YAJEM-57591; No of Pages 7

American Journal of Emergency Medicine xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

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Trauma team activation criteria and outcomes of geriatric trauma:

10 year single centre cohort study
Kevin Kei-ching Hung, FHKCEM a,b, Janice H.H. Yeung, PhD a,b, Catherine S.K. Cheung, MSc a,
Ling-yan Leung, PhD a, Raymond C.H. Cheng, FHKCEM a,b, N.K. Cheung, FHKCEM a,b, Colin A. Graham, MD a,b,⁎
a
Accident & Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Hong Kong
b
Accident & Emergency Department, Prince of Wales Hospital, Shatin, New Territories, Hong Kong

a r t i c l e i n f o a b s t r a c t

Article history: Background: With the aging population, the number of older patients with multiple injuries is increasing. The aim
Received 26 February 2018 of this study was to understand the patterns and outcomes of older patients admitted to a major trauma centre in
Received in revised form 14 May 2018 Hong Kong from 2006 to 2015, and investigate the performance of the trauma team activation (TTA) criteria for
Accepted 5 June 2018 these elderly patients.
Available online xxxx
Methods: This was a retrospective cohort study from a university hospital major trauma centre in Hong Kong
from 2006 to 2015. Patients aged 55 or above who entered the trauma registry were included. Patients were di-
Keywords:
Geriatrics
vided into those aged 55–70, and above 70. To test the performance of the TTA criteria, we defined injured pa-
Trauma centres tients with severe outcomes as those having any of the following: death within 30 days; the need for surgery;
Trauma severity indices or the need for intensive care unit (ICU) care.
Multiple trauma Results: 2218 patients were included over the 10 year period. The 30-day mortality was 7.5% for aged 55–70 and
Accidental falls 17.7% for those aged above 70. The sensitivity of TTA criteria for identifying severe outcomes for those aged 55 or
Traffic accidents above was 35.6%, with 91.6% specificity. The under-triage rate was 59% for age 55–70, and 69.1% for those aged
Cohort studies above 70.
Outcomes
Conclusion: There is a need to consider alternative TTA criteria for our geriatric trauma population, and to more
Hong Kong
clearly define the process and standards of care in Hong Kong.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction Association for the Surgery of Trauma practice management guideline

With the aging population and rapid urbanisation, geriatric trauma
is a growing burden around the world. There were 901 million people
aged 60 years or above worldwide in 2015 [1]. In Hong Kong, persons
aged 65 or above accounted for 15.3% of the total population in 2015
[2], up from 12.4% in 2006 [3]. The number of road traffic crash casual-
ties aged 60 and over increased from 11.3% in 2005 to 14.6% of total
deaths in 2012 in Hong Kong [4]. Studies in Europe showed an increas-
ing mean age for all trauma deaths; with the mortality shifting towards
in-hospital deaths compared with pre-hospital deaths [5].
Many different age cut offs exist for geriatric trauma. The TRISS
methodology uses age 55 or above as a cut off, due to a higher predicted
mortality [6], but this data is now N30 years old. The American College of
Surgeons Trauma Quality Improvement Program did not specify an age
cut off in their geriatric trauma management guideline [7]. The Eastern
⁎ Corresponding author at: Accident and Emergency Medicine Academic Unit, The
Chinese University of Hong Kong, Trauma & Emergency Centre, Prince of Wales Hospital,
Shatin, New Territories, Hong Kong.
E-mail address: cagraham@cuhk.edu.hk (C.A. Graham).
refers to geriatric patients as aged 65 years or older [8], whereas the
London Major Trauma System uses the definition of aged 70 years or
older [9]. In a survey of members of the American Association for Sur-
gery of Trauma, the majority of members felt that both age and comor-
bidities should be considered when defining geriatric trauma [10].
Joseph et al. suggested the use of the Frailty Index over chronological
age for risk stratification [11]. However, problems with the lack of stan-
dard measures for frailty, and the issues of applicability have limited its
use. In a 2016 systematic review, 32 frailty assessment tools were identi-
fied [12]. The authors assessed objectivity, feasibility and usefulness in the
clinical assessment of trauma patients, and they concluded that few tools
met all of these criteria. Two approaches were used in the tools, the rules
based approach (5/32 tools) and the accumulation of deficits model (27/
32 tools). The rules based approach was based on the five domains in the
frailty phenotype paradigm. The accumulation of deficits model defined
frailty as a sum of the number of impairments in the domains evaluated.
Although 93% of the 29 tools were predictive of adverse patient outcomes,
only 15% were found to be objective and feasible [12].
Maxwell et al. assessed the feasibility of three selected brief screen-
ing instruments (b5 min screening time) within 48 h of admission [13],

