Impact of a physician-led pre-hospital critical care team on outcomes after major trauma.

The deployment of physician-led pre-hospital enhanced care teams capable of critical care interventions at the scene of injury may confer a survival benefit to victims of major trauma. However, the evidence base for this widely adopted model is disputed. Failure to identify a clear survival benefit has been attributed to several factors, including an inherently more severely injured patient group who are attended by these teams. We undertook a novel retrospective analysis of the impact of a regional enhanced care team on observed vs. predicted patient survival based on outcomes recorded by the UK Trauma Audit and Research Network (TARN). The null hypothesis of this study was that attendance of an enhanced care team would make no difference to the number of 'unexpected survivors'. Patients attended by an enhanced care team were more seriously injured. Analysis of Trauma Audit and Research Network patient outcomes did not demonstrate an improved adjusted survival rate for trauma patients who were treated by a physician-led enhanced care team, but confirmed differences in patient characteristics and severity of injury for those who were attended by the team. We conclude that a further prospective multicentre analysis is warranted. An essential prerequisite for this would be to address the current blind spot in the Trauma Audit and Research Network database - patients who die from trauma before ever reaching hospital. We speculate that early on-scene critical care may convert this cohort of invisible trauma deaths into patients who might survive to reach hospital. Routine collection of data from these patients is warranted to include them in future studies.

Exploring patient attitudes to behaviour change before surgery to reduce peri-operative risk: preferences for short- vs. long-term behaviour change.

Pre-operative intervention to improve general health and readiness for surgery is known as prehabilitation. Modification of risk factors such as physical inactivity, smoking, hazardous alcohol consumption and an unhealthy weight can reduce the risk of peri-operative morbidity and improve patient outcomes. Interventions may need to target multiple risk behaviours. The acceptability to patients is unclear. We explored motivation, confidence and priority for changing health behaviours before surgery for short-term peri-operative health benefits in comparison with long-term general health benefits. A total of 299 participants at three UK hospital Trusts completed a structured questionnaire. We analysed participant baseline characteristics and risk behaviour profiles using independent sample t-tests and odds ratios. Ratings of motivation, confidence and priority were analysed using paired sample t-tests. We identified a substantial prevalence of risk behaviours in this surgical population, and clustering of multiple behaviours in 42.1% of participants. Levels of motivation, confidence and priority for increasing physical activity, weight management and reducing alcohol consumption were higher for peri-operative vs. longer term benefits. There was no difference for smoking cessation, and participants reported lower confidence for achieving this compared with other behaviours. Participants were also more confident than motivated in reducing their alcohol consumption pre-operatively. Overall, confidence ratings were lower than motivation levels in both the short- and long-term. This study identifies both substantial patient desire to modify behaviours for peri-operative benefit and the need for structured pre-operative support. These results provide objective evidence in support of a 'pre-operative teachable moment', and of patients' desire to change behaviours for health benefits in the short term.

Clinical guideline and recommendations on pre-operative exercise training in patients awaiting major non-cardiac surgery.

Despite calls for the routine implementation of pre-operative exercise programmes to optimise patient fitness before elective major surgery, there is no practical guidance for providing safe and effective exercise in this specific context. The following clinical guideline was developed following a review of the evidence on the effects of pre-operative exercise interventions. We developed a series of best-practice and, where possible, evidence-based statements to advise on patient care with respect to exercise training in the peri-operative period. These statements cover: patient selection for exercise training in surgical patients; integration of exercise training into multi-modal prehabilitation programmes; and advice on exercise prescription factors and follow-up. Although we acknowledge that further research is needed to identify the optimal exercise prescription in different clinical scenarios, we urge peri-operative teams to make use of these recommendations.

Reliability of repeated arm-crank cardiopulmonary exercise tests in patients with small abdominal aortic aneurysm.

Arm-crank ergometry may be useful in patients unable to pedal, for instance due to peripheral arterial disease. Twenty participants with small abdominal aortic aneurysm undertook two serial arm-crank tests and then a pedal test, four of whom had indeterminate anaerobic thresholds, precluding analysis. The mean (SD) peak arm and leg oxygen consumptions in 16 participants were 13.71 (2.62) ml.kg-1 .min-1 and 16.82 (4.44) ml.kg-1 .min-1 , with mean (SD) individual differences of 3.11 (2.48) ml.kg-1 .min-1 , p = 0.0001. The respective values at the anaerobic thresholds were 7.83 (1.58) ml O2 .kg-1 .min-1 and 10.09 (3.15) ml O2 .kg-1 .min-1 , with mean (SD) individual differences of 2.26 (2.34) ml O2 .kg-1 .min-1 , p = 0.0001. The correlation coefficients (95%CI) for peak oxygen consumption and anaerobic threshold were 0.88 (0.62-1.0) and 0.70 (0.32-1.0). There were no significant differences in serial arm-crank tests, with intracluster correlations (95%CI) of 0.87 (0.86-0.88) and 0.65 (0.61-0.69) for peak oxygen consumption and anaerobic threshold, respectively.

