ACCURATE TRIAGE AND SPECIALIZED ASSESSMENT

NEEDS OF THE GERIATRIC TRAUMA PATIENT

WHO EXPERIENCES LOW-ENERGY TRAUMA
Authors: Lynette R. Fair, RN, Nancy Stephens Donatelli, RN, MS, CEN, NE-BC, and
Joan Somes, RNC, PhD, CEN, CPEN, FAEN,
Slippery Rock, New Wilmington, PA, and St Paul, MN
Section Editors: Nancy Stephens Donatelli, RN, MS, CEN, NE-BC, and Joan Somes, RNC, PhD, CEN, CPEN, FAEN
Introduction
Accurate triage and specialized needs assessment of the ger-
iatric trauma patient experiencing low-energy trauma
(LET) is an important patient outcome consideration.
Assessment of the patient must include the physiological
affect of injury on the older adult, medications that mask
abnormal vital signs, chronic medical problems or health
risks that increase mortality and morbidity, and the unde-
tected injury patterns of LET. Geriatric patients who are
not appropriately triaged to their level of injuries experience
delays in care.
1-4
Discussion
Triage, or prioritization of patients according to the severity
of their injuries, occurs prehospital and once again when the
patient arrives in the acute-care setting. Undertriage can be
defined as prioritizing the patient as less injured than what is
revealed after examination, or, in the prehospital setting, it
can be defined as not transporting an injured patient to the
appropriate trauma-certified center deemed necessary for the
injury detected after examination.
5-8
The considerations that are special to the geriatric trau-
ma patient contribute to undertriage of the injured older
adult and delay care and transport to an appropriate trauma
certified facility. Older adults experiencing lower energy
mechanisms of injury, such as falls from a standing position
or motor vehicle crashes less than 5 mph, are often under-
triaged. Initial assessments may appear benign, but once
examined, test results reveal serious injury patterns. When
compared to younger adults with the same injury patterns,
older adults experience longer recovery periods and higher
mortality rates.
1,9,10
Injury severity scores have long been used as predictors
of outcomes and for prioritization of treatment of the
severely injured. Based on the type, amount, and location
of injuries, these scales create a score for healthcare providers
to predict the seriousness of underlying or undetected inju-
ries and also death. Prehospital triage guidelines developed
for treatment and transport decisions no longer utilize injury
scales alone. Decision trees begin with assessments of airway,
breathing, and circulation, or ABCs. If the patient is stable,
factors move to mechanism of injury, high energy or low
energy, and finally to special considerations such as age,
bleeding disorders or blood thinners, pregnancy, burns,
etc.
8
Injury severity scores (ISS) and revised trauma scores
(RTS) are helpful in predicting outcomes of patients
admitted after injury because these scales have been tested
and shown to be statistically accurate in detecting mortality
and morbidity.
11
These scales are not used alone when prior-
itizing patients to appropriate care centers. It is widely
thought that overtriage of patients may use resources and
incur additional financial costs by implementing higher-
than-needed levels of trauma care; however, the undertriage
of patients can miss potentially life-threatening injuries.
12,13
Case Study
Mrs. Smith, a 90-year-old woman, arrives at the emergency
department at 0825 hours via ambulance. The report from
emergency medical services (EMS) states the call was for a
patient who fell. The patient was found lying on the bed-
room floor between a bedside commode, dresser, and bed.
EMS state the patient was awake and able to speak but
could not remember the fall. The son reported to EMS that
Lynette R. Fair, CODE Chapter ENA, is Clinical Manager of the Emergency
Department, Grove City Medical Center, Grove City, PA.
Nancy Stephens Donatelli, Member, CODE Chapter ENA, is Assessment
Nurse, Shenango Presbyterian SeniorCare, New Wilmington, PA.
Joan Somes, Member, Greater Twin Cities Chapter, is Staff Nurse/Department
Educator, St Josephs Hospital, St Paul, MN.
For correspondence, write: Lynette R. Fair, 1207 West Park Road, Slippery
Rock, Pennsylvania 16057; E-mail: ltwinettie@zoominternet.net.