https://doi.org/10.1016/j.ajem.2018.06.011
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Please cite this article as: Hung KK, et al, Trauma team activation criteria and outcomes of geriatric trauma: 10year single centre cohort study,
American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2018.06.011
2 K.K. Hung et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx
and found that completion was highly dependent on the presence of a
surrogate respondent. They found 22% of patients had delirium, and an-
other 37% were unable to be interviewed secondary to their medical
conditions. Given this limitation, the feasibility of screening and the
availability of a surrogate respondent will be even more limited in the
emergency department (ED) setting. Nonetheless, the association of
frailty with longer term outcomes has been demonstrated, including
higher mortality at twelve [14] and six months [15], and higher proba-
bility of trauma-related readmissions and/or repeated falls at six
months [15]. The use of preinjury frailty in geriatric trauma is currently
limited, but may become a promising tool in the future.
Regardless of the controversies for chronological and physiological
age cut offs, most of the studies have found varying degrees of increased
mortality with increasing age [16-21]. Goodmanson et al. found in-
creased odds of 5.58 for death at 57 years of age compared with
19 year old patients [16]. A systematic review conducted in 2013 sug-
gested that the overall pooled mortality rate for trauma patients aged
65 or older was 14.8%, further increasing to 17.1% for patients older
than 74 [17]. It was found that the odds of dying continued to increase
with increasing age. Patients aged 75 years or above have a 1.67 times
greater odds of dying than those aged 65–74. Apart from age, the higher
mortality rate was associated with various factors including the injury
severity score (ISS) and low systolic blood pressure (SBP) of below
110 mm Hg [17]. Studies have also suggested that the presence of rib
fractures [18], the degree of anticoagulation [19], the use of beta
blockers preinjury [20], and osteoporosis [21] were all associated with
increased mortality for geriatric trauma patients.
Papers published as early as 1988 by DeMaria et al. demonstrated
that aggressive trauma care can result in satisfactory long-term func-
tional outcomes and return to independent living [22]. Tools were pro-
posed to evaluate outcomes, and the authors had therefore advocated
routine aggressive care for geriatric patients with moderate injuries
[23]. Demetriades et el subsequently demonstrated that for patients
aged 70 or above with major trauma (ISS N 15) trauma team activation
(TTA) were able to reduce the mortality from 53.8 to 34.2%, and even for
the more severe subgroup of ISS N20 [24]. At the same time, Trunkey
et al. reported that the therapy withdrawal decision making, albeit com-
monly encountered, was strongly influenced by the opinion of individ-
ual trauma surgeons and not adequately documented with full
pertinent information [25].
Yeung et al. has previously reported the mortality rate of 24.4% for pa-
tients aged 55 or above in four of the five trauma centres in Hong Kong
from 2002 to 2004 [26]. The presence of co-morbidity, ISS, age, and de-
creasing GCS were significant predictors of mortality. Our centre has
also found different mechanisms of injury, injury patterns, and a higher
mortality rate in a study comparing those older and younger than age
65 from 2000 to 2005 [27]. Only 38.6% of major trauma patients aged
65 or above had TTA, compared with 53.3% in the younger age group [27].
This raises the question of the performance of our current TTA
criteria and the outcomes of the trauma system in Hong Kong for the
various age groups of geriatric trauma patients. Currently in our trauma
system, the management of trauma patients does not differ between
adults and older patients. In the London Major Trauma System, the
TTA criteria have been specifically designed for patients aged 70 or
over, and included risk factors including rib fractures [9]. In this
10 year cohort study, we aimed to identify the outcome of geriatric
trauma from 2006 to 2015 and understand the performance of our cur-
rent TTA criteria in patients with older age.
2. Methods
This was a retrospective review of prospectively collected cohort
data from 2006 to 2015 at the Prince of Wales Hospital (PWH), one of
