Administration of Emergency Medicine THE AGE OF UNDERTRIAGE: CURRENT TRAUMA TRIAGE CRITERIA UNDERESTIMATE THE ROLE OF AGE AND COMORBIDITIES IN EARLY MORTALITY Elizabeth R. Benjamin, MD, PHD, FACS, Desmond Khor, MD, Jayun Cho, MD, Subarna Biswas, MD, Kenji Inaba, MD, FACS, and Demetrios Demetriades, MD, PHD, FACS Division of Trauma and Acute Care Surgery, Department of Surgery, LAC+USC Medical Center, Los Angeles, California Corresponding Address: Elizabeth R. Benjamin, MD, PHD, FACS, LAC+USC Medical Center, Department of Surgery, 2051 Marengo Street, IPT C5L-100, Los Angeles, CA 90033 , Abstract—Background: National guidelines recommend that prehospital and emergency department (ED) criteria identify patients who might benefit from trauma center triage and highest-level trauma team activation. However, some patients who are seemingly ‘‘stable’’ in the field and do not meet the standard criteria for trauma activation still die. Objectives: The purpose of this study was to identify these at-risk patients to potentially improve triage algo- rithms. Methods: Patients enrolled in the National Trauma Data Bank (2007–2012) were included. All adult blunt trauma patients that were stable in the field and upon arrival to the ED (defined as a Glasgow Coma Scale score of 13–15, a heart rate #120 beats/min, systolic blood pres- sure $90 mm Hg, and diastolic blood pressure #200 mm Hg) and did not meet the standard criteria for the highest- level trauma team activation as defined by the American College of Surgeons were included. Demographic, clinical, and injury data including comorbidities, ED vitals, and outcome were collected. Regression models were used to identify independent risk factors for mortality. Results: A total of 1,003,350 patients were stable in both the field and ED. Of these 11,010 (1.1%) died, including 1785 (0.2%) who died within 24 hours of hospital admission. The mortal- ity in patients $60 years of age was 2.6%, and in patients $60 years of age with either a cerebrovascular accident (CVA) or congestive heart failure (CHF) was 5.4%. Age $60 years was a significant independent predictor of early mortality (odds ratio [OR] 4.53, p < 0.001). CHF (OR 1.88, p < 0.001) and a history of stroke (OR 1.52, p < 0.001) were also significant independent predictors of mortality. Conclusions: Despite apparent evidence of both prehospital stability and stability upon arrival to the ED, patients $60 years of age and with a history of CHF or CVA have a significantly increased risk of early mortality after blunt trauma. These patients are at risk for subsequent clinical deterioration and should be considered for early transfer to a trauma center with highest-level activation. Ó 2018 Elsevier Inc. All rights reserved. , Keywords—age; comorbidities; trauma; undertriage INTRODUCTION The recent growth of the annual mortality rate from trauma has outpaced the rate of growth of the population. From 2000 to 2010, trauma deaths increased by 22.8% while the population increased by 9.7% (1). During this time, the median age in the United States by census data increased from 35.3 to 37.2 years old with a 15.1% increase in persons >65 years of age (https:// www.census.gov/prod/cen2010/briefs/c2010br-03.pdf). Although immediate on-scene mortality may be amelio- rated with preventative measures, improving in-hospital Presented at the 2016 Clinical Congress, American College of Surgeons, October 21–25, 2016, Washington, DC. Reprints are not available from the authors. RECEIVED: 29 April 2017; FINAL SUBMISSION RECEIVED: 4 February 2018; ACCEPTED: 6 February 2018 1 The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–10, 2018 Ó 2018 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter https://doi.org/10.1016/j.jemermed.2018.02.001