Frailty and Long-Term Mortality Following Emergency Laparotomy: A Comparison Between the 11-Item and 5-Item Modified Frailty Indices.

INTRODUCTION: Emergency laparotomy (EL) is a high-risk operation which is increasingly performed on an aging patient population. Objective frailty assessment using a validated index has the potential to improve preoperative risk stratification. This study aimed to assess the correlation between frailty and long-term mortality and morbidity outcomes for older EL patients. Secondary aims were to compare the 11-item and shortened five-item modified frailty indices (mFIs) in terms of value and predictive validity. METHODS: A prospective multicenter observational study of patients aged ≥55 y undergoing EL was conducted across five hospitals in New Zealand between 2017 and 2022. Frailty was measured using the 11-item and abbreviated five-item mFIs. Multivariable logistic regression was used to determine whether frailty was independently associated with one-year postoperative mortality and other morbidity outcomes. Correlation between the two frailty indices were assessed with the Spearman's correlation coefficient (P). RESULTS: Frailty assessments were performed in 861 participants, with the prevalence being 18.7% and 29.8% using the 11-item and five-item mFIs, respectively. Both frailty indices demonstrated similar associations with one-year mortality (two-fold increased risk), major complications, admission to intensive care unit, rehabilitation, and 30-d readmission. The 11-item mFI demonstrated a greater association with early mortality (four-fold increased risk), reoperations, and increased length of stay compared with the five-item frailty index. Spearman P was 0.6 (P < 0.001). CONCLUSIONS: Frailty, as identified by the 11-item and five-item mFIs, was associated with one-year mortality and other important morbidity outcomes for older EL patients. These forms of frailty assessment provide important information that may aid in risk assessment and patient-centered decision-making.

Frailty using the Clinical Frailty Scale to predict short- and long-term adverse outcomes following emergency laparotomy: meta-analysis.

BACKGROUND: Emergency laparotomy has high morbidity and mortality rates. Frailty assessment remains underutilized in this setting, in part due to time constraints and feasibility. The Clinical Frailty Scale has been identified as the most appropriate tool for frailty assessment in emergency laparotomy patients and is recommended for all older patients undergoing emergency laparotomy. The prognostic impact of measured frailty using the Clinical Frailty Scale on short- and long-term mortality and morbidity rates remains to be determined. METHODS: Observational cohort studies were identified by systematically searching Medline, Embase, Scopus and CENTRAL databases up to February 2024, comparing outcomes following emergency laparotomy for frail and non-frail participants defined according to the Clinical Frailty Scale. The primary outcomes were short- and long-term mortality rates. A random-effects model was created with pooling of effect estimates and a separate narrative synthesis was created. Risk of bias was assessed. RESULTS: Twelve articles comprising 5704 patients were included. Frailty prevalence was 25% in all patients and 32% in older adults (age ≥55 years). Older patients with frailty had a significantly greater risk of postoperative death (30-day mortality rate OR 3.84, 95% c.i. 2.90 to 5.09, 1-year mortality rate OR 3.03, 95% c.i. 2.17 to 4.23). Meta-regression revealed that variations in cut-off values to define frailty did not significantly affect the association with frailty and 30-day mortality rate. Frailty was associated with higher rates of major complications (OR 1.93, 95% c.i. 1.27 to 2.93) and discharge to an increased level of care. CONCLUSION: Frailty is significantly correlated with short- and long-term mortality rates following emergency laparotomy, as well as an adverse morbidity rate and functional outcomes. Identifying frailty using the Clinical Frailty Scale may aid in patient-centred decision-making and implementation of tailored care strategies for these 'high-risk' patients, with the aim of reducing adverse outcomes following emergency laparotomy.

Patient and healthcare practitioner evaluation of patient-reported outcomes in bariatric surgery - a modified Delphi study.