the five major trauma centres in Hong Kong. Ethical approval for this
study has been obtained from our local institutional review board
(CREC Ref. No.: 2017.585). PWH is a university teaching hospital with
Please cite this article as: Hung KK, et al, Trauma team activation criteria and outcomes of geriatric trauma: 10year single centre cohort study,
American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2018.06.011
1650 beds, it serves as the regional trauma centre of New Territories
East (NTE) region with a population of 1.3 million. Under the arrange-
ment with the ambulance service, trauma patients in the NTE region
who fulfil the set criteria under the primary trauma diversion (PTD)
will be transported directly to PWH.
The Emergency Department (ED) of PWH has an annual attendance
of around 140,000 patients. A two tiered system for trauma exists, with
the first response involving a team of three emergency physicians. The
second tier is the hospital trauma team, which includes two general sur-
geons, an orthopaedic surgeon, and an intensive care physician. The ac-
tivation of the trauma team follows the TTA criteria (supplementary).
2.1. Study design
Trauma patients with significant mechanism of injury, unstable
physiological parameters, or significant anatomical injury will be
triaged as category 1 (critical) or 2 (emergency) and included in the
trauma registry. Trauma deaths and patients admitted to the intensive
care unit (ICU) or high dependency area will also be included in the
trauma registry. Patients aged 55 or above who entered the trauma reg-
istry were included in this study. The trauma nurse coordinator (JHHY)
regularly collects a set of data for the trauma registry. Patient character-
istics, co-morbidity, injury causes, physiological parameters including
the revised trauma score (RTS), anatomic parameters including the Ab-
breviated Injury Scale (AIS) 2005 version, process and outcome data are
included. Comorbidities were graded according to the four levels of se-
verity by the trauma nurse coordinator, and the Glasgow Outcome Scale
(GOS) assessed at discharge from PWH. TRISS coefficients were used to
calculate the probability of survival (Ps). Under-call for PTD or TTA was
retrospectively identified by the trauma nurse coordinator, and is de-
fined as those who fulfilled the criteria for activation in the protocol,
but the protocol not activated by the ED physician.
2.2. Statistical analysis
All statistical analyses were performed using SPSS version 23 (IBM
Corp, Armonk, NY). Patients were dichotomised into those aged 55–70
and those aged N70. Baseline characteristics were compared using chi-
square test, t-test and Mann-Whitney U test as appropriate. A P value of
b0.05 was considered statistically significant and all tests were two tailed.
The use of PTD, TTA, need for operation, ICU admission, 30 day mortality
and the Glasgow Outcome Score (GOS) on discharge were compared with
the different age groups and ISS subgroups. The unadjusted and adjusted
odds ratio for the 30-day mortality and good recovery (GR)/moderate dis-
ability (MD) of the GOS were calculated using logistic regression.
To test the performance of the TTA criteria, we defined injured pa-
tients with severe outcomes as those having any of the following:
death within 30 days; the need for surgery; or the need for ICU care.
The sensitivity, specificity and positive predictive value (PPV) of the
TTA criteria were calculated. The perceived under-triage was defined
as 1-sensitivity, and over-triage as 1-PPV according to Lossius et al.
[28]. The concept of under and over-triage is to understand whether
the use of the current TTA criteria was appropriate, and is different to
those of under-call.
3. Results
2218 patients were included in the study. There has been increasing
geriatric trauma cases over the 10 years (Fig. 1). The increase in geriatric
trauma cases were 270% for aged 55–70 and 280% for aged N70, signifi-
cantly greater than the increased number of older persons in the popu-
lation (58% and 29% increase for the respective age groups from 2006 to
2016) [29].
There were major differences between the patient and trauma char-
acteristics of those aged 55–70 and those N70 (Table 1). The proportion
of low energy falls significantly increased for those aged N70
 K.K. Hung et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx 3

