In the UK, the population is rapidly ageing. One in four people will be aged 65 or over by 2040. The fastest growing age group are those over 85 years.1 As a consequence, the demographics of patients presenting to emergency departments is also changing rapidly. The proportion of major trauma patients aged over 75 years has risen sharply from 8.1 to 26.9% between 1990 and 2013.2 These projections suggest that those aged over 75 years will soon represent the single largest group of patients suffering major trauma.2 Low level falls (<2 metres) are now the leading cause of trauma in the UK.2

Fractures of the upper cervical spine in elderly patients are rising globally and are due to low energy trauma where underlying bone is characterised by osteopenia and degenerative changes.3 Mortality associated with cervical spine fractures in elderly patients is less well -studied.4 Several studies have shown a risk of acute (in-hospital) mortality of >20% for elderly patients with isolated cervical spine fractures.5 Another study identified that mortality at one year for patients over 65 years (mean age 80 years) was 28%.6

Cervical spine injury is a potentially life-threatening trauma. Given the increase in the number of patients presenting to the emergency department (ED) who are elderly and who have fallen and sustained trauma, it has become challenging to manage this cohort.

Older people with cervical spine fractures have complex ongoing healthcare needs with high prevalence of frailty, delirium and dementia. Pressure sores are also a well-recognised complication of rigid cervical spine immobilisation.7 A systematic review found incidence of collar-related pressure ulcers ranging from 6.8% to 38% typically at the occiput, chin, shoulders and back.8

Complex care needs demand complex care interventions with input from various healthcare professionals working as a multidisciplinary team (MDT). A geriatrician cannot be introduced to the situation as a stand-alone.

There is compelling evidence that comprehensive geriatric assessment (CGA) is the most effective way to improve outcomes for older people with frailty.9

Geriatricians are trained in delivering CGA in collaboration with multidisciplinary team and these principles of CGA should be incorporated in the assessment and management of older cervical spine fracture patients.

We propose that in addition to the diagnostic challenges and complex care needs in the elderly population, a robust, integrated care pathway and comprehensive geriatric assessment with involvement of a geriatrician is essential. This would provide effective care to patients who require cervical collar care after cervical spine injury reducing morbidity and mortality.

Intervention

Data was gathered about the patient’s demographics, nature of cervical spine injury, care required from Jan 2013 till Nov 2016 (pre intervention) and from Nov 2016 till Oct 2017 (post intervention). Current practice was reviewed, which showed significant variability in provision of care for cervical spine injury patients including collar care. We noted that these patients were scattered around the hospital in various medical wards with staff not trained on the management of these patients including collar care.

An integrated care pathway (ICP) (Figure 1) was designed with the involvement of MDT members to standardise the care of this cohort of patients in our hospital. The boxes highlighted in blue were the new interventions.

This included early identification of patients with cervical spine injury and co-locating all patients with cervical spine fracture in the orthogeriatric ward.

Orthogeriatric review for a comprehensive geriatric assessment

Guidelines for caring for patients who have sustained a cervical spine fracture requiring a Miami J Collar were developed to help standardise practice throughout the patient’s journey from A&E, to admission to the ward and discharge into the community. This was to ensure that patients are monitored safely, receive the appropriate care and therefore reduce the risk of harm as a result of their cervical injury.

Developing nursing expertise for cervical collar care (including fitting, changing pads, checking pressure areas, log roll, head hold, sizing and fitting of collar) was another significant intervention. The senior trauma nurse practitioner, lead physiotherapist and clinical nurse leader ensured teaching for all the registered nurses, physiotherapists, clinical associate practitioners and therapy technicians. The team also identified that our rapid response community teams needed to complete the training and competency programme. Training these staff in post discharge collar care also helped to improve the interface with the primary care team and ensured the safety of these patients in the community following their discharge.

A Collar Care Record was also created to ensure visual inspection at least three times a day, which included checking the collar is fitted correctly, checking pressure areas (sternum, clavicle, chin, ears, occiput) daily and changing collar pads on alternate days.

Optimising comfort was also crucial, ensuring the collar was correctly sized/fitted and switched to soft padded collar if necessary.

The team also ensured that patients were sat up early to prevent complications like aspiration and reduce pressure sores in other areas such as the sacrum, elbows and heels. Early nutritional support was also essential by involving the ward dietician.

Outcome measures in patients over 75 years were recorded. These included length of stay (LOS), inpatient mortality and mortality at 6 and 12 months.

Results

There were 54 patients who were aged over 75 years that presented to our Trust with cervical spine fractures between Jan 2013 and Oct 2017 with an average age of 86.6 years. Of these patients, 34 (63%) were female. The data has shown that with the quality improvement interventions, our LOS has reduced from 17 to 10.89 days; with in-patient mortality improving from 22.85% to 0% during the intervention period. There was also an improvement in mortality at six months and at one year.