J Emerg Nurs 2012;38:378-80.
0099-1767/$36.00
Copyright 2012 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
doi: 10.1016/j.jen.2012.06.002
G E R I A T R I C U P D A T E
378 JOURNAL OF EMERGENCY NURSING VOLUME 38 ISSUE 4 July 2012
the patient has a history of Alzheimers, hypothyroidism,
insulin-dependent diabetes mellitus (IDDM), hyperten-
sion, deep vein thrombosis, hyperlipidemia, osteoporosis,
overactive bladder, gastro-esophageal reflux, and right
shoulder pain due to rotator cuff injury. The patient is
known to be on warfarin. While assessing the patient for
the fall, she was noted to have a large hematoma with dis-
coloration above the left eye. Spinal precautions were
implemented by EMS prior to transport.
Assigned to bay 5, Mrs. Smith is transferred from the
EMS stretcher to the ED stretcher and triaged by the pri-
mary registered nurse (RN). Spinal precautions are main-
tained, with the patient remaining on the long board
with the stiff-neck collar intact.
Initial nursing assessment includes temperature 97.0F
temporal, pulse 80 beats per minute, respiration rate 20
per minute, blood pressure 150/71 mm Hg, initial Glas-
gow Coma Score (CGS) 11, and an RTS of 19. Injury
assessment includes ecchymotic area to the left side of
the forehead, skin tears to the left arm, abrasion to the left
hip and left knee, and left hip pain noted by the patient;
assessment is negative for left leg rotation or shortening.
Categorized as nonurgent, the patient does not exhibit
life-threatening injuries, arrhythmias, or vital signs other
than hypertension. Mrs. Smith is awake but not talkative.
The EMS crew at the bedside reports to the RN that blood
glucose on transport was 40 mg/dL, and oral glucagon was
administered. Bedside glucose check is now 64 mg/dL.
The ED physician is notified, and a medical examination
is performed.
The primary nurse categorized Mrs. Smith as nonur-
gent. In this case, the nursing assessment should include
special factors that impact geriatric trauma patients. When
the older adult is injured, physiological response for recov-
ery is altered and diminished due to coinciding disease pro-
cesses.
3,6,9
For a variety of reasons, elderly patients
respond differently to the physiological insult of trauma
than their younger counterparts. For example, it is widely
held that the physiological reserve across all major organs
declines with aging.
4
In addition, the common use of med-
ications such as Beta blockers limits the ability of an elderly
patient to mount normal systemic manifestations of shock,
namely hypotension and tachycardia.
3
Other considera-
tions are osteoporosis increasing the likelihood of bone
fractures, and pneumonia due to loss of elasticity in the
pulmonary system.
9
In Mrs. Smiths case, although her
injuries proved to be extensive enough to warrant a direct
transport from the scene to a trauma certified center,
8
once
she arrived, the nurses needed to implement a rapid assess-
ment. Geriatric LET patients should be prioritized as
urgent to facilitate early physician examination, expedite
radiological examinations, and allow for rapid transfer to
the appropriate level of care.
The reason for prioritizing geriatric LET patients as
urgent is that high-energy trauma (HET) and LET patients
are categorized differently even though mortality and mor-
bidity rates are nearly the same for both geriatric HET and
LET patients. An HET patients injuries are not as
obscured by pathophysiological response and include major
trauma, which dictates the rapid transfer of these patients
to appropriate trauma centers.
4
Often, geriatric LET
patients are not immediately transported to trauma facil-
ities; they are delayed, spending time moving through the
emergency department before being transported to tertiary
care facilities.
4
Other than elevated blood pressure due to her chronic
hypertension, Mrs. Smiths vital signs are noted to be with-
in normal limits. She is not on beta blockers that would
mask symptoms of shock. Blood thinners are noted, pla-
cing Mrs. Smith at high risk for bleeding, and osteoporosis
places her at risk for fractures. Although her low glucose
levels were treated, her altered mental status is difficult to
assess due to her history of Alzheimers. Mrs. Smith is still
not verbal, which raises questions, such as, is Mrs. Smiths
altered mental status due to Alzheimers itself? What is her
baseline functioning? Is this due to the hypoglycemia she is
experiencing? Is her current state due to the acute head
injury? Because her family believes she fell from either a
standing position or from sitting on the commode, her
injury is considered to be LET.
