A national study of 23 major trauma centres to investigate the effect of frailty on clinical outcomes in older people admitted with serious injury in England (FiTR 1): a multicentre observational study

Optimising prehospital trauma triage for older adults: challenges, limitations, and future directions

The ageing population presents significant challenges for prehospital trauma care, with older adults experiencing higher rates of undertriage and overtriage due to age-related physiological changes, frailty, and polypharmacy. Standard trauma triage tools, primarily designed for younger populations, often fail to accurately assess injury severity in older adults, leading to delays in definitive care or unnecessary resource use. This narrative review synthesises current evidence on the limitations of existing trauma triage tools for older adults, highlighting challenges such as inconsistent implementation, paramedic training gaps, and age-related biases. The review explores the role of adjusted systolic blood pressure thresholds, frailty assessments, and geriatric-specific triage protocols in improving triage accuracy. While these modifications show promise, their integration into prehospital care remains limited due to logistical and clinical barriers. Key findings suggest that incorporating frailty assessments, refining age-specific triage criteria, and enhancing paramedic education can improve the precision of prehospital trauma triage for older adults. However, significant research gaps remain, including the need for large-scale prospective studies on geriatric-specific triage tools and investigations into the impact of triage modifications on long-term patient outcomes. Standardising geriatric triage protocols, leveraging digital decision-support tools, and addressing disparities in trauma centre access are critical to optimising prehospital care for older trauma patients. Future research should focus on refining triage strategies to enhance decision-making and ensure that older adults receive timely, appropriate trauma care, ultimately reducing preventable morbidity and improving patient outcomes.

Decision-making in interhospital transfer of traumatic brain injury patients: exploring the perspectives of surgeons at general hospitals and neurosurgeons at neurotrauma centres

BACKGROUND

Traumatic brain injury (TBI) is a significant public health concern. Advancing age and comorbidities are associated with a reduced probability of being transferred to neurotrauma centres (NTCs) from non-neurosurgical acute care trauma hospitals (ACTHs). However, the extent to which these decisions reflect well-considered treatment-limiting decisions and which influence other factors have on the decision-making process remains unclear.

OBJECTIVE

To increase the understanding of adults' access to NTC care by exploring the decision-making process for interhospital transfer of patients with isolated TBI, elucidating factors influencing these decisions.

METHODS

Fifteen surgeons and neurosurgeons from four hospitals in Norway were recruited through purposive sampling to four semi-structured focus group interviews. Surgeons represented ACTHs and neurosurgeons NTCs, and all participants were responsible for TBI patients' initial care and transfer decisions. Interviews were thematically analysed.

RESULTS

We identified several factors influencing transfer decisions, captured in six main themes under one overarching theme; 'The chance of a favourable outcome'. The six main themes reflect surgeons' and neurosurgeons' decision-making process, which included clinical and system-level factors: (A) 'Establish TBI severity: Glasgow Coma Scale score and head CT', (B) 'Preinjury health status: comorbidity, functioning, and age', (C) 'Distance from ACTH to NTC: distance is time and time is brain', (D) 'Uncertainty and insecurity', (E) 'Capacity at NTC', and (F) 'Next of kin involvement'.

CONCLUSION

On-call surgeons and neurosurgeons responsible for making transfer decisions for TBI patients emphasise the importance of patient-centred decisions, including individual patients' risk factors and overall health status.

Frailty across the adult age spectrum and its effects on outcomes: Experience from a level 1 trauma centre

BACKGROUND

Recent evidence suggests that frailty may be a more reliable measure than age to predict outcomes following trauma. Frailty leads to prolonged hospitalisation and increased burden on the hospital system in older patients. The aim of this study is to review the prevalence of frailty in our trauma patients and the association of frailty with hospital-based and twelve-month outcomes.

METHODS

Patient demographics, discharge destination, hospital length of stay (LOS), and functional status at 12 months were reviewed. Frailty was assessed using the Clinical Frailty Scale (score <4 non frail, 4 vulnerable, >4 frail). Factors associated with frailty and outcomes including discharge destination (home or inpatient care) and LOS (p value <0.2) were included in multivariate models.

