Configurations and outcomes of acute hospital care for frail and older patients with moderate to major trauma: a systematic review

OBJECTIVE

To systematically review research on acute hospital care for frail or older adults experiencing moderate to major trauma.

SETTING

Electronic databases (Medline, Embase, ASSIA, CINAHL Plus, SCOPUS, PsycINFO, EconLit, The Cochrane Library) were searched using index and key words, and reference lists and related articles hand-searched.

INCLUDED ARTICLES

Peer-reviewed articles of any study design, published in English, 1999-2020 inclusive, referring to models of care for frail and/or older people in the acute hospital phase of care following traumatic injury defined as either moderate or major (mean or median Injury Severity Score ≥9). Excluded articles reported no empirical findings, were abstracts or literature reviews, or referred to frailty screening alone.

METHODS

Screening abstracts and full text, and completing data extractions and quality assessments using QualSyst was a blinded parallel process. A narrative synthesis, grouped by intervention type, was undertaken.

OUTCOME MEASURES

Any outcomes reported for patients, staff or care system.

RESULTS

17 603 references were identified and 518 read in full; 22 were included-frailty and major trauma (n=0), frailty and moderate trauma (n=1), older people and major trauma (n=8), moderate or major trauma (n=7) 0r moderate trauma (n=6) . Studies were observational, heterogeneous in intervention and with variable methodological quality.Specific attention given to the care of older and/or frail people with moderate to major trauma in the North American context resulted in improvements to in-hospital processes and clinical outcomes, but highlights a relative paucity of evidence, particularly in relation to the first 48 hours post-injury.

CONCLUSIONS

This systematic review supports the need for, and further research into an intervention to address the care of frail and/or older patients with major trauma, and for the careful definition of age and frailty in relation to moderate or major trauma. INTERNATIONAL PROSPECTIVE REGISTER OF SYSTEMATIC REVIEWS PROSPERO: CRD42016032895.

03 The prehospital 12 lead electrocardiogram is associated with improved outcomes in patients with acute coronary syndromes presenting to emergency medical services: a nationwide linked cohort study

Background

Use of the Pre-Hospital 12-lead Electrocardiogram (PHECG) is recommended in patients presenting to emergency medical services (EMS) with suspected acute coronary syndrome (ACS).

Objectives

To investigate differences in mortality between those who did/did not receive PHECG.

Methods

Population-based, linked cohort study using Myocardial Ischaemia National Audit Project (MINAP) data from 2010-2017.

Results

Of 330,713 patients, 263,420 (79.6%) had PHECG, 67,293 (20.3%) did not. 30-day mortality was 7.8% overall, 7.1% with PHECG vs 10.9% without PHECG (adjusted Odds Ratio [aOR] 0.772, 95% confidence interval [CI] 0.748-0.795, p<0.001). 1 year mortality was 16.1% overall, 14.2% with PHECG vs 23.2% without (aOR 0.692, 95% CI 0.676-0.708, p<0.001). 144,254 patients had ST segment elevation myocardial infarction (STEMI); 130,240 (90.2%) had PHECG, 30 day mortality 8.8% overall, 8.0% with PHECG vs 15.9% without (aOR 0.588, 95% CI 0.557-0.622, p<0.001), 1 year mortality 13.1% overall, 12.1% with PHECG vs 22.8% without (aOR 0.585, 95% CI 0.557-0.614, p<0.001). 186,459 patients had non-STEMI; 133,180 (71.4%) had PHECG. 30-day mortality 7.1% overall, 6.1% with PHECG vs 9.6% without (aOR 0.677, 95%CI 0.652-0.704, p<0.001), 1 year mortality 18.3% overall, 16.3% with PHECG vs 23.3% without (aOR 0.694, 95% CI 0.676-0.713, p<0.001). 110,571 STEMI patients received primary PCI, 103,741 (93.8%) had PHECG. 30 day mortality 5.4% overall, 5.3% with PHECG vs 7.0% without (aOR 0.739, 95% CI 0.667-0.829, p<0.001). 1 year mortality 8.5% overall, 8.4% with PHECG vs 9.8% without (aOR 0.833, 95% CI 0.762-0.911, p<0.001). 26,127 (18.1%) STEMI patients received no reperfusion; 19,873 (76%) had PHECG. Mortality at 30 days 22.1% overall, 21.3% with PHECG vs 24.7% without (aOR 0.911, 95% CI 0.847-0.980, p=0.013), 1 year mortality 32.2% overall, 30.9% with PHECG, 36.4% without (aOR 0.865, 95% CI 0.810-0.925, p<0.001).

Conclusion

PHECG was associated with lower mortality at 30 days and 1 year in both STEMI and non-STEMI patients.

Has the proportion of patients diagnosed with myocardial infarction that receives a 12 ECG in the prehospital setting in the UK changed over time?

Background

Two thirds of patients with Acute Myocardial Infarction (AMI) arrive at hospital in the UK by ambulance, usually staffed by paramedics who routinely carry out 12 lead ECGs for patients with suspected heart attack. However, recent research found that prehospital ECGs were missing for 40% of these patients, with better survival prospects in those who had received one.

Purpose

We are investigating reasons for non-administration of 12 lead ECG for patients diagnosed with AMI, in order to develop an intervention to improve practice. Firstly we explored whether the proportion of patients with AMI that receive a prehospital ECG has changed over time.

Methods

Interrogation of national UK national heart attack register (MINAP) database, extraction of data related to patients brought by ambulance by year.

Results

The cohort of patients diagnosed with AMI and taken to hospital by ambulance ranged from 32410 in 2005 to 60265 in 2017; the proportion with a prehospital ECG increased steadily across this period, from 51% to 78%, an average increase of 1.9% per annum.

