Major Trauma

Background

Perioperative services must adapt to the needs of an increasingly older surgical population. Perioperative medicine for Older People undergoing Surgery (POPS) services integrate geriatric medicine teams into surgical pathways to provide quality and cost-effective medical care. This project aims to examine value-based outcomes (clinical and financial impact) of embedding a POPS service at a district general hospital.

Methods

Following a period of implementation on an acute Trauma and Orthopaedic (T&O) ward, a two-week pilot was undertaken. All emergency fragility fracture admissions aged over 65 years with Clinical Frailty Scores (CFS) of ≥5 were included. Patients with hip fractures were excluded. The POPS service provided medical consultation, medicine rationalisation, proactive treatment escalation planning and shared decision making, as well as leading multidisciplinary team meetings. Outcome metrics: geriatric medicine consults, medical emergency team (MET)/cardiac arrest calls, staff/patient satisfaction and clinical coding. The REDUCE trial cost calculator was used to estimate savings.

Results

35 patients were included, mean age 84 years, mean CFS score 7. Ward MET calls and cardiac arrest calls were reduced from a weekly average of 2.5 to 0, and weekly referrals to geriatric medicine reduced from 3 to 0. Experience-based design surveys identified thematic improvements relating to leadership, communication, dignity and respect. Improved quality of documentation resulted in the comorbidity score tariff increasing from £3325 to £6096 per patient. For services introduced by POPS including Comprehensive Geriatric Assessment and delirium assessments, the REDUCE trial cost calculator estimated an additional saving of £2926 per patient totalling hospital savings of £2 million per year (for an estimated 700 patients per year).

Conclusion

Implementation of a POPS service at a district general hospital can lead to cost savings, improved patient and staff experience, and improved clinical outcomes within a sustainable workforce model.

Introduction: The incidence of fragility fractures is rising with increased life expectancies. Most hip fractures require surgery. Acute kidney injury (AKI) is a preventable clinical syndrome that raises the risk of mortality. The aim of this study was to investigate the prevalence of AKI in hip fracture patients.

Methods: Data relevant to reported risk factors for developing AKI were collected before and after surgery within hip fracture patients in 2020. This included serum blood tests, anthropometric data, surgical factors and length of inpatient hospital stay.

Results: A total of 190 patients were included in this study. The pre-operative prevalence of AKI was 2.1%. The post-operative prevalence of AKI was 19.8%. The overall prevalence of AKI was 21.6%. Higher weight (p=0.046), increased length of hospital stay (p<0.001) and route of admission (p=0.046) significantly increased post-operative AKI. Mortality rate was significantly higher (p=0.002) in patients who developed AKI (59.5%) compared to non-AKI patients (29.8%).

Conclusion: Approximately one-fifth of all patients presenting with hip fractures in this study developed AKI peri-operatively, significantly increasing mortality rate. Obesity, inpatient hip fractures and longer hospital stay pose the highest risk of post-operative AKI. Close monitoring, early diagnosis and treatment are important for this vulnerable patient group.

An 86-year-old lady, presented with an unwitnessed fall with no obvious head injury. Her Glasgow Coma Scale (GCS) was 15 on arrival. She denied precipitating factors, taking blood thinners or seizure medication. Her examination revealed tongue biting, suprapubic tenderness, and pain in both hips and arms. An X-ray of the possible affected joints was ordered. Bloods and venous blood gas (VBG) were unremarkable. Within a few hours, she had a witnessed tonic-clonic seizure with a swollen tongue, for which lorazepam and adrenaline were administered. Repeat VBG (post-ictal) revealed a high lactate with hypoxia and hypotension. Intravenous fluids and oxygen were administered with a full body trauma series and a Contrast-Enhanced Pulmonary Angiogram. This showed a large retroperitoneal haematoma, a comminuted fracture of the superior pubic ramus and an unstable thoracic fracture.  She was referred to surgeons and orthopaedics for further management.

Trauma in older patients with polymorbidities can be missed as they are poor historians with conflicting collateral histories and atypical presentations. The “Silver trauma” emphasises early diagnostics, intervention and outcome including rehabilitation, decreasing mortality and morbidity. (1) The most common trauma is a fall of less than two metres from standing. (2)  They should be searched for more than one injury (2) in this case, suprapubic tenderness. They can have atypical observations compared to younger people sustaining trauma. (1) Example, a higher baseline blood pressure due to significant aortic disease. Similarly, tachycardia can be masked by medications such as beta blockers.