RESULTS

There were 1230 patients admitted to the trauma ward between November 2020-August 2021 who had linked registry data. Of these, 217 (17.6 %) were deemed frail with 131 (10.7 %) being vulnerable. In the group over 65 years, 38.6 % were frail and 16.1 % were vulnerable. Accounting for confounding factors (including age), being frail was associated with discharge to further inpatient care (AOR 4.82 (3.02 - 7.68), p value <0.001). At 12 months post injury, the mortality rate of patients with frailty was 28 %, compared to 2 % for the rest of the population and patients reported significantly more problems with undertaking daily tasks such as mobility and self-care.

CONCLUSION

After adjusting for confounding factors, frailty is associated with nearly five times the increase in odds of a discharge to further inpatient care. Long term outcomes are also significantly poorer for patients with frailty. Identifying frailty on admission may help outcomes by targeting this patient group and optimising healthcare resource usage.

Frailism: a scoping review exploring discrimination against people living with frailty

People living with frailty can experience discrimination, but unlike the characteristics of age and disability, frailty is not protected by law. Frailty is a clinical syndrome associated with ageing in which health deficits increase a person's vulnerability to illness, disability, and death. This scoping review, conducted by a team of methodologists, clinicians, lawyers, and patients, aimed to investigate the extent of discrimination against people living with frailty described in health-care literature. We searched five health-care databases from inception up to June, 2022, and grey literature, to identify 144 texts. The texts were classified by the types of discrimination (direct discrimination, indirect discrimination, harassment, and victimisation) and inductively developed into contextual themes. The median age of the participants was 77 years (IQR 69·9-82·0), and 65·4% were women. The most common types of discrimination were direct (in 90 [63%]), indirect (in 66 [46%]), and harassment (in one [1%]) of the 144 texts, with no instances of victimisation reported. Nine themes of discriminatory actions were developed. Discrimination against people living with frailty overlapped with discrimination based on established protected characteristics, including age, disability, race, and sex. Evidence indicated that frailty discrimination replaces, mediates, masks, and potentiates age discrimination. Discrimination against people with frailty seemed to be both an independent event and one that interacts with established protected characteristics. Future research should focus on preventing frailty-based discrimination and establishing whether frailty should be considered a new protected characteristic by law.

The impact of frailty on long-term functional outcomes in severely injured geriatric patients

BACKGROUND

The incidence of severe injury in the geriatric population is increasing. However, the impact of frailty on long-term outcomes after injury in this population remains understudied. Therefore, we aimed to understand the impact of frailty on long-term functional outcomes of severely injured geriatric patients.

METHODS

We conducted a retrospective cohort study, including patients ≥65 years old with an Injury Severity Score ≥15, who were admitted between December 2015 and April 2022 at one of 3 level 1 trauma centers in our region. Patients were contacted between 6 and 12 months postinjury and administered a trauma quality of life survey, which assessed for the presence of new functional limitations in their activities of daily living. We defined frailty using the mFI-5 validated frailty tool: patients with a score ≥2 out of 5 were considered frail. The impact of frailty on long-term functional outcomes was assessed using 1:1 propensity matching adjusting for patient characteristics, injury characteristics, and hospital site.

RESULTS

We included 580 patients, of whom 146 (25.2%) were frail. In a propensity-matched sample of 125 pairs, frail patients reported significantly higher functional limitations than nonfrail patients (69.6% vs 47.2%; P < .001). This difference was most prominent in the following activities: climbing stairs, walking on flat surfaces, going to the bathroom, bathing, and cooking meals. In a subgroup analysis, frail patients with traumatic brain injuries experienced significantly higher long-term functional limitations.

CONCLUSION

Frail geriatric patients with severe injury are more likely to have new long-term functional outcomes and may benefit from screening and postdischarge monitoring and rehabilitation services.

Association between clinical factors and mortality in older adult trauma patients: A systematic review and meta-analysis

BACKGROUND

This study reviews and meta-analysis factors affecting mortality in older adult trauma patients, addressing previously unidentified heterogeneity and risk burden.

