Trauma scoring systems for evaluating trauma center triage criteria in older adults: a retrospective cohort study

Abstract

Standardized trauma assessment is essential for early clinical decision-making; however, it remains challenging in older adults because age-related physiological changes may obscure injury severity. Accurate triage is critical to ensure timely access to trauma centers (TCs). While triage decisions must rely on immediately available clinical findings, advanced trauma scoring systems are typically based on diagnostic data obtained later in the course of care. Although these tools are not suitable for real-time triage, they are established predictors of mortality and may provide an objective basis for evaluating TC qualification criteria. Because current national TC qualification criteria do not adequately account for age-specific factors, they may contribute to undertriage in older patients. This study aimed to retrospectively identify the trauma scoring system most suitable for evaluating TC qualification criteria in geriatric trauma patients. We conducted a retrospective cohort study of patients admitted to the emergency department of a single clinical hospital with a TC between 2017 and 2020. Among 155,320 ED admissions, 6,541 trauma patients aged ≥ 65 years were identified. Injury severity and physiological status were assessed using the coded Revised Trauma Score (RTSc), Injury Severity Score (ISS), and Trauma and Injury Severity Score (TRISS). A predefined subgroup of patients meeting national TC qualification criteria (TC group 65+) was analyzed separately. Predictive performance for in-hospital mortality was evaluated using receiver operating characteristic (ROC) curve analysis. TRISS showed the highest discrimination for in-hospital mortality (AUC 0.888), followed by ISS (0.867) and RTSc (0.687). In the TC group 65+ , the mean TRISS-predicted survival probability was 34.58%, whereas observed in-hospital survival was 48.72%. The estimated undertriage rate was 73.47%, suggesting that current national TC qualification criteria may perform inadequately in older trauma patients. Current national TC qualification criteria may contribute to undertriage among older patients, potentially delaying access to advanced trauma care. Among the evaluated scoring systems, TRISS demonstrated the highest discriminatory performance for in-hospital mortality and appears to be the most suitable retrospective reference standard for assessing TC qualification criteria in geriatric trauma patients.