Regional Trauma Systems

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Regional tRauma systemsinteRim guidance foR commissioneRs

tHe inteRcollegiate gRouP on tRauma standaRdsdecembeR 2009


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Produced by the Publications Department, The Royal College o Surgeons o England

Printed by Hobbs the Printers, Brunel Road, Totton, Hampshire, SO40 3WX

Proessional Standards and Regulation Directorate

The Royal College o Surgeons o England

3543 Lincolns Inn Fields

London

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The Royal College o Surgeons o England 2009Registered charity number 212808

All rights reserved. No part o this publication may be reproduced, stored in a retrieval system

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otherwise, without the prior written permission o The Royal College o Surgeons o England.

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publication, no guarantee can be given that all errors and omissions have been excluded. No

responsibility or loss occasioned to any person acting or reraining rom action as a result o thematerial in this publication can be accepted by The Royal College o Surgeons o England and

the contributors.


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Contents

Frr. 3

Auhr.a.aliai. 41. H..u.hi.cum. 5

2. Cx

2.1 Next Stage Review .................................................................................................................................. 7

2.2 Future commissioning o regional trauma systems .................................................................... 7

3. Iruci..rauma.a.rauma.ym

3.1 What is trauma?........................................................................................................................................9

3.2 What is major trauma? ...........................................................................................................................9

3.3 How common is major trauma? .........................................................................................................9

3.4 What are the priorities in trauma care? .........................................................................................103.5 What is a regional trauma system? .................................................................................................10

3.6 What is a major trauma centre?........................................................................................................11

3.7 What is a trauma unit? .........................................................................................................................11

4. UK.rauma.car:.h.ca.r.chag.12

5. A.rgial.rauma.ym.ml.r.h.UK

5.1 Key components o a regional trauma system ...........................................................................13

5.2 Pathways o care within the regional trauma system ..............................................................14

5.3 Clinical governance, quality assurance and perormance improvement .........................14

6. th.cmmiiig.cycl

6.1 Assessing needs .....................................................................................................................................16

6.2 Reviewing service provision ..............................................................................................................16

6.3 Planning capacity and managing demand ..................................................................................16

6.4 Shaping the structure o supply.......................................................................................................17

6.5 Managing perormance ......................................................................................................................18

6.6 Seeking public and patient views ...................................................................................................19

6.7 Finance ......................................................................................................................................................19

7. ohr.cirai

7.1 Paediatrics ................................................................................................................................................21

7.2 Burns ..........................................................................................................................................................217.3 Rehabilitation..........................................................................................................................................21

7.4 Emergency preparedness ...................................................................................................................21

7.5 Cross-boundary cooperation ............................................................................................................21

8. Appic

8.1 The injury severity score .....................................................................................................................22

8.2 Trauma audit and research network: overview ..........................................................................22

8.3 Pathways o care as dened in the London process .................................................................24

8.4 Optimal resources or designation o trauma networks .........................................................26

8.4.1 Governance and culture ................................................................................................................278.4.2 Quality and saety ............................................................................................................................28

8.4.3 Network eectiveness....................................................................................................................29

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8.4.4 Rehabilitation ....................................................................................................................................30

8.4.5 Education and training ..................................................................................................................31

8.4.6 Research and development .........................................................................................................31

8.4.7 Prevention strategies ......................................................................................................................318.5 Optimal resources or designation o major trauma centres

8.5.1 Institutional commitment ............................................................................................................32

8.5.2 Service .................................................................................................................................................34

8.6 Optimal resources or designation o trauma units

8.6.1 Institutional commitment ............................................................................................................48

8.6.2 Service and process ........................................................................................................................50

8.7 Optimal resources or designation o rehabilitation services

8.7.1 Service and process ........................................................................................................................54

9. Rrc55

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FoRewoRd

Over recent months I have had the pleasure o chairing an intercollegiate group, brought

together to develop standards and guidance to support those involved in the planning,commissioning and delivery o high-quality trauma care.

For many years the medical proession has called or an overhaul o trauma services and or

those services to be organised into networks that covered a dened region and met the needs o

all trauma patients. The ndings rom the Next Stage Review conrmed what we already knew:

the care o severely injured patients was largely suboptimal. That virtually all o the strategic

health authorities (SHAs) visions arising rom the review cited improvements in trauma care as a

priority was gladly welcomed, as was the appointment o the National Clinical Director, Proessor

Keith Willett.

Our group, comprising key royal colleges, specialty associations and aculties, as well asvital patient and public representation, has sought to develop inormation and guidance on

the benets o regional trauma systems across the country. NHS London has very much led

the way in developing robust and transparent criteria to support the designation o trauma

services within the capital. I make no apologies or drawing heavily on their excellent work. The

Healthcare or London team and the supporting clinical expert group are to be commended.

We are o course acutely aware o the demographic dierences between various parts o the

country. Individual SHAs will need to interpret the guidance to meet their own needs. There is no

t-all scenario.

I should point out that the document deals largely with adult trauma. While this orms the

bulk o trauma care provision, the intercollegiate group ully acknowledges that urther work

is urgently required to look specically at paediatric trauma care, burns care and rehabilitation

services.

I would like to thank the intercollegiate group, in particular Proessor Karim Brohi and

Proessor Tim Coats, or bringing this work to ruition. I would also like to thank Mrs Jo Cripps or

her administrative support. I hope you will nd the document useul. I certainly commend it to

you as a vital support tool as you develop and implement your integrated trauma care systems.

Richar.Clli

Chairman, Intercollegiate Group on Trauma Standards

Vice-President, The Royal College o Surgeons o England

Foreword 3


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AUtHoRs.And.AFFILIAtIons

Prr.Karim.Brhi Proessor o Trauma Sciences, Queen Mary School o Medicine and

Dentistry, London; Consultant and Vascular Surgeon, Barts and the London NHS TrustM.tracy.Parr Trauma Network Development Manager, Healthcare or London

Prr.timhy.Ca Chairman, Trauma Audit and Research Network

INtercollegIate group oN trauma StaNdardS

Mr.Richar.Clli (Chair) Vice-President, The Royal College o Surgeons o England

Prr.timhy.Ca Chairman, Trauma Audit and Research Network

Prr.Julia.Bi and Prr.Chri.d The Royal College o Anaesthetists

dr.ty.nichl.The Royal College o Radiologists

Mr.d.MacKchi Vice-President, The College o Emergency Medicinedr.Ia.Macchi The Royal College o Paediatrics and Child Health

M.suza.shal Lay member o council, The College o Emergency Medicine

M.Kar.wil Care Quality Commission

trauma StaNdardS workINg group

Prr.Kih.Prr The Faculty o Pre-Hospital Care

Prr.Jam.Rya Military Surgery

Liua.Cll.Jh.ehrig Rehabilitative Care

dr.Chrii.Clli The Royal College o Physicians

dr.Rbr.Cruch.The Royal College o Nursing

Mr.Paul.su South East Coast Ambulance Service

Mr.Ahy.Marh West Midlands Ambulance Service

Mr.Bb.wir Intensive Care Society

Prr.Chri.Mra British Orthopaedic Association

AuthorsAndAFFiliAtions4


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1. How.to.Use.tHIs.doCUMent

purpoSe

This document aims to provide generic inormation on trauma and trauma systems, andpresents a proven practical and evidence-based model suitable or regional trauma systems in

the UK. It is aimed at regional commissioners and other stakeholders involved in the assessment

o the provision o trauma care and the reconguration o services to regionalised trauma

systems.

BackgrouNd

This document was produced by an intercollegiate trauma standards working group, comprised

o nominated representatives o medical royal colleges, specialty associations and patient

representatives rom the bodies listed on the previous page. The document pertains particularlyto the management o adult trauma. We have incorporated some general recommendations or

the consideration o paediatric services and rehabilitation. Further guidance is expected to be

orthcoming.

The trauma-system model is built in large part upon the results o the ongoing Healthcare

or London major trauma project. This model in turn is based upon public health models o

trauma systems operating in North America, Australasia and Europe. These have proven ecacy

in reducing death and disability rom severe injury.

