Is level 1 trauma care necessary for all severely injured older patients? Evaluating undertriage and feasibility of care in major and non-major trauma centres in the Netherlands

Purpose
Undertriage remains a challenge within the severely injured older patients. The survival benefit in major trauma centres (MTCs) compared to non-major trauma centres (nMTCs) has been disputed. This study aimed to assess the differences in patient characteristics of severely injured older patients treated in MTCs and nMTCs and to regard whether these characteristics could be related to pre-hospital triage decisions and influence clinical outcomes in MTCs and nMTCs.

Methods
A retrospective cohort study was conducted, using the Dutch National Trauma Registry to identify all patients of 70 and above with an ISS >= 16 during 2016-2022. Patient characteristics and outcomes between MTCs, nMTCs and directly transferred patients were compared. Backward logistic regression analyses were performed to identify factors predicting mortality.

Results
A total of 10,899 patients were included. Patients in nMTCs harboured more octo- and nonagenarians than MTCs (44.6% vs. 37.2% and 15.1% vs. 6.7% resp., p < 0.001). The ISS was significantly lower in nMTCs (median 19 [IQR 17-25] vs. 22 [17-27], p < 0.001), with severe head injury and a low GCS being more prevalent in MTCs. High energy falls were more often observed in MTCs (15.6% vs. 7.7%, p < 0.001). Mortality was significantly lower in nMTCs (OR 0.59, 95%-CI 0.54-0.65), with a GCS 3-8 strongly associated with an increased risk for mortality in both nMTCs and MTCs (OR 19.93, p < 0.001 and OR 7.87, p < 0.001 resp.).

Conclusion
The differences in patients presented in MTCs and nMTCs indicate factors contributing to undertriage; severely injured older patients with recognizable injuries and trauma mechanisms are more likely to be presented in a MTC. Whether feasible care for severely injured older patients should be provided in MTCs or nMTCs should not only be dependent on ISS and mortality rates; patient-centred care goals harbouring broader perspectives as frailty and health- and quality-of-life benefit of aggressive injury treatment should also contribute in triage- and treatment decision-making. Level of evidence and study typeLevel III, prognostic/epidemiological.