Configurations and outcomes of acute hospital care for frail and older patients with moderate to major trauma: a systematic review

Abstract

ObjectiveTo systematically review research on acute hospital care for frail or older adults experiencing moderate to major trauma.SettingElectronic databases (Medline, Embase, ASSIA, CINAHL Plus, SCOPUS, PsycINFO, EconLit, The Cochrane Library) were searched using index and key words, and reference lists and related articles hand-searched.Included articlesPeer-reviewed articles of any study design, published in English, 1999–2020 inclusive, referring to models of care for frail and/or older people in the acute hospital phase of care following traumatic injury defined as either moderate or major (mean or median Injury Severity Score ≥9). Excluded articles reported no empirical findings, were abstracts or literature reviews, or referred to frailty screening alone.MethodsScreening abstracts and full text, and completing data extractions and quality assessments using QualSyst was a blinded parallel process. A narrative synthesis, grouped by intervention type, was undertaken.Outcome measuresAny outcomes reported for patients, staff or care system.Results17 603 references were identified and 518 read in full; 22 were included—frailty and major trauma (n=0), frailty and moderate trauma (n=1), older people and major trauma (n=8), moderate or major trauma (n=7) 0r moderate trauma (n=6) . Studies were observational, heterogeneous in intervention and with variable methodological quality.Specific attention given to the care of older and/or frail people with moderate to major trauma in the North American context resulted in improvements to in-hospital processes and clinical outcomes, but highlights a relative paucity of evidence, particularly in relation to the first 48 hours post-injury.ConclusionsThis systematic review supports the need for, and further research into an intervention to address the care of frail and/or older patients with major trauma, and for the careful definition of age and frailty in relation to moderate or major trauma.International Prospective Register of Systematic Reviews (PROSPERO)CRD42016032895.

The older the injured, the worse the outcomes: A comparison of injury patterns and in-hospital outcomes between younger and older adult trauma patients at a tertiary hospital in Northern Tanzania.

“…Within our population, older adults had a significantly higher rate of diabetes and hypertension compared to younger adults, which impacted care provisions (17,31). Frailty due to aging may have also impacted recovery and increased the risk of complications in our population, as frailty has been shown to negatively impact health outcomes by 2-5 times (15,36,37,39). Comprehensive geriatric assessment and tailored treatment approaches are essential for optimizing outcomes in older adult trauma patients given they already have delays in reaching care, stay longer in hospitals following injuries, and are more likely to die compared to younger adults (54)(55)(56).…”

“…The scale assesses patients according to three aspects of responsiveness: eyeopening with a score of 4, motor with a score of 6, and verbal responses with a score of 5 with a total score of 15 (26). The GCS was categorized as mild (for scores of [13][14][15], moderate (for scores of [9][10][11][12], and severely impaired level of consciousness (for scores of 3-8).…”

“…Understanding these challenges will allow for evidence-based practices to be put in place for this population. In high-income countries (HICs), clinical practice guidelines for older adult trauma patients have been implemented and reduced older adult injury patient mortality rates by up to 20% and shown 10% lower rates of complications following trauma (11)(12)(13)(14)(15). Currently, there are no guidelines for older adult trauma patients in Tanzania.…”

Trauma in the elderly: a bilateral rectus sheath haematoma

“…Changes in elderly physiology necessitate the tailoring of clinical care. Elderly trauma guidelines use different physiological parameters for triage and reduced thresholds for senior review23–25 as a result of TARN recommendations 21. Special considerations must be applied to all aspects of the primary survey as summarised in table 3.…”

“…Many guidelines suggest geriatric assessment within 72 hours; geriatric input has a well-established reduction in mortality, complications, delirium and length of stay in critical care 23 32. Such individualistic approaches improve care and ultimately reduce mortality 24 33 34. A large multicentre study32 did identify an increased length of stay following geriatric assessment, but there is evidence to suggest that geriatric review compliance is variable in the UK 30.…”