Transforming Major Trauma Care the future

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Transforming Major Trauma Care - the future
Prof. Keith Willett National Clinical Director
for Trauma Care
24th September 2009 Neurotrauma Conference
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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
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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

MAJOR TRAUMA
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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)

MAJOR TRAUMA
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NCEPOD Trauma Who cares?

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

MAJOR TRAUMA
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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

MAJOR TRAUMA
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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
MAJOR TRAUMA
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Serious head injury casemix adjusted odds of
deathsUK Neurosciences Centre versus Non-Neuro
Centre
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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
• 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

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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 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
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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  

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

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. . . 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
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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 and patient representation
• (supporting data co-ordinators)
• Quality Assurance Committee
• Trauma 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

MAJOR TRAUMA
. . . . . . . . . . agreement on key interventions
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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
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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

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

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