Numerous inormation sources exist that describe dierent aspects o trauma-care delivery.

These range rom evaluations o trauma-care perormance to descriptions o trauma systems.

The document synthesises this inormation into a ormat that can be used by commissioners.

It should be used as a guide to the establishment o a commissioning and quality-assurance

process or trauma-care improvement on a regional level.

Structure

1.. H..u.hi.cum.(this section)

2.. Cx

Current drivers or regionalisation and the national process or trauma system

development

3. Iruci..rauma.a.rauma.ymBackground inormation on trauma and the evidence or reconguration to regional

trauma systems

4. UK.rauma.car:.h.ca.r.chag

The current state o trauma care in the UK and the potential impact o regionalisation

5. A.rgial.rauma-ym.ml.r.h.UK

The structure, unction and perormance assessment o a UK regional trauma system

6. th.cmmiiig.cycl

A stepwise approach to service assessment, system designation and implementation

7. ohr.ciraiRelated services and systems not included in this report

8. Appic

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Description o the injury severity score (ISS)

8. Appic.(ciu)

Trauma Audit and Research Network (TARN)

Trauma pathwaysDesignation criteria or trauma systems, major trauma centres and trauma units

9. Rrc

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2. ConteXt

2.1 NeXt Stage reVIew

Over a number o years in the UK, several reports have been produced that have examined thequality o trauma care delivered to injured patients.1,2 The consensus view contained in these

reports was highly critical o the quality o service provided to trauma patients. Despite these

reports the quality o trauma care has remained poor in the UK in relation to other international

comparators.3

In 2008 the Department o Health published the nal report o the Next Stage Review or

the NHS.4 The overarching theme o the document was putting quality at the heart o the NHS.

Entitled High Quality Care or All, it set out the visions o each NHS region in England. These were

developed in conjunction with local clinicians and other health and social care proessionals

in each area. Acute care groups ormed in each o the regions gave compelling arguments orcreating specialised centres or certain conditions, including major trauma. These plans or

developing major trauma care across the UK are now at varying stages.

An earlier vision describing the necessity or improving the quality o services in London

was published in 2007.A Framework or Action identied improvements in major trauma as being

a priority or the capital.5 A project was set up that year under the auspices o the Healthcare

or London (HL) programme to look at options to deliver this vision. A signicant amount o

work has been undertaken during this time to develop these proposals. This led to a public

consultation on the options or delivering major trauma care in London. Following this a decision

has been taken by the Joint Committee o Primary Care Trusts in London to commission our

trauma networks to deliver trauma care.

2.2 Future commISSIoNINg oF regIoNal trauma SYStemS

A national process or the delivery o regional trauma systems will be led by the National Clinical

Director or Trauma Care, Proessor Keith Willett. For the purpose o this document he has stated

that:

The resulting programme, through the development o clinical advisory

groups, is investigating the evidence, national and international guidance and

research required to assist SHAs in the successul execution o trauma networks.

The programme will aim to deliver treatment or everyone which a) is based aroundthe needs o individuals irrespective o where they suer those injuries, b) delivers

the patient as rapidly and saely as possible to the hospital that can manage

the defnitive care o their injuries either directly or by expedited inter-hospital

transer, c) supports the victims amily, d) defnes a comprehensive prescription or

rehabilitation and, importantly, e) moves the responsibility or defnitive patient

care rom the receiving clinical team to the trauma network when the initial

receiving unit is incapable o that care.

Such change can only occur by leadership at SHA-level steering

commissioning or acute hospitals and ambulance services and working withdesignated trauma leads in each acute trust to develop bespoke direct transer and

reerral policies. Currently many regions do not have key specialties

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(eg neurosurgery, orthopaedic trauma, plastics) co-located. The provision o pre-

hospital airway skills, use o retrieval teams, open access policies, modes o transer

(including helicopters), 24-hour trauma team leaders, immediate access trauma

theatres and intensive care and rehabilitation acilities will be components o eachnetworks individual solutions.

December 2009

Other areas o work that the National Clinical Director will examine will include the

contribution o commissioning, audit, modelling, metrics, standards, payment by results,

healthcare resource groups, critical care capacity, interventional radiology, rehabilitation,

behavioural change, workorce, and training needs to improve outcomes o patients who have

suered major trauma.

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3. IntRodUCtIon.to.tRAUMA.And.tRAUMA.sYsteMs

3.1 wHat IS trauma?

Trauma is a disease caused by physical injury.The word trauma means wounding due to physical injury. It is important, however, to

understand trauma as a disease entity. Although there are many ways to cause injury (road trac

incidents, alls, sporting injuries, occupational hazards, knie and gun injuries), they all result in

trauma.

Trauma as a disease is a leading global public health problem aecting 135 million

people a year and is responsible or about 5.8 million deaths annually (approximately 10% o all

deaths).6 Around 50 million people are moderately or severely disabled due to injury and over

180 million disability-adjusted lie years are lost annually. Trauma exacts a major toll on amilies,

communities and society.

7

The global burden o disease due to trauma is expected to increasedramatically in coming years, becoming the third leading cause o death by 2020.

In the UK, trauma is a leading cause o death in British citizens across all age groups, with

over 16,000 deaths due to injury in England and Wales each year.8 It is one o the ew disease

categories in which mortality is increasing.9,10 The annual cost to the NHS o treating trauma

injuries is currently estimated at 1.6 billion, about 7% o the total annual NHS budget.11

3.2 wHat IS maJor trauma?

Major trauma is trauma that may cause death or severe disability.

For the purposes o trauma systems quality assurance and perormance improvement, major

trauma is dened as those patients with an injury severity score (ISS) o more than 15. (See

Appendix 8.1 or a description o the injury severity score.)

For the purposes o a regional system, major trauma also includes any injury so complex

that it exceeds the capabilities or expertise o the receiving unit.

Some patients with an ISS below 15 are also at risk o death and disability. For example, the

elderly or very young may be more likely to die rom a more moderate injury than a young adult.

These patients should also be managed in a major trauma centre and triage protocols should be

designed to enable this. In addition, patients with multiple ractures and musculoskeletal injuries

oten have an ISS15) are estimated at 2733 patients per 100,000

population per year (about 40% o trauma deaths occur at the scene o the incident.) About 15%

o all injured patients have sustained major trauma. Major trauma represents less than 1 in every

1,000 emergency department admissions.

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The exact numbers o major trauma patients in England and Wales are unknown due to

lack o robust population-based data collection. The quality o available data varies rom region

to region.

3.4 wHat are tHe prIorItIeS IN trauma care?

The overall goal of a regional trauma system is to reduce death and disability following major

trauma.

The major trauma patient pathway is described as a trauma chain o survival. Trauma patients

lives are saved by immediate pre-hospital interventions and then transer to specialist surgical

acilities in which bleeding can be controlled, traumatic brain injury managed and specialist

critical care instituted. The trauma chain o survival thereore depends on an optimised pathway

that includes pre-hospital care, emergency departments, specialist operating teams and critical

care acilities. The chain continues into a phase o reconstruction, in which injuries are repairedand rebuilt, ollowed by rehabilitation and reintegration into society.

Priorities are thereore:

identiying major trauma patients at the scene o the incident who are at risk o death or

disability;

immediate interventions to allow sae transport;

rapid dispatch to major trauma centres or surgical management and critical care;

coordinated specialist reconstruction; and

targeted rehabilitation and repatriation.

3.5 wHat IS a regIoNal trauma SYStem?

A regional trauma system delivers optimal trauma care to a population on a public health model.

A regional trauma system serves a dened population to reduce death and disability ollowing

injury. The trauma system includes public health, injury prevention, emergency medical services,

all trauma-receiving hospitals, major trauma centres, rehabilitation services, research, education

and systems governance.

The trauma system optimises the use o resources, so a trauma patient is treated in the

right place at the right time by the right specialists. Major trauma patients are treated at major

trauma centres, while other trauma patients are treated at trauma units. (Not all trauma patients

should be treated at major trauma centres see 3.7 below).This requires optimisation o pre-hospital triage, bypass protocols, development o trauma

unit emergency management protocols and rapid inter-hospital major trauma centre transer

capability. Acute rehabilitation services and repatriation pathways allow targeted patient

rehabilitation in trauma units or dedicated rehabilitation acilities close to the patients home.

