Disparity in time to hemorrhage control surgery for injured older adults.

Abstract

Trauma centers are increasingly caring for injured older adults, and a subset of these patients requires surgery for hemorrhage control. Prolonged time to surgery for hemorrhage control is associated with increased mortality. We hypothesized that older adults requiring hemorrhage control surgery have a longer time to surgery than younger adults. We analyzed Trauma Quality Improvement Program data (2017-2019) for adult patients taken directly from the emergency department to the operating room for hemorrhage control surgery. We excluded patients who were functionally dependent or had an advanced directive. Multivariable Poisson regression was used to determine the difference in time to surgery between younger adults (aged 18-64 years) and older adults (65 years and older) while controlling for potential confounders. We identified 29,406 adult patients who underwent surgery for hemorrhage control, including 2,586 older adults (8.8%). On unadjusted analysis, older adults had longer median time to surgery than younger adults (83 vs. 55 minutes, p < 0.001). On multivariable Poisson regression, controlling for patient demographics, injury mechanism, Injury Severity Score, trauma center level, and type of surgery, adjusted time to surgery was 9.4 minutes longer for older adults (95% confidence interval, 7.3-11.5; p < 0.001). Adding medical comorbidities to the model decreased the adjusted time difference to 6.2 minutes (95% confidence interval, 4.2-8.2; p < 0.001). Shock index ≥1 was less common in older adults (36% vs. 49%, p < 0.001), and the time to surgery disparity was lower among older adults with shock index ≥1 at presentation compared with those with shock index <1. Older adults have a longer time to surgery for hemorrhage control than younger adults. This difference is partially mediated by a higher burden of medical comorbidities and physiologic differences that impact the presentation of shock among older adults. Trauma centers should work to streamline decisions regarding surgical intervention for older adults in hemorrhagic shock. Therapeutic/Care Management; Level IV.