They should be investigated for polytrauma following an unwitnessed fall with a low threshold for a full CT trauma series.

 Furthermore, early reversal of anticoagulation should be implemented with adequate pain relief hydration to prevent delirium. (2) Knowing local pathways for referral to specialist services, and considering of patient’s and relatives’ previous wishes are key for early mobilisation and discharge. (1)

Background

North Central London Integrated Care System has invested in a pre-hospital programme where geriatricians and emergency physicians support London Ambulance Service via a telephone ‘Silver Triage’ in their clinical decision making on whether to convey an older person living with frailty to hospital. The results of the scheme are described elsewhere.

Methods

452 cases were discussed with Silver Triage between November 2021 and January 2023. Paramedics using the service were sent a survey including a free text question on how the scheme could be improved which was analysed using thematic analysis.

Results

We received 103 comments on how we could improve which fell into three key themes each with subsequent subthemes:

1. Improving access to the service – this included expanding into a 24-hour service, accessible in other areas of London, available to emergency medicine technicians and for people not living in care or nursing homes.

2. Improving information about the service – this included education for paramedics on who to refer but also increasing awareness of the scheme in local emergency departments.

3. Improving delivery of the service – this included requests for video conferencing, reported technology issues and frustrations with pathway breakdown following triage. For example if the agreed plan was not to convey and to support through rapid response or district nurse services, lack of availability led to conveyance to hospital contrary to outcome of triage.

Conclusion

Whilst the Silver Triage scheme has been well received by paramedics there are clear areas for improvement to ensure sustainable and equitable pre-hospital care for older people living with frailty.

Background & Aim: While the significance of prehospital trauma care is increasingly recognised for older patients, limited research has been conducted to gain in-depth understanding of current paramedic practice. We aimed to explore Saudi paramedics and emergency medical technicians’ understanding of impacts of ageing changes, how they acquire and apply relevant knowledge as well as the barriers and facilitators to providing improved care for older trauma patients.

Methods: We undertook semi-structured qualitative interviews with 20 paramedics and ambulance technicians from the Saudi Red Crescent Authority’s ambulance stations. We used MAXQDA software to manage and code data, and framework approach’s five stages for analysis.

Results: Participants identified ageing, societal, behavioural, and organisational challenges when responding to older trauma patients. They perceived that older and younger trauma patients receive care differently due to comorbidities and polypharmacy, along with the influence of organisational and societal challenges on geriatric care. They identified a lack of adequate acquired relevant knowledge prior to employment in ambulance services, and no relevant courses or sponsors providing such courses after employment but were reluctant to admit their own knowledge gaps. They reported that family members and local culture can create challenges in applying acquired knowledge and experience when responding to female older patients.

Conclusion: Few studies have explored the challenges encountered while responding to and caring for older trauma patients. Prehospital trauma care could be improved through the development of clear guidelines, trauma care pathways, training for paramedics and EMTs, and increased awareness of cultural barriers.

Introduction:

Major trauma including Traumatic Brain Injury (TBI) is an increasingly common cause of hospitalisation in older adults. We studied post-discharge recovery from TBI using a remote healthcare monitoring system that captures data on activity and sleep. We aim to assess the feasibility and acceptability of this technology to monitor recovery at home following a significant acute clinical event in Older adults.

Methods:

We installed Minder, a remote healthcare monitoring system, in recently discharged patients >60 years with moderate-severe TBI. We present descriptive analyses of post-discharge recovery for two males, corroborating data from Minder against verified activities and events. We recorded semi-structured interviews assessing acceptability.

Results:

We present 6 months of sleep and activity data from Minder and feedback from interviews. Data observed from Participant 1 revealed habitual patterns of activity and sleep. These remained stable, despite discrete clinical events. Conversely, Participant 2's data revealed irregular sleep patterns that became increasingly fragmented. Activity was detected in multiple rooms throughout the house at night, consistent with carer reports of night-time wandering. Increased overnight activity coincided with multiple falls, prompting increased care provision. Initial feedback from interviews was the technology helped participants and those involved in their care feel supported.

Conclusions:

As pressure on services mounts, novel approaches to post-discharge care are of increasing importance. Remote healthcare monitoring can provide high temporal resolution data offering ‘real world’ insights into the effects of significant health events in Older adults. Our provisional results support our hypothesis that use of this technology is feasible and acceptable for frail, multi-morbid participants and highlights the substantial potential of this technology to help clinicians improve community-based care and more effectively monitor interventions and chronic conditions.