Evaluating Elderly-Specific Triage Tools in a Pre-hospital Setting: A Systematic Review (Resubmission 2)

Main Article Content

Jom Bhumitrakul





Evaluating Elderly-Specific Triage Tools in a Pre-hospital Setting: A Systematic Review



An aging global population results in significant changes in the demographic of major trauma patients. Despite this, current triage protocols in the United Kingdom do not include geriatric-specific parameters, leading to under-triage amongst the elderly population.

The aim of this review is to analyse the quality of elderly-focused triage systems implemented worldwide and interpret findings in the context of the United Kingdom.

Primary outcome: sensitivity and specificity of the triage tool. 


Secondary outcome: percent change in-hospital mortality after elderly-specific tool implementation.




Literature search from Pubmed and Imperial databases were used to identify primary research into Geriatric Trauma and the triage tools. PRISMA criteria was used to narrow down papers. Studies were appraised using the Quality Assessment of Diagnostic Accuracy Studies-2 and the Quality Assessment Tool for Quantitative Studies accordingly by two independent reviewers. Results from the studies were evaluated using narrative synthesis. 





For the primary outcome, all 7 studies demonstrated an increase in sensitivity when compared to the non-specific protocol (17% to 160% increase). Sensitivity ranged from 13% to 96%. Only one tool met the American College of Surgeons Committee on Trauma (ACS-COT) sensitivity target (95%). All elderly-focused tools demonstrated a decrease in specificity (6.1% to 81% decrease). Specificity ranged from 17% to 93%. Three criteria met the ACS-COT specificity target (75%).


No tools met the ACS-COT targets for sensitivity and specificities simultaneously. 


For the secondary outcome, 4 studies showed a percentage decrease in mortality ranging from -10.9% to -32.9%. 



Despite an improvement in sensitivity of geriatric-focused triage tools, their overall diagnostic efficacy in identifying elderly trauma needs remains inadequate. Elderly-focused triage correlated with decreased mortality rates in older adults but the extent in which triage tools affected mortality was unquantified.

Article Details

How to Cite
Bhumitrakul, J. (2021) “Evaluating Elderly-Specific Triage Tools in a Pre-hospital Setting: A Systematic Review (Resubmission 2)”, Journal of Asian Medical Students’ Association. Kuala Lumpur, Malaysia. Available at: https://jamsa.amsa-international.org/index.php/main/article/view/334 (Accessed: 26July2021).
Scientific Papers (AMSC Academic Competition)


Rep. No. The global burden of disease: 2004 update (2004).

van Breugel, J.M.M., Niemeyer, M.J.S., Houwert, R.M. et al. Global changes in mortality rates in polytrauma patients admitted to the ICU—a systematic review. World J Emerg Surg 15, 55 (2020). https://doi.org/10.1186/s13017-020-00330-3

National Audit Office. Major Trauma Care in England. HC213. [Internet]. 2010 [cited 2021]. Available from https://www.nao.org.uk/wp-content/uploads/2010/02/0910213.pdf

Kehoe A, Smith JE, Edwards A, et al The changing face of major trauma in the UK Emergency Medicine Journal 2015;32:911-915.

Hildebrand F, Pape HC, Horst K, Andruszkow H, Kobbe P, Simon TP, Marx G, Schürholz T. Impact of age on the clinical outcomes of major trauma. Eur J Trauma Emerg Surg. 2016 Jun;42(3):317-32.

Joseph B, Phelan H, Hassan A, Orouji Jokar T, O'Keeffe T, Azim A, Gries L, Kulvatunyou N, Latifi R, Rhee P. The impact of frailty on failure-to-rescue in geriatric trauma patients: A prospective study. J Trauma Acute Care Surg. 2016 Dec;81(6):1150-1155.

