical transport providers, defined the activities involved in the working relationship between EMS and air medical transport. Ideas were refined into statements and placed into a 16-item Likert scale questionnaire distributed to EMS agencies throughout Ohio. Exploratory factor analysis was performed to identify subscales within the questionnaire. RESULTS: 380 questionnaires were returned over 2009, 2010, and 2011. Factor analysis of the initial responses from 2009 revealed themes similar to those identified by the focus group: patient care, user-friendly helicopter EMS (HEMS) operations, response time accuracy, operational feedback, and general system issues. The measure had good internal reliability, with alphas for subscales in the 0.85-0.88 range. A modified questionnaire used in 2010 and 2011 actually performed as a single scale. CONCLUSION: Using qualitative and quantitative approaches, a survey instrument was developed to assess satisfaction with HEMS care from the EMS provider's perspective. Evaluating the EMS perspective on the working relationship with HEMS is a new field of discovery for the air medical transport industry and process improvement activities.

Prehospital factors associated with mortality in injured air medical patients.

BACKGROUND: Air medical transport provides rapid transport to definitive care. Overtriage and the expense and risk of transport may offset survival benefits. OBJECTIVE: We assessed the ability of prehospital factors to predict resource need for helicopter-transported patients. METHODS: We performed a prospective, observational cohort analysis of injured scene patients taken to one of two level I trauma centers from October 2009 to September 2010. Variables analyzed included patient demographics, diagnoses, and clinical outcomes (in-hospital mortality, emergent surgery within 24 hours, blood transfusion within 24 hours, and intensive care unit [ICU] admission ≥24 hours, as well as a combined outcome of all clinical outcomes). Prehospital variables were prospectively obtained from air medical providers at the time of transport and included past medical history, mechanism of injury, and clinical factors. We compared those variables with and without the outcomes of interest via χ(2) analysis and the Kruskal-Wallis test, where appropriate. Multivariate logistic regression identified factors associated with outcomes of interest with the intent of developing a clinical prediction tool. RESULTS: Five hundred fifty-seven patients were transported during the study period. The majority of the patients were male (67%) and white (95%) and had an injury that occurred in a rural location (58%). Most injuries were blunt (97%), and patients had a median Injury Severity Score (ISS) of 9. The overall mortality was 4%; 48% of the patients had one of the four outcomes. The most common reasons for requesting air transport were motor vehicle collision (MVC) with high-risk mechanism (18%), MVC at a speed greater than 20 mph (18%), Glasgow Coma Scale score (GCS) less than 14 (15%), and loss of consciousness (LOC) greater than 5 minutes (15%). Factors associated with mortality were age greater than 44 years, GCS less than 14, systolic blood pressure (SBP) less than 90 mmHg, and flail chest. This model had 100% sensitivity and 50% specificity and missed no deaths. The combined endpoint of all four outcomes (death, receipt of blood, surgery, ICU admission) included intubation by emergency medical services, two or more fractures of the humerus/femur, presence of a neurovascular injury, a crush injury to the head, failure to localize to pain on examination, GCS less than 14, or the presence of a penetrating head injury. This model had a sensitivity of 57% (53%-61%) and a specificity of 78% (75%-87%). CONCLUSIONS: Very few prehospital criteria were associated with clinically important outcomes in helicopter-transported patients. Evidence-based guidelines for the most appropriate utilization of air medical transport need to be further evaluated and developed for injured patients.

Rocuronium versus succinylcholine in air medical rapid-sequence intubation.

