Christopher Moran

Aims: This study aimed to assess the association between surgical delay due to non-medical reasons and one-year mortality in patients with hip fracture, and to explore whether a dose-response relationship exists between increasing time to surgery and mortality risk. Methods: A retrospective cohort analysis was performed using prospectively collected data from the Nottingham Hip Fracture Database. A total of 5,414 patients aged ≥ 60 years admitted with a fragility femoral fracture to a major trauma centre between April 2016 and March 2023 were reviewed. Time to theatre was measured from emergency department arrival to anaesthetic start. Delays beyond 36 hours were categorized as either medical or logistical. The primary outcome was all-cause one-year mortality with a secondary outcome being length of stay (LOS). Multivariable Cox proportional hazards models were used to assess associations, adjusting for age, sex, comorbidity, and cognition. Results: Of the cohort, 38.5% (n = 2,083) experienced surgical delay beyond 36 hours; 27.5% (n = 1,490) due to limited surgical capacity and 11.0% (n = 593) due to medical unfitness. After adjusting for age, sex, comorbidity, and cognition, delay due to logistical factors was associated with a 20% increase in one-year mortality (hazard ratio (HR) 1.20 (95% CI 1.06 to 1.36); p = 0.004). A secondary analysis excluding medically unfit patients demonstrated a stepwise increase in hazard with increasing time to theatre, suggesting a dose-response effect. LOS was also increased with delay to theatre by one day in this cohort. Conclusion: Delayed surgery beyond 36 hours, due to lack of surgical capacity, is independently associated with increased mortality following hip fracture. These findings reinforce the need for protected surgical capacity and prioritization of prompt surgery to improve outcomes in this vulnerable population. Cite this article: Bone Joint J 2026;108-B(8):1021–1028.

Background: Triage at major incidents has traditionally relied on assessing physiology, and in the UK, this role has usually been performed by healthcare responders. However, recent major incidents have shown that this approach, particularly in the initial phases, may be inappropriate due to potential delays in the delivery of key life-saving interventions (LSIs).The Ten Second Triage (TST) tool has been developed to expedite the triage process and the delivery of key LSIs. The aim of this study was to determine the performance characteristics of the TST, including the time to deliver LSIs, in a simulated major incident setting, by both healthcare and non-healthcare responders. Methods: A prospective observational study was conducted as part of a simulated major incident exercise, incorporating a variety of trauma pathologies. Responders from all three emergency services – Police, Fire, and Ambulance - participated. Eight simulations were conducted, each involving ten responders and a team leader from the respective single service groups. The NHS Major Incident Triage Tool (MITT), the TST alone, and a combination of both were assessed. Quantitative assessments for each simulation included overall triage time, time to delivery of LSI, and accuracy of triage tool categorisation. Results: Using the TST alone, the mean overall triage time was 377 s (10.2 s per casualty). In comparison, the mean overall triage time of the MITT alone was 1500 s (40.5 s per casualty). However, when the MITT was applied following the TST, it was completed more quickly, with a mean time of 960 s (25.9 s per casualty). When the TST was used, we observed a clinically significant reduction in the time to deliver key LSIs (491 s) compared to the MITT (1377 s). Overall triage accuracy was comparable between TST (80.3%) and MITT (79.3%), and TST performance was similar between healthcare and non-healthcare responders. Conclusion: This simulation study demonstrated that the TST is a rapid and accurate early scene triage method that enables the timely delivery of key lifesaving interventions. It facilitates the administration of these LSIs faster than existing physiological triage methods. These findings support the NHS England endorsement of the TST.

Background: The most common cause of preventable death after injury is haemorrhage. Resuscitative endovascular balloon occlusion of the aorta is intended to provide earlier, temporary haemorrhage control, to facilitate transfer to an operating theatre or interventional radiology suite for definitive haemostasis. Objective: To compare standard care plus resuscitative endovascular balloon occlusion of the aorta versus standard care in patients with exsanguinating haemorrhage in the emergency department. Design: Pragmatic, multicentre, Bayesian, group-sequential, registry-enabled, open-label, parallel-group randomised controlled trial to determine the clinical and cost-effectiveness of standard care plus resuscitative endovascular balloon occlusion of the aorta, compared to standard care alone. Setting: United Kingdom Major Trauma Centres. Participants: Trauma patients aged 16 years or older with confirmed or suspected life-threatening torso haemorrhage deemed amenable to adjunctive treatment with resuscitative endovascular balloon occlusion of the aorta. Interventions: Participants were randomly assigned 1 : 1 to: standard care, as expected in a major trauma centre standard care plus resuscitative endovascular balloon occlusion of the aorta. Main outcome measures: Primary: Mortality at 90 days. Secondary: Mortality at 6 months, while in hospital, and within 24, 6 and 3 hours; need for haemorrhage control procedures, time to commencement of haemorrhage procedure, complications, length of stay (hospital and intensive care unit-free days), blood product use. Health economic: Expected United Kingdom National Health Service perspective costs, life-years and quality-adjusted life-years, modelled over a lifetime horizon. Data sources: Case report forms, Trauma Audit and Research Network registry, NHS Digital (Hospital Episode Statistics and Office of National Statistics data). Results: Ninety patients were enrolled: 46 were randomised to standard care plus resuscitative endovascular balloon occlusion of the aorta and 44 to standard care. Mortality at 90 days was higher in the standard care plus resuscitative endovascular balloon occlusion of the aorta group (54%) compared to the standard care group (42%). The odds ratio was 1.58 (95% credible interval 0.72 to 3.52). The posterior probability of an odds ratio > 1 (indicating increased odds of death with resuscitative endovascular balloon occlusion of the aorta) was 86.9%. The overall effect did not change when an enthusiastic prior was used or when the estimate was adjusted for baseline characteristics. For the secondary outcomes (3, 6 and 24 hours mortality), the posterior probability that standard care plus resuscitative endovascular balloon occlusion of the aorta was harmful was higher than for the primary outcome. Additional analyses to account for intercurrent events did not change the direction of the estimate for mortality at any time point. Death due to haemorrhage was more common in the standard care plus resuscitative endovascular balloon occlusion of the aorta group than in the standard care group. There were no serious adverse device effects. Resuscitative endovascular balloon occlusion of the aorta is less costly (probability 99%), due to the competing mortality risk but also substantially less effective in terms of lifetime quality-adjusted life-years (probability 91%). Limitations: The size of the study reflects the relative infrequency of exsanguinating traumatic haemorrhage in the United Kingdom. There were some baseline imbalances between groups, but adjusted analyses had little effect on the estimates. Conclusions: This is the first randomised trial of the addition of resuscitative endovascular balloon occlusion of the aorta to standard care in the management of exsanguinating haemorrhage. All the analyses suggest that a strategy of standard care plus resuscitative endovascular balloon occlusion of the aorta is potentially harmful. Future work: The role (if any) of resuscitative endovascular balloon occlusion of the aorta in the pre-hospital setting remains unclear. Further research to clarify its potential (or not) may be required. Trial registration: This trial is registered as ISRCTN16184981. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/199/09) and is published in full in Health Technology Assessment; Vol. 28, No. 54. See the NIHR Funding and Awards website for further award information.