Conclusions

Evidence based guidelines supporting the use of 12 lead ECG by ambulance paramedics may have contributed to improvements in care. However, 1 in 5 patients brought to hospital by ambulance still does not receive an ECG prior to arrival, which we know compromises their survival prospects. In order to optimise care we need to establish whether non-administration is a question of misdiagnosis, patient refusal or lack of availability of trained crews/equipment.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation

Use and impact of the prehospital 12-lead ECG in the primary PCI era (PHECG2): protocol for a mixed-method study

Introduction

Use of the prehospital 12-lead ECG (PHECG) is recommended in patients presenting to emergency medical services (EMS) with suspected acute coronary syndrome (ACS). Prior research found that although PHECG use was associated with improved 30-day survival, a third of patients (typically women, the elderly and those with comorbidities) under EMS care did not receive a PHECG.

The overall aim of the PHECG2 study is to update evidence on care and outcomes for patients eligible for PHECG, specifically addressing the following research questions: (1) Is there a difference in 30-day mortality, and in reperfusion rate, between those who do and those who do not receive PHECG? (2) Has the proportion of eligible patients who receive PHECG changed since the introduction of primary percutaneous coronary intervention networks? (3) Are patients that receive PHECG different from those that do not in terms of social and demographic factors, or prehospital clinical presentation? (4) What factors influence EMS clinicians’ decisions to perform PHECG?

Methods and analysis

This is an explanatory, mixed-method study comprising four work packages (WPs). WP1 is a population-based, linked-data analysis of a national ACS registry (Myocardial Ischaemia National Audit Project). WP2 is a retrospective chart review of patient records from three large regional EMS. WP3 comprises focus groups of EMS personnel. WP4 will synthesise findings from WP1–3 to inform the development of an intervention to increase PHECG uptake.

Ethics and dissemination

The study has been approved by the London-Hampstead Research Ethics Committee (ref: 18LO1679). Findings will be disseminated through feedback to participating EMS, conference presentations and publication in peer-reviewed journals.

Trial registration number

NCT03699137

PP19 Use and impact of the pre-hospital 12-lead electrocardiogram in the primary PCI era (PHECG2): mixed methods study protocol

Background

The pre-hospital 12-lead electrocardiogram (PHECG) is recommended in patients presenting to emergency medical services (EMS) with suspected acute coronary syndrome (ACS). Prior research found PHECG was associated with improved 30-day survival, but a third of ACS patients under EMS care did not have PHECG. Such patients tended to be female, older and/or with comorbidities. This previous study was undertaken when thrombolytic treatment was the main treatment for ST segment elevation myocardial infarction (STEMI); practice has since shifted to a predominant interventional strategy – primary percutaneous coronary intervention (pPCI). Moreover, the previous study relied solely on data collected by the Myocardial Ischaemia National Audit Project (MINAP), which does not include information on symptoms, EMS personnel gender, and other factors that may influence decision-making. The PHECG2 study addresses the following research questions: a) Is there a difference in 30-day mortality and reperfusion between those who do and do not receive PHECG? b) Has the proportion of eligible patients who receive PHECG changed since the introduction of pPCI networks? c) Are patients that receive PHECG different from those that do not in social and demographic factors, and in pre-hospital clinical presentation? d) What factors do EMS clinicians report as influencing their decision to perform PHECG?

Methods

Explanatory sequential Quan-Qual mixed methods study comprising 4 Work Packages (WPs): WP1 a population based, linked data analysis of MINAP from 2010–2017 (n=510,000); WP2 retrospective chart review of EMS records from 3 EMS; WP3 focus groups with personnel from 3 EMS. WP4 will synthesise findings from WP1-3.

Conclusions

Gaining an understanding into the clinical and non-clinical factors influencing EMS clinicians’ decisions to record PHECG will enable us to develop (and later test through a randomised trial) an intervention to improve PHECG uptake and patient outcomes following an ACS event.

Feasibility of data linkage in the PARAMEDIC trial: a cluster randomised trial of mechanical chest compression in out-of-hospital cardiac arrest

OBJECTIVES

There is considerable interest in reducing the cost of clinical trials. Linkage of trial data to administrative datasets and disease-specific registries may improve trial efficiency, but it has not been reported in resuscitation trials conducted in the UK. To assess the feasibility of using national administrative and clinical datasets to follow up patients transported to hospital following attempted resuscitation in a cluster randomised trial of a mechanical chest compression device in out-of-hospital cardiac arrest.

METHODS

Hospital data on trial participants were requested from Hospital Episode Statistics (HES), the Intensive Care National Audit and Research Centre, and Myocardial Ischaemia National Audit Project and National Audit of Percutaneous Coronary Interventions, using unique patient identifiers. Linked data were received between June 2014 and June 2015.

RESULTS

Of 4471 patients randomised in the pre-hospital randomised assessment of a mechanical compression device in cardiac arrest (PARAMEDIC) trial, 2398 (53.6%) were not known to be deceased at emergency department arrival and were eligible for linkage. We achieved an overall match rate of 86.7% in the combined HES accident and emergency, inpatient and critical care dataset, with variable match rates (4.2%-80.4%) in individual datasets. Patient demographics, cardiac arrest-related characteristics and major outcomes were predominantly similar between HES matched and unmatched groups, in the linkage apart from location, response time and return of spontaneous circulation (ROSC) at handover.

CONCLUSIONS

This study shows that it is feasible to track patients from the prehospital setting through to hospital admission using routinely available administrative datasets with a moderate to high degree of success. This approach has the potential to complement the trial data with the demographic and clinical management information about the studied cohort, as well as to improve the efficiency and reduce the costs of follow-up in cardiac arrest trials.

CLINICAL TRIAL REGISTRATION

ISRCTN08233942; Post-results.