There is an active injury prevention programme to reduce the overall burden o injury or

a population. The system is underpinned by on going research and education activities. There

is a robust public system perormance improvement programme, which monitors the health o

the trauma system, develops new policy and assures implementation. Inclusive regional trauma

systems combined with the designation o high-volume major trauma centres can reducemortality rom major trauma by 40%.14

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3.6 wHat IS a maJor trauma ceNtre?

A major trauma centre (MTC) is a specialist hospital responsible for the care of major trauma

patients across the region.

The MTC has a clinical culture and management systems that refect the importance ointegrated trauma care. The centre has a regional leadership role with responsibility or

optimising the pathways and care o major trauma patients wherever they are injured in the

region. It has senior clinical and executive commitment to the care o major trauma patients and

an integrated trauma service responsible or the ongoing care o all major trauma patients in the

hospital.

The MTC has all surgical specialties and support services to provide care or major trauma

patients regardless o their pattern o injury. It supports the other trauma units, pre-hospital care

and rehabilitation providers in the region in optimising the trauma chain o survival. The centre

has its own robust trauma clinical governance and perormance improvement programmes andassists in delivering quality assurance and quality improvement across the network. The MTC has

active and relevant research, education and injury prevention programmes that support trauma

care across the region.

It is clearly recognised that there is a volume and outcome relationship in major trauma

care and it is recommended that the MTC should see at least 400 major trauma patients each

year. Major trauma centres with a sucient volume o work to gain experience in managing

these patients have a 1520% improvement in outcomes (at 600+ patients per year).15

Conversely, low-volume MTCs have little impact on patient outcomes. Each MTC should

thereore serve a minimum population o approximately 23 million people.

MTCs will also manage a certain proportion o trauma patients who are not major trauma.

These patients come rom their local catchment area and rom over-triage o trauma patients to

the centre. On average the ratio o trauma patients to major trauma patients seen in an MTC is

2:1. Regional trauma systems operate within existing systems and should not compromise care

o other emergency or elective patients. Instituting a trauma system has been shown to improve

the care o other non-trauma emergency patients, reducing emergency department waiting

times, improving operating room access and reducing hospital stays.16

3.7 wHat IS a trauma uNIt?

A trauma unit (TU) manages injured patients in its local catchment area.A TU is responsible or the management o trauma patients who are not classied as having

major trauma. Patients with less severe injuries (ISS15) do no better and may do worse i

managed in an MTC. This is in part because they may be de-prioritized compared to the major

trauma patients or operations, rehabilitation resources, etc.

TUs may also receive major trauma patients either due to under-triage errors or because

patients require immediate lie-saving interventions prior to continued care at an MTC. TUs

have close links with the MTC through the network and immediate transer agreements with

the centre when a major trauma patient is received at a TU. The TUs have a responsibility to

engage in trauma system activities including data collection, governance and perormanceimprovement, research, education and injury prevention.

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4. UK.tRAUMA.CARe:.tHe.CAse.FoR.CHAnGe

Injury is a leading cause o death in British citizens across all age groups, with over 16,000

deaths due to injury in England and Wales each year.8

In the absence o a trauma system, over 30% o all in-hospital trauma deaths in the UK are

preventable and due to substandard management.17

Implementation o a regionalised trauma system can rapidly reduce the preventable death

rate to close to zero.1820

Regionalisation o care to specialist trauma units reduces mortality by 25% and length o stay

by our days.21

High-volume trauma centres reduce death rom major injury by up to 50%.15

Time rom injury to denitive surgery is the primary determinant o outcome in major trauma

(not time to arrival in the nearest emergency department).

22

Major trauma patients managed initially in local hospitals are 1.5 to 5 times more likely to die

than patients transported directly to trauma centres.23

There is an average delay o 6 hours in transerring patients rom a local hospital to a major

trauma centre. Delays o 12 hours or more are not uncommon. Across the UK, almost all

ambulance bypasses can be achieved in less than 30 minutes.23,24

Longer pre-hospital times have minimal eect on trauma mortality or morbidity even in

very rural areas such as the west o Scotland.24

Trauma centres have signicant improvements in quality and process o care. This eect

extends to non-trauma patients managed in these hospitals.25,26

Costs per lie saved and per lie-year saved are very low compared with other comparable

medical interventions.27,28

Currently UK mortality or severely injured trauma patients who are alive when they reach a

hospital is 40% higher than in the US.29

Without regionalisation, trauma mortality and morbidity in the UK will remain unacceptably

high. The likelihood o dying rom injuries has remained static since 1994 despite

improvements in trauma care, education and training.26,30

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5. A.ReGIonAL.tRAUMA.sYsteM.ModeL.FoR.tHe.UK

5.1 keY compoNeNtS oF a regIoNal trauma SYStem

A philosophy that the injured patient anywhere in the region is the clinical responsibility othe trauma system and that clinicians have a clinical responsibility that extends outside their

traditional boundaries.

A culture o integrated multi-disciplinary working across specialist and proessional groups,

with trauma care seen as a specialist area o expertise.

A regional system integrating hospital and pre-hospital care to identiy and deliver patients to

a place o denitive care quickly and saely.

A pre-hospital care system closely integrated into the trauma system, with dened triage,

bypass and inter-hospital transer protocols.

A network o hospitals designated as trauma units and major trauma centres, each withdened capability and capacity, and predetermined transer agreements or optimising

casualty fow.

A specialist major trauma centre that has responsibility or the management o all major

trauma patients in the region.

Acute rehabilitation services to improve outcomes and restore casualties back to productive

roles in society.

A continuous process o system evaluation, governance and perormance improvement

across the network.

Ongoing training and education or all pre-hospital, hospital and community healthcare

proessionals involved in the care o injured patients.

An active injury prevention programme to reduce the burden o injury or the population the

network serves.

A responsibility towards research into trauma and its eects, to improve continuously care

and outcomes ollowing injury.

Integration with emergency preparedness and the ability to implement a system-wide

response to disaster and mass casualty incidents.

A clinical and administrative structure to oversee system activities, led by a clinician.

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pre-hospital

trauma

unit

major trauma

centre

majortrauma

injured

patients

rehabilitation

5.2 patHwaYS oF care wItHIN tHe regIoNal trauma SYStem

The system is designed to match severity of injury to optimal resources and expertise.

Major trauma patients are identied at the incident scene through the use o a triage protocol

and transported directly to MTCs.

Major trauma patients may be seen at TUs i:

pre-hospital providers elect to take a major trauma patient to a TU i they require an

immediate lie-saving intervention;

the ull extent o the patients injuries are not appreciated initially; or

the patient is brought to the TU by amily/riends or via another non-standard route.

The system must be able to manage under-triage. There is thereore a specic pathway or

immediate notication and transer o patients rom TUs to MTCs.Once identied as a patient requiring transer to a MTC, responsibility or timely and

appropriate denitive care rests with the MTC.

There are predened pathways or major trauma patient rehabilitation and repatriation ater

the end o the acute phase o care.

Detailed pathways o care used in the London process are given in Appendix 8.3.

5.3 clINIcal goVerNaNce, QualItY aSSuraNce aNd perFormaNce ImproVemeNt

A robust perormance improvement programme underpins the public health model o the

regional trauma system.A dened dataset is collected on all injured patients across the network by pre-hospital care

providers, TUs and MTCs.

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A regional trauma system clinical governance and perormance improvement programme

assesses the health o the system, institutes policy development and assures implementation.

A similar process occurs in TUs, MTCs and pre-hospital care services. These programmes eed

into the regional process.The system is assessed by measuring key perormance indicators (KPIs) across the pathway o

care. KPIs will assess markers o quality assurance, patient saety and patient experience.

Key perormance indicators will all into categories o process o care, governance standards,

clinical outcomes, resource utilisation, training and education, and patient experience.