METHODS

Databases (PubMed, Embase, Cochrane and Scopus) were searched for studies from January 1, 2000, to April 30, 2024. Inclusion criteria were patients aged ≥65 years with trauma, assessing survival or death outcomes. Two authors independently screened and extracted data using the PRISMA checklist; disagreements were resolved by a third author.

RESULTS

Eighteen retrospective studies were included (425,355 patients), showing an overall mortality rate of 9.6 ​%. Falls were the predominant cause of injury. Demographic mortality risk factors included advanced age, frailty, male sex, and comorbidities (blood/bleeding disorders, liver disease, cancer, kidney disease, and lung disease). Injury risk factors were identified as contributing to the outcome, including low systolic blood pressure, Glasgow Coma Scale, Injury Severity Score, Revised Trauma Score, and surgical intervention.

CONCLUSION

Trauma significantly elevates the mortality rate in older adults, with advanced age, gender, comorbidities, injury severity, frailty, and surgical intervention being key factors.

The RELIEF feasibility trial: topical lidocaine patches in older adults with rib fractures

BACKGROUND

Lidocaine patches, applied over rib fractures, may reduce pulmonary complications in older patients. Known barriers to recruiting older patients in emergency settings necessitate a feasibility trial. We aimed to establish whether a definitive randomised controlled trial (RCT) evaluating lidocaine patches in older patients with rib fracture(s) was feasible.

METHODS

This was a multicentre, parallel-group, open-label, feasibility RCT in seven hospitals in England and Scotland. Patients aged ≥65 years, presenting to ED with traumatic rib fracture(s) requiring hospital admission were randomised to receive up to 3×700 mg lidocaine patches (Ralvo), first applied in ED and then once daily for 72 hours in addition to standard care, or standard care alone. Feasibility outcomes were recruitment, retention and adherence. Clinical end points (pulmonary complications, pain and frailty-specific outcomes) and patient questionnaires were collected to determine feasibility of data collection and inform health economic scoping. Interviews and focus groups with trial participants and clinicians/research staff explored the understanding and acceptability of trial processes.

RESULTS

Between October 23, 2021 and October 7, 2022, 206 patients were eligible, of whom 100 (median age 83 years; IQR 74-88) were randomised; 48 to lidocaine patches and 52 to standard care. Pulmonary complications at 30 days were determined in 86% of participants and 83% of expected 30-day questionnaires were returned. Pulmonary complications occurred in 48% of the lidocaine group and 59% in standard care. Pain and some frailty-specific outcomes were not feasible to collect. Staff reported challenges in patient compliance, unfamiliarity with research measures and overwhelming the patients with research procedures.

CONCLUSION

Recruitment of older patients with rib fracture(s) in an emergency setting for the evaluation of lidocaine patches is feasible. Refinement of data collection, with a focus on the collection of pain, frailty-specific outcomes and intervention delivery are needed before progression to a definitive trial.

TRIAL REGISTRATION NUMBER

ISRCTN14813929.

The effect of frailty on mortality and hospital admission in patients with benign pleural disease in Wales: a cohort study

BACKGROUND

Pleural disease is common, representing 5% of the acute medical workload, and its incidence is rising, partly due to the ageing population. Frailty is an important feature and little is known about disease progression in patients with frailty and pleural disease. We aimed to examine the effect of frailty on mortality and other relevant outcomes in patients diagnosed with pleural disease.

METHODS

In this cohort study in Wales, the national Secure Anonymised Information Linkage databank was used to identify a cohort of individuals diagnosed with non-malignant pleural disease between Jan 1, 2005, and March 1, 2023, who were not known to have left Wales. Frailty was assessed at diagnosis of pleural disease using an electronic Frailty Index. The primary outcome was time from diagnosis to all-cause mortality for all patients. Data were analysed using multilevel mixed-effects Cox proportional hazards regression adjusting for the prespecified covariates of age, sex, Welsh Index of Multiple Deprivation quintile, smoking status, comorbidity, and subtype of pleural disease.