Fig. 1. Number of geriatric trauma cases from year 2006–2015.

(supplementary), and the proportion of major trauma (ISS N15) in- Table 1
creased from 43% to 52.6%. Head and neck injuries and extremity inju- Patient and trauma characteristics of 2218 trauma patients in trauma centre.
ries increased as a result of the increase in low energy falls Age 55–70 Age N70 P value
(supplementary). The older patient group has higher levels of pre-
Male 898 (75.1%) 511 (50.0%) b0.001a
injury comorbidity (Fig. 2). Median ISS 10 (4–21) 16 (9–25) b0.001c
The 30-day mortality rate was 7.5% for those aged 55–70, versus Type of injury
17.7% for those aged N70 (Fig. 3). The proportion achieving the good Blunt 1080 (90.4%) 963 (94.1%) 0.003a
functional outcome (good recovery/moderate recovery of GOS) was Penetrating 50 (4.2%) 21 (2.1%)
Burn 65 (5.4%) 39 (3.8%)
86.4% at age 55–70, reducing to 73.2% for age N70. However, there
RTS
remained a significant proportion of those age N70 with ISS N 15 achiev- 0–3.00 14 (1.2%) 9 (0.9%) 0.004a
ing good functional outcome at discharge (55.2%) (Table 2). 3.01–4.00 7 (0.6%) 3 (0.3%)
Only 15.7% fulfilled the criteria for PTD for those aged N70, with 1.4% 4.01–5.00 24 (2.1%) 30 (3.1%)
recognised as under-calls retrospectively. 17.1% received TTA in the ED, 5.01–6.00 52 (4.5%) 58 (6.0%)
6.01–7.84 105 (9.1%) 131 (13.5%)
however a further 4.7% was identified as under-call which warranted 7.8408 952 (82.5%) 741 (76.2%)
TTA according to the existing physiological and injury criteria. 10% re- Ps
quired ICU admission and 26.3% required at least one operation for pa- 0–0.25 40 (3.7%) 25 (2.7%) b0.001a
tients aged N70. 0.26–0.50 31 (2.9%) 44 (4.8%)
0.51–0.75 50 (4.6%) 42 (4.5%)
Multivariate analyses showed that age N70 had an increased ad-
0.76–0.95 377 (34.9%) 433 (46.8%)
justed odds of 3.1 (2.2 to 4.4, 95% CI) for 30-day mortality compared 0.96–1.00 583 (53.9%) 382 (41.3%)
with age 55–70. ISS N 15, those having burns rather than blunt injuries, PTD activated 161 (13.5%) 160 (15.7%) 0.32a
those with TTA, and patients not having surgery were all significantly Under call 19 (1.6%) 14 (1.4%)
associated with 30-day mortality (Table 3). For the GOS, age 55–70, TTA 288 (24.1%) 175 (17.1%) b0.001a
Under call 20 (1.7%) 48 (4.7%)
ISS b 16, no TTA, and not requiring ICU admission were significantly as-
Received operation 459 (38.4%) 269 (26.3%) b0.001a
sociated with good recovery or moderate disability (at least indepen- ICU admission 228 (19.8%) 98 (10.0%) b0.001a
dent at home) at discharge. ICU LOS (days) 3.00 (1.00–8.00) 2.70 (1.00–5.00) 0.15b
The sensitivity of TTA in identifying severe outcomes decreases as Hospital LOS (days) 6.0 (2.0–13.0) 7.0 (2.0–15.0) 0.035b
Mortality at 30 days 89 (7.5%) 181 (17.7%) b0.001a
the age increases, but the specificity increases (Table 4). The overall sen-
GOS
sitivity for TTA for identifying the severity for those aged 55 or above Death/PVS/SD 162 (13.6%) 274 (26.8%) b0.001a
was 35.6% with 91.6% specificity. The under-triage rate was 59% for GR/MD 1028 (86.4%) 748 (73.2%)
age 55–70, and 69.1% for those aged N70. Percentages may not add up to 100% due to rounding.
ISS: injury severity score; RTS: revised trauma score; Ps: probability of survival; PTD: pri-
4. Discussion mary trauma diversion; GOS: glasgow outcome scale; TTA: trauma team activation; ICU:
intensive care unit; LOS: length of stay; PVS: persistent vegetative state; SD: severe dis-
ability; MD: moderate disability; GR: good recovery.
This study has found significant differences between the two differ- a
Chi-square test.
ent geriatric age groups, 55–70 and those above 70. The gap between b
t-Test.
30-day mortality of the two geriatric age groups widens as the ISS c
Mann-Whitney U test.