Do first impressions count? Frailty judged by initial clinical impression predicts medium-term mortality in vascular surgical patients.

Recognising frailty during pre-operative assessment is important. Frail patients experience higher mortality rates and are less likely to return to baseline functional status following the physiological insult of surgery. We evaluated the association between an initial clinical impression of frailty and all-cause mortality in 392 patients attending our vascular pre-operative assessment clinic. Prevalence of frailty assessed by the initial clinical impression was 30.6% (95% CI 26.0-35.2%). There were 133 deaths in 392 patients over a median follow-up period of 4 years. Using Cox regression, adjusted for age, sex, revised cardiac risk index and surgery (yes/no), the hazard ratio for mortality for frail vs. not-frail was 2.14 (95% CI 1.51-3.05). The time to 20% mortality was 16 months in the frail group and 33 months in the not-frail group. The initial clinical impression is a useful screening tool to identify frail patients in pre-operative assessment.

Prevalence and implications of a difference in systolic blood pressure between one arm and the other in vascular surgical patients.

Inter-arm differences in blood pressure may confound haemodynamic management in vascular surgery. We evaluated 898 patients in the vascular pre-assessment clinic to determine the prevalence of inter-arm differences in systolic and mean arterial pressure, quantify the consequent risk of clinical error in siting monitoring peri-operatively and evaluate systolic inter-arm difference as a predictor of all-cause mortality (median follow-up 49 months). The prevalence of a systolic inter-arm difference ≥ 15 mmHg was 26% (95% CI 23-29%). The prevalence of an inter-arm mean arterial pressure difference ≥ 10 mmHg was 26% (95% CI 23-29%) and 11% (95% CI 9-13%) for a difference ≥ 15 mmHg. Monitoring could be erroneously sited in an arm reading lower for systolic pressure once in every seven to nine patients. The hazard ratio for a systolic inter-arm difference ≥ 15 mmHg vs < 15 mmHg was 1.03 (95% CI 0.78-1.36, p = 0.84). Large inter-arm blood pressure differences are common in this population, with a high potential for monitoring errors. Systolic inter-arm difference was not associated with medium-term mortality. [Correction added on 17 October 2013, after first online publication: In the Summary the sentence beginning 'We evaluated 898 patients' was corrected from (median (IQR [range]) follow-up 49 months) to read (median follow up 49 months)].

Systematic development and feasibility testing of a multibehavioural digital prehabilitation intervention for patients approaching major surgery (iPREPWELL): A study protocol.

Improving outcomes for people undergoing major surgery, specifically reducing perioperative morbidity and mortality remains a global health challenge. Prehabilitation involves the active preparation of patients prior to surgery, including support to tackle risk behaviours that mediate and undermine physical and mental health and wellbeing. The majority of prehabilitation interventions are delivered in person, however many patients express a preference for remotely-delivered interventions that provide them with tailored support and the flexibility. Digital prehabilitation interventions offer scalability and have the potential to benefit perioperative healthcare systems, however there is a lack of robustly developed and evaluated digital programmes for use in routine clinical care. We aim to systematically develop and test the feasibility of an evidence and theory-informed multibehavioural digital prehabilitation intervention 'iPREPWELL' designed to prepare patients for major surgery. The intervention will be developed with reference to the Behaviour Change Wheel, COM-B model, and the Theoretical Domains Framework. Codesign methodology will be used to develop a patient intervention and accompanying training intervention for healthcare professionals. Training will be designed to enable healthcare professionals to promote, support and facilitate delivery of the intervention as part of routine clinical care. Patients preparing for major surgery and healthcare professionals involved with their clinical care from two UK National Health Service centres will be recruited to stage 1 (systematic development) and stage 2 (feasibility testing of the intervention). Participants recruited at stage 1 will be asked to complete a COM-B questionnaire and to take part in a qualitative interview study and co-design workshops. Participants recruited at stage 2 (up to twenty healthcare professionals and forty participants) will be asked to take part in a single group intervention study where the primary outcomes will include feasibility, acceptability, and fidelity of intervention delivery, receipt, and enactment. Healthcare professionals will be trained to promote and support use of the intervention by patients, and the training intervention will be evaluated qualitatively and quantitatively. The multifaceted and systematically developed intervention will be the first of its kind and will provide a foundation for further refinement prior to formal efficacy testing.