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Transforming Major Trauma Care the future

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Non-Members: NO DATA. Ashford and St. Peter's Hospitals NHS Trust ... Brighton and Sussex University Hospitals NHS Trust. Hurstwood Park Neurosciences Centre ... – PowerPoint PPT presentation

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Title: Transforming Major Trauma Care the future


1
Transforming Major Trauma Care - the future
Prof. Keith Willett National Clinical Director
for Trauma Care
24th September 2009 Neurotrauma Conference
2
Fragility Fractures my other policy!
  • Hip fractures 87 of total cost of all
    fragility fractures top 10 HRGs
  • 70,000 per annum, 200,000 fragility fractures
  • 400 million per year acute care
  • 13 million per PCT acute care
  • 50 million on-going care
  • 2.0 billion total care cost

FRAGILITY FRACTURES
2
3
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

MAJOR TRAUMA
3
4
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)

MAJOR TRAUMA
4
5
NCEPOD Trauma Who cares?
  • November 2007
  • 60 of ISS gt16 received a standard of care less
    than good practice

MAJOR TRAUMA
5
6
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

MAJOR TRAUMA
6
7
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

MAJOR TRAUMA
7
8
Ben Bradshaw, 11th June 2008 House of Commons
debate
  • NCEPOD report
  • the government intends to take forward the
    (NCEPOD) report recommendations on regional
    trauma services

9
Whats the evidence for trauma systems?
10
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
MAJOR TRAUMA
10
11
Serious head injury casemix adjusted odds of
deaths UK Neurosciences Centre versus Non-Neuro
Centre
MAJOR TRAUMA
11
12
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
  • What is a Major Trauma Centre?
  • a component of a network that
  • i) a facility with all trauma specialties
  • ii) a unit in which there is a cultural and
    institutional focus on trauma


MAJOR TRAUMA
12
13
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


MAJOR TRAUMA
13
14
. . . . 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

MAJOR TRAUMA
14
15
. . . . so what will the problems be?

MAJOR TRAUMA
15
16
. . . . so how many will transfer?

MAJOR TRAUMA
16
17

The South East Coast SHA TARN returns
  • Brighton and Sussex University Hospitals NHS
    Trust
  • Royal Sussex County Hospital  99.8
  • Frimley Park NHS Foundation Trust  
  • Frimley Park Hospital  99.8
  • Royal Surrey County Hospital NHS Trust  
  • Royal Surrey County Hospital  99.2
  • Western Sussex Hospitals NHS Trust
  • Worthing Hospital  96.8
  • New Members no data
  • East Sussex Hospitals NHS Trust
  • Conquest Hospital
  • Eastbourne District General Hospital
  • Surrey and Sussex Healthcare NHS Trust
  • East Surrey Hospital 

MAJOR TRAUMA
17
18

The South East Coast SHA TARN returns
Non-Members NO DATA Ashford and St. Peters
Hospitals NHS Trust   St Peters Hospital,
Chertsey  Brighton and Sussex University
Hospitals NHS Trust Hurstwood Park Neurosciences
Centre Dartford Gravesham NHS Trust Darent
Valley Hospital  East Kent Hopsitals University
NHS Trust Queen Elizabeth, Queen Mother
Hospital  William Harvey Hospital  Maidstone and
Tunbridge Wells NHS Trust Kent Sussex
Hospital  Maidstone General Hospital  Medway NHS
Foundation Trust Medway Maritime
Hospital  Western Sussex Hospitals NHS Trust St.
Richard's Hospital  

MAJOR TRAUMA
19

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

MAJOR TRAUMA
19
20
. . . 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
MAJOR TRAUMA
20
21
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
MAJOR TRAUMA
21
22
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 Service TARN data
MAJOR TRAUMA
22
23
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
MAJOR TRAUMA
23
24
. . . . 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

MAJOR TRAUMA
24
25
. . . . 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
  • Every hospital is integral to the network major
    trauma centre, trauma unit, local hospital

MAJOR TRAUMA
25
26
. . . and how should the network develop?
  • Prescription for physical and neuropsychological
    rehabilitation / priority repatriation / key
    worker
  • By auditing key quality measures of care (TARN),
    develop locally sensitive protocols for
    communication, transfers, repatriation and
    rehabilitation
  • Networks linked

MAJOR TRAUMA
. . . Commissioning for the Quality Agenda
26
27
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 and patient representation
  • (supporting data co-ordinators)
  • Quality Assurance Committee
  • Trauma Education and Research Programmes

MAJOR TRAUMA
27
28
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

MAJOR TRAUMA
. . . . . . . . . . agreement on key interventions
28
29
Changing trauma practice for quality improvement
in the NHS . . . my plan
Clinical options KEY IMPACT INTERVENTIONS
Clinical Advisory Groups
Research Review of all current guidelines
Measurable Commissionable Cost-effective
MAJOR TRAUMA
SHA
Combined datasets from TARN, HES and NCEPOD
NICE Health Economics
29
30
Project Timeline
  • 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

MAJOR TRAUMA
30
31
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 Feb / Mar 2010
  • Specialist Commissioning
  • network not SHA
  • Transfer times, geography, facilities, expertise
  • Payment by Results
  • HRG definitions
  • Tariffs (?contemporary data, ?accumulative score
    banding)

MAJOR TRAUMA
31
32
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