The regional system, MTCs and TUs will eed data to national audit bodies including the

Trauma Audit and Research Network (TARN) (see Appendix 8.2).

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6. tHe.CoMMIssIonInG.CYCLe

6.1 aSSeSSINg NeedS

The case or change outlined earlier describes in detail the need or regionalised trauma systemsin order to deliver patient outcomes comparable to those in many parts o the world.

6.2 reVIewINg SerVIce proVISIoN

Current service provision.

Clinical work streams should be established to understand how current service provision meets

expected needs, designation criteria and quality measures. These need to be actioned within

potential major trauma centres as well as across the region. The latter will eed into the regional

governance structure.

Work streams include:Pre-hospital care

Emergency departments

Urgent diagnostics

Specialist surgical services

Emergency operating acilities

Interventional radiology

Critical care access

Ward beds

Rehabilitation acute, general and specialist

Emergency preparedness and major incident planning

For those involved in contributing to the work streams at a regional level, a clear

understanding o the amount o time that needs to be committed should be stated. For those

giving large amounts o time, arrangements should be made to second them into the SHA to

ensure their ability to devote the necessary input to the project.

In addition, there will be a need or a team o people to drive the project deliverables

linked in with the project governance arrangements. The skills required will include project

management, data analysis and external communications.

6.3 plaNNINg capacItY aNd maNagINg demaNdDetermining the incidence of trauma and major trauma.

Understanding the incidence o trauma and especially major trauma in the region is key to

system design and development. For most regions, robust population data on major trauma

patients do not exist, as less than hal o all hospitals routinely collect injury severity data on

trauma patients.

A number o data sources are available rom which population estimates may be

extrapolated:

Existing TARN submission (see Appendix 8.2)

Hospital episode statistics (HES) dataAmbulance service data

Intensive Care National Audit and Research Centre (ICNARC)

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Other in-hospital trauma registries

Extrapolating rom other regions with similar population distributions

Instituting data collection (through TARN data submission) at all hospitals early in the

systems development process will signicantly improve patient estimates and enable accuratestrategic planning.

Understanding distances and travel times.

Key times or system unctioning are:

time rom injury to arrival o pre-hospital teams; and

time rom injury to denitive care.

Understanding the geography o the region and main transport routes will aid decision-

making regarding the deployment o paramedic services, the degree o expertise required,

expected distribution o patients between MTCs and TUs and requirement or secondary transerand retrieval services.

Existing ambulance service data can be analysed to produce travel time contours to

anticipated MTCs. There will be dierent analyses required or urban and rural environments.

In London or example, travel times were undertaken by sourcing ambulance records and

comparing them with normal road journey times sourced rom a commercial database.

Additional inormation was used in the calculation to determine the eects o rush-hour

trac and the increase in speed when travelling by blue-light ambulance. This enabled maps

illustrating contours o equal journey time around specied locations (known as isochrones) to

be generated. Further inormation on this methodology is available.31

An understanding o the journey times involved in getting patients to denitive care

and the ability to explain the impact o these on patient outcomes is an important aspect o

implementing a regional trauma system.

6.4 SHapINg tHe Struc ture oF SupplY

Structuring the regional system and core components.

The regional system must deliver trauma care to optimal standards o clinical quality, patient

saety and patient experience, and meet key perormance indicators (KPIs) intended to monitor

system health. The pathways and resources used to deliver the standards are not prescribed and

trauma networks must develop local solutions, given local capability and capacity.The designation criteria or networks, MTCs and TUs given in Appendices 8.48.7 are

suggested resource and system requirements and are based on available expertise and

contemporary wisdom.

Core system inrastructure is required to implement and monitor the evolution o the

regional system. These components include a regional trauma systems oce, system director, a

system manager and system data collection and perormance monitoring teams. The regional

trauma oce will work closely with commissioners and providers to report on and improve the

perormance o the system. An annual report will provide a regular progress report examples

are available.32

thecommissioningcycle 17


21/60

Links also need to be made with neighbouring trauma systems as there will need to be

some common practices, demand sharing, emergency preparedness planning and boundary-

zone planning across regions.

Identifying potential major trauma centres.

Within a region the number o hospitals that would be candidates or major trauma centre status

is limited. However, it is likely that not all required services will be present on a single site, or that

these services will not be operationally capable o providing service to a level required o a MTC

either rom a quality or volume standpoint.

A candidate list o major trauma centres will determine the number o networks within the

region and inorm the transormation process in terms o major trauma patient densities, access,

geography and costs associated with reconguration o services.

6.5 maNagINg perFormaNce

Establishing a framework for developing a regional trauma system.

Individual SHAs will establish their own arrangements or approaching the establishment o a

trauma system within their geographical area. This will include clear governance arrangements

or decision-making and accountability. Following the commissioning cycle ensures that the

appropriate planning, design o services and monitoring is undertaken.

Monitoring the process and quality of care KPIs

Trauma systems will be monitored and assessed through continuous measurement o outcomes

and the process o care delivery. KPIs will be used to ensure that the networks, major trauma

centres and trauma units are delivering resource-ecient optimal trauma care. A select ew o

these KPIs will be used as a basis or ongoing commissioning.

KPIs will all under the ollowing broad categories:

Resource

Example: (MTC) trauma teams are consultant-led at all times

Example: (MTC) emergency resh-rozen plasma is available within 15 minutes o request

Process

Example: (MTC) emergency CT scan is perormed within 30 minutes o arrival

Example: (network) emergency neurosurgery (craniotomy) is perormed within ourhours o injury

Example: (MTC) spinal assessment is complete within our hours o injury

Outcome

Example: (MTC) mortality rom haemorrhagic shock is below 30%

Governance

Example: (network) complete submission o required trauma datasets to TARN

Example: (MTC) specialty liaisons attend perormance improvement meetings



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Training and education

Example: (MTC) All trauma team members have current ATLS/ATNC/TNCC or equivalent

certication

Example: (MTC) specialty surgeons are current in trauma-specic continuingproessional development

Patient experience

Example: (network) repatriation or rehabilitation occurs within 72 hours

The nal set o key perormance indications has not yet been dened or the London

system.

6.6 SeekINg puBlIc aNd patIeNt VIewS

Due to the complex nature o injuries sustained by major trauma patients, there is no one patientbody that represents major trauma patients with whom linkages can be made in order to inorm

the development o regionalised trauma systems. A number o voluntary sector organisations

exist that are equipped to provide patient input, along with the patient representative groups

rom the royal colleges and other proessional bodies. In addition, other input rom patients on a

local level may be obtained through the Local Involvement Networks (LINks,

www.dh.gov.uk/en/Managingyourorganisation/PatientAndPublicinvolvement/DH_076366).

6.7 FINaNce

Major trauma is not as easily dened as other surgical groupings using existing management

inormation and so there is likely to be no comprehensive or systematic count o the volume

or nature o major trauma activity taking place across SHAs. In addition, as the activity is

imperectly captured by healthcare resource groups (HRG) v3.5, the spell costs are only poorly

represented in the payment-by-results (PbR) taris at present.

The HL project used the ISS system to categorise trauma into major and non-major. The

ISS is an anatomical scoring system that provides an overall score or patients with multiple

injuries. The score can be rom 0 to 75 and a reasonably accepted denition o major trauma

is activity with an ISS score o higher than 15. ISS scoring is provided by the Trauma and Audit

Research Network (TARN). While this system is clinically meaningul it should be noted that it has

not been designed to refect resource consumption.The publication o HRG v4 with a subchapter on polytraumatic injury is a step towards

better identiying major trauma-type activity. Even so only 50% o major trauma, as dened

by ISS, alls into this subchapter. Also the PbR tari or this activity still does not properly

remunerate the spell cost o the activity.

HL proposed a specication or its major trauma centres. In considering the additional

costs o the major trauma service in London an element o the costs was deemed to be xed and

driven by the specication; this could be met by the payment o a quality premium (possibly

through a Commissioning or Quality and Innovation-type mechanism). The other noteworthy

element o system cost relates to the concentrating o under-remunerated activity into a ewcentres; this has led to the consideration o a tari top-up. At the time o publication, neither

o these unding elements has been nally agreed but SHAs may wish to consider appropriate

thecommissioningcycle 19


23/60

unding or trauma care.