BACKGROUND: Patient-reported outcomes are an important emerging metric increasingly utilised in clinical, research and registry settings. These outcomes, while vital, are underutilised and require refinement for the specific patient population of those undergoing bariatric surgery. This study aimed to investigate and compare how pre-surgical patients, post-surgical patients, and healthcare practitioners evaluate patient-reported outcomes of bariatric surgery to identify outcomes that are considered most important. METHODS: A modified Delphi survey was distributed to patients pre- and post-surgery, and to a variety of healthcare practitioners involved in bariatric care. Across two rounds, participants were asked to rate a variety of physical and psychosocial outcomes of bariatric surgery from 0 (Not Important) to 10 (Extremely Important). Outcomes rated 8-10 by at least 70% of participants were considered highly important (prioritised). The highest-rated outcomes were compared between the three groups as well as between medical and allied health practitioner subgroups. RESULTS: 20 pre-surgical patients, 95 post-surgical patients, and 28 healthcare practitioners completed both rounds of the questionnaire. There were 58 outcomes prioritised, with 21 outcomes (out of 90, 23.3%) prioritised by all three groups, 13 (14.4%) by two groups, and 24 (26.7%) prioritised by a single group or subgroup. Unanimously prioritised outcomes included 'Co-morbidities', 'General Physical Health', 'Overall Quality of Life' and 'Overall Mental Health'. Discordant outcomes included 'Fear of Weight Regain', 'Suicidal Thoughts', 'Addictive Behaviours', and 'Experience of Stigma or Discrimination'. CONCLUSION: While there was considerable agreement between stakeholder groups on many outcomes, there remain several outcomes with discordant importance valuations that must be considered. In particular, healthcare practitioners prioritised 20 outcomes that were not prioritised by patients, emphasising the range of priorities across stakeholder groups. Future work will consider these priorities to ensure resulting measures encompass all important outcomes and are beneficial and valid for end users.

Association between frailty, long-term mortality and functional outcomes for older adults undergoing emergency laparotomy.

BACKGROUND: An increasing number of older patients are undergoing emergency laparotomy (EL). Frailty is thought to contribute to adverse outcomes in this group. The best method to assess frailty and impacts on long-term mortality and other important functional outcomes for older EL patients have not been fully explored. METHODS: A prospective multicenter study of older EL patients was conducted across four hospital sites in New Zealand from August 2017 to September 2022. The Clinical Frailty Scale (CFS) was used to measure frailty-defined as a CFS of ≥5. Primary outcomes were 30-day and one-year mortality. Secondary outcomes were postoperative morbidity, admission for rehabilitation, and increased care level on discharge. A multivariate logistic regression analysis was conducted, adjusting for age, sex, and ethnicity. RESULTS: A total of 629 participants were included. Frailty prevalence was 14.6%. Frail participants demonstrated higher 30-day and 1-year mortality-20.7% and 39.1%. Following adjustment, frailty was directly associated with a significantly increased risk of short- and long-term mortality (30-day aRR 2.6, 95% CI 1.5, 4.3, p = <0.001, 1-year aRR 2.0, 95% CI 1.5, 2.8, p < 0.001). Frailty was correlated with a 2-fold increased risk of admission for rehabilitation and propensity of being discharged to an increased level of care, complications, and readmission within 30 days. CONCLUSION: Frailty was associated with increased risk of postoperative mortality up to 1-year and other functional outcomes for older patients undergoing EL. Identification of frailty in older EL patients aids in patient-centered decision-making, which may lead to improvement in outcomes.

Investigating major trauma in Maori youth at Te Whatu Ora Counties Manukau.

BACKGROUND: The Ninth Perioperative Mortality Review Committee (POMRC) report found the likelihood of death was over three times higher in Maori youth compared to non-Maori (age: 15-18 years) in the 30-days following major trauma. The aim of our study is to investigate variations in care provided to Maori youth presenting to Te Whatu Ora Counties Manukau (TWO-CM) with major trauma, to inform policies and improve care. METHODS: This was a retrospective, observational study of 15-18-year-olds admitted to Middlemore Hospital from January 2018 to December 2021 following major trauma (Injury Severity Score (ISS) >12 or with (ISS) <12 who died). Data were obtained from the New Zealand Trauma Registry (NZTR). Six key performance indicators were studied against hospital guidelines/international consensus: Deaths, Cause-of-death, trauma call, RedBlanket activations, time-to-computed tomography (CT), and time-to-operating theatre (OT). RESULTS: Of 77 patients, five deaths occurred, four non-Maori, and one Maori (P = 0.645). Five trauma calls were not activated (P = 0.642). There was no statistically significant difference for both median time to CT (P = 0.917) and time to CT for patients with GCS >13 (P = 0.778) between Maori and non-Maori. Five patients did not meet guidelines for time-to-OT (three non-Maori and two Maori) (P = 0.377). CONCLUSION: No statistically significant variations in care were present for Maori youth presenting with major trauma, these findings did not match the national trend.