BACKGROUND: It is not known how rocuronium compares with succinylcholine in its effect on intubation success during air medical rapid-sequence intubation (RSI). OBJECTIVE: To examine the impact of succinylcholine use on the odds of successful prehospital intubation. METHODS: We performed a retrospective analysis of a critical care transport service administrative database containing patient encounters from 2004 to 2008. Rotor transports of patients ≥ 18 years old, requiring airway management (intubation or backup airway: laryngeal mask airway, Combitube, or cricothyrotomy), and receiving either rocuronium or succinylcholine were included in the analysis. Patients receiving both drugs were excluded. Multiple imputation was used to account for records that were missing data elements. A propensity score based on patient and encounter characteristics was calculated to control for the effect of clinical factors on the choice of drug by air medical personnel. Logistic regression was used to assess the impact of succinylcholine use on the odds of first-attempt intubation. Ordinal logistic regression was used to assess the impact of succinylcholine on the number of attempts required to intubate (1, 2, or ≥ 3 or backup airway). RESULTS: A total of 1,045 patients met the criteria for analysis; 761 (73%) were male, and the median age was 41 years (interquartile range 26-56). Eight hundred seventy-six (84%) were transported from the scene, and 484 (46%) received succinylcholine. Six hundred twelve (59%) were intubated on the first attempt, 322 (31%) required two attempts, 69 required three or more attempts (7%), and 42 required a backup airway (4%). After propensity score adjustment, succinylcholine was associated with a higher incidence of first-attempt intubation (odds ratio 1.4, 95% CI 1.1-1.8), as well as improved odds for requiring fewer attempts to intubate (odds ratio 1.5, 95% CI 1.2-1.9), as compared with rocuronium. CONCLUSIONS: Rapid-sequence intubation was more successful with fewer attempts in patients intubated by air medical crews with succinylcholine as opposed to rocuronium. Prospective, randomized studies are needed to confirm these findings and to explore the impact of succinylcholine on the outcomes of air medical-transported patients. Key words: airway management; critical care; emergency medical services; neuromuscular blockade; succinylcholine; rocuronium; rapid-sequence intubation; intubation; air medical transport.

Transmission of 12-lead electrocardiographic tracings by Emergency Medical Technician-Basics and Emergency Medical Technician-Intermediates: a feasibility study.

INTRODUCTION: Prehospital transmission of the electrocardiogram (ECG) in ST-elevation myocardial infarction patients has been shown to reduce door to treatment time and improve outcome. Acquisition of the ECG tracing is a paramedic skill, thus limiting the benefit of early ECG transmission to primarily urban areas. The purpose of this investigation was to determine whether prehospital ECGs could be transmitted by nonparamedic personnel. METHODS: A prospective case series of consecutive patients with a chief complaint of chest pain was conducted. An ECG was transmitted on all eligible patients. Proper lead placement was verified, and the diagnostic quality of the ECG was assessed on emergency department arrival. Time on scene was recorded and compared with historical controls. RESULTS: Ninety patients were enrolled in the study. An ECG was transmitted successfully in 89 (98.9%) of 90 patients. Accurate lead placement was noted in 89 (98.9%) of 90, and the ECG was of "diagnostic quality" in 85 (95.5%) of 89 patients. There was no increase in scene time during the study period. CONCLUSION: Prehospital transmission of diagnostic-quality ECG can be reliably performed by nonparamedic providers.

Brightness mode quality ultrasound imaging examination technique (B-QUIET): quantifying quality in ultrasound imaging.

OBJECTIVES: Ultrasound image interpretation and education relies on obtaining a high-quality ultrasound image; however, no literature exists to date attempting to define a high-quality ultrasound image. The purpose of this study was to design and perform a pilot reliability study of the Brightness Mode Quality Ultrasound Imaging Examination Technique (B-QUIET) method for ultrasound quality image assessment. METHODS: A single sonologist performed a Trinity hypotensive ultrasound protocol on 3 participants of varying body types. Each participant's ultrasound examination was repeated in 4 locations; static clinic location, mobile ambulance, airplane, and helicopter. Images were reviewed by a sonographer, radiologist, and emergency medicine physician using the B-QUIET method and underwent statistical analysis using generalizability theory for reliability of the assessments using the tool. RESULTS: The B-QUIET method showed high reliability of most subscale items. Approximately two-thirds of the reviewed images had complete inter-rater reliability on 90% of the items. There was relatively low inter-rater reliability for the Identification/ Orientation subscale items. The inter-rater reliability κ value was calculated as 0.676 overall for the method. CONCLUSIONS: The need for a standardized method to evaluate the quality of an ultrasound image is well documented. The B-QUIET method represents the first attempt to quantify the sonographer component of ultrasound images. Further reliability and validation studies of this method will be needed; however, it represents a tool for standardized ultrasound interpretation, ultrasound training, and institutional quality assessment.