Please cite this article as: Hung KK, et al, Trauma team activation criteria and outcomes of geriatric trauma: 10year single centre cohort study,
American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2018.06.011
4 K.K. Hung et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx

Fig. 2. Distribution of comorbidity.

advances. Caterino et al. have also found significant increases in mortal-
ity with the age cut off at 70 or more, and suggest that this could better
serve as the specific geriatric triage criteria in their US cohort [30].
The proportion of patients admitted to ICU was lower compared to
published US studies, probably due to the differences in ICU bed avail-
ability for major trauma patients. While all cases that required TTA
will be seen by an ICU physician, the decision for admission was on a
case by case basis. The severity of the injury, pre-morbid conditions, ex-
pected clinical course and monitoring necessary and factors like the
need for and fitness for surgery all contribute towards whether ICU ad-
mission was warranted. Taylor et al. reported results from 26,237
patients with blunt trauma from US, with an overall 42.7% ICU admis-
sion rate and a mean ICU LOS of 5.77 days [31]. It was also found that
with increasing ISS the ICU admission rates increase, but admission re-
duced with increasing age. Patients aged 65 or above with a lower ad-
mission rate of 36.7% but longer ICU LOS of 6.7 days. Trunkey et al.
highlighted that decisions for withdrawing aggressive treatments
were not made transparently and documentation can be poor [25]. It
is important to understand the differences in the factors associated
with ICU admissions, in order to decide whether it is appropriate to in-
clude as an indicator for outcome, or used to reflect the severity of the
patient's conditions.

Fig. 3. Percentage of death at 30 days by injury severity.

Please cite this article as: Hung KK, et al, Trauma team activation criteria and outcomes of geriatric trauma: 10year single centre cohort study,
American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2018.06.011
 K.K. Hung et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx 5

Table 2
Comparisons of clinical outcomes, primary trauma diversion and trauma team activation by age groups and ISS groups.

ISS ≤ 15 ISS N 15

Age 55–70 Age N70 P value Age 55–70 Age N70 P value

PTD activated 63 (9.2%) 78 (16.7%) b0.001 95 (19.0%) 76 (14.1%) 0.036

Trauma team activation 69 (10.1%) 33 (7.0%) 0.072 216 (43.2%) 136 (25.2%) b0.001
Received operation 226 (33.1%) 163 (34.8%) 0.557 231 (46.1%) 105 (19.4%) b0.001
ICU admission 33 (5.0%) 21 (4.7%) 0.823 194 (40.1%) 75 (14.4%) b0.001
D30-mortality 4 (0.6%) 10 (2.1%) 0.019 78 (15.6%) 162 (30.0%) b0.001
GOS on discharge
Death/PVS/SD 5 (0.7%) 22 (4.7%) b0.001 148 (29.6%) 242 (44.8%) b0.001
GR/MD 675 (99.3%) 446 (95.3%) 352 (70.4%) 298 (55.2%)

