Geriatric patients on antithrombotic therapy as a criterion for trauma team activation leads to over triage Zachary M. Callahan, Stephen P. Gadomski II * , Deepika Koganti, Pankaj H. Patel, Alec C. Beekley, Patricia Williams, Julie Donnelly, Murray J. Cohen, Joshua A. Marks Division of Trauma and Acute Care Surgery, Department of Surgery, Thomas Jefferson University Hospital,1015 Walnut St, Curtis Building Suite 620, Philadelphia, PA, 19107, USA article info Article history: Received 19 October 2018 Received in revised form 29 March 2019 Accepted 16 April 2019 Keywords: Geriatric trauma Antithrombotic Triage Undertriage Overtriage Anticoagulation abstract Background: Our institution amended its trauma activation criteria to require a Level II activation for patients 65 years old on antithrombotic medication presenting with suspected head trauma. Methods: Our institutional trauma registry was queried for geriatric patients on antithrombotic medi- cation in the year before and after this criteria change. Demographics, presentation metrics, level of activation, and outcomes were compared between groups. Results: After policy change, a greater proportion of patients received a trauma activation (19.9 vs. 74.9%, P < 0.001) and a greater proportion of these patients were discharged directly home without injury (4.3 vs. 44%, P < 0.001). However, a smaller proportion of patients with a critical Emergency Department disposition or traumatic intracranial hemorrhage failed to receive a trauma activation (65.1 vs. 23.5%, P < 0.001; 70.7% vs. 27.3%, P < 0.001). There was no change in mortality (4.3 vs. 2.0%, P ¼ 0.21). Conclusions: Implementing new criteria increased overtriage, decreased undertriage, and had little effect on mortality. © 2019 Elsevier Inc. All rights reserved. Introduction Appropriate triage of geriatric patients is a challenge faced by trauma centers around the world. The repercussions of under- triaging this high-risk group has encouraged some centers to use age or anticoagulation status as a sole criterion for trauma team activation. 1e3 The effects of these interventions are difficult to measure and more data are needed to determine the best way to safely treat this patient population while still minimizing unnec- essary trauma activations. Increased mortality in geriatric trauma patients is well- established. Unreliable presenting vital signs, poor physiologic reserve, and misleading Glasgow coma scores may lessen the effectiveness of standard triage criteria in identifying ill patients. 4e6 Additionally, undertriaging this patient population is particularly dangerous because these patients tend to have multiple medical comorbidities, poor nutritional status, and an increased likelihood of being on anticoagulation medication. 7e9 Several studies have suggested that including age or anticoagulation status in activation criteria can effectively increase the proportion of elderly patients evaluated by trauma teams at an increase in resource utilization and cost. 3, 10 Few institutions are poised to investigate the effects of tailoring activation criteria to the elderly as many trauma centers have already adopted geriatric-focused criteria while others may be unwilling to do so because of the vast impact such changes could have. Our institution underwent a major change in activation criteria by requiring at least a Level II trauma activation for elderly patients on antiplatelet or anticoagulation therapy presenting with suspected head trauma. Our study aims to evaluate the conse- quences of this policy change with a particular interest in the rate of over and undertriage. We hypothesize that this change resulted in an increase in overtriage and a decrease in undertriage. A second- ary hypothesis is that these changes would not impact length of stay or mortality. * Corresponding author. E-mail addresses: Zachary.Callahan@jefferson.edu (Z.M. Callahan), Stephen. gadomski@jefferson.edu (S.P. Gadomski), koganti.deepi@gmail.com (D. Koganti), Pankaj.Patel@crozer.org (P.H. Patel), Alec.Beekley@jefferson.edu (A.C. Beekley), Patricia.Williams@jefferson.edu (P. Williams), Julie.Donnelly@jefferson.edu (J. Donnelly), Murray.Cohen@jefferson.edu (M.J. Cohen), Joshua.Marks@jefferson. edu (J.A. Marks). Contents lists available at ScienceDirect The American Journal of Surgery journal homepage: www.americanjournalofsurgery.com https://doi.org/10.1016/j.amjsurg.2019.04.011 0002-9610/© 2019 Elsevier Inc. All rights reserved. The American Journal of Surgery 219 (2020) 43e48