Association between major trauma centre care and outcomes of adult patients injured by low falls in England and Wales.

BACKGROUND: Disability and death due to low falls is increasing worldwide and disproportionately affects older adults. Current trauma systems were not designed to suit the needs of these patients. This study assessed the association between major trauma centre (MTC) care and outcomes in adult patients injured by low falls. METHODS: Data were obtained from the Trauma Audit and Research Network on adult patients injured by falls from <2 m between 2017 and 2019 in England and Wales. 30-day survival, length of hospital stay and discharge destination were compared between MTCs and trauma units or local emergency hospitals (TU/LEHs) using an adjusted multiple logistic regression model. RESULTS: 127 334 patients were included, of whom 27.6% attended an MTC. The median age was 79.4 years (IQR 64.5-87.2 years), and 74.2% of patients were aged >65 years. MTC care was not associated with improved 30-day survival (adjusted OR (AOR) 0.91, 95% CI 0.87 to 0.96, p<0.001). Transferred patients had a significant impact on the results. After excluding transferred patients, MTC care was associated with greater odds of 30-day survival (AOR 1.056, 95% CI 1.001 to 1.113, p=0.044). MTC care was also associated with greater odds of 30-day survival in the most severely injured patients (AOR 1.126, 95% CI 1.04 to 1.22, p=0.002), but not in patients aged >65 years (AOR 1.038, 95% CI 0.982 to 1.097, p=0.184). CONCLUSION: MTC care was not associated with improved survival compared with TU/LEH care in the whole cohort. Patients who were transferred had a significant impact on the results. In patients who are not transferred, MTC care is associated with greater odds of 30-day survival in the whole cohort and in the most severely injured patients. Future research must determine the optimum means of identifying patients in need of higher-level care, the components of care which improve patient outcomes, develop patient-focused outcomes which reflect the characteristics and priorities of contemporary trauma patients, and investigate the need for transfer in specific subgroups of patients.

What influences decisions to transfer older care-home residents to the emergency department? A synthesis of qualitative reviews.

BACKGROUND: care home residents aged over 65 have disproportionate rates of emergency department (ED) attendance and hospitalisation. Around 40% attendances may be avoidable, and hospitalisation is associated with harms. We synthesised the evidence available in qualitative systematic reviews of different stakeholders' experiences of decisions to transfer residents to the ED. METHODS: six electronic databases, references and citations of included reviews and relevant policy documents were searched. Reviews of qualitative studies exploring factors that influenced care home staff, medical practitioners, residents' family or residents' experiences and factors influencing decisions to transfer residents to the ED were included. Thematic analysis was used to synthesise findings. RESULTS: six previous reviews were included, which synthesised the findings of 34 primary studies encompassing 152 care home residents, 283 resident family members or carers and 447 care home staff. Of the primary studies, 19 were conducted in the North America, seven in Australia, five were conducted in Scandinavia, two in the United Kingdom and one in Holland. Three themes were identified: (i) power dynamics between residents, family members, care home staff and health care professionals (external to the care home) influence decisions; (ii) admission can be necessary; however, (iii) some decisions may be driven by factors other than clinical need. CONCLUSION: transfer decisions are complex and are determined not just by changes in health status interventions aimed at reducing avoidable transfers need to address the key role family members have in transfer decisions, the medical legal fears of care home staff and barriers to accessing community services.

Factors associated with increased Emergency Department transfer in older long-term care residents: a systematic review.

The proportion of adults older than 65 years is rapidly increasing. Care home residents in this age group have disproportionate rates of transfer to the Emergency Department (ED) and around 40% of attendances might be avoidable. We did a systematic review to identify factors that predict ED transfer from care homes. Six electronic databases were searched. Observational studies that provided estimates of association between ED attendance and variables at a resident or care home level were included. 26 primary studies met the inclusion criteria. Seven common domains of factors assessed for association with ED transfer were identified and within these domains, male sex, age, presence of specific comorbidities, polypharmacy, rural location, and care home quality rating were associated with likelihood of ED transfer. The identification of these factors provides useful information for policy makers and researchers intending to either develop interventions to reduce hospitalisations or use adjusted rates of hospitalisation as a care home quality indicator.

Care of the older trauma patient following low-energy transfer trauma-highlighting a research void.