The effectiveness of venous thromboembolism prophylaxis interventions in trauma patients: A systematic review and network meta-analysis.

BACKGROUND: Venous thromboembolism (VTE) is a major complication of trauma. Currently, there are few studies summarising the evidence for prophylaxis in trauma settings. This review provides evidence for the use of VTE prophylactic interventions in trauma patients to produce evidence-based guidelines. METHODS: A PRISMA-compliant review was conducted from Sep 2021 to June 2023, using Embase, Medline and Google Scholar. The inclusion criteria were: randomized-controlled trials (RCTs) in English published after 2000 of adult trauma patients comparing VTE prophylaxis interventions, with a sample size higher than 20. The network analysis was conducted using RStudio. The results of the pairwise comparisons were presented in the form of a league table. The quality of evidence and heterogeneity sensitivity were assessed. The primary outcome focused on venous thromboembolism (VTE), and examined deep vein thrombosis (DVT) and pulmonary embolism (PE) as separate entities. The secondary outcomes included assessments of bleeding and mortality. PROSPERO registration: CRD42021266393. RESULTS: Of the 7,948 search results, 23 studies with a total of 21,312 participants fulfilled screening criteria, which included orthopaedic, spine, solid organ, brain, spinal cord, and multi-region trauma. Of the eight papers comparing chemical prophylaxis medications in patients with hip or lower limb injuries, fondaparinux and enoxaparin were found to be significantly superior to placebo in respect of prevention of DVT, with no increased risk of bleeding. Regarding mechanical prophylaxis, meta-analysis of two studies of inferior vena cava filters failed to provide significant benefits to major trauma patients. CONCLUSION: Enoxaparin and fondaparinux are safe and effective options for VTE prevention in trauma patients, with fondaparinux being a cheaper and easier administration option between the two. Inconclusive results were found in mechanical prophylaxis, requiring more larger-scale RCTs.

Does the National Bariatric Prioritization Tool predict health outcomes?

BACKGROUND: The National Bariatric Prioritization Tool (NBPT), developed in Aotearoa New Zealand (AoNZ), has not been validated using real patient data. The aim was to determine the predictive validity of the NBPT on health outcomes. METHODS: An observational study was undertaken of consecutive patients undergoing elective bariatric surgery at Middlemore Hospital using the NBPT from December 2014 to December 2016. The primary outcome was the correlation between prioritization score and percentage total weight loss (%TWL) at 18 months follow-up, with secondary outcomes being correlation with change in HbA1c, lipids, resolution of OSA, resolution of hypertension, and reduction in arthritis medications. Equity of access was measured by the relationship to age group, gender and ethnicity. RESULTS: There were 294 patients included. There was no correlation between %TWL and prioritization score (correlation -0.09, P = 0.14). The benefit score correlated with %TWL (correlation 0.25, P < 0.0001). There were correlations between prioritization score and HbA1c reduction (correlation 0.28, P < 0.0001), resolution of OSA (correlation 0.20, P < 0.001) and resolution of hypertension (correlation 0.20, P < 0.001). There was a significant difference in prioritization score based on ethnicity, with Maori and Pasifika scoring higher than New Zealand European (P = 0.0023). CONCLUSIONS: While the NBPT does not correlate with %TWL, it may have predictive validity through correlations with improvement of comorbidities such as diabetes, OSA and hypertension. Given higher rates of obesity and comorbidities in Maori and Pasifika, the higher scores may suggest the tool may be used to achieve equity of access. Further modifications should be considered to optimize outcomes.

Consensus-defined sarcopenia predicts adverse outcomes after elective abdominal surgery: meta-analysis.