At a national level, consideration will have to be given to ensuring that HRG v4 better

discriminates polytrauma and that the costs associated with this activity are properly compiled

by trusts so that the resultant PbR taris are calculated correctly. This will not happen in theshort term and due to the averaging eects o PbR and coding, may not ever refect truly the

cost o this activity in the tari. SHAs may wish to ollow the above model with a xed element o

unding and a top-up on tari.



24/60

7. otHeR.ConsIdeRAtIons

7.1 paedIatrIcS

The provision o care or seriously injured children should be considered alongside that o adultsin order to realise the benets o co-locating services. There are too ew injured children in the

UK to give sucient experience or separate systems to treat children. The injured child thereore

needs to be the responsibility o the trauma system but with additional expertise drawn rom

paediatric specialists. There will be considerable variation between SHAs in their approach to this

depending on availability o specialist childrens services. Links with regional childrens retrieval

services might be helpul in dening the pathway or injured children.

7.2 BurNS

It is uncommon or burns to be associated with multiple other injuries. Burns care also benetsrom integration with the trauma system. Ideally burns care should be co-located within a MTC.

I such care is not co-located robust arrangements need to be in place to deliver multi-specialist

care (or transport o the patient to a place in which such care can be given). Care or the child

with burns can be delivered more eectively i burn and paediatric services are co-located.

However, such services may need to be delivered on a national rather than a regional pattern.

7.3 reHaBIlItatIoN

Organised and integrated rehabilitation is key to the unctioning and sustainability o a major

trauma system. Signicant deciencies exist in the capacity and capability o rehabilitation

services across the UK. This is across all domains, including physical and psychological, and

pertains to acute and chronic rehabilitation. Future work steams are planned and seek to address

these deciencies. It is recommended that development o a trauma system incorporates

assessment o rehabilitation within all phases o design and implementation.

7.4 emergeNcY preparedNeSS

Emergency preparedness and major incident planning is best undertaken in the context o a

regional trauma system. Existing capabilities need to be taken into account when developing a

regional trauma system to ensure resilience, eective emergency response and appropriate use

o resources. Cross-regional plans or mutual aid between regional trauma systems must be inplace.

7.5 croSS-BouNdarY cooperatIoN

Patients who are injured near to the boundary between regions may, depending on the

geography o local services, be better cared or in a neighbouring system (or example the

nearest MTC may be in another region). Each trauma system should have robust agreements

with its neighbours that dene how cross-boundary treatment and repatriation issues are

handled.

otherconsiderAtions 21


25/60

Rgi Ijury.cripi AIs squar.p.hr

Head and neck Cerebral contusion 3 9

Face No injury 0

Chest Flail chest 4 16

AbdomenSplenic contusion 2

Complex liver injury 5 25Extremity Fracture emur 3

External No injury 0

Ijury.vriy.cr 50

8. APPendICes

8.1 tHe INJurY SeVerItY Score

The injury severity score (ISS) is an anatomical scoring system that provides an overall score orpatients with multiple injuries.33 Each injury is assigned an abbreviated injury scale (AIS) score,

allocated to one o six body regions (head, ace, chest, abdomen, extremities (including pelvis)

and external). Only the highest AIS score in each body region is used. The three most severely

injured body regions have their score squared and added together to produce the ISS score.

The ISS takes values rom 0 to 75. I an injury is assigned an AIS o 6 (incompatible with lie),

the ISS score is automatically assigned to 75. The ISS correlates with mortality, morbidity, hospital

stay and other measures o severity.

Its weaknesses are that any error in AIS scoring increases the ISS error; many dierent injury

patterns can yield the same ISS score; and injuries to dierent body regions are not weighted.Also, as a ull description o patient injuries is not known prior to ull investigation and operation,

the ISS (along with other anatomical scoring systems) is not useul as a triage tool. The system

is not currently included in the training curricula or pathology, radiology or surgery so clinical

injury descriptions (or example in operating notes, radiology reports or post-mortem reports)

seldom use the AISs internationally recognised terminology or describing injuries.

Its strengths are that it is internationally accepted, giving a common language by which

injuries can be described. It is well validated, reproducible and provides a well-established tool.

It provides the basis or probability o survival scores, which can be used to identiy cases (the

unexpected survivors and deaths) or urther detailed review in multidisciplinary trauma audit

meetings. These scores can also be used to compare institutional or system perormance.

Example ISS calculation

8.2 trauma audIt aNd reSearcH Network: oVerVIew

The Trauma Audit and Research Network (TARN) has been working with NHS trusts across

England and Wales or 20 years. It aims to improve emergency healthcare systems by collating

and analysing trauma patient care data within each trust. The registry o more than 250,000

injured patients provides a statistical base to support clinical audit and is a rich source oinormation to support trauma service improvement.

Appendices:theinjuryseverityscore22


26/60

-12 +120

-3.5% to -2.1%

2.8 additional deaths out

of every 100 patients

oucm (survival or death) ater trauma

are best measured by the number o those

who actually survive compared with the

number who are expected to survive.

The numbers o expected survivors

are generated rom the TARN database o

thousands o patients who have already

been treated or similar injuries.

The horizontal white line in the chart

represents a 95%.cfc.irval.Figure courtesy o TARN

TARN produces monthly clinical and quarterly comparative reports or 60% o hospitals

in England and Wales. These aid multispecialty clinical case review and systems o trauma

care evaluation. The epidemiology and level o trauma care can be accurately assessed and

developed within a hospital or network o care.TARN is a non-prot organisation (part o the University o Manchester) and is unded by

participation ees. The trauma registry has already provided long-term stability or trauma audit

and has been viewed as a potential uture model or other national clinical audits. This non-

prot-making unding model has enabled TARN to exist or 17 years with widespread support.2,34

Both reports recommend that all NHS trusts should take part in national trauma audit through

TARN, thus ensuring the continued strength o the organisation.

The data collection and reporting system is web-based and generically designed so that

data may be entered on interventions, observations, investigations, surgical procedures and the

details o the clinicians who attended the patient. Since a trauma patient may be treated in manydepartments in the pre-hospital and hospital setting, the design encourages data entry at any o

these locations.

Comparisons o trauma care were successully published in August 2007 on an open access

website (www.tarn.ac.uk) with ull agreement o NHS trust medical directors and in accordance

with national recommendations that patients and the public have direct access to outcome

inormation. The inormation on the website has been collected rom many o the hospitals

that treat trauma patients in England and Wales and shows rates o survival and adherence to

standards o trauma care. Other hospitals, which do not currently collect this inormation, are

also listed or completeness.

Rates o survival and adjustment or risk are displayed as ollows:

Yearly gures or rates o survival are reported in two-year intervals so that the hospital

sta and patients are able to monitor the eectiveness o their local trauma care closely. It is

important to review how injured patients are cared or at regular intervals since treatment and

practice at the hospital may change.

Data quality is assured by internal system validation and checks against other national

systems. The inormation provided on the website is collected in dierent ways by dierent

hospitals. Some hospitals have better resources than others or collecting data and this may

aect the quality and completeness o the data.

Appendices:tArnoverview 23


27/60

PreventionInitial

contact

Pre-hospital

assessment

Acute

trauma care

Acute or

specialist

rehabilitation

Community

or general

rehabilitation

Incident

Contact with

emergency

services

Remote

assessmentDispatch

Pre-hospital

assessment

Other

Critical

intervention

Alert and

transfer

Major

trauma

centre

Initial

contact

Assessment

by ambulance

crew

Trauma

unit

Additional

teams

Pre-hospital

assessment

MT

reception

MT

diagnosticsSurgery

ICU

HDU

Follow-on

surgery

Specialist

wardRehabilitation

Other

Other stageof pathway

Leavepathway

8.3 patHwaYS oF care aS deFINed IN tHe loNdoN proceSS

High-lvl.majr.rauma.pahay

Iiial.cac..uli

Pr-hpial.am..uli

Majr.rauma.cr..uli

Ky

Appendices:pAthwAysoFcAreAsdeFinedinthelondonprocess24


28/60

Pre-hospitalassessment

Traumareception

Traumadiagnostics

Surgery

ICU

HDU

Follow-on

surgery

Specialistward

Rehabilitation

Other

Assessment

by trauma

team

Critical

intervention

Alert and

transfer

Major trauma

centre

Inpatient

ward

Outpatient

therapy

Community

or general

rehabilitation

Home and

GP-led care

Other

Long termrehabilitation

or care

Major trauma

centre

Specialist

ward

Acute or

specialist

rehabilitation

Outpatient

therapy

Community

therapy

Home and

GP-led care

Other

Other stageof pathway

Leavepathway

trauma.ui..uli

Acu.r.pciali.rhabiliai..uli

.