Development of statewide geriatric patients trauma triage criteria.

INTRODUCTION: The geriatric population is unique in the type of traumatic injuries sustained, physiological responses to those injuries, and an overall higher mortality when compared to younger adults. No published, evidence-based, geriatric-specific field destination criteria exist as part of a statewide trauma system. The Trauma Committee of the Ohio Emergency Medical Services (EMS) Board sought to develop specific criteria for geriatric trauma victims. METHODS: A literature search was conducted for all relevant literature to determine potential, geriatric-specific, field-destination criteria. Data from the Ohio Trauma Registry were used to compare elderly patients, defined as age >70 years, to all patients between the ages of 16 to 69 years with regards to mortality risk in the following areas: (1) Glasgow Coma Scale (GCS) score; (2) systolic blood pressure (SBP); (3) falls associated with head, chest, abdominal or spinal injury; (4) mechanism of injury; (5) involvement of more than one body system as defined in the Barell matrix; and (6) co-morbidities and motor vehicle collision with one or more long bone fracture. For GCS score and SBP, those cut-off points with equal or greater risk of mortality as compared to current values were chosen as proposed triage criteria. For other measures, any criterion demonstrating a statistically significant increase in mortality risk was included in the proposed criteria. RESULTS: The following criteria were identified as geriatric-specific criteria: (1) GCS score <14 in the presence of known or suspected traumatic brain trauma; (2) SBP <100 mmHg; (3) fall from any height with evidence of traumatic brain injury: (4) multiple body-system injuries; (5) struck by a moving vehicle; and (6) the presence of any proximal long bone fracture following motor vehicle trauma. In addition, these data suggested that elderly patients with specific co-morbidities be given strong consideration for evaluation in a trauma center. CONCLUSIONS: The state of Ohio is the first state to develop evidence-based geriatric-specific field-destination criteria using data from its state-mandated trauma registry. Further analysis of these criteria will help determine their effects on over-triage and under-triage of geriatric victims of traumatic injuries and the impact on the overall mortality in the elderly.

Airway management success and hypoxemia rates in air and ground critical care transport: a prospective multicenter study.

OBJECTIVE: To assess critical care transport (CCT) crews' endotracheal intubation (ETI) attempts, success rates, and peri-ETI oxygenation. METHODS: Participants were adult and pediatric patients undergoing attempted advanced airway management during the period from July 2007 to December 2008 by crews from 11 CCT programs varying in geography, crew configuration, and casemix; all crews had access to neuromuscular-blocking agents. Data collected included airway management variables defined per national consensus criteria. Descriptive analysis focused on ETI success rates (reported with exact binomial 95% confidence intervals [CIs]) and occurrence of new hypoxemia (oxygen saturation [SpO(2)] dropping below 90% during or after ETI); to assess categorical variables, Fisher's exact test, Pearson chi(2), and logistic regression were employed to explore associations between predictor variables and ETI failure or new hypoxemia. For all tests, p < 0.05 defined significance. RESULTS: There were 603 total attempts at airway management, with successful oral or nasal ETI in 582 cases, or 96.5% (95% CI 94.7-97.8%). In 182 cases (30.2%, 95% CI 26.5-34.0%), there were failed ETI attempts prior to CCT crew arrival; CCT crew ETI success on these patients (96.2%, 95% CI 92.2-98.4%) was just as high as in the patients in whom there was no pre-CCT ETI attempt (p = 0.81). New hypoxemia occurred in only six cases (1.6% of the 365 cases with ongoing SpO(2) monitoring; 95% CI 0.6-3.5%); the only predictor of new hypoxemia was pre-ETI hypotension (p < 0.001). A requirement for multiple ETI attempts by CCT crews was not associated with new hypoxemia (Fisher's exact p = 0.13). CONCLUSIONS: CCT crews' ETI success rates were very high, and even when ETI required multiple attempts, airway management was rarely associated with SpO(2) derangement. CCT crews' ETI success rates were equally high in the subset of patients in whom ground emergency medical services (EMS) ETI failed prior to arrival of transport crews.