FINDINGS

54 566 individuals were included in the final sample (median age 66 years [IQR 47-77]; 26 477 [48·5%] were female and 28 089 [51·5%] were male). By the end of the study period, 25 698 (47·1%) participants had died, with a median follow-up of 1·0 years (IQR 0·2-3·6). There was an association between frailty and all-cause mortality, which increased as frailty worsened. Compared with fit individuals, there was increasing mortality for those with mild frailty (adjusted hazard ratio 1·11 [95% CI 1·08-1·15]; p<0·0001), moderate frailty (1·25 [1·20-1·31]; p<0·0001), and severe frailty (1·36 [1·28-1·44]; p<0·0001).

INTERPRETATION

Independent of age and comorbidities, frailty status at diagnosis of pleural disease appeared to be useful as a prognostic indicator. Patients with moderate or severe frailty had a rapid decline in health. Future patients should be assessed for frailty at the time of diagnosis of pleural disease and might benefit from optimised care and advance care planning.

FUNDING

Cardiff University's Wellcome Trust iTPA funding award.

Frailty Is More Predictive of Mortality than Age in Patients With Hip Fractures

OBJECTIVES

To investigate the association between the Comprehensive Geriatric Assessment-based Frailty Index and adverse outcomes in older adult patients undergoing hip fracture surgery.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Academic Level 1 Trauma Center.

PATIENTS

All patients aged 65 or older who underwent surgical repair of a hip fracture between May 2018 and August 2020 were identified through institutional database review.

OUTCOME MEASURES AND COMPARISONS

Data including demographics, FI, injury presentation, and hospital course were collected. Patients were grouped by FI as nonfrail (FI < 0.21), frail (0.21 ≤ FI < 0.45), and severely frail (FI > 0.45). Adverse outcomes of these groups were compared using Kaplan Meier survival analysis. Risk factors for 1-year rehospitalization and 2-year mortality were evaluated using Cox hazard regression.

RESULTS

Three hundred sixteen patients were included, with 62 nonfrail, 185 frail, and 69 severely frail patients. The total population was on average 83.8 years old, predominantly white (88.0%), and majority female (69.9%) with an average FI of 0.33 (SD: 0.14). The nonfrail cohort was on average 78.8 years old, 93.6% white, and 80.7% female; the frail cohort was on average 84.5 years old, 92.4% white, and 71.9% female; and the severely frail cohort was on average 86.4 years old, 71.0% white, and 55.1% female. Rate of 1-year readmission increased with frailty level, with a rate of 38% in nonfrail patients, 55.6% in frail patients, and 74.2% in severely frail patients (P = 0.001). The same pattern was seen in 2-year mortality rates, with a rate of 2.8% in nonfrail patients, 36.7% in frail patients, and 77.5% in severely frail patients (P < 0.0001). Being classified as frail or severely frail exhibited greater association with mortality within 2 years than age, with hazard ratio of 17.81 for frail patients and 56.81 for severely frail patients compared with 1.19 per 5 years of age.

CONCLUSIONS

Increased frailty as measured by the Frailty Index is significantly associated with increased 2-year mortality and 1-year hospital readmission rates after hip fracture surgery. Degree of frailty predicts mortality more strongly than age alone. Assessing frailty with the Frailty Index can identify higher-risk surgical candidates, facilitate clinical decision making, and guide discussions about goals of care with family members, surgeons, and geriatricians.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does frailty impact failure-to-rescue in geriatric trauma patients?

BACKGROUND

Failure-to-rescue (FTR), defined as death following a major complication, is a metric of trauma quality. The impact of patient frailty on FTR has not been fully investigated, especially in geriatric trauma patients. This study hypothesized that frailty increased the risk of FTR in geriatric patients with severe injury.

METHODS

A retrospective cohort study was conducted using the TQIP database between 2015 and 2019, including geriatric patients with trauma (age ≥65 years) and an Injury Severity Score (ISS) > 15, who survived ≥48 hours postadmission. Frailty was assessed using the modified 5-item frailty index (mFI). Patients were categorized into frail (mFI ≥ 2) and nonfrail (mFI < 2) groups. Logistic regression analysis and a generalized additive model (GAM) were used to examine the association between FTR and patient frailty after controlling for age, sex, type of injury, trauma center level, ISS, and vital signs on admission.