Cmmuiy.r.gral.rhabiliai..uli

Ky

Appendices:pAthwAysoFcAreAsdeFinedinthelondonprocess 25


29/60

8.4 optImal reSourceS For deSIgNatIoN oF trauma NetworkS

Lvl..imprac..criri in the HL designation process, each criterion was allocated a

level o importance rom 1 to 5, with 5 being the most important. When evaluating the bids or

trauma networks it was deemed that all level 4 and 5 criteria should be achieved in order or thebid to pass.

Appendices:optimAlresourcesFordesignAtionoFtrAumAnetworKs26


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Appendices:optimAlresourcesFordesignAtionoFtrAumAnetworKs 27

Cririaumbr

dcrip

i

evicrquir

Mhf

am

Lv

lf

imprac

cri

ri

1.C

linicalleadership

Identiednetworkdirector

andnetworkboard(thismay

bethenetworkdirectororthe

majort

raumacentreoratrauma

unit):clearstructure,r

olesand

responsibilities

Atraum

adirectorineachmajor

trauma

centreandtraumaunit

Nameoindividualsinpostor

networks

Demonstratehowappointme

ntto

postswilltakeplace

Existingorproposednetwork

boardstructureincludingdirector

Networkboardtermsoreerence

includinghowlinksandreporting

lineswillbesetupwithprima

ry

caretrusts

Document

inspection

Sitevisit

4

2.N

etworkcooperation

Evidence-basednetworkguidelines

andpro

tocolsormanagement

otraum

aandmajortrauma

patient

stoensureconsistencyo

management

Forumorsharingideasand

practiceordevelopingthenetwork

includinginputromambulance

service

Updatedprotocolsandguide

lines

Processorregularreviewo

protocolsandguidelines

Networkmeetingagendaand

minutes

Document

inspection

4

3.N

etworkinormation

System

orcommunicatingwithall

thoseinvolvedinthenetwork:this

maytaketheormoanewsletter

orawe

bsite

Newsletterorwebsiteaddress

Document

inspection

2

8.4.1goVerNaNceaNdculture


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Cririaumbr

dcrip

i

evicrquir

Mhf

am

Lv

lf

imprac

cri

ri

4.E

ectivetransero

patien

ts

Patientswhoareunder-triaged

tothet

raumaunitarerapidly

transerredtothemajortrauma

centrewithoutdelay

Patientssuitableorlocalrehab-

ilitation

aretranserredwhenready

Protoco

lsareinplacetosupport

theabo

vetransers

Structu

resareinplacetoensure

ambula

nceserviceinputand

involve

mentintonetworktranser

protocolsandauditotriage

Transerprotocolsromtraum

aunit

tomajortraumacentre

Repatriationprotocolsorpat

ients

suitableorrehabilitation

Auditotransers,r

epatriation

and

reasonsordelay

Document

inspection

5

5.R

eviewoclinical

perormance

Regularreviewopatientoutcomes

Regularmulti-proessionalreviews

oindiv

idualcases(morbidityand

mortality(MandM)meetings)

throughoutthenetworktoidentiy

areasogoodpracticeandareasor

improvement

Traumaregistry,TARNdata

AgendaandminutesorMan

dM

meetings

Document

inspection

4

6.R

isk

management

Process

esinplaceoridentication

andmo

nitoringonetwork-related

criticalincidentsandactionplans

designedtoimproveperormance

Riskmanagementstructure

Minutesoriskmanagement

meetings

Document

inspection

4

8.4.2QualItYaNdSaFetY


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Cririaumbr

dcrip

i

evicrquir

Mhf

am

Lv

lf

imprac

cri

ri

7.M

ed

icalEmergency

ResponseIncidentTeam

(MERIT

)availability

AMERITteamavailablewithinthe

networ

katalltimesordeployment

tothes

ceneoamajorincidenti

require

deitherwithinthenetwork

ororanincidentwithinanother

networ

k.(

NBnaldesignation

othiscriterionshouldbein

accordancewiththeDepartment

oHealthemergencypreparedness

guidance.)

MERITteammemberstructur

e

Rota

TrainingprogrammeorMERIT

teammembers

Document

inspection

Sitevisit

4

8.M

ajorincidentcapability

Abilitytocontinueunctioning

asanetworkduringamajor

inciden

tdemonstratingeective

commu

nicationandabilityto

deliver

majortraumaandtrauma

care

Networkmajorincidentpolicy

Auditomajorincidentplan

eectiveness

Document

inspection

4

8.4.3N

etworkeFFectIVeNeSS


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Criri

aumbr

dcrip

i

evicrquir

Mhf

am

Lv

lf

imprac

cri

ri

9.A

pproachto

rehabilitation

improvement

Aclearoutlineohownetwork

rehabilitationproviderswillbegin

tomap

thecurrentanduture

pathwa

ysorrehabilitationto

deliver

improvementthrough

commissioning.

Involvementopatientsin

redesig

ningrehabilitationservices

Outlinerehabilitationproject

brie

Outlineprojectplan

Rehabilitationimprovement

teammembershipincluding

commissionersandpatients

Termsoreerenceorehabilitation

improvementgroup

Document

inspection

4

8.4.4reHaBIlItatIoN


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Cririaumbr

dcrip

i

evicrquir

Mhf

am

Lv

lf

imprac

cri

ri

10

.Trainingacrossnetwork

Provisio

nomulti-proessional

training

opportunitiesacross

organis

ationalboundaries

Networkeducationtimetable

Document

inspection

3

11

.Op

portunitiestogain

experienceacrossnetwork

Opport

unitiestorotatethrough

dieren

torganisationswithin

networ

ktogainbreadthotrauma

experie

nceandmaintainskills

Networkpolicyonrotationan

d

secondment

Document

inspection

2

8.4.5educatIoNaNdtraININg

Cririaumbr

dcrip

i

evicrquir

Mhf

am

Lv

lf

imprac

cri

ri

12

.Inv

olvementintrauma

research

Acomm

itmenttoparticipatein

multi-centretrials

Commitmenttoresearch

involvement

Document

inspection

3

8.4.6reSearcHaNddeVelopmeNt

Cririaumbr

dcrip

i

evicrquir

Mhf

am

Lv

lf

imprac

cri

ri

13

.Injuryprevention

progra

mme

Aprogrammeopubliceducation

deliveredacrossthenetwork

designedtoreducethenumber

otraum

ainjuriesthiscouldbe

deliveredonasystem-w

idebasis

Programmeoactivities

Document

inspection

2

8.4.7preVeNtIoNStrategIeS


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Appendices:optimAlresourcesFordesignAtionoFmAjortrAumAcentres32

Criri

aumbr

dcrip

i

evicrquir

Mhf

am

Lv

lf

imprac

cri

ri

14

.Institutional

commitment

Commitmentromexecutiveteam

andsen

iorstatotheprovisiono

ahighqualitymajortraumaservice

withinthetrust

Presenc

eoamajortrauma

managementstructurethat

supportsthedeliveryoahigh

quality

majortraumaserviceled

byaclinicaldirectorortrauma

togetherwithadesignatedmajor

trauma

programmemanagerand

datamanager

Presenc

eoaclinicalstructurethat

supportsthedeliveryoahigh

quality

majortraumaservice

Presenc

eoagovernancestructure

thatass

uresqualityoserviceand

allowsorcontinuousmeasurement

andimprovement

Writtenmemorandumo

commitmentromtrustboard

(or

minutes)

Businessplan

Managementstructure

organisationalchartwithnam

eso

thoserolesalreadylled

Clinicalstructure

Governanceramework

Evidenceoauditandimprovement

orutureplansinotinplace

Evidenceoregularcaserevie

w

meetings

SubscriptiontoTARN

Educationprogrammes

Patientboard/representation

Document

inspection

Sitevisit

5

85

o

PtIMALResoURCesFo

RdesIGnAtIonoFMAJ

oRtRAUMACentRes

8.5.1IN

StItutIoNalcommItmeNt


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Appendices:optimAlresourcesFordesignAtionoFmAjortrAumAcentres 33

14

.Institutional

commitment(continued)

Commitmenttoengagein

theprocessocontinuous

improvement

Submis

sionoulldatasettoTARN

annually

Provisio

noeducationeg

ATLS,ALS

,CCriSP,ATNC

,TNCCor

equivalentandothereducational

opportunities.

