Background

In the past major trauma was considered to be serious injury resulting from high velocity mechanisms that usually involved young men, such as motorbike accidents.

The Emergency Medical Journal article ‘The Changing Face of Major Trauma’ (2015) first challenged this concept and pointed to a demographic that was rapidly overtaking young men, those over the age of 65 years.

Read more about it here –  The Changing Face of Trauma in the UK

In 2017 the Trauma Audit and Research Network (TARN) published the report ‘Older People and Major Trauma’.

The report again set out statistics and data that challenged what has always been considered to be common perception – that major trauma consisted of a certain demographic – young, male patients involved in dangerous, high velocity incidents.

Having studied the data we now know that major trauma is often the exact opposite of this – older patients, low mechanism, low velocity injuries resulting in devastating, life-limiting consequences.

Over 65 year olds with falls <2m are now the largest group of major trauma patients nationally.

You can read the report here TARN report – Major Trauma in Older People 2017

All staff working with older trauma patients should be trained to understand the effects of altered physiological reserve and increased comorbid diseases common in older patients.

We are unable to assume frailty in the over 65 age group or any other, but what we do know is there are many challenges within this demographic that require careful assessment and an adapted, systematic approach.

There are currently 11.5 million people aged over 65 living in the UK. The office for national statistics (ONS) estimates that by 2040 1 in 4 people in the UK will be aged 65 or over (1)

What does frailty mean?

There is no clear definition of frailty. You don’t have to be old to be frail, and you don’t have to be frail if you’re old.

The GM MTN has produced an aide memoire for identification of different frailty groups.

You can view the document here Different Frailty Groups

When we consider the older frail patient we often equate this with multiple co-morbidities, multiple medications, and challenges with mobility.Older patients present many challenges, but so does the concept of frailty. With no clear definition, we’d be forgiven for thinking only the old can be frail. Frailty, or elements of it, exists in many patient groups – chronic illness, deprivation, substance dependence, and pregnancy to name but a few. For the purpose of major trauma TARN data collection the concept of frailty refers to those over the age of 65 years.

There are currently 11.5 million people aged over 65 living in the UK. The office for national statistics (ONS) estimates that by 2040 1 in 4 people in the UK will be aged 65 or over

The Challenges of Frailty

People are living longer than ever before, and it is estimated that by 2030 there will be a 50% increase in those over the age of 65 and 100% more 85 year olds and above compared to now.

In examining TARN data we also know that his group often have delayed presentations, are not recognised as being severely injured (by pre-hospital and ED staff), wait for longer and are seen by more junior doctors. We know from data that they are more likely to have serious injuries from low mechanisms, and are more likely to receive X-Rays rather than CT scans.

In short, there are unacceptable differences in care compared to younger patients.

In the past older people with trauma may previously have been denied surgical intervention based on their age alone. With an ageing population and improved management of chronic conditions the TARN Older People Major Trauma Report (2017) shows positive results from a pro-active, multi-disciplinary approach with early geriatrician input.

As with many presentations, major trauma has a spectrum. There is certainly a recognised difference between being a ‘well’ trauma patient and a patient being recognised as ‘unwell’.

North West Ambulance Service (NWAS) utilise the NWAS Major Trauma Pathfinder when assessing all patients with traumatic injuries. The majority of patients will be assessed and quickly recognised as not seriously injured (these patients then follow the NWAS Trauma Pathfinder). For the cohort that is recognised as seriously injured, the flow chart takes the attending crew through a series of questions that assess the level of risk and instructs an outcome and onward destination.

You can view the NWAS Major Trauma Pathfinder here MT Adult Pathfinder 2015

There are a number of circumstances to take into account when assessing potential major trauma issues in this demographic. Presentation, potential injuries and appropriate onward destination are to name but a few. There are also a series of ‘red flags’ to consider, which make this group the ‘exception to the rule’.

Patients over the age of 65 years with low mechanisms of injury should be treated with caution. There is a high incidence of delayed presentation, occult injury and cases where patients develop illness as a result of underlying injury. An example of such a case would be a patient presenting with a chest infection as a result of rib fractures sustained following a previous fall.