RESULTS

Among 52,312 geriatric trauma patients, 34.6% were frail (mean mFI: frail: 2.3 vs. nonfrail: 0.9, p < 0.001). Frail patients were older (age, 77 vs. 74 years, p < 0.001), had a lower ISS (19 vs. 21, p < 0.001), and had a higher incidence of FTR compared with nonfrail patients (8.7% vs. 8.0%, p = 0.006). Logistic regression analysis revealed that frailty was an independent predictor of FTR (odds ratio, 1.32; confidence interval, 1.23-1.44; p < 0.001). The GAM plots showed a linear increase in FTR incidence with increasing mFI after adjusting for confounders.

CONCLUSION

This study demonstrated that frailty independently contributes to an increased risk of FTR in geriatric trauma patients. The impact of patient frailty should be considered when using FTR to measure the quality of trauma care.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

The association between frailty and survival in patients with pleural disease: a retrospective cohort study

BACKGROUND

There are currently no data on the relationship between frailty and mortality in pleural disease. Understanding the relationship between frailty and outcomes is increasingly important for clinicians to guide decisions regarding investigation and management. This study aims to explore the relationship between all-cause mortality and frailty status in patients with pleural disease.

METHODS

In this retrospective analysis of a prospectively collected observational cohort study, outpatients presenting to the pleural service at a tertiary centre in Bristol, UK with a radiologically confirmed, undiagnosed pleural effusion underwent comprehensive assessment and were assigned a final diagnosis at 12 months. The modified frailty index (mFI) was calculated and participants classified as frail (mFI ≥ 0.4) or not frail (mFI ≤ 0.2).

RESULTS

676 participants were included from 3rd March 2008 to 29th December 2020. The median time to mortality was 490 days (IQR 161-1595). A positive association was found between 12-month mortality and frailty (aHR = 1.72, 95% CI 1.02-2.76, p = 0.025) and age ≥ 80 (aHR = 1.80, 95% CI 1.24-2.62, p = 0.002). Subgroup analyses found a stronger association between 12-month mortality and frailty in benign disease (aHR = 4.36, 95% CI 2.17-8.77, p < 0.0001) than in all pleural disease. Malignancy irrespective of frailty status was associated with an increase in all-cause mortality (aHR = 10.40, 95% CI 6.01-18.01, p < 0.0001).

CONCLUSION

This is the first study evaluating the relationship between frailty and outcomes in pleural disease. Our data demonstrates a strong association between frailty and 12-month mortality in this cohort. A malignant diagnosis is an independent predictor of 12-month mortality, irrespective of frailty status. Frailty was also strongly associated with 12-month mortality in patients with a benign underlying cause for their pleural disease. This has clinical relevance for pleural physicians; evaluating patients' frailty status and its impact on mortality can guide clinicians in assessing suitability for invasive investigation and management.

TRIAL REGISTRATION

This study is registered with the Health Research Authority (REC reference 08/H0102/11) and the NIHR Portfolio (Study ID 8960).

Muscularity of older trauma patients at intensive care unit admission, association with functional outcomes, and relationship with frailty: A retrospective observational study

BACKGROUND

Older individuals are at an increased risk of delayed recovery following a traumatic injury. Measurement of muscularity and frailty at hospital admission may aid with prognostication and risk stratification.

OBJECTIVE

This study aimed to describe muscularity at intensive care unit (ICU) admission in patients admitted following trauma and assess the relationship between muscularity and clinical, long-term functional outcomes and frailty at ICU admission.

METHODS

This retrospective study utilised data from a prospective observational study investigating frailty in patients aged ≥50 years, admitted to the ICU following trauma. Patients were eligible if they had a Computed Tomography (CT) scan including the third lumbar vertebra at ICU admission. Specialist software was used to quantify CT-derived skeletal muscle cross-sectional area. Muscularity status was classified as normal or low using published sex-specific cut-points. Demographic data, frailty, clinical, and long-term functional outcomes (Glasgow Outcome Scale-Extended and EQ-5DL-5L Visual analogue scale and utility score) were extracted from the original study.

