Major Trauma

Introduction:

Traumatic Brain Injury (TBI) is the most common fall-related injury among adults 65 and older, despite the high incidence there is a paucity of research to guide management of older adult TBI . Simple passive remote home monitoring systems can be used to unobtrusively track markers of health and function in older adults and enhance clinical decision making in community-based care models, such as ‘hospital at home’. There are few studies to-date examining healthcare practitioners (HCPs) views on this technology. We aimed to explore HCPs insights on how to best develop the technology and examined barriers and facilitators to the adoption of passive remote monitoring in the community to track health and function in older adults following TBI.

Method:

This was a multi-center mixed methodology qualitative study. HCPs opinions were explored during and online focus group and individual interviews. Purposive sampling was used to provide balanced representation of healthcare professionals (physicians, nurses and therapists) from both community and acute multidisciplinary teams. Data were analysed using the framework approach.

Results:

The perspectives of 6 HCPs were analysed. Potential barriers to adoption were HCPs lack of familiarity with technology, skepticism over the reliability of technology, the potential for nefarious use of patient’s data and concerns over how data will be managed and interpreted for clinical use. Facilitators were the promotion of safety and independence at home, reduced workload for HCPS, the potential to target appropriate healthcare interventions and flag issues early in cognitively impaired older adults.

Conclusion(s):

HCPs felt that passive remote monitoring holds potential to improve care for older adults following TBI. However, its implementation demands thoughtful planning and clear guidelines for its use and interpretation of data. Iterative development of these systems, incorporating HCPs insights will be key to successful and sustained use in research and clinical practice.

Introduction: It is well established that older adults with hip fracture benefit from comprehensive geriatric assessment (CGA), but there is less evidence for its use in major trauma. Since 2012 Major Trauma Centres(MTCs) have opened across the UK, with varying access to CGA. We report the requirement and impact of CGA in a MTC in its first year of opening.

Methods: We reviewed all adult patients admitted under the South-East Scotland MTC included in the Scottish Trauma Audit Group (STAG) database from 1st November 2021 – 31st October 2022. We compared: patients under 65y, patients ≥65y who did not undergo CGA, and patients ≥65y who underwent CGA. Outcomes were: review by ED consultant within one hour of presentation, trauma team activation, injury severity score (ISS), CGA within 7 days if CFS≥5, and mortality at 30 days.

Results: 1322 patients were identified: <65y (n=632, median age 48y), ≥65y without CGA (n=397, 77y), and ≥65y with CGA (n=289, 85y). The commonest mechanism of injury in all three groups was fall from standing height (29%, 60%, and 73% respectively). ED consultant review within 1 hour occurred in 37%, 26% and 17% of cases, with trauma team activation occurring in 34%, 20% and 9%. Median ISS were: 10, 10 and 9, and commonest sites of injury in those over 65 were external (e.g. skin), chest and limb. CGA was undertaken within 7 days in 95.1% of those with a documented CFS≥5. Mortality at 30 days was 2.9%, 12% and 8%.

Conclusions: A fifth of patients admitted to our MTC in the first year were older adults with CFS≥5. These patients were undertriaged at several stages despite comparable average ISS across groups. CGA may reduce 30 day mortality. We recommend further research into the benefit of CGA within MTCs.

Introduction:

In-hospital CPR has survival rates of 15-20%[BMA. Decisions on CPR, 3^rdedition, 2016], further reduced with frailty and multimorbidity. Successful CPR is associated with significant morbidity and prolonged suffering. Do not attempt resuscitation (DNACPR) is an advanced medical decision, aimed at preventing harm where CPR is considered futile.[GMC Guidance.p128-145]

Aims:

To reduce the burden of inappropriate CPR within surgical specialties using the following standards:

1. DNACPR status reviewed on admission, and all decisions implemented within 24hours of clerking.
2. DNACPR decisions implemented prior to surgery.
3. To assess clinician perceptions regarding DNACPR decisions.

Methods

This second cycle follows the intervention of a poster and departmental education in January 2020.

A survey was sent to clinicians of all grades in Trauma and Orthopaedics (T&O) and General Surgery in January 2023. Data on implementation of DNAR decisions was retrospectively collected over January and February 2023 for all T&O emergency and elective admissions >60-years-old.

Results

26 survey responses were obtained with all participants having had DNACPR discussions. 80.7% self-reported as confident/very confident in having these discussions.

Out of 264 patients included, 80 discussions took place, of which 64 (80%) were implemented. 69% were implemented within 24hours of clerking, a 23% increase from cycle 1. 90% of community DNACPRs (9/10) were applied within 24hours, however the one remaining patient received inappropriate CPR. Of the 47 patients with DNACPR who had surgery, 87% were implemented prior to surgery, a 12% increase from cycle 1.

Conclusion

Improvement was demonstrated on both standards between cycles. This QI focused on implementation of DNACPR following discussions, however, did not consider patients in whom DNACPR may have been appropriate but not discussed. Further areas to explore include appropriateness of CPR/ DNACPR decisions in advance of surgical interventions and the understanding behind limitations of treatment offered separate to CPR.

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.