Commitmenttoadherenceto

majortraumasystemperormance

Framew

orkandmonitoring

Involvementopatientsin

developingservicestomeetpatient

need


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gloSSarYoFSerVIceleVelS

Lvl

dcripi

Consultantavailableimmediatelyonsite(thesamehospita

lsite)24hours,7

daysaweek;availabletoleadmajortraum

ateam

Consultant-ledserviceavailableonsite(thesamehospitalsite)24hours,7

daysaweekw

ithcontinuousjuniorpresenc

eouto

hoursandconsultantavailab

leonsitewithin30minutes

Consultantavailablewithin3

0minutes.Nocommitmentto

provideongoingcontinuous

careonsite(maybeprovided

within

network)

1.

2.

3.

Cririaam

dcripi

Lv

l

examplfvic

Am

L

vlf

im

prac

f

criri

1

2

3

15

.Designatedmajor

traumaresuscitation

team

Responsibleorreceiving,

resuscitating,c

oordinating

careandtrea

tingtrauma

patientsinclu

dingundertaking

resuscitative

thoracotomy

Theteamsho

uldbeledby

aconsultantwithon-s

ite

presenceata

lltimeswith

immediatere

sponse

Responsibleorcareothe

patientuntiladmittedundera

specialtylead

Listoconsultantsinv

olved

indeliveringmajortrauma

careandtheirlevelo

service

commitmenttotraum

a,e

gull

time,h

altime

Validationoresuscita

tive

thoracotomyskills

ListospecialistnursingAHP

rolessupportingtraumacare

Teammembershipandstructure

Organisationalchart

Activationprotocol(statelevels)

Document

inspection

Sitevisit

5

8.5.2SerVIce


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16

.On

goingpatient

carete

am

Responsibleoradmitting

patientsunderspecialtyand

coordinating

ongoingcare

undertheres

ponsibilityoa

designatedle

adconsultant.

Thismayincluderolessuchas

traumanurse

coordinatorto

acilitatecare

coordination

Descriptionohowa

consultant-ledservice

or

ongoingcoordination

ocareor

patientswithpolytrau

mawillbe

delivered

Listoconsultantsinv

olved


careandtheirlevelo

service

commitmenttotraum

a,e

gull

time,h

altime

Listospecialistnursingand

AHProlessupporting

trauma

care

Rotas

Teammembershipan

d

structure

Organisationalchart

Sampleplanopatien

tcare

Dedicatedtraumawa

rdorco-

locationopatients

Sitevisit

4


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Cririaam

dcripi

Lv

l

examplfvic

Am

L

vlf

im

prac

f

criri

1

2

3

17

.Resuscitation

baywithequipment

appropriateor

treatin

gpatientswith

polytrauma

Resuscitation

baythatcan

accommodatethemajortrauma

teamandsup

portingteams

with:

resuscitationtrolley

basicand

advancedairway

managem

entequipment

xedandportableventilator

andgassupply

anaesthet

icmachinecapable

odeliveringoxygen,a

irand

volatilean

aestheticagent

Entonoxc

ylinderand

deliverysystem

ultrasoundandx-ray

machines

bloodgas

andelectrolyte

machine

spinalimm

obilisation

Notapplicable

tothiscriterion

Sitevisit

Sitevisit

4


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17

.Resuscitation

baywithequipment

appropriateor

treatin

gpatients

withpolytrauma

(contin

ued)

monitorin

g(invasive/non-

invasive)compatiblewith

thatused

intheatresand

intensivecareunitsand

abletosto

reparameters.

Functions

mustinclude

abilitytoundertakearterial,

CVP,pulse

oximetry,CO

2and

temperaturemonitoring

packsorperipheraland

centralvenousaccess

(including

cut-downand

intraosseo

us)

chestdraininsertionpack

thoracoto

mytray

arteriallin

espack

pressurise

dhigh-volume

heatedfu

iddeliverydevice

limbsplin

tsandpelvic

binders

amilyroo

m


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Cririaam

dcripi

Lv

l

examplfvic

Am

L

vlf

im

prac

f

criri

1

2

3

18

.Em

ergency

department(ED)

Responsibleorsupporting

themajortraumaresuscitation

teaminitsrole

,receiving,

resuscitating,s

tabilising,

perorminge

mergency

procedures

Listoconsultantsinvolved

indeliveringmajortra

uma

careandtheirleveloservice

commitmenttotraum

a,e

gull

time,h

altime

Atleastband-7nursecoveror

EDatalltimes

Listospecialistnursin

gandAHP

rolessupportingtraum

acare

Rota

Sitevisit

3

19

.Neurosurgery

Responsibleoradviceand/or

treatmento

alltraumapatients

withheadinjuries

Provisionoa

leadconsultant

responsibleorcoordinatingall

careorpatie

ntsadmittedinto

specialty

Aneurosurgicaltraumaliaison

consultantsh

ouldbeidentied

withintheservicewith

responsibility

orliaisingwith

themajortraumaservice

Listoconsultantsinvo

lvedin

deliveringmajortraum

acareand

theirleveloserviceco

mmitment

totrauma,e

gulltime,h

altime

Describehowaneurosurgery

traumaliaisonpostisc

urrentlyor

willbedelivered

Describehowlongitw

illtaketo

haveaseniorspecialty

trainee

(StR)inattendance

Listospecialistnursin

gandAHP

rolessupportingtraum

acare

Rota

Document

inspection

5


42/60


20

.Spinalinjury

service

Responsibleoradvice,n

on-

surgicalandsurgicaltreatment

ospinalinjuries

Descriptionohowsp

inal

servicewillbedeliveredinthe

centre,e

itheronsiteorthrough

useoexpertiseositewith

reerralprotocols

Protocolsorhowpatientswith

spinaltraumawillbeassessed

andmanaged

Document

inspection

4

21

.Generalsurgery


on-


Provisionoa

leadconsultant

responsibleorcoordinatingall

careorpatie

ntsadmittedinto

specialty

Ageneralsur

gerytrauma

liaisonconsultantshouldbe

identiedwithintheservice

withresponsibilityorliaising

withthemajortraumaservice

Listoconsultantsinv

olved


careandtheirlevelo

service

commitmenttotraum

a,e

ghal

time,

ulltime

Describehowageneralsurgery

traumaliaisonpostis

currently

orwillbedelivered

Describehowlongitwilltaketo

haveaStRinattendance


AHProlessupporting

trauma

care

Rota

Document

inspection

4


43/60


44/60


45/60


Cririaam

dcripi

Lv

l

examplfvic

Am

L

vlf

im

prac

f

criri

1

2

3

26

.Radiology:

ultraso

und

Availabilityoultrasound

scanninginE

Dresuscitation

room

Rota

Sitevisit

4

27

.Radiology:CT

AvailabilityoCTimagingwithin

30minutes

Saetranser,

monitoringand

resuscitation

acilitiesavailable

FacilitiesorC

Treportingby

radiologyconsultantwithinone

hour.Service

available7days

perweek

Commitmenttoteleradiology

oraccesstoimagingacrossthe

network

Rota

Letterromclinicaldirectoro

radiologyconrming

levelo

consultant-ledreporting

Sitevisit

4

28

.Radiology:

interve

ntional

Interventionalprocedures

within30min

utes,withsae

transer,mon

itoringand

resuscitation

acilities

Rota

Sitevisit

4

29

.Radiology:MRI

MRIimaging

availablewithin

24hourswith

saetranser,

monitoringa

ndresuscitation

acilities

Rota

Sitevisit

3


46/60


30

.Theatre

Immediately

available

,ully

equippedanddedicated

staedtraum

atheatrewith

secondavaila

bleiservices

overwhelmed

Routineorthopaedictrauma

lists,staeds

eparatelytothe

emergencylists,available7days

perweek

.