RESULTS

One hundred patients were screened; 71 patients had a CT scan on admission with 66 scans suitable for muscle assessment. Patients with low muscularity (n = 25, 38%) were older and had a higher Acute Physiology and Chronic Health Evaluation II score and lower body mass index than patients with normal muscularity. Low muscularity was associated with frailty at admission (32% vs 5%, p = 0.005) but not with long term outcomes at 6 or 12 months. As a continuous variable, lower muscle cross-sectional area was associated with a poorer outcome on the Glasgow Outcome Scale-Extended at 6 months (mean [standard deviation]: 150 [43] and 180 [44], respectively; p = 0.014), no association was observed after adjustment for age p = 0.43).

CONCLUSION

In a population of older adults hospitalised following trauma, low muscularity at ICU admission was prevalent. Low muscularity was associated with frailty but not long-term functional outcomes. Larger studies are warranted to better understand the relationship between muscularity and long-term functional outcomes.

30-Day Mortality among Very Old Patients Admitted to European Intensive Care Units for Major Trauma

INTRODUCTION

Cases of major trauma in the very old (over 80 years) are increasingly common in the intensive care unit (ICU). Predicting outcome is challenging in this group of patients as chronological age is a poor marker of health and poor predictor of outcome. Increasingly, decisions are guided by the use of organ dysfunction scores of both acute conditions (e.g., sequential organ failure assessment [SOFA] score) and chronic health issues (e.g., clinical frailty scale [CFS]). Recent work suggests that increased CFS is associated with a worse outcome in elderly major trauma patients. We aimed to test whether this association held true in the very old (over 80) or whether SOFA had a stronger association with 30-day outcome.

METHODS

Data from the very elderly intensive care patient (VIP)-1 and VIP-2 studies for patients over 80 years old with major trauma admissions were merged. These participants were recruited from 20 countries across Europe. Baseline characteristics, level of care provided, and outcome (ICU and 30-day mortality) were summarised. Uni- and multivariable regression analyses were undertaken to determine associations between CFS and SOFA score in the first 24 h, type of major trauma, and outcomes.

RESULTS

Of the 8,062 acute patients recruited to the two VIP studies, 498 patients were admitted to intensive care because of major trauma. Median age was 84 years, median SOFA score was 6 (IQR 3, 9), and median CFS was 3 (IQR 2, 5). Survival for 30 days was 54%. Median and interquartile range of CFS were the same for survivors and non-survivors. In the logistic regression analysis, CFS was not associated with increased mortality. SOFA score (p < 0.001) and trauma with head injury (p < 0.01) were associated with increased mortality.

CONCLUSIONS

Major trauma admissions in the very old are not uncommon, and 30-day mortality is high. We found that CFS was not a helpful predictor of mortality. SOFA and trauma with head injury were associated with worse outcomes in this patient group.

Frailty is associated with long-term outcomes in older trauma patients: A prospective cohort study

BACKGROUND

Most major trauma admissions are older adults, many of whom are living with frailty - a recognised risk factor for post-injury mortality.

OBJECTIVES

To describe the effect of frailty, and geriatrician review on mortality up to 4-years after hospitalisation following trauma.

METHODS

This prospective cohort study included patients 65 years or older admitted to North Bristol NHS Trusts' Major Trauma Centre from November 2018 to September 2019. The primary outcome was time-to-mortality, assessed with an adjusted multivariable Cox regression model. Analyses were adjusted for factors known to be associated with mortality including age, sex, comorbidities, injury factors, surgical procedure, and complications.

RESULTS

573 patients were included: median age was 81 years; 67.5 % were living with frailty (Clinical Frailty Scale, CFS 4-8). Mortality was 45.2 % at the end of the study. Compared to fit patients (CFS 1-2), risk of death increased in those living with very mild frailty (CFS 4; aHR 3.22 [95 % CI 1.53-6.77]), mild frailty (CFS 5; aHR 4.97 [95 % CI 2.40-10.28]), moderate frailty (CFS 6; aHR 5.94 [95 % CI 2.83-12.44]), and moderate to severe frailty (CFS 7-8; aHR 9.63 [95 % CI 4.35-21.32]). Geriatrician review was associated with less mortality (aHR 0.55, 95 % CI 0.38-0.79).

