Title: A study to develop and validate a Clinical Decision Rule (CDR) for paramedics to triage patients with traumatic brain injury who are 60 years and older who require a neurosurgical intervention at a major trauma centre.
Funder: Health Education England

Abstract: Introduction In the last 20 years, mortality and morbidity have doubled in older (60years+) traumatic brain injury (TBI) patients. Falls from standing height is the leading cause of major trauma in the older population, and the head is the body region most commonly injured. An emergency ambulance is the most common form of transportation to the hospital, and this means that a paramedic is often responsible for the triage and transport of TBI patients. Research, however, suggests that paramedics under-triage older trauma patients and that current triage tools are inadequate at accurately detecting significant TBI. Using risk stratification, this research will seek to develop a clinical decision rule that will allow paramedics to identify older patients with significant TBI and subsequently transport them directly to a major trauma centre for neurosurgical intervention. Research questionIn patients 60 years or older with a traumatic brain injury, what are the risk factors that could accurately determine whether a paramedic should transport these patients directly to a major trauma centre for neurosurgical intervention?Objectives Identify the key risk factors recognised in the literature as predictors of TBI in older patients. Test the relationships between these risk factors and patient outcomes to produce a CDR that determines the primary indicators of older patients with TBI requiring transportation to an MTC for neurosurgical intervention. Test the sensitivity and specificity of the CDR to determine its suitability for prehospital application; Test the CDR in a feasibility study. Explore the acceptability of the CDR to paramedics in clinical practice.Method A pragmatic sequential explanatory mixed methods design will be used to develop a CDR, this will be conducted in four parts: In conjunction with an expert panel and lay representatives, a systematic review of the literature will identify the primary components of the CDR. Build and develop the CDR using data captured at an MTC. Multiple logistic regression will be used to test the relationships between factors in the CDR. The CDR will be validated with a patient cohort from the MTC. A feasibility study of the CDR, testing its applicability in the prehospital setting. Focus groups comprising patients, ambulance paramedics and other clinicians will be convened to explore the CDR's acceptability in clinical practice.Project timeline Year 1: systematic literature review and expert panel develop the CDR.Year 2: derivation and validation of the CDR within the MTC.Year 2-3: the feasibility study of the CDR in a prehospital setting and focus groups with patients, paramedics and other clinicians to ensure acceptability of the CDR; dissemination of findings. Anticipated impact and disseminationAn accurate tool that aids paramedics in their triage of TBI has considerable implications for trauma care for the older population and could minimise rates of death and disability seen over the last 20 years in this patient group. The results of this research will be shared with health and social care professionals and the wider NHS through peer-reviewed publications, conference and poster presentations and professional bodies who review TBI guidelines

Lay abstract: In the last 20 years, death and disability have doubled in older adults (60years+) with traumatic brain injury (TBI); the leading cause of TBI is falling from standing height. An emergency ambulance is the most common form of transport used by TBI patients to get to a hospital which means ambulance paramedics are responsible for deciding which hospital a TBI patient is taken to. Current decision tools used by paramedics are inadequate for older TBI patients and research suggests that paramedics inaccurately triage older trauma patients. This means that an older trauma patient is likely to be transported to a hospital that does not have the appropriate services to deliver the right care to the patient. Signs and symptoms associated with a TBI will be developed into a clinical decision rule (CDR) to identify older patients who require direct transportation to a hospital with specialist trauma services. The primary objectives of the study are to: Identify the key risk factors recognised in the literature as predictors of TBI in older patients Test the relationships between these risk factors and patient outcomes to produce a CDR that determines the primary indicators of older patients with TBI who need to be taken to a hospital with specialist trauma services Test the accuracy of the CDR to determine its suitability for prehospital use Test the feasibility of the CDR with paramedics in clinical practice Explore the acceptability of such a rule in clinical practice.The proposed study will involve older TBI patients from a major trauma centre (MTC) to test a novel CDR that will help paramedics to recognise older patients with a TBI ensuring the right care is delivered to the right patient in an acceptable time. By undertaking a review of previous research, I will comprehensively search, retrieve and examine the existing literature to identify primary risk factors to be included in the CDR with the support of an expert panel including patient representatives. Using advanced statistics on TBI patient data from an MTC, I will test the strength of relationships between the factors and patient outcomes to determine the principal predictors of TBI requiring intervention in older patients and produce a CDR. Finally, the CDR will be tested in a small prehospital study with paramedics. Focus groups will be convened to allow participants to feedback about the experiences of using the CDR, to understand and ensure its acceptability and relevance for practitioners and patients. Past patients and lay people associated with South East Coast Ambulance Service have expressed a desire for more research to be conducted on the prehospital care of older patients with brain injury; this led to the development of this project. In discussion with Patient and Public Involvement (PPI) members, support was gained for research examining how to better identify those patients at risk of significant TBI to ensure they are transported directly to an appropriate hospital. This Plain English summary has been reviewed and amended by PPI members. A steering committee made up of patients, expert clinicians, and statisticians will support the study throughout. This work has considerable potential for wider implementation should the tool be shown to be accurate. The CDR will be shared with Trusts and incorporated into paramedics' clinical practice. The long-term aim is that this tool will improve the accuracy of paramedic triage of older TBI patients, resulting in better patient outcomes, reduced mortality and decreased costs associated with hospitalisation and over-triage of patients. The results of this research will be shared with professionals and the wider NHS through peer-reviewed publications, conference and poster presentations and professional bodies who review TBI guidelines.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: NEUROLOGICAL