BACKGROUND: Sarcopenia refers to the progressive age- or pathology-associated loss of skeletal muscle. When measured radiologically as reduced muscle mass, sarcopenia has been shown to independently predict morbidity and mortality after elective abdominal surgery. However, the European Working Group on Sarcopenia in Older People (EWGSOP) recently updated their sarcopenia definition, emphasizing both low muscle 'strength' and 'mass'. The aim of this systematic review and meta-analysis was to determine the prognostic impact of this updated consensus definition of sarcopenia after elective abdominal surgery. METHODS: MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched for studies comparing prognostic outcomes between sarcopenic versus non-sarcopenic adults after elective abdominal surgery from inception to 15 June 2022. The primary outcomes were postoperative morbidity and mortality. Sensitivity analyses adjusting for confounding patient factors were also performed. Methodological quality assessment of studies was performed independently by two authors using the QUality in Prognosis Studies (QUIPS) tool. RESULTS: Twenty articles with 5421 patients (1059 sarcopenic and 4362 non-sarcopenic) were included. Sarcopenic patients were at significantly greater risk of incurring postoperative complications, despite adjusted multivariate analysis (adjusted OR 1.56, 95 per cent c.i. 1.39 to 1.76). Sarcopenic patients also had significantly higher rates of in-hospital (OR 7.62, 95 per cent c.i. 2.86 to 20.34), 30-day (OR 3.84, 95 per cent c.i. 1.27 to 11.64), and 90-day (OR 3.73, 95 per cent c.i. 1.19 to 11.70) mortality. Sarcopenia was an independent risk factor for poorer overall survival in multivariate Cox regression analysis (adjusted HR 1.28, 95 per cent c.i. 1.13 to 1.44). CONCLUSION: Consensus-defined sarcopenia provides important prognostic information after elective abdominal surgery and can be appropriately measured in the preoperative setting. Development of targeted exercise-based interventions that minimize sarcopenia may improve outcomes for patients who are undergoing elective abdominal surgery.

Weekend effect in emergency laparotomy: a propensity score-matched analysis.

BACKGROUND: The 'weekend effect' is the term given to the observed discrepancy regarding patient care and outcomes on weekends compared to weekdays. This study aimed to determine whether the weekend effect exists within Aotearoa New Zealand (AoNZ) for patients undergoing emergency laparotomy (EL), given recent advances in management of EL patients. METHODS: A cohort study was conducted across five hospitals, comparing the outcomes of weekend and weekday acute EL. A propensity-score matched analysis was used to remove potential confounding patient characteristics. RESULTS: Of the 487 patients included, 132 received EL over the weekend. There was no statistically significant difference between patients undergoing EL over the weekend compared to weekdays. Mortality rates were comparable between the weekday and weekend cohorts (P = 0.464). CONCLUSIONS: These results suggest that modern perioperative care practice in New Zealand obviates the 'weekend' effect.

Development of the national bariatric prioritization tool in Aotearoa New Zealand.

BACKGROUND: Bariatric surgery is a proven effective method of reducing obesity and reversing or preventing obesity-related comorbidities. The aim of this study is to describe the development of a tool to assist with the prioritization of patients with obesity for bariatric surgery. The tool would meet the criteria for being evidence-based, fair, implementable and transparent. METHODS: The development of the tool involved a validated step-by-step process based on the consensus of clinical judgement of the New Zealand Ministry of Health working party. The process involved elicitation of criteria, clinical ranking of vignettes and creation of weightings using the 1000Minds® tool. The concurrent validity was tested by comparing tool rankings of vignettes to clinical judgement rankings. RESULTS: Four major criteria (impact on life, likelihood of achieving maximum benefit with respect to control of diabetes, duration of benefit and surgical risk) are used to characterize the need and potential to benefit. The impact on life criterion has the largest weighting (up to 44.3%). There was good concurrent validity with a correlation coefficient r = 0.67. CONCLUSION: The tool as presented is evidence-based, transparent and internally valid. The next step is to assess the predictive validity of the tool using real patient data to evaluate the effectiveness of the tool and determine what modifications may be required.

The length of hospital stay following bariatric surgery in Australia: the impact of patient, procedure, system and surgeon.

BACKGROUND: The length of a patient's stay (LOS) in a hospital is one metric used to compare the quality of care, as a longer LOS may flag higher complication rates or less efficient processes. A meaningful comparison of LOS can only occur if the expected average length of stay (ALOS) is defined first. This study aimed to define the expected ALOS of primary and conversion bariatric surgery in Australia and to quantify the effect of patient, procedure, system, and surgeon factors on ALOS. METHODS: This was a retrospective observational study of prospectively maintained data from the Bariatric Surgery Registry of 63 604 bariatric procedures performed in Australia. The primary outcome measure was the expected ALOS for primary and conversion bariatric procedures. The secondary outcome measures quantified the change in ALOS for bariatric surgery resulting from patient, procedure, hospital, and surgeon factors. RESULTS: Uncomplicated primary bariatric surgery had an ALOS (SD) of 2.30 (1.31) days, whereas conversion procedures had an ALOS (SD) of 2.71 (2.75) days yielding a mean difference (SEM) in ALOS of 0.41 (0.05) days, P < 0.001. The occurrence of any defined adverse event extended the ALOS of primary and conversion procedures by 1.14 days (CI 95% 1.04-1.25), P < 0.001 and 2.33 days (CI 95% 1.54-3.11), P < 0.001, respectively. Older age, diabetes, rural home address, surgeon operating volume and hospital case volume increased the ALOS following bariatric surgery. CONCLUSIONS: Our findings have defined Australia's expected ALOS following bariatric surgery. Increased patient age, diabetes, rural living, procedural complications and surgeon and hospital case volume exerted a small but significant increase in ALOS. STUDY TYPE: Retrospective observational study of prospectively collected data.