Identification of an age cutoff for increased mortality in patients with elderly trauma.

OBJECTIVES: The chosen age cutoff for considering patients with trauma to be "elderly" has ranged from 55 to 80 years in trauma guidelines and studies. The goal of this study was to identify at what age mortality truly increases for older victims of trauma. METHODS: We performed a cross-sectional study of the Ohio Trauma Registry, a statewide database of all injured patients who died or were admitted for more than 48 hours to both trauma and nontrauma centers. Patients 16 years or older entered into the registry between January 1, 2003, and December 31, 2006, were included. Inhospital mortality rates were obtained and stratified by 5-year age intervals and by injury severity score (ISS). Rates between age groups were compared using logistic regression to identify significant differences in mortality. RESULTS: Included were 75 658 patients. In logistic regression, patients 70 to 74 years of age had significantly greater mortality than all younger age groups when stratified by ISS (P < or = .001-.004). When considering other 5-year age groups as referent (40-44, 45-49, 50-54, 55-59, 60-64, 65-69 years old), no other group was associated with significantly increased mortality, as compared to younger groups (P > .05 for all). CONCLUSION: Patients 70 to 74 years of age have significantly greater mortality than all younger age groups when stratified by ISS. Age cutoffs based on younger ages are not associated with significant increases in mortality. An age of 70 years should be considered as an appropriate cutoff for considering a patient to be elderly in future studies of trauma and development of geriatric trauma triage criteria.

Characteristics of scene trauma patients discharged within 24-hours of air medical transport.

INTRODUCTION: Helicopters play an important role in trauma; however, this service comes with safety risks, high transport costs, and downstream care charges. OBJECTIVE: Our objective was to determine the characteristics of early discharged trauma patients (<24 h length of stay) in order to reduce overtriage. METHODOLOGY: Data were obtained from the trauma registries at one of two Level 1 trauma centers. Eligible patients included all scene trauma patients transported by helicopter to the Level 1 trauma centers from January 1, 2016, to December 31, 2017, who had a length of stay of 24 h or less. Patient factors such as age, gender, scene location, loaded miles, and transportation costs were collected. Trauma type, mechanism of injury, Abbreviated Injury Scale (AIS), Injury Severity Score, Revised Trauma Score, and prehospital vital signs were documented. Driving distances between the accident scene to local hospital, home of record to local hospital, and home of record to the Level I trauma center were also calculated for patients transported to Level 1 trauma center. RESULTS: Two hundred and twenty-six of 1042 total patients (21.7%) were discharged within 24 h of helicopter transport from the accident scene to trauma center. Less than 2% of patients were in the age group of 70 years or older. Only 2 (0.88%) patients discharged within 24 h had a prehospital systolic blood pressure <90 mmHg. For patients transported to Level 1 trauma center, the average loaded miles were 50.51 ± 14.99, with average transport charges being $27,921.19± $3536.61. Twenty-one percent of Level 1 trauma center patients were self-pay, and families typically drove 71.7 ± 123.23 miles to Level 1 trauma center versus 28.74 ± 40.62 to their local emergency department. CONCLUSIONS: A significant number of patients transported from the scene are discharged within 24 h of admission to a trauma center. These patients rarely have prehospital hypotension, do not receive significant volumes of crystalloid resuscitation, and are infrequently over 70 years of age. One in five patients has no third-party coverage and assumes $27,921.19 in average transport charges.