CONCLUSIONS

Frailty predicts long-term mortality in older trauma. Our findings have implications for clinician-patient discussions of prognosis and therapy goals. Furthermore, our results lend support to the routine provision of geriatrician input in trauma pathways.

Investigating the effects of frailty on six-month outcomes in older trauma patients admitted to UK major trauma centres: a multi-centre follow up study

BACKGROUND

Pre-injury frailty is associated with adverse in-hospital outcomes in older trauma patients, but the association with longer term survival and recovery is unclear. We aimed to investigate post discharge survival and health-related quality of life (HRQoL) in older frail patients at six months after Major Trauma Centre (MTC) admission.

METHODS

This was a multi-centre study of patients aged ≥ 65 years admitted to five MTCs. Data were collected via questionnaire at hospital discharge and six months later. The primary outcome was patient-reported HRQoL at follow up using Euroqol EQ5D-5 L visual analogue scale (VAS). Secondary outcomes included health status according to EQ5D dimensions and care requirements at follow up. Multivariable linear regression analysis was conducted to evaluate the association between predictor variables and EQ-5D-5 L VAS at follow up.

RESULTS

Fifty-four patients died in the follow up period, of which two-third (64%) had been categorised as frail pre-injury, compared to 21 (16%) of the 133 survivors. There was no difference in self-reported HRQoL between frail and not-frail patients at discharge (Mean EQ-VAS: Frail 55.8 vs. Not-frail 64.1, p = 0.137) however at follow-up HRQoL had improved for the not-frail group but deteriorated for frail patients (Mean EQ-VAS: Frail: 50.0 vs. Not-frail: 65.8, p = 0.009). There was a two-fold increase in poor quality of life at six months (VAS ≤ 50) for frail patients (Frail: 65% vs. Not-frail: 30% p < 0.009). Frailty (β-13.741 [95% CI -25.377, 2.105], p = 0.02), increased age (β -1.064 [95% CI [-1.705, -0.423] p = 0.00) and non-home discharge (β -12.017 [95% CI [118.403, 207.203], p = 0.04) were associated with worse HRQoL at follow up. Requirements for professional carers increased five-fold in frail patients at follow-up (Frail: 25% vs. Not-frail: 4%, p = 0.01).

CONCLUSIONS

Frailty is associated with increased mortality post trauma discharge and frail older trauma survivors had worse HRQoL and increased care needs at six months post-discharge. Pre-injury frailty is a predictor of poor longer-term HRQoL after trauma and recognition should enable early specialist pathways and discharge planning.

The Randomised Evaluation of early topical Lidocaine patches In Elderly patients admitted to hospital with rib Fractures (RELIEF): feasibility trial protocol

Background

Topical lidocaine patches, applied over rib fractures, have been suggested as a non-invasive method of local anaesthetic delivery to improve respiratory function, reduce opioid consumption and consequently reduce pulmonary complications. Older patients may gain most benefit from improved analgesic regimens yet lidocaine patches are untested as an early intervention in the Emergency Department (ED). The aim of this trial is to investigate uncertainties around trial design and conduct, to establish whether a definitive randomised trial of topical lidocaine patches in older patients with rib fractures is feasible.

Methods

RELIEF is an open label, multicentre, parallel group, individually randomised, feasibility randomised controlled trial with economic scoping and nested qualitative study. Patients aged ≥ 65 years presenting to the ED with traumatic rib fracture(s) requiring admission will be randomised 1:1 to lidocaine patches (intervention), in addition to standard clinical management, or standard clinical management alone. Lidocaine patches will be applied immediately after diagnosis in ED and continued daily for 72 hours or until discharge. Feasibility outcomes will focus on recruitment, adherence and follow-up data with a total sample size of 100. Clinical outcomes, such as 30-day pulmonary complications, and resource use will be collected to understand feasibility of data collection. Qualitative interviews will explore details of the trial design, trial acceptability and recruitment processes. An evaluation of the feasibility of measuring health economics outcomes data will be completed.

