The process of identifying major trauma in the older person in a single major trauma centre: A service evaluation

Diagnosis of major trauma in the older person is increasingly recognised as clinically challenging with recent reports finding that older patients sustaining major trauma are commonly under-recognised and subsequently are not receiving gold standard major trauma care. This paper is a service evaluation of the processes of major trauma (ISS > 15) care for patients > 65 years presenting to a UK major trauma centre. To identify modifiable factors within the patient journey that might inform future service improvement initiatives. TARN audit data and retrospective notes review of 190 patients > 65 presenting to UHS ED from 1st January 2018 – 31st December 2018 who did not receive a level 1 trauma call on arrival were used to achieve the dataset. Descriptive statistics were combined with multiple logistic regression to look for associations between specific process factors and a missed or delayed diagnosis. The evaluation found that, of the cohort not receiving a level 1 trauma call, 42 (22.1%) patients received a level 2 trauma call; 87 (45.7%) patients were seen initially by a senior clinician, with only 31 (16.3%) patients meeting best practice tariff for consultant within 5 min; 60 (31.5%) patients were seen directly in the resuscitation room; 48 (25.2%) patients received a trauma CT scan with only 27 (14.2%) meeting BPT for CT head within 1 h; 142 (74.7%) patients were admitted to a trauma specialty after discharge from ED. A total of 76 (40%) patients had a missed diagnosis of major trauma with 80 (42%) having a delayed diagnosis. Logistic regression showed a significant association between being seen in a standard initial assessment area (referred to as pitstop in this article) vs the resuscitation room as a first location (p = 0.007) with a delayed diagnosis; and a significant association between plain film imaging vs CT imaging (p = 0.000) and no trauma call vs trauma call (p = 0.009) with a missed diagnosis of major trauma. The findings of this service evaluation suggest that service improvement initiatives should be aimed at the early stages of the patient journey to improve missed or delayed diagnoses of major trauma in this patient group.