Provision of acute care pathways for older major trauma patients in the UK

Abstract

Background The introduction of specific pathways of care for older trauma patients has been shown to decrease hospital length of stay and the overall rate of complications. The extent and scope of pathways and services for older major trauma patients in the UK is not currently known. Objective The primary objective of this study was to map the current care pathways and provision of services for older people following major trauma in the UK. Methods A cross-sectional survey of UK hospitals delivering care to major trauma patients (major trauma centres and trauma units). Data were collected on respondent and site characteristics, and local definitions of older trauma patients. To explore pathways for older people with major trauma, four clinical case examples were devised and respondents asked to complete responses that best illustrated the admission pathway for each. Results Responses from 56 hospitals were included in the analysis, including from 25 (84%) of all major trauma centres (MTCs) in the UK. The majority of respondents defined ‘old’ by chronological age, most commonly patients 65 years and over. The specialty team with overall responsibility for the patient in trauma units was most likely to be acute medicine or acute surgery. Patients in MTCs were not always admitted under the care of the major trauma service. Assessment by a geriatrician within 72 hours of admission varied in both major trauma centres and trauma units and was associated with increased age. Conclusions This survey highlights variability in the admitting specialty team and subsequent management of older major trauma patients across hospitals in the UK. Variability appears to be related to patient condition as well as provision of local resources. Whilst lack of standardisation may be a result of local service configuration this has the potential to impact negatively on quality of care, multi-disciplinary working, and outcomes.

Trauma in the elderly: a bilateral rectus sheath haematoma

“…The most recent trauma audit and research network report on trauma in older patients identified shortcomings in care. Older patients were found to be under triaged, and there were fewer prealerts, transfers to major trauma centres, activation of trauma calls and senior reviews 30. It was hypothesised that lower-impact mechanisms provided false reassurance and drove under-reporting.…”

“…Older patients have lower energy transfer mechanisms of injury, and the most common cause of major trauma in this group is a fall from standing. Due to comorbidity and diagnostic delay, there is an increased risk of death 30…”

“…In 2019, the advanced trauma life support guidelines introduced elderly patients with trauma as a special population that requires bespoke considerations for safe care 31. There are numerous elderly trauma local guidelines in use in EDs globally, with modifications to all aspects of care 23 30. 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. Geriatric assessment within 72 hours has been reported to be as low as 41–53.7%30 32 nationally.…”

“…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. Geriatric assessment within 72 hours has been reported to be as low as 41–53.7%30 32 nationally. Geriatric review was proportional to increasing age,30 32 but trauma team activation was inversely proportional 34.…”