A high index of suspicion should remain until appropriate diagnostics confirm the absence of injury.

Increasingly older people, many with multiple comorbidities and degrees of frailty, are the main body of work in acute care settings and account for the biggest activity, spend, and unsurprisingly the biggest variations in care. An example of this is CT imaging; criteria are often directed by mechanism of injury, and subsequently younger patients are more likely to receive scans rather than plain films. This is despite a body of evidence that suggests CT scans are optimal in the diagnosis rib fractures and subsequent underlying injury. There is additional emerging evidence that suggests in excess of 50% of injuries are missed on chest X-Rays alone.

A common misconception is concern regarding Acute Kidney Injury (AKI) and potential harm caused by contrast. Concern regarding renal function in the elderly often erroneously necessitates eGFR results prior to scanning with contrast despite evidence this is not necessary, also delaying time to CT.In the clinically unstable and urgent patient this should not prevent a timely CT scan.

You can read the supporting evidence here Risk of AKI following Contrast Medium Administration (2016)

What we know

• Older patients that fall are more likely to be conveyed to hospital by ambulance
• They are often ill as well as injured (think of ‘found on floor’ presentations with a Urinary Tract Infection)
• Low mechanisms (think ‘roll out of bed’ presentations) can cause serious, life-threatening injuries. Frailty is a large contributing factor in elderly patients sustaining ISS>15 injuries
• The NWAS Major Trauma Pathfinder uses a combination of observations and identifiable anatomical injuries. The current pathway is not sensitive to the physiological differences of this sub-group and injuries are often occult and difficult to identify
• The NWAS pathway refers to ‘frail or elderly’ and ‘dangerous or significant mechanism’ – this is subjective
• These patients are not always discussed with trauma cell as they may not flag as major trauma patients
• They are not recognised as potential major trauma patients in the Emergency Department and as a consequence wait longer, are more likely to be seen by a junior clinician and are more likely to receive x-rays rather than CT scans initially
• As a consequence they are more likely to have occult injuries
• Older patients are more likely to receive delayed CT scans, this often happens following clinical deterioration on the admitting ward

How has the Network responded to this?

Having reviewed the TARN Older People and Major Trauma report and studying the local data we have produced a new pathway that sits beneath the NWAS Major Trauma Pathfinder to identify older patients.

The Frail Injured Patient Pathway (FrIP) is a secondary method of capture for frail patients who do not meet the requirements of a major trauma pre alert to the MTC but clinical concern remains.

NWAS crews can contact the Trauma Cell and a Senior Paramedic will offer guidance and determine if a ‘Frail Injured Patient (FrIP) amber pre-alert’ to the nearest hospital is necessary. Any hospital across Greater Manchester can receive the pre-alerts and they allow clinical concern to be conveyed to the receiving team in the Emergency Department.

How departments respond is entirely down to local policy however the FrIP alert promotes recognition of major trauma injuries, early senior review and timely diagnostics

You can view the guidance document here Frail Injured Patient (FrIP) guidance

The Greater Manchester Major Trauma Network also recognises that many older patients self-present to emergency departments and the ‘Meet Harry’ document was produced as an aide memoire to triage nurses and clinicians to assist in assessment.

You can view the ‘Meet Harry’ Document here ‘Meet Harry’

The ‘Meet Harry’ document has already been shared in over 90 sites across the UK and hospitals in Canada, the US, Australia and New Zealand now utilise the document. Across Europe hospitals in France, Germany and Switzerland are now sharing the aide memoire.

There is also a version specific to hospital wards and community care facilities that can be found here Ward Harry

The GM MTN is happy to share both documents. If you wish to receive a PDF version via email please see our contacts page.

The Network, working alongside the Greater Manchester Ambulance Service will audit the impact of the initiatives and feed back to clinicians. This ensures our work is relevant and effective.

Further work will be undertaken in this area including producing an education pack for frailty teams about major trauma and a regional ‘Frailty Platform’ will bring together experts in this area to develop services and improvements.