Bariatric Surgery Efficiency, Safety and Health Outcomes in Government Versus Privately Funded Hospitals.

PURPOSE: This study aims to determine if the hospital efficiency, safety and health outcomes are equal in patients who receive bariatric surgery in government-funded hospitals (GFH) versus privately funded hospitals (PFH). MATERIALS AND METHODS: This is a retrospective observational study of prospectively maintained data from the Australia and New Zealand Bariatric Surgery Registry of 14,862 procedures (2134 GFH and 12,728 PFH) from 33 hospitals (8 GFH and 25 PFH) performed in Victoria, Australia, between January 1st, 2015, and December 31st, 2020. Outcome measures included the difference in efficacy (weight loss, diabetes remission), safety (defined adverse event and complications) and efficiency (hospital length of stay) between the two health systems. RESULTS: GFH treated a higher risk patient group who were older by a mean (SD) 2.4 years (0.27), P < 0.001; had a mean 9.0 kg (0.6) greater weight at time of surgery, P < 0.001; and a higher prevalence of diabetes at day of surgery OR = 2.57 (CI95%2.29-2.89), P < 0.001. Despite these baseline differences, both GFH and PFH yielded near identical remission of diabetes which was stable up to 4 years post-operatively (57%). There was no statistically significant difference in defined adverse events between the GFH and PFH (OR = 1.24 (CI95% 0.93-1.67), P = 0.14). Both healthcare settings demonstrated that similar covariates affect length of stay (LOS) (diabetes, conversion bariatric procedures and defined adverse event); however, these covariates had a greater effect on LOS in GFH compared to PFH. CONCLUSIONS: Bariatric surgery performed in GFH and PFH yields comparable health outcomes (metabolic and weight loss) and safety. There was a small but statistically significant increased LOS following bariatric surgery in GFH.

Tube thoracostomy for trauma at Counties Manukau District Health Board, Aotearoa New Zealand.

BACKGROUND: Tube thoracostomy (TT) in trauma is lifesaving. A previous audit at Counties Manukau District Health Board (CMDHB), New Zealand, showed a 22% complication rate for trauma TT. Subsequently CMDHB introduced a procedural guideline to reduce complications. The Health and Disability Commission published a report concerning oversights in TT removal. This led us to evaluate complications, documentation and procedural monitoring to identify ways to improve patient safety. METHOD: A 30-month retrospective audit of patients presenting to CMDHB, with injuries which may require TT. Those who had a TT in situ, did not require a TT or whose presentation was not secondary to trauma were excluded. RESULTS: One hundred and forty-three TTs were performed in one hundred and fifteen patients. About 87% had injuries secondary to blunt mechanism. Penetrating injuries were more likely to require TT (P = 0.015). Non-accidental injuries were more likely to need TT (P = 0.025). The complication rate was 25.2%. TT prior to imaging had a 31% complication rate (P < 0.03). About 23% had no TT insertion note. 40% had no TT removal note. About 9% TT insertions had no tertiary information to identify the proceduralist and a complication rate of 46%. About 22% of insertions and 4% of removals documented consent. About 2% of insertions documented anticoagulation status. Interventional radiology had the best documentation of data points assessed (P < 0.0001). Post-procedural monitoring recommendations were documented in 1% insertions and 11% removals. CONCLUSIONS: The complication rate has not reduced despite introduction of a guideline. Procedural documentation and monitoring were inadequate, potentially impacting patient safety.

Identifying data-fields for a gastrointestinal cancer clinical quality and safety registry: a systematic literature review.

