An economic evaluation of triage tools for patients with suspected severe injuries in England

Background Many health care systems triage injured patients to major trauma centres (MTCs) or local hospitals by using triage tools and paramedic judgement. Triage tools are typically assessed by whether patients with an Injury Severity Score (ISS) ≥ 16 go to an MTC and whether patients with an ISS < 16 are sent to their local hospital. There is a trade-off between sensitivity and specificity of triage tools, with the optimal balance being unknown. We conducted an economic evaluation of major trauma triage tools to identify which tool would be considered cost-effective by UK decision makers. Methods A patient-level, probabilistic, mathematical model of a UK major trauma system was developed. Patients with an ISS ≥ 16 who were only treated at local hospitals had worse outcomes compared to being treated in an MTC. Nine empirically derived triage tools, from a previous study, were examined so we assessed triage tools with realistic trade-offs between triage tool sensitivity and specificity. Lifetime costs, lifetime quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for each tool and compared to maximum acceptable ICERs (MAICERs) in England. Results Four tools had ICERs within the normal range of MAICERs used by English decision makers (£20,000 to £30,000 per QALY gained). A low sensitivity (28.4%) and high specificity (88.6%) would be cost-effective at the lower end of this range while higher sensitivity (87.5%) and lower specificity (62.8%) was cost-effective towards the upper end of this range. These results were sensitive to the cost of MTC admissions and whether MTCs had a benefit for patients with an ISS between 9 and 15. Conclusions The cost-effective triage tool depends on the English decision maker’s MAICER for this health problem. In the usual range of MAICERs, cost-effective prehospital trauma triage involves clinically suboptimal sensitivity, with a proportion of seriously injured patients (at least 10%) being initially transported to local hospitals. High sensitivity trauma triage requires development of more accurate decision rules; research to establish if patients with an ISS between 9 and 15 benefit from MTCs; or, inefficient use of health care resources to manage patients with less serious injuries at MTCs.

A service evaluation examining the requirement for Level 2 critical care in a major trauma centre

Critical care provision is fundamental in all developed health systems in which severe disease and injury is managed. This is especially true in major trauma centres and high-acuity establishments, where acutely unstable patients can be admitted at any time, requiring clinical monitoring and interventions appropriate for their burden of illness. This single-centre, prospective service evaluation applied validated scoring systems to a surgical population, sampling and following those considered “high-risk” through to discharge or death, alongside all intensive care unit (ICU) admissions during 2019. Primarily we aimed to quantify the number of patients objectively suitable for Level 2 critical care, conventionally provided in a high-dependency unit (HDU) setting. Secondary outcome measures included ICU readmission rate, in-hospital mortality, and delays to ICU admission and discharge. Of the “high-risk” surgical patients, more than eight per week were found to have peri-operative Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) scores that would advocate critical care admission. Only one individual received scheduled peri-operative critical care. Post-operative mortality in this group was 6.1%, though none of these patients was admitted to ICU prior to death. There were 605 ICU admissions in 2019, with 32.1% of admitted days spent at the equivalent of Level 2 critical care, which could have been administered in a HDU if one was available. The ICU readmission rate was 6.45%. This data demonstrates substantial unmet critical care needs, with patients not uncommonly managed in clinically inappropriate areas for extended periods due to delays accessing ICU. A designated HDU may mitigate clinical risk from this subgroup, reducing morbidity and in-hospital mortality, and this methodology for assessing requirements could be used in other similar institutions.

Intravenous ketamine as an analgesia in prehospital adult trauma patients

Background: Prehospital traumatic pain is common, but the quality of pain management in these patients is poor. Current practice recommends morphine as the first-line analgesia in major trauma but this carries high risks and is often contraindicated. Alternative paramedic-administered analgesia does not provide adequate pain relief or may be contraindicated. As a result, many patients remain in pain. Analgesic ketamine is used safely and effectively in international civilian and military settings and by paramedics with additional training, education and qualifications. Aim: The study had two aims. Namely, these were to find out whether intravenous ketamine: provides effective relief of prehospital traumatic pain in adults; and is safe for prehospital administration by non-specialist paramedics. Method: Three databases, CINAHL, MEDLINE and AMED, were searched to identify articles published between 2009 and 2021. Exclusion criteria were applied and results subjected to critical appraisal and evaluation. Findings: Four studies were included in the review. Two themes were identified for thematic analysis: therapeutic effectiveness; and the safety of IV ketamine administration by paramedics. The evidence drew predominantly homogenous conclusions, but was substandard regarding external validity, which limited the quality of these conclusions. Conclusion: Ketamine provides effective pain relief in line with morphine and is safe for paramedics to administer. However, clear gaps in the evidence mean the research questions are not fully answered, so changes to current paramedic practice cannot be recommended.

A retrospective observational study to investigate the effect of frailty on outcomes of older adults admitted with major trauma.

The majority of major injuries admitted to hospital are now in older people, with a fall from standing height being the most common reason for injury. Our study will look at older adults admitted to hospital with serious traumatic injuries across England. It will aim to work out firstly if there is an effect of frailty on peoples' survival after injury. Frailty is the reserve a person has to cope with illness and is a measure of a person slowing down over time usually due to the collection of lots of health problems. Secondly, we will look at if being seen by an old age specialist (geriatrician) has an effect on a person's chances of surviving their injuries. The records we will look at are held collected routinely and held by a national database run by the Trauma and Audit Research Network (TARN) from the University of Manchester. They collect information from the 22 centres of major trauma excellence around the country and help researchers to work with them to access the anonymous data for specific research questions. We aim to use these results to help clinicians and health systems to improve how the fund and deliver care for older people.