Quantifying the healthcare costs of treating severely bleeding major trauma patients: a national study for England.

INTRODUCTION: Severely bleeding trauma patients are a small proportion of the major trauma population but account for 40% of all trauma deaths. Healthcare resource use and costs are likely to be substantial but have not been fully quantified. Knowledge of costs is essential for developing targeted cost reduction strategies, informing health policy, and ensuring the cost-effectiveness of interventions. METHODS: In collaboration with the Trauma Audit Research Network (TARN) detailed patient-level data on in-hospital resource use, extended care at hospital discharge, and readmissions up to 12 months post-injury were collected on 441 consecutive adult major trauma patients with severe bleeding presenting at 22 hospitals (21 in England and one in Wales). Resource use data were costed using national unit costs and mean costs estimated for the cohort and for clinically relevant subgroups. Using nationally available data on trauma presentations in England, patient-level cost estimates were up-scaled to a national level. RESULTS: The mean (95% confidence interval) total cost of initial hospital inpatient care was £19,770 (£18,177 to £21,364) per patient, of which 62% was attributable to ventilation, intensive care, and ward stays, 16% to surgery, and 12% to blood component transfusion. Nursing home and rehabilitation unit care and re-admissions to hospital increased the cost to £20,591 (£18,924 to £22,257). Costs were significantly higher for more severely injured trauma patients (Injury Severity Score ≥15) and those with blunt injuries. Cost estimates for England were £148,300,000, with over a third of this cost attributable to patients aged 65 years and over. CONCLUSIONS: Severely bleeding major trauma patients are a high cost subgroup of all major trauma patients, and the cost burden is projected to rise further as a consequence of an aging population and as evidence continues to emerge on the benefits of early and simultaneous administration of blood products in pre-specified ratios. The findings from this study provide a previously unreported baseline from which the potential impact of changes to service provision and/or treatment practice can begin to be evaluated. Further studies are still required to determine the full costs of post-discharge care requirements, which are also likely to be substantial

COVID-19: Rapid antigen detection for SARS-CoV-2 by lateral flow assay: A national systematic evaluation of sensitivity and specificity for mass-testing

Background Lateral flow device (LFD) viral antigen immunoassays have been developed around the world as diagnostic tests for SARS-CoV-2 infection. They have been proposed to deliver an infrastructure-light, cost-economical solution giving results within half an hour. Methods LFDs were initially reviewed by a Department of Health and Social Care team, part of the UK government, from which 64 were selected for further evaluation from 1st August to 15th December 2020. Standardised laboratory evaluations, and for those that met the published criteria, field testing in the Falcon-C19 research study and UK pilots were performed (UK COVID-19 testing centres, hospital, schools, armed forces). Findings 4/64 LFDs so far have desirable performance characteristics (orient Gene, Deepblue, Abbott and Innova SARS-CoV-2 Antigen Rapid Qualitative Test). All these LFDs have a viral antigen detection of >90% at 100,000 RNA copies/ml. 8951 Innova LFD tests were performed with a kit failure rate of 5.6% (502/8951, 95% CI: 5.1–6.1), false positive rate of 0.32% (22/6954, 95% CI: 0.20–0.48). Viral antigen detection/sensitivity across the sampling cohort when performed by laboratory scientists was 78.8% (156/198, 95% CI 72.4–84.3). Interpretation Our results suggest LFDs have promising performance characteristics for mass population testing and can be used to identify infectious positive individuals. The Innova LFD shows good viral antigen detection/sensitivity with excellent specificity, although kit failure rates and the impact of training are potential issues. These results support the expanded evaluation of LFDs, and assessment of greater access to testing on COVID-19 transmission. Funding Department of Health and Social Care. University of Oxford. Public Health England Porton Down, Manchester University NHS Foundation Trust, National Institute of Health Research

6.4 Transfusion management and haemostatic changes in major obstetric haemorrhage in the UK.

UNLABELLED: : Blood transfusion is fundamental to improving outcomes during major obstetric haemorrhage (MOH). Current guidelines recommend that fresh frozen plasma (FFP), cryoprecipitate and platelets are transfused when PT/APTT is >1.5 × baseline, fibrinogen 1.5x baseline, fibrinogen <1.0 g/dL and platelet <50 × 10(9)/L respectively. FFP, cryoprecipitate and platelets were transfused in 99%, 61% and 77% of women. The median (IQR) RBC, FFP and cryoprecipitate transfused were: 10 (8-1), 6 (4-8), and 2 units (2-4), with the first FFP and cryoprecipitate transfused after a median of 4 (3-6) and 7 RBC units (6-9) respectively. 45% of women underwent hysterectomy, 2 died, 82% were admitted to ITU/HDU, and 28% developed additional major morbidity. CONCLUSION: Guideline criteria for plasma/platelet transfusion were fulfilled in only 25% of these severe cases, indicating that further research is needed to define transfusion triggers in MOH