Jiang L, Zheng Z, Zhang M. The incidence of geriatric trauma is increasing and comparison of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients. World J Emerg Surg. 2020;15(1):59. Published 2020 Oct 19. doi:10.1186/s13017-020-00340-1

Griffiths R, Surendra Kumar D. Major trauma in older people: implications for anaesthesia and intensive care medicine. Anaesthesia. 2017;72(11):1302-1305. doi:10.1111/anae.14027

Trauma audit and research network, England and Wales. Major trauma in older people 2017. https://www.ta rn.ac.uk/Content.aspx?c=3793

Ichwan B, Darbha S, Shah MN, et al. Geriatric-specific triage criteria are more sensitive than standard adult criteria in identifying need for trauma center care in injured older adults. Ann Emerg Med. 2015;65(1):92-100.e3. doi:10.1016/j.annemergmed.2014.04.019

Shenkin SD, Harrison JK,Wilkinson T, Dodds RM, Ioannidis JPA. Systematic reviews: guidance relevant for studies of older people. Age Ageing. 2017; 46(5):722–728.

Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151:264–269, W64.

Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM, QUADAS-2 Group. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155:529–536.

Effective Public Health Practice Project. (1998). Quality Assessment Tool For Quantitative Studies. Hamilton, ON: Effective Public Health Practice Project. Available from: https://merst.ca/ephpp/

American College of Surgeons Committee on Trauma (ACS-COT). Resources for optimal care of the injured patient 2014. Chicago, IL: The Committee; 2014. Available at: https://www.facs.org/-/media/files/qualityprograms/ trauma/vrc-resources/resources-for-optimal-care.ashx. Accessed 09-04-2020.

Centre for Reviews and Dissemination. Systematic Reviews: CRD’s Guidance for Undertaking Reviews in Health Care. York: Centre for Reviews and Dissemination; 2009.

McKenzie JE BS, Ryan RE, Thomson HJ, Johnston RV. Chapter 9: summarizing study characteristics and preparing for synthesis. 2019. In: Cochrane Handbook for Systematic Reviews of interventions version 6.0 (updated July 2019) [Internet]. Cochrane, 2019. Available at: https://training. cochrane.org/handbook.

British Medical Journal Best Practice. What is GRADE? [Internet] [Updated 2021]. Available from: https://bestpractice.bmj.com/info/toolkit/learn-ebm/what-is-grade/

Brozek JL, Canelo-Aybar C, Akl EA, et al. GRADE Guidelines 30: the GRADE approach to assessing the certainty of modeled evidence-An overview in the context of health decision-making. J Clin Epidemiol. 2021;129:138-150. doi:10.1016/j.jclinepi.2020.09.018

Caterino JM, Raubenolt A, Cudnik MT. Modification of Glasgow Coma Scale criteria for injured elders. Acad Emerg Med. 2011;18(10):1014-1021. doi:10.1111/j.1553-2712.2011.01164.x

Sahr SM, Webb ML, Renner CH, Sokol RK, Swegle JR. Implementation of a rib fracture triage protocol in elderly trauma patients. J Trauma Nurs. 2013;20(4):172-177. doi:10.1097/JTN.0000000000000008

Ichwan, B. et al. (2013) Evaluation for Ohio’s Geriatric Specific Trauma Triage Criteria: Assessing Implementation and Improvement in Outcomes for Ohio’s Elders. Annals of emergency medicine. [Online] 62 (4), S115–S115.

Foo CL, Siu VW, Ang H, Phuah MW, Ooi CK. Risk stratification and rapid geriatric screening in an emergency department - a quasi-randomised controlled trial. BMC Geriatr. 2014;14:98. Published 2014 Aug 30. doi:10.1186/1471-2318-14-98

Brown JB, Gestring ML, Forsythe RM, et al. Systolic blood pressure criteria in the National Trauma Triage Protocol for geriatric trauma: 110 is the new 90. J Trauma Acute Care Surg. 2015;78(2):352-359. doi:10.1097/TA.0000000000000523

Caterino JM, Brown NV, Hamilton MW, et al. Effect of Geriatric-Specific Trauma Triage Criteria on Outcomes in Injured Older Adults: A Statewide Retrospective Cohort Study. J Am Geriatr Soc. 2016;64(10):1944-1951. doi:10.1111/jgs.14376

Newgard CD, Holmes JF, Haukoos JS, et al. Improving early identification of the high-risk elderly trauma patient by emergency medical services. Injury. 2016;47(1):19-25. doi:10.1016/j.injury.2015.09.010

