Networks for Major Trauma - changing the face of trauma care

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Networks for Major Trauma - changing the face of
trauma care
Prof. Keith Willett National Clinical Director
for Trauma Care
November 2009 UKABIF Conference
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Major Trauma Challenge

• Regional Networks for Major Trauma
• Currently
• No formal infrastructure
• historical referral pathways only
• poor communication and image transfer
• variety of commissioning methods
• Delayed and inappropriate care pathways
• leading to poor outcomes

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Current trauma care in the UK

• 214 acute receiving hospitals for 60 million pop.
• each serving 150K to 950K (25K-150K ED
  attendances)
• most with Emergency Department supported by
• anaesthesia
• trauma and orthopaedics
• general surgery
• intensive care, acute medicine, (paediatrics,
  obstetrics)
• Regional (1.5 - 2.5 million) ad hoc support
• neurosurgery, burns, cardiothoracic, plastics,
  vascular, maxillofacial, major orthopaedic
  trauma (pelvis, acetabulum, complex articular,
  brachial plexus and spinal surgery)

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NCEPOD Trauma Who cares?

• November 2007
• 60 of ISS gt16 received a standard of care less
  than good practice

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NCEPOD Trauma Who cares?

• Reasons
• Disorganised pre-hospital care
• Inadequate airway management
• Low frequency (lt one per week)
• Inadequate trauma team response
• Lack of seniority in immediate hospital care
• lack of appreciation of seriousness
• Lack of urgency
• Incorrect decision making

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NCEPOD Trauma who cares?

• Principle Recommendations
• Pre-hospital RSI airway skills
• A regional trauma service
• Designation of Level 1 trauma centres
• All serious HIs transferred to Neurosciences
  Unit
• 24/7 trauma team (Consultant led)
• Routine trauma CT scan series
• Consultant Surgeon for trauma laparotomy
• CT head in less than 1 hour of arrival
• Standardised transfer documentation

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Ben Bradshaw, 11th June 2008House of Commons
debate

• NCEPOD report
• the government intends to take forward the
  (NCEPOD) report recommendations on regional
  trauma services

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Whats the evidence for trauma systems?
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International Comparators Victoria State

• 2006-7 data
• 42 per 100K pop
• 85 ISS gt15
• 71 direct transfer
• gt1 hour to hospital
• 44 of non-trapped
• 74 trapped

Preventable Deaths Trauma Centre
20 Teaching 40 Metropolitan 41 Large
Regional 53 Small Regional 62 victrauma.health.
vic.gov.au
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Serious head injury casemix adjusted odds of
deathsUK Neurosciences Centre versus Non-Neuro
Centre
Number of patients Group Adjusted Odds Ratio (95 CI) for predicting death when treated in NNC versus NC
3069 SHI with complete RTS 2.29 (1.89-2.76)
6921 All SHI patients 2.65 (2.35-2.99)
456 Isolated, non-surgical SHI (Age 16-65) with complete RTS 2.11 (1.21-3.67)
894 All isolated, non-surgical SHI (Age 16-65) patients 1.56 (1.12-2.18)
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How good is the evidence?

• A reduction in mortality from 7?Cameron 2008,
  Demetriades 2005
• How will it be achieved - if not by volume?
• Services, facilities, organisation,
  training Nathen 2001
• What about bypass - direct transfer?
• Rivara 2008
• Can we be sure who it is safe to move for longer
  distances/times? Triage tools?
• 95 sensitive, 8 specific 2-5x over triage
  Lerner 2006
• 70 non life-threatening Bledsoe 2006
• HR variability/complexity 75 specificity and 33
  PPV Cancio 2008, King 2009
• Does a doctor improve triage?
• Direct from scene transfers up 28 to
  70 Meisler 2009
• Secondary transfers down 70 to 30
• But ISS of direct 5 (1-17) and secondary 17
  (14-26)
• Under overtriage anaesthetists better vs
  paramedic Reim 2009

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How good is the evidence?

• What about prehospital interventions?
• Difficult to separate one intervention from a
  system effect
• e.g.
• Systematic review of H versus EMS
• 23 eligible studies no level 1, 5 level II,
  rest level III
• 14 demonstrated improved survival, 9 didnt
• none cost-effective?
• Contrasting evidence from Liberman
• Helicopter
• Remote locations, airway (physician) team to
  scene rapidly, preferential hospital,
  inter-hospital transfers

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How good is the evidence?

• Reviews
• Mann J Trauma 1999
• Celso J Trauma 2006
• 15-20 improvement in survival amongst seriously
  injured
• Future research must use more sophisticated study
  designs . . . . with outcome measures to assess
  the whole continuum of care, including
  prehospital, rehabilitation, and long term
  quality of life

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. . . . so what will the problems be?

• Transfers
• NCEPOD (194) underestimate
• only those within 72 hours
• specialist management of injuries
• 62 neurosurgery
• 10 burns and plastics
• 4 cardiothoracic
• 3 PICU
• Omitted maxillofacial
• complex pelvis and acetabular fractures
• unstable spinal column injuries
• open and complex fractures
• need urgent not emergency surgery

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. . . . so what will the problems be?