Although we have not captured data on the complications for our
trauma patients in our study, it is well know that it is a major cause of
mortality for geriatric trauma patients. Adams et al. found that elderly
trauma patients suffered from the same complications as their younger
counterparts, but at different rates [32]. The increased risk of complica-
tion started at 45 years of age, and the complications included skin ul-
cers (decubiti), renal, pulmonary, cardiac, thromboembolic and sepsis.
The careful prevention and monitoring for these events will no doubt
improve the outcomes of our geriatric trauma patients. It has been
found that frail patients were more likely to develop in-hospital compli-
cations with adjusted odds ratio of 2.5 (95% CI 1.5 to 6) [11].
In contrast to the trauma system in the US, the criteria for pre-
hospital triage and PTD does not automatically result in TTA in Hong
Kong. Various studies have reported that geriatric trauma patients
were under triaged [33-36] and suffer from under-calls [37]. It can be
difficult to demonstrate whether the under-triage has led to worse out-
come and higher mortality rates, with previous study suggesting the
60 day mortality after adjusted analysis was no different for those
with TTA or not [36]. Chang et al. sought to seek logical explanation
for the under triage of older trauma patients and found the problem of
age bias [34]. The most common reasons included inadequate training,
the perception of justifying the spending of resources on elderly pa-
tients by the healthcare providers, lack of familiarity with protocols,
providers not being welcome when an elderly trauma patient is admit-
ted, and perceived poorer prognosis by treating trauma teams.
Apart from the under call found in previous studies, our study has
found low sensitivity and high level of under-triage with our current
TTA criteria for dealing with geriatric trauma patients. There has been
much debate on whether separate TTA criteria should be made for geri-
atric patients, and what modifications might best serve this purpose.
The Ulleval University Hospital in Oslo has included the suggestion of
‘lower threshold for elderly and patients with chronic diseases’ in
their TTA anatomical category [38]. Kohn et al. found the TTA criteria
of age N 65 to have limited additional value, and resulted in only one
meaningful activation out of five [39].
Studies have suggested modifying the various physiological factors
including raising the GCS cut off from 13 to 14 [40-43], changing the sys-
tolic BP cut off from 100 [42] and 110 [43], and modifying the anatom-
ical criteria of one long bone fracture rather than two [42] etc. It has
been demonstrated that the sensitivity could be increased from 61% to
93% by Ichwan et al. [42], and with the new set protocol from 75.9% to
92.1% by Newgard et al. [43]. These promising results have highlighted
the possible improvement with our current TTA criteria. Supplementary
table 1 compared the TTA criteria for our centre and selected geriatric
TTA from London [9] and Ohio [42]. However, this decision must be
carefully balanced with the increase in resources for the trauma centres
with the increasing volume.
5. Limitations
This study has several limitations. Due to the retrospective nature of
the study, the nature of the association between the TTA and the out-
comes including the 30-day mortality cannot be ascertained. The TTA it-
self would like to have influenced the outcome, and therefore the
performance indicators of sensitivity, specificity, PPV cannot be
interpreted in the same way as the traditional diagnostic test studies.
Secondly, we acknowledge that the definition of the ‘severe out-
come’ could be subject to debate. The need for surgery and the ICU ad-
mission criteria are subject to individual physician judgements, and
therefore may not be the most reliable indicators to truly reflect the sen-
sitivity of the TTA criteria.
Another limitation was that the PWH trauma registry did not include
those who maybe under diverted by the ambulance services in Hong
Kong and patients transferred to non-trauma centres. We tried out
best to screen for cases that were under-called, but cannot guarantee
that none of the cases has been missed. The important measure of
pre-injury levels of activities of daily living or frailty were not available.
The trauma registry included a wide range of patients with different
mechanisms of injury and injury severities, some with more trivial low
energy falls and others with poor premorbid conditions, and maybe

Table 3
Predictors for 30-day mortality and good recovery/moderate disability.