Newgard CD, Lin A, Eckstrom E, et al. Comorbidities, anticoagulants, and geriatric-specific physiology for the field triage of injured older adults. J Trauma Acute Care Surg. 2019;86(5):829-837. doi:10.1097/TA.0000000000002195

Covino M, Zaccaria R, Bocci MG, et al. Blood Glucose Levels Combined with Triage Revised Trauma Score Improve the Outcome Prediction in Adults and in Elderly Patients with Trauma. Prehosp Disaster Med. 2021;36(2):175-182. doi:10.1017/S1049023X2000148X

World Health Organisation. Violent Injury Prevention. [2005][Online]

National Institute for Health and Care Excellence. Major trauma: service delivery. 2006. NICE guideline [NG40]

National Healthcare System. London Major Trauma System: Management of elderly major trauma patients – Second Edition. 2018.

Office for National Statistics. Living longer: how our population is changing and why it matters. 2018.

Nakamura Y, Daya M, Bulger EM, et al. Evaluating age in the field triage of injured persons. Ann Emerg Med. 2012;60(3):335-345. doi:10.1016/j.annemergmed.2012.04.006

Rogers A, Rogers F, Bradburn E, et al. Old and undertriaged: a lethal combination. Am Surg. 2012;78(6):711-715. doi:10.1177/000313481207800628

Lehmann R, Beekley A, Casey L, Salim A, Martin M. The impact of advanced age on trauma triage decisions and outcomes: a statewide analysis. Am J Surg. 2009;197(5):571-575. doi:10.1016/j.amjsurg.2008.12.037

Newgard CD, Richardson D, Holmes JF, et al. Physiologic field triage criteria for identifying seriously injured older adults. Prehosp Emerg Care. 2014;18(4):461-470. doi:10.3109/10903127.2014.912707

Fisher JM, Bates C, Banerjee J. The growing challenge of major trauma in older people: a role for comprehensive geriatric assessment? Age Ageing. 2017

Lindner T, Slagman A, Senkin A,MöckelM, Searle J.Medical history of elderly patients in the emergency setting: not an easy point-of-care diagnostic marker. Emerg Med Int. 2015

Dixon J, Dewar S. The NHS plan. BMJ. 2000;321(7257):315-316. doi:10.1136/bmj.321.7257.315

Tweedie D. Burning issues for 2018: long term funding of the NHS. BMJ. 2018;360:k643. Published 2018 Feb 15. doi:10.1136/bmj.k643

Hoyle AC, Biant LC, Young M. Undertriage of the elderly major trauma patient continues in major trauma centre care: a retrospective cohort review. Emerg Med J. 2020;37(8):508-514. doi:10.1136/emermed-2019-208541

National Health System. Regional Networks for Major Trauma NHS Clinical Advisory Groups Report. London. 2010. Available at: https://www.uhs.nhs.uk/Media/SUHTInternet/Services/Emergencymedicine/Regionalnetworksformajortrauma.pdf

Evans DC, Gerlach AT, Christy JM, et al. Pre-injury polypharmacy as a predictor of outcomes in trauma patients. Int J Crit Illn Inj Sci. 2011;1(2):104-109. doi:10.4103/2229-5151.84793

Garfinkel D, Zur-Gil S, Ben-Israel J. The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people. Isr Med Assoc J. 2007;9(6):430-434.

Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc. 1999;47(7):850-853. doi:10.1111/j.1532-5415.1999.tb03843.x

Ailabouni N, Mangin D, Nishtala PS. DEFEAT-polypharmacy: deprescribing anticholinergic and sedative medicines feasibility trial in residential aged care facilities. Int J Clin Pharm. 2019;41(1):167-178. doi:10.1007/s11096-019-00784-9

Fuller G, Pandor A, Essat M, et al. Diagnostic accuracy of prehospital triage tools for identifying major trauma in elderly injured patients: A systematic review. J Trauma Acute Care Surg. 2021;90(2):403-412. doi:10.1097/TA.0000000000003039