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. . . . so how many will transfer?

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The issues to address in Major Trauma
Low numbers, high acuity, unpredictable Commonly
exceed local healthcare services Managed at the
regional tier (SHA) of NHS No infrastructure Poor
triage tools The positives Professional
consensus on standards National professional
audit (TARN) Overlaps with stroke, PCI, Critical
Care Networks Recent military (DMS)
experience Likely to be highly cost-effective

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. . . how should transfers be secured?
It is illogical for the unit that is incapable
of delivering the required care to remain
primarily responsible for the patient
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Principles of treatment
To deliver the patient rapidly and safely to a
hospital that can manage the definitive care of
their injuries irrespective of where they suffer
those injuries
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Principles of treatment
To deliver the patient rapidly and safely to a
hospital that can manage the definitive care of
their injuries irrespective of where they suffer
those injuries
Design for the usual and plan for the
unusual Ambulance TARN data
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Principles of treatment
to deliver the patient rapidly and safely to a
hospital that can manage the definitive care of
their injuries irrespective of where they suffer
those injuries . . . . . . . . . Evolve care
models and pathways based on local expertise,
geography, facilities, transport options and the
ongoing monitoring of performance against
professional standards - bespoke inclusive
networks
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. . . . so how can this be achieved?

• Establish TRAUMA NETWORKS of hospitals
• Charge the regional network / specialist unit
  with the responsibility for achieving the
  definitive standard and the patient placement
• facilitate prompt quality transfers
• Direct transfer protocols (30 - 45 mins journey)
• Open access airway and just send policy
• Indirect transfer triage, resuscitate and early
  transfer
• Then determine the valid role for
• retrieval or intercept teams
• helicopters

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. . . . so how can this be achieved?

• Consultant Medical Co-ordination of Network
• network desk, digital radio links,
• monitoring, decision making, and tasking
• Separate H from EMS
• what do you need?
• Immediate CT scan is our best triage tool
• REACT-Trial (Netherlands)
• Every hospital is integral to the network

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EMS Assurance Medical direction integrated into
EMS System wide triage criteria to ensure
appropriate route of care Well coordinated
transportation 2006
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The rehabilitation challenges . . . . .

• Facts
• There is inadequate provision
• Earlier rehabilitation is more effective, reduces
  physical, psychological and cognitive disability
• There is no focus in most Acute Trusts
• Early care would reduce hospitalisation

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It is illogical that rehabilitation units only
become responsible for the patient when they
receive them
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. . . and how should the network develop?

1. Prescription for physical and neuropsychological
   rehabilitation / priority repatriation / key
   worker
2. Linked directory of all rehabilitation services
3. Director of rehabilitation in each Trauma unit
4. Unbundle the rehabilitation element of tariff
5. By auditing key quality measures of care (TARN),
   develop locally sensitive protocols for
   communication, transfers, repatriation and
   rehabilitation

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Changing trauma practice for quality improvement
in the NHS . . . my vision

• Reporting and monitoring of patient-important
  outcomes
• Regional Trauma Board
• Regional Director for Trauma, Network Manager
• Ambulance and Hospital Trusts Trauma Leads
• SHA, PCT, Rehab unit and patient rep
• (supporting data co-ordinators)
• Quality Assurance Committee
• Trauma Prevention, Education and Research
  Programmes

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Changing trauma practice for quality improvement
in the NHS . . . my plan

• Five clinical and patient advisory groups
• Pre-hospital and inter-hospital transfers
• Patient reception, emergency surgery/critical
  care
• Network organisation / modus operandi, public
  and patient education, quality assurance
• On-going care, reconstruction surgery
• Rehabilitation

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. . . . . . . agreement on UK options to consider
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Changing trauma practice for quality improvement
in the NHS . . . my plan
Options and KEY IMPACT INTERVENTIONS
Clinical Advisory Groups
Research Review of all current guidelines
Measurable Commissionable Cost-effective
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SHA
Combined datasets from TARN, HES and NCEPOD
NICE Health Economics
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Project TimelinePolicy Initiation Document

• NCD to meet all SHA and Ambulance Service MDs
• 6 month time-limited CAG work
• SHA Guidance Document by mid 2010
• Regional co-production workstreams
• Parallel work with
• NICE health economics
• NHS Evidence
• PbR major trauma and rehabilitation HRGs
• TARN report structures
• Defence Medical Services
• UK Search and Rescue Framework

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Levers and Commissioning

• National Audit Office
• 2 reviews of public spending (2009) on
• Major Trauma
• Defence Medical Services
• NAO report Nov Dec 2009
• Public Accounts Committee Jan/Feb 2010
• Specialist Commissioning
• initiate network development
• Payment by Results
• HRG definitions for multiple trauma
• Tariffs (normative data) link to quality metrics
  (?)

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