Discussion

Interventions to improve outcomes in elderly patients with rib fractures are urgently required. This feasibility trial will test a novel early intervention which has the potential of fulfilling this unmet need. The Randomised Evaluation of early topical Lidocaine patches In Elderly patients admitted to hospital with rib Fractures (RELIEF) feasibility trial will determine whether a definitive trial is feasible.

ISRCTN Registration

ISRCTN14813929 (22/04/2021).

Severe trauma with associated pelvic fractures: The impact of regional trauma networks on clinical outcome

Lately, the care of severely injured patients in the United Kingdom has undergone a significant transformation. The establishment of regional trauma networks (RTN) with designated Major Trauma Centers (MTCs) and satellite hospitals called Trauma Units (TUs) has centralized the care of severely injured patients in the MTCs. Pelvic fractures are notoriously linked with hypovolemic shock or even death from excessive blood loss. The aim of this prospective cohort study is to compare the profile of severely injured patients with combined pelvic fractures and their mortality between two different distinct eras of an advanced healthcare system. Anonymized consecutive patient records submitted to TARN UK between 2002 and 2017 by NHS England hospitals were analyzed. Records of patients without a pelvic fracture, or with isolated pelvic fractures (no other serious injury with abbreviated injury scale AIS >2) were excluded. All patients with known outcomes were included and were divided into 2 distinct periods (pre-RTN era: between January 2002 and March 2008 (control group); and RTN era April 2013 to June 2017 (study group)). Data from the transition period from April 2008 to March 2013 were excluded to minimize the effect of variations between the developing networks and MTCs during that era. Overall, the study group included 10,641 patients, whereas the control group was 3152 patients, with a median age of 52.4 and 35.1 years and an ISS of 24 and 27 respectively. A systolic blood pressure below 90mmHg was observed in 7.2% of patients in the study group and 10.4% in the control group. A significant increase of the median time to death (from 8hrs to 188hrs) was observed between the two eras. The cumulative mortality of severely injured patients with pelvic fractures decreased significantly from 17.8% to 12.4% (p<0.0001). The recorded improvement of survivorship in the subgroup of severely injured patients with a pelvic fracture (32% lower in the post-RTN than in the pre-RTN period: OR 1.32  (95% CI 1.21 - 1.44), following the first 5 years of established regional trauma networks in NHS England, is encouraging, and should be attributed to a wide range of factors that translate to all levels of trauma care.

A national study of 23 major trauma centres to investigate the effect of a geriatrician assessment on clinical outcomes in older people admitted with serious injury in England (FiTR 2): a multicentre observational cohort study

BACKGROUND

Older people are at the greatest risk of poor outcomes after serious injury. Evidence is limited for the benefit of assessment by a geriatrician in trauma care. We aimed to determine the effect of geriatrician assessment on clinical outcomes for older people admitted to hospital with serious injury.

METHODS

In this multicentre observational study (FiTR 2), we extracted prospectively collected data on older people (aged ≥65 years) admitted to the 23 major trauma centres in England over a 2·5 year period from the Trauma Audit and Research Network (TARN) database. We examined the effect of a geriatrician assessment within 72 h of admission on the primary outcome of inpatient mortality in older people admitted to hospital with serious injury, with patients censored at discharge. We analysed data using a multi-level Cox regression model and estimated adjusted hazard ratios (aHRs).

FINDINGS

Between March 31, 2019, and Oct 31, 2021, 193 156 patients had records held by TARN, of whom 35 490 were included in these analyses. Median age was 81·4 years (IQR 74·1-87·6), 19 468 (54·9%) were female, and 16 022 (45·1%) were male. 28 208 (79·5%) patients had experienced a fall from less than 2 m. 16 504 (46·5%) people received a geriatrician assessment. 4419 (12·5%) patients died during hospital stay, with a median time from admission to death of 6 days (IQR 2-14). Of those who died, 1660 (37·6%) had received a geriatrician assessment and 2759 (62·4%) had not (aHR 0·43 [95% CI 0·40-0·46]; p<0·0001).

INTERPRETATION

Geriatrician assessment was associated with a reduced risk of death for seriously injured older people. These data support routine provision of geriatrician assessment in trauma care. Future research should explore the key components of a geriatrician assessment paired with a health economic evaluation.

FUNDING

None.