Physician documentation notes that the patient is
unable to talk due to Alzheimers diagnosis, making review
of systems unobtainable. Noted in the physician assess-
ment are ecchymosis left periorbital, left hip tenderness,
and skin tear left forearm. Diagnostic testing is initiated
with EKG, blood work, and CT scan, followed by hip
and pelvis radiographs.
Results are the following: white blood cell count 7.7;
hemoglobin 11.6; hematocrit 35.7; platelet count 213; pro-
time 21.5 seconds; prothrombin time 32.2 seconds; interna-
tional normalized ratio 2.3; sodium 141 mmol/L; potassium
3.6 mmol/L; chloride 102 mmol/L; glucose 70 mg/dL; blood
urea nitrogen 35 mg/dL; creatinine 1.41 mg/dL; glomerular
filtration rate 35 mL/min; and troponin I < 0.06 ng/mL. Mrs.
Smith is found to have subarachnoid hemorrhage and subdur-
al bleed. After reviewof the test results, type and crossmatch of
2 units of fresh frozen plasma (FFP) is ordered. The family is
at the bedside to discuss treatment options with the ED phy-
sician. An agreement is reached to transfer Mrs. Smith to a
tertiary care, trauma-certified facility for assessment by a neu-
rosurgeon. The critical care transport teamis notified of trans-
port. One unit of FFP is obtained and initiated. The second
Fair et al/GERIATRIC UPDATE
July 2012 VOLUME 38 ISSUE 4 WWW.JENONLINE.ORG 379
unit is sent with the critical care team. Mrs. Smith is trans-
ferred to the care of the critical care team at 1125 hours and
transported to the trauma center. The length of time from
EMS response to trauma center transfer was 180 minutes.
Outcome of Care
Mrs. Smith was admitted and treated at the trauma certi-
fied center, where her length of stay was 9 days. Discharge
diagnosis was left subdural hematoma, minimal acute sub-
arachnoid hemorrhage, malnutrition, right shoulder pain,
rapid atrial fibrillation, left upper extremity skin tear, right
upper extremity thrombophlebitis, and left upper extremity
cellulitis. Multidiscipline consultations consisted of neuro-
surgery, physical and occupational therapy, case manage-
ment, social services, cardiology, and dietary. Mrs. Smith
received a neuropsychology evaluation prior to discharge.
The assessment notes that she had some limited cognitive
abilities, which may have been exacerbated by the recent
head injury, predisposing her to limited cognitive recovery.
She was discharged to a skilled care facility near her home.
Follow-up with the skilled nursing facility (SNF) revealed
the patient was recovering from her injuries and complica-
tions. She is walking as tolerated and requires at least one
assist with activities of daily living to ensure that no further
injuries or falls occur.
Conclusion
It is important for healthcare providers to understand
special considerations when assessing injury in the geria-
tric patient. Injuries occurring in the younger adult that
pose little risk or short recovery times cannot be categor-
ized or triaged in the same way for the older adult
patient. Geriatric injury patients presenting to the emer-
gency department require an adapted specialized needs
assessment by healthcare workers proficient in complica-
tions and risks specific to this vulnerable population.
Educating physicians and staff through this process will
promote better patient outcomes toward reaching the
goal of quickly stabilizing and transferring the patient
to a higher level of care.
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Submissions to this column are encouraged and may be sent to
Joan Somes, RNC, PhD, CEN, CPEN, FAEN
somes@black-hole.com or
Nancy Stephens Donatelli, RN, MS, CEN, NE-BC
question4gene@gmail.com
GERIATRIC UPDATE/Fair et al
380 JOURNAL OF EMERGENCY NURSING VOLUME 38 ISSUE 4 July 2012