BACKGROUND: in high-income countries trauma patients are becoming older, more likely to have comorbidities, and are being injured by low-energy mechanisms. This systematic review investigates the association between higher-level trauma centre care and outcomes of adult patients who were admitted to hospital due to injuries sustained following low-energy trauma. METHODS: a systematic review was conducted in January 2021. Studies were eligible if they reported outcomes in adults admitted to hospital due to low-energy trauma. In the presence of study heterogeneity, a narrative synthesis was pre-specified. RESULTS: three studies were included from 2,898 unique records. The studies' risk of bias was moderate-to-serious. All studies compared outcomes in trauma centres verified by the American College of Surgeons in the USA. The mean/median ages of patients in the studies were 73.4, 74.5 and 80 years. The studies reported divergent results. One demonstrated improved outcomes in level 3 or 4 trauma centres (Observed: Expected Mortality 0.973, 95% CI: 0.971-0.975), one demonstrated improved outcomes in level 1 trauma centres (Adjusted Odds Ratio 0.71, 95% CI: 0.56-0.91), and one demonstrated no difference between level 1 or 2 and level 3 or 4 trauma centre care (adjusted odds ratio 0.91, 95% CI: 0.80-1.04). CONCLUSIONS: the few relevant studies identified provided discordant evidence for the value of major trauma centre care following low-energy trauma. The main implication of this review is the paucity of high-quality research into the optimum care of patients injured in low-energy trauma. Further studies into triage, interventions and research methodology are required.

Risk assessment models for venous thromboembolism in hospitalised adult patients: a systematic review.

INTRODUCTION: Hospital-acquired thrombosis accounts for a large proportion of all venous thromboembolism (VTE), with significant morbidity and mortality. This subset of VTE can be reduced through accurate risk assessment and tailored pharmacological thromboprophylaxis. This systematic review aimed to determine the comparative accuracy of risk assessment models (RAMs) for predicting VTE in patients admitted to hospital. METHODS: A systematic search was performed across five electronic databases (including MEDLINE, EMBASE and the Cochrane Library) from inception to February 2021. All primary validation studies were eligible if they examined the accuracy of a multivariable RAM (or scoring system) for predicting the risk of developing VTE in hospitalised inpatients. Two or more reviewers independently undertook study selection, data extraction and risk of bias assessments using the PROBAST (Prediction model Risk Of Bias ASsessment Tool) tool. We used narrative synthesis to summarise the findings. RESULTS: Among 6355 records, we included 51 studies, comprising 24 unique validated RAMs. The majority of studies included hospital inpatients who required medical care (21 studies), were undergoing surgery (15 studies) or receiving care for trauma (4 studies). The most widely evaluated RAMs were the Caprini RAM (22 studies), Padua prediction score (16 studies), IMPROVE models (8 studies), the Geneva risk score (4 studies) and the Kucher score (4 studies). C-statistics varied markedly between studies and between models, with no one RAM performing obviously better than other models. Across all models, C-statistics were often weak (<0.7), sometimes good (0.7-0.8) and a few were excellent (>0.8). Similarly, estimates for sensitivity and specificity were highly variable. Sensitivity estimates ranged from 12.0% to 100% and specificity estimates ranged from 7.2% to 100%. CONCLUSION: Available data suggest that RAMs have generally weak predictive accuracy for VTE. There is insufficient evidence and too much heterogeneity to recommend the use of any particular RAM. PROSPERO REGISTRATION NUMBER: Steve Goodacre, Abdullah Pandor, Katie Sworn, Daniel Horner, Mark Clowes. A systematic review of venous thromboembolism RAMs for hospital inpatients. PROSPERO 2020 CRD42020165778. Available from https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=165778https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=165778.

Closing the dura: dural hitching versus surgicel and tisseel overlay graft in craniocervicaldecompression for Chiari 1 malformation.

BACKGROUND: This study compares dural hitching to surgicel and tisseel overlay graft following craniocervical decompression and C1 laminectomy with simple durotomy for Chiari I malformation. Outcome measures were syrinx decompression, headache resolution and complication rates. METHODS: A retrospective analysis of case notes was conducted. Patients who had undergone craniocervical decompression (CCD) were grouped by method of dural closure. Outcomes compared were rates of syrinx decompression, headache resolution, and post-operative complications. Statistical analysis was conducted using SPSS v20. RESULTS: We identified 32 adult patients for inclusion in this study. 53.1% (n = 17) had asyrinx, and 78.1% (n = 25) had a pre-operative headache. All were treated with suboccipital craniectomy, C1 laminectomy (with or without C2 laminectomy), and durotomy. The dura was either left open by dural hitching (n = 23) or closed with surgicel and tisseel overlay graft (n = 9). We found a statistically significant association between the method of dural closure and the rate of syrinx resolution. Resolution occurred in 91.7% (n = 11) of the hitching group, compared to 20.0% (n = 1) of the overlay graft group: Χ2(1) = 5.6, p = .018. There were no statistically significant differences between the two groups in the rates of headache resolution or other complications. CONCLUSIONS: In patients with symptomatic Chiari I malformation and associated syringomyelia, syrinx resolution is more likely if the dura is hitched open rather than closed bysurgicel and tisseel overlay graft after durotomy.