BACKGROUND: Despite considerable advancements in Upper Gastrointestinal Cancer (UGIC) care in Australia and Aotearoa New Zealand (AAoNZ), the absolute number of deaths remains high. Clinical Quality and Safety Registries (CQRs) enable benchmarking and performance appraisal, however an AAoNZ CQR does not exist. To create this, we first aim to identify all national and international UGIC CQRs and amalgamate their data fields and definitions through a systematic review. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) compliant systematic review was performed using Scopus, Embase, Cochrane and MEDLINE databases. Human studies, in English, reporting on the development of and/or results of all CQRs focused on UGIC were included. Individual data fields were extracted and placed into four categories. Data fields could be further synthesized into data field subcategories if there were direct similarities among studies. RESULTS: A total of 32 studies-23 national audits or registries and nine international benchmarking studies-were included, encompassing 899 073 patients in 48 countries. Of the total of 1710 individual data fields, 1526 (89.2%) were reported with a definition. The most number of data fields related to Treatment Factors (41.2%), with least number pertaining to Outcomes (7.8%). CONCLUSIONS: This systematic review has amalgamated all data fields and definitions from UGIC CQRs or studies. Establishing an AAoNZ Clinical and Quality Safety Registry for our population will enable us to benchmark the performance of our UGIC care internationally. Further studies are indicated in the context of the use of the Delphi method to facilitate this process.

Surgeon Engagement with Patient-Reported Measures in Australian and Aotearoa New Zealand Bariatric Practices.

PURPOSE: Patient-reported measures are an important emerging metric in outcome monitoring; however, they remain ill-defined and underutilized in bariatric clinical practice. This study aimed to determine the characteristics of patient-reported measures employed in bariatric practices across Australia and Aotearoa New Zealand, including barriers to their implementation and to what extent clinicians are receptive to their use. METHODS: An online survey was distributed to all bariatric surgeons actively contributing to the Australian and Aotearoa New Zealand Bariatric Surgery Registry (n = 176). Participants reported their use of patient-reported measures and identified the most important and useful outcomes of patient-reported data for clinical practice. RESULTS: Responses from 64 participants reported on 120 public and private bariatric practices across Australia and Aotearoa New Zealand. Most participants reported no collection of any patient-reported measure (39 of 64; 60.9%), citing insufficient staff time or resources as the primary barrier to the collection of both patient-reported experience measures (34 of 102 practices; 33.3%) and patient-reported outcome measures (30 of 84 practices; 35.7%). Participants indicated data collection by the Registry would be useful (47 of 57; 82.5%), highlighting the most valuable application to be a monitoring tool, facilitating increased understanding of patient health needs, increased reporting of symptoms, and enhanced patient-physician communication. CONCLUSION: Despite the current lack of patient-reported measures, there is consensus that such data would be valuable in bariatric practices. Widespread collection of patient-reported measures by registries could improve the collective quality of the data, while avoiding implementation barriers faced by individual surgeons and hospitals.

The Red Blanket Protocol in a tertiary centre in Aotearoa New Zealand: does this trauma protocol improve time to surgery and clinical outcomes?

BACKGROUND: Patients who are haemodynamically unstable from surgical emergencies require prompt surgical intervention, and delay to surgery may lead to poorer clinical outcomes. The Red Blanket Protocol (RBP) is a communication algorithm intended to facilitate surgery as expediently and safely as possible. By developing a protocol for these channels of communication, RBP may reduce the time to surgical intervention and improve patient outcomes. Our aim was to identify whether patient outcomes, including time to surgery, blood product use and survival were improved by the Red Blanket protocol. METHODS: Haemodynamically unstable adults in Middlemore Hospital, Aotearoa New Zealand from 1/1/2014 to 31/12/2015 were compared with RBP patients from 1/4/2017 to 1/4/2020. Time from emergency department (ED) to knife-to-skin (KTS) was compared between the groups. The number of blood products used, LOS and 30- and 90-day survival were also compared between the pre-protocol and RBP groups. RESULTS: Thirty-two patients were identified in the pre-protocol group, and 25 in the RBP group. The median time from ED to KTS reduced from 84 to 70.5 min after the implementation of RBP (P = 0.044). The median number of blood products was 21 pre-protocol and 11.5 in the RBP group (P = 0.102). The median LOS was 8 versus 4 days in the RBP group (P = 0.204). 30-day survival rate was comparable in the two groups (65% versus 60% (P 0.71)). CONCLUSION: RBP was associated with a shorter time to knife-to-skin for haemodynamically unstable patients. There was no significant difference in clinical outcomes between the two groups. Larger studies are required to assess clinical outcomes of the RBP.