A Major Problem for A Major Problem for the Health Servicethe Health Service

Worldwide injury is a major public health problem The commonest cause of death between the ages

of 1 and 40 years is injury For every fatality there are 2 survivors with serious and

permanent disability There appears to be a strong relationship between social

deprivation and injury Facilities for treatment of the injured and their

effectiveness varies across the UK

Our Healthier NationOur Healthier Nation

Quotes from this document indicate the importance of ‘injury’ and its consequences:

“ It is clearly important that we continue to reduce the number of deaths from accidents.”

“… many people suffer prolonged distress and poor quality of life as the result of a serious accident ”

Is there potential for improvement Is there potential for improvement in the care of injured patients?in the care of injured patients?

Working Party on the

Management of Patients with Major Injury,

Royal College of Surgeons 1988

“….this report reveals significant deficiencies

in the management of seriously injured patients.”

“Standards of hospital care of the injured should be monitored through a national audit scheme…..”

Improvements in systems of trauma Improvements in systems of trauma care may be achieved by :-care may be achieved by :-

Enhancing pre-hospital care, ensuring– appropriate medical intervention

– rapid transfer to best local facility

Assessing the use of helicopters Adopting ATLS principles Integrating trauma care services within

and between hospitals Investing in rehabilitation services

and Auditing and Researching injury and systems of care

Trauma NetworkTrauma NetworkBackground 1988 the Major Trauma Outcome Study was

established 1992 1st REPORT published in BMJ:

- UK mortality rate higher than US- large interhospital variation- slow response time- lack of senior input

1994 Statistical analysis was improved and modified 1996 New funding system1998 104 hospitals in Europe audited their trauma services

through the Network

Widespread ParticipationWidespread Participation

Annual new Attendances

at A &E Departments

< 30,000

30,001 - 40,000

40,001 - 50,000

50,000 - 60,000

60,001 - 70,000

70,001 - 80,000

>80,000

Total

Active members

October 1998

13

18

31

15

8

7

10

104

Trauma NetworkTrauma NetworkObjectives

collect and analyse

clinical and epidemiological data

provide a statistical base

to support clinical audit

aid the development of trauma services

and inform the research agenda

Quality CycleQuality Cycle

Health Care Systems

Measurement

Analysis

MeasurementMeasurementData collection should be:

Accurate

Complete

Comprehensive

Measurement / Data CollectionMeasurement / Data Collection

Simple vs Complex

Accurate, complete, comprehensive

Patient Inclusion CriteriaPatient Inclusion Criteria Admission > 72 hours Admission to an intensive care area Transfers for continuing care > 72 hours All deaths

Excluding:

Fractures of the femoral neck or single pubic rami

(age > 65yrs)

OR SIMPLE isolated injuries

The Trauma NetworkAnalysis

INPUT PROCESS OUTPUT

Common standards for severity measurement

Common measures for performance assessment

Assessment of Trauma Severity

Anatomical Injury Physiological Measurements

AgeBlunt/Penetrating

Probability of survival of individual patientsProbability of survival of individual patients

Hospital ComparisonsHospital Comparisons

Physiological - Physiological - Revised Trauma ScoreRevised Trauma Score

Is a physiological measurement and by convention, recorded on arrival at

hospital

The RTS includes: Respiratory rate Systolic blood pressure Glasgow Coma Scale

Abbreviated Injury Scale (AIS 90)

1 injury = 1 code with a range of 0 - 6

Injury Severity Score (ISS)Uses a formula to represent multiple injuries in 1 number with a range of 0 - 75

INJURY SEVERITY SCORE INJURY SEVERITY SCORE Example

Abbreviated Injury Scale

Small subdural haematoma 4

Parietal lobe swelling 3

Major liver laceration 4

Upper tibial fracture (displaced) 3

ISS = 42 + 42 + 32 = 41

Ps cannot be applied to individualsPs cannot be applied to individuals

If the Probability of Survival (Ps) of an injured patient = 0.4

Then, on average, 6 out of 10 patients will die

The Trauma Network ReportsThe Trauma Network ReportsMonthly:

Clinical activities

Quarterly:

Outcome statistics (anonymous)

Process filters

Ad Hoc Reports

Formatted data

Process Measures Time intervals

– injury and arrival at A&E

– arrival in A&E and 1st doctor seeing the patient

– transfer to another hospital Seniority of staff

Haemo/pneumothorax– evidence of chest drains

# skull, brain & spinal injury (AIS3+ )– evidence of CT scan

– immobilisation of spine

– recorded GCS

Hospital comparisons 1994 - 1998 Summary Ws scores and 95%CI. Blunt injuries, excl. referrals

-9

-7

-5

-3

-1

1

3

5

7

9

Ws

& 9

5% C

I

The UK TRAUMA Audit & Research NETWORKCompiled November 1998

More survivors

More deaths

Morbidity

Wider variation than with mortality Inadequate scoring systems What to estimate?

– temporary– permanent

Trauma Audit - Closing the loop

D Yates, J Bancewicz, M Woodford, P Driscoll, RAC Jones, R Kishen, D Marsh, S Hollis.

Injury (1994) 25:511

Conclusions and lessons learnt

Close inter-disciplinary cooperation and clinical improvement at a senior level.

Application of protocols to provide continuity of care from the scene of the accident through to the hospital ward.

Frequent statistical analysis of performance at audit meetings to ‘close the loop’ is an essential part of the strategy to improve trauma care.

Setting quality standards

National Institute for Clinical Excellence

Clinical Governance

Commission for Health Improvement

National Service Frameworks