30-day mortality Good recovery/moderate disability

Crude OR (95% CI) P value AOR (95% CI) P value Crude OR (95% CI) P value AOR (95% CI) P value

Age
N70 vs. 55–70 2.67 (2.04–3.49) b0.001 3.12 (2.23–4.36) b0.001 0.43 (0.35–0.53) b0.001 0.3 (0.22–0.4) b0.001
ISS
N15 vs. b15 24.36 (14.1–42.06) b0.001 15.8 (9–27.72) b0.001 0.04 (0.03–0.06) b0.001 0.06 (0.04–0.1) b0.001
Type of injury
Penetrating vs. blunt 0.2 (0.05–0.84) 0.028 0.66 (0.08–5.33) 0.696 8.69 (2.12–35.59) 0.003 3.95 (0.5–31.47) 0.194
Burn vs. blunt 0.82 (0.43–1.56) 0.547 2.33 (1.03–5.29) 0.043 1.65 (0.93–2.93) 0.088 0.85 (0.4–1.8) 0.676
Trauma call activation
Yes vs. No 5.41 (4.14–7.07) b0.001 4.62 (3.23–6.6) b0.001 0.18 (0.14–0.23) b0.001 0.27 (0.2–0.37) b0.001
ICU admission
Yes vs. No 2.38 (1.76–3.21) b0.001 1.19 (0.75–1.88) 0.455 0.26 (0.2–0.34) b0.001 0.63 (0.45–0.9) 0.011
Operation
Yes vs. No 0.7 (0.53–0.94) 0.016 0.54 (0.36–0.82) 0.004 0.98 (0.78–1.22) 0.846 –

Please cite this article as: Hung KK, et al, Trauma team activation criteria and outcomes of geriatric trauma: 10year single centre cohort study,
American Journal of Emergency Medicine (2017), https://doi.org/10.1016/j.ajem.2018.06.011
6 K.K. Hung et al. / American Journal of Emergency Medicine xxx (2017) xxx–xxx
Table 4
Performance of the trauma call activation criteria in identifying injured patients with severe outcome.a
Age Sensitivity (95% CI) Specificity (95% CI)
All (age 55 or above) 36.4% (32.6%–38.6%) 91.6% (90%–93.1%)
Age 55–70 41.0% (35.8%–44.3%) 89.9% (87.1%–92.0%)
Age N70 30.9% (26.6%–34.9%) 93.4% (91.7%–95.6%)
ISS ≤15 13.2% (9.4%–15.6%) 93.6% (91.8%–95.4%)
ISS N15 53.9% (49.2%–57.6%) 88.4% (85.7%–91.3%)
a
Injured patient with severe outcome defined as patients who died within 30 days upon admission or who required operation or admitted to ICU.
considered futile by the treating emergency physicians. The decision of
withdrawing aggressive treatment had not be explicitly recorded. A
prospective study to look into this specific issue might be warranted
in the future.
6. Conclusions
This study has found significant mortality for geriatric trauma pa-
tients, especially for those aged above 70. There is a need to consider al-
ternative TTA criteria for our geriatric trauma population, and to more
clearly define the process and standards of care in Hong Kong.
Funding
This research did not receive any specific grant from funding agen-
cies in the public, commercial, or not-for-profit sectors.
Author contributions
Study concept and design (KKCH, JHHY, CAG), acquisition of the data
(JHHY, RCHC, NKC), analysis and interpretation of the data (KKCH,
CSKC, LYL, CAG), drafting of the manuscript (KKCH, CAG), critical revi-
sion of the manuscript for important intellectual content (KKCH, JHHY,
CSKC, LYL, RCHC, NKC, CAG), statistical expertise (CSKC, CAG).
Conflict of interest
None declared.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.ajem.2018.06.011.
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