Background

Previously major trauma was considered to be serious injury resulting from high velocity incidents e.g. young men involved in road traffic collisions. This concept was challenged in 2015 with an article in the Emergency Medical Journal article ‘The Changing Face of Major Trauma’ that pointed to a demographic that was rapidly overtaking young men i.e. patients over the age of 65 years.

Having studied the data it is clear that older patients with low mechanism, low velocity injuries are now the largest group of major trauma patients nationally. Most common mechanism of injury is a fall from less than 2 meters. There are currently 11.5 million people aged over 65 living in the UK. This population is going to grow as we are living longer; the office for national statistics (ONS) estimates that by 2040, 1 in 4 people in the UK will be aged 65 or over

It is important that staff working in the GM trauma network are aware of the effects of altered physiological reserve and increased co-morbidities common in the older patient. We are unable to assume frailty in the over 65 age group or any other but it is important that staff use a systematic approach to carefully assess this particular group of patients.

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 staff in the Emergency Departments around the city to assist with identification of 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 frailty, or elements of it, exists in many other patient groups – chronic illness, deprivation, substance dependence, and pregnancy.

The Challenges of Frailty

This group of patients 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 the data that they are likely to have serious injuries from low mechanisms however they are more likely to receive X-Rays rather than CT scans.

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. e.g a patient presenting with a chest infection as a result of rib fractures sustained following a previous fall.

What we do know

• Older patients that fall are more likely to be conveyed to hospital by ambulance
• They are often ill as well as injured
• Low mechanisms e.g ‘roll out of bed’ can cause serious, life-threatening injuries.
• The NWAS Major Trauma Pathfinder uses a combination of observations and identifiable anatomical injuries.
• The NWAS pathway refers to ‘frail or elderly’ and ‘dangerous or significant mechanism’ – which can be 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 can wait longer to be seen
• As a consequence they are more likely to have occult injuries

How has the Network responded to this?

The Network has 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 where there are clinical concerns.

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

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.

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 also using this aide memoire.

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 continue to develop improvements in services.