Discussion

Our quality improvement programme has shown that older patients with cervical spinal fracture are best managed in collaboration with a multidisciplinary team and that the principles of CGA should be incorporated in the assessment and management of these patients.

Elderly patients are at high risk of complications like pressure ulcers, pneumonia, dysphagia and delirium with prolonged cervical immobilisation.10 It is therefore crucial that nurses and therapists involved in the management of these patients have been trained and developed expertise especially for collar care.

Delirium is a recognised risk factor for poor outcome and increase in-hospital mortality in elderly patients.11 The benefit of maintaining compliance with cervical collars must be carefully weighed against the potential harm that comes with sedation. Early involvement by a geriatrician helps with the prompt management of delirium as well as early liaison with family.

Our team ensured that patients with rigid collars were switched to collars with softer padding and greater adjustability such as the Miami J collar, or even a soft collar that would ensure comfort and reduce the risk of delirium. Studies have shown that the motion recorded during various functional tasks was not significantly different for 13 of 15 functional activities of daily living, regardless of whether a rigid or soft collar was used.12

Pneumonia remains the most frequent complication of cervical spine immobilisation in several case studies of elderly patients.13 Patients on the ward were sat up as soon as possible to reduce the risk of pneumonia and were also encouraged to mobilise on the ward.

Mortality rates following a cervical spine fracture in older patients are higher (>20% in-patient mortality and one-year mortality—28%)5 than hip fractures (30 day mortality 6.7% with one-year mortality—21%).13,14 Having geriatricians involved in managing hip fractures with the involvement of the National Hip Fracture Database (NHFD), the 30-day mortality has been improving year on year since NHFD inception in 2007 from 10.9% to 8.5% in 2011 and to 6.7% in 2016.14 In our cohort, involvement of a geriatrician played a key role in reducing overall mortality along with CGA and the ICP.

Prior to the quality improvement interventions, our inpatient mortality was comparable to published data but mortality at one-year was higher than the published data. Following the interventions, our LOS and mortality has improved, and it is better than the published data. The post intervention data had only 19 patients and hence a significant limitation in our study. We need more data to confirm whether this improvement was statistically significant. However, our quality improvement programme does suggest that having a system like hip fractures with geriatrician involvement and benchmarking data can help to drive up standards in the care of older people with cervical fractures.

Conclusion

Cervical spine injuries are common in older patients who are at greater risk of falls and thus sustaining injuries. Early identification and management of these patients in a clinical area with a multidisciplinary approach and appropriate expertise is key to reducing LOS and adverse outcome including mortality.

 

Conflict of interest: none declared

References

  1. ONS. Annual Mid-year Population Estimates 2015. https://www.ons.gov.uk/peoplepopulationandcommunity
  2. Kehoe A, Smith JE, Edwards A, et al. The changing face of major trauma in the UK. Emerg Med J 2015; 32: 911–15
  3. Wantanabe M, Sakai D, Yamamoto Y, et al. Upper cervical spine injuries: age-specific clinical features. J Orthop Sci 2010; 15: 485–92
  4. Smith DP, Enderson BL, Maull KI. Trauma in the elderly: determinants of outcome. South Med J 1990; 83: 171–77
  5. Golob JF Jr, Claridge JA, Yowler CJ, et al. Isolated cervical spine fractures in the elderly: a deadly injury. J Trauma 2008; 64: 311–15
  6. Harris M, Reichmann W, Bono C, et al. Mortality in Elderly Patients after cervical spine fractures. J Bone joint Surg Am 2010; 92: 567–74
  7. Webber-Jones JE, Thomas CA, Bordeaux RE. Jr., The management and prevention of rigid cervical collar complications. Orthop Nurs 2002; 21: 19–25
  8. Ham W, Schoonhoven L, Schuurmans MJ, Leenen LP. Pressure ulcers from spinal immobilization in trauma patients: a systematic review. J Trauma Acute Care Surg 2014: 76: 1131–41
  9. Ellis G, Whitehead MA, Robinson D, et al. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 2011; 343: d6553
  10. Peck G, Shipway D, Tsang K, Fertleman M. Cervical spine immobilisation in the elderly: a literature review. British Journal of Neurosurgery
  11. Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing 2006; 35: 350–64
  12. Miller CP, Bible JE, Jegede KA, et al. The effect of rigid cervical collar height on full, active, and functional range of motion during fifteen activities of daily leaving. Spine (Phila Pa 1976) 2010; 35: E1546–52
  13. Schnell S, Friedman S, Mendelson D, et al. The 1-year mortality of patients treated in a hip fracture program for elders. Geriatri Orthop Surg Rehabil 2010; 1(1): 6-14
  14. National Hip Fracture Database Report https://nhfd.co.uk/files/2017ReportFiles/NHFD-AnnualReport2017.pdf

R Lisk, C Negasan, A Manzoor, H Watters, P Enwere, K Yeong, R Mahmood

Ashford and St Peter’s NHS Foundation Trust, Guildford Street, Chertsey

radcliffe.lisk@asph.nhs.uk