6.4 Transfusion management and haemostatic changes in major obstetric haemorrhage in the UK.

UNLABELLED: : Blood transfusion is fundamental to improving outcomes during major obstetric haemorrhage (MOH). Current guidelines recommend that fresh frozen plasma (FFP), cryoprecipitate and platelets are transfused when PT/APTT is &gt;1.5 × baseline, fibrinogen &lt;1 g/dL and platelet count &lt;50 × 10(9)/L, respectively. However, these recommendations are not evidence-based. AIMS: to describe coagulation abnormalities and transfusion requirements during MOH (defined as transfusion of ≥8 units of RBC within 24 hrs of delivery). METHODS: Cases were identified using the UK Obstetric Surveillance System, between July 2012 and June 2013. RESULTS: We identified 181 cases; 68% delivered by caesarean. The median estimated blood loss was 6000 mL (IQR: 4500-8000). The main causes for MOH were uterine atony (40%) and placenta accreta/increta/percreta (16%). The median (IQR) platelet count, APTT-ratio and fibrinogen (worst values) were 68 x 10(9)/L (50-95), 1.3 (1.0-1.9) and 1.4 (0.8-2.2) respectively. In 33%, 27% and 25% of cases APTT-ratio was &gt;1.5x baseline, fibrinogen &lt;1.0 g/dL and platelet &lt;50 × 10(9)/L respectively. FFP, cryoprecipitate and platelets were transfused in 99%, 61% and 77% of women. The median (IQR) RBC, FFP and cryoprecipitate transfused were: 10 (8-1), 6 (4-8), and 2 units (2-4), with the first FFP and cryoprecipitate transfused after a median of 4 (3-6) and 7 RBC units (6-9) respectively. 45% of women underwent hysterectomy, 2 died, 82% were admitted to ITU/HDU, and 28% developed additional major morbidity. CONCLUSION: Guideline criteria for plasma/platelet transfusion were fulfilled in only 25% of these severe cases, indicating that further research is needed to define transfusion triggers in MOH

Study protocol: first nationwide comparative audit of acute lower gastrointestinal bleeding in the UK.

INTRODUCTION: Acute lower gastrointestinal bleeding (LGIB) is a common indication for emergency hospitalisation worldwide. In contrast to upper GIB, patient characteristics, modes of investigation, transfusion, treatment and outcomes are poorly described. There are minimal clinical guidelines to inform care pathways and the use of endoscopy, including (diagnostic and therapeutic yields), interventional radiology and surgery are poorly defined. As a result, there is potential for wide variation in practice and clinical outcomes. METHODS AND ANALYSIS: The UK Lower Gastrointestinal Bleeding Audit is a large nationwide audit of adult patients acutely admitted with LGIB or those who develop LGIB while hospitalised for another reason. Consecutive, unselected presentations with LGIB will be enrolled prospectively over a 2-month period at the end of 2015 and detailed data will be collected on patient characteristics, comorbidities, use of anticoagulants, transfusion, timing and modalities of diagnostic and therapeutic procedures, clinical outcome, length of stay and mortality. These will be audited against predefined minimum standards of care for LGIB. It is anticipated that over 80% of all acute hospitals in England and some hospitals in Scotland, Wales and Northern Ireland will participate. Data will be collected on the availability and organisation of care, provision of diagnostic and therapeutic GI endoscopy, interventional radiology, surgery and transfusion protocols. ETHICS AND DISSEMINATION: This audit will be conducted as part of the national comparative audit programme of blood transfusion through collaboration with specialists in gastroenterology, surgery and interventional radiology. Individual reports will be provided to each participant site as well as an overall report and disseminated through specialist societies. Results will also be published in peer-reviewed journals. The study has been funded by National Health Services (NHS) Blood and Transplant and the Bowel Disease Research Foundation and endorsed by the Association of Coloproctology of Great Britain and Ireland

Study protocol: first nationwide comparative audit of acute lower gastrointestinal bleeding in the UK.

INTRODUCTION: Acute lower gastrointestinal bleeding (LGIB) is a common indication for emergency hospitalisation worldwide. In contrast to upper GIB, patient characteristics, modes of investigation, transfusion, treatment and outcomes are poorly described. There are minimal clinical guidelines to inform care pathways and the use of endoscopy, including (diagnostic and therapeutic yields), interventional radiology and surgery are poorly defined. As a result, there is potential for wide variation in practice and clinical outcomes. METHODS AND ANALYSIS: The UK Lower Gastrointestinal Bleeding Audit is a large nationwide audit of adult patients acutely admitted with LGIB or those who develop LGIB while hospitalised for another reason. Consecutive, unselected presentations with LGIB will be enrolled prospectively over a 2-month period at the end of 2015 and detailed data will be collected on patient characteristics, comorbidities, use of anticoagulants, transfusion, timing and modalities of diagnostic and therapeutic procedures, clinical outcome, length of stay and mortality. These will be audited against predefined minimum standards of care for LGIB. It is anticipated that over 80% of all acute hospitals in England and some hospitals in Scotland, Wales and Northern Ireland will participate. Data will be collected on the availability and organisation of care, provision of diagnostic and therapeutic GI endoscopy, interventional radiology, surgery and transfusion protocols. ETHICS AND DISSEMINATION: This audit will be conducted as part of the national comparative audit programme of blood transfusion through collaboration with specialists in gastroenterology, surgery and interventional radiology. Individual reports will be provided to each participant site as well as an overall report and disseminated through specialist societies. Results will also be published in peer-reviewed journals. The study has been funded by National Health Services (NHS) Blood and Transplant and the Bowel Disease Research Foundation and endorsed by the Association of Coloproctology of Great Britain and Ireland