Notapplicable

tothiscriterion

Rotaoremergencytheatre1

Rotaoremergencytheatre2

Protocoloractivation

o

emergencytheatre2iservices

areoverwhelmed

Document

inspection

Sitevisit

4

31

.Anaesthetics

Availableorairway

managementandsurgery

Equipmentavailableor

advanced/co

mplexairway

management

Invasivemon

itoringcompatible

withEDsyste

m

Seniorpersonnelavailable

andexperien

cedintrauma

anaesthesia

Ananaesthesialiaison

consultantid

entiedwithin

theservicew

ithresponsibility

orliaisingwithmajortrauma

service

Listoconsultantsinv

olved


careandtheirlevelo

service

commitmenttotraum

a,e

ghal

time,

ulltime

Describehowananae

sthesia

traumaliaisonpostis

currently

orwillbedelivered

Rota

Document

inspection

Sitevisit

4


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dcripi

Lv

l

examplfvic

Am

L

vlf

im

prac

f

criri

1

2

3

32

.Criticalcare

Availableorintensivecare

supportom

ajortrauma

patients.

Notapplicable

tothiscriterion

Numberobedsavailableor

majortraumapatientsandbed

managementprotoco

l

Networkcontingency

plani

nobedsavailableorc

apacity

exceeded

Dialysisacility

Intracranialmonitorin

g

Document

inspection

4

33

.Criticalcareteam

Responsibleorintensivecare

managementomajortrauma

patients

Criticalcareliaisonconsultant

identiedwithintheservice

withresponsibilityorliaising

withthemajortraumaservice

Describehowacritica

lcare

traumaliaisonpostis

currently

orwillbedelivered


AHProlessupporting

trauma

care

Document

inspection

4

34

.Lab

oratory

service

s

(haematology,

coagulation,c

linical

chemistryand

microb

iology)

Staedlaboratoryavailableor

immediateanalysisobloodand

otherspecim

ens24hoursaday,

7daysperweek

Notapplicable

tothiscriterion

Rota

Sitemap/visit

Document

inspection

Sitevisit

4


48/60


35

.Blo

odbank

Availableorprovidingblood

andbloodproductswith

massivetransusionprotocol

Linkedwith2

4/7haematology

advice

Provisionoa

leadconsultant

responsibleorpolicy

developmentandquality

assurancewithtraumaservices

Notapplicable

tothiscriterion

Rota

Sitemap/visit

Massivetransusionp

rotocol

Document

inspection

Sitevisit

4

36

.Pla

sticsurgery


on-


(*NB:icentr

edesignatedas

burnscentre

thenitbecomes

level2)

*

Rota

Document

inspection

3

37

.Ob

stetricsand

gynaecology)


treatment

Rota

Document

inspection

2

38

.Generalmedicine


treatment

Rota

Document

inspection

3

39

.Uro

logy


treatment

Rota

Document

inspection

3

40

.Ma

xilloacial


treatment

Rota

Document

inspection

4

41

.Op

hthalmology


treatment

Rota

Document

inspection

2

42

.ENT


treatment

Rota

Document

inspection

3

43

.Cardiology


treatment

Rota

Document

inspection

2


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Cririaam

dcripi

Lv

l

examplfvic

Am

L

vlf

im

prac

f

criri

1

2

3

44

.Nephrology


treatment

Rota

Document

inspection

2

45

.Careothe

elderly


treatment

Rota

Document

inspection

3

46

.Psy

chiatry


treatment

Rota

Document

inspection

3

47

.Endocrinology


treatment

Rota

Document

inspection

1

48

.Nu

tritionservice

Responsibleoradviceand

providingtotalparenteral

nutritionand

oralsupplements

24/7advice

95/5daysper

weekonsite

Rota

Notassessed

atthisstage

49

.TPNservice

ResponsibleorprovidingTPN

24/7

Rota

Notassessed

atthisstage

50

.Tra

nsplant

coordinatorservice

Responsibleortransplant

servicecoord

inationodonor

organs

24/7advice

within60

minutese

Rota

Notassessed

atthisstage

51

.Speechand

langua

ge


treatment

95/5daysper

week

Rota

Notassessed

atthisstage

52

.SpecialistED

traumanursing

Nursesrespo

nsibleorspecialist

nursing,c

oor

dinatingroleor

nurseconsultantsaspartothe

majortraumaresuscitationteam

orservice;listnurseconsultants,

CNS

,ANP

24/7oras

needed

Rota

Jobdescriptions

Notassessed

atthisstage


50/60


53

.Acute

physio

therapy


treatment

24/7with

in30

minutes

Rota

Notassessed

atthisstage

54

.Occupational

therap

y


treatment

95/5daysper

week

Rota

Notassessed

atthisstage

55

.Acutepsychology


treatment

95/5daysper

week

Rota

Notassessed

atthisstage

56

.Socialservices


treatment

24/7advice

95/5daysper

week

Rota

Notassessed

atthisstage

57

.Pro

visionor

vulnerableadults

Facilitiesand

processestodeal

withvulnerableadults

24/7

Protocol

Notassessed

atthisstage

58

.Acute

rehabilitation

physician


treatment

95/5daysper

week

Rota

Notassessed

atthisstage

59

.Specialist

rehabilitation

coordinator

Responsibleorrehabilitation

adviceandcoordination.L

istall

thosestain

thiskindorole

bothqualiedandunqualied

95/5daysper

week

Rota

Jobdescriptions

Notassessed

atthisstage

Paedia

trics

NBpaediatric

swasnotincludedintheHLrst-stagetraumaprocess(see

section7

.1)e


51/60

Appendices:optimAlresourcesFordesignAtionoFtrAumAunits48

86

o

PtIMALResoURCesFoRdesIGnAtIonoFtRAUMAUnIts

8.6.1IN

StItutIoNalcommItmeNt

Criri

aumbr

dcrip

i

examplfvic

Am

Lv

lf

imprac

cri

ri

60

.Institutional

commitment

Commitmentromexecutiveteam

andsen

iorstatotheprovisionoa

high-qu

alitytraumaservicewithin

thetrust

Presenc

eoatraumamanagement

structurethatsupportsthedelivery

oahig

h-qualitymajortrauma

service

ledbyadesignatedtrauma

medica

ldirector

Presenc

eoaclinicalstructurethat

supportsthedeliveryoahigh-

quality

traumaservice

Presenc

eoagovernancestructure

thatass

uresqualityoserviceand

allowsorcontinuousmeasurement

andimprovement

Commitmenttoengageinthe

process

ocontinuousimprovement,

includin

gworkingcloselywiththe

majortraumacentre

Writtenmemorandumo

commitmentromtrustboard

(or

minutes)

Businessplan

Organisationalchart

Clinicalstructure

Governanceramework

Evidenceoauditandimprovement

orutureplansinotinplace

Evidenceoregularcaserevie

w

meetings

SubscriptiontoTARN

Educationalprogrammes

Networktranserprotocol(un

der

networksection)

Patientboard

Document

inspection

Sitevisit

5


52/60

Appendices:optimAlresourcesFordesignAtionoFtrAumAunits 49

60

.Ins

titutional

comm

itment(continued)

Submis

sionoulldatasetto

Trauma

AuditandResearch

Network(TARN)annually

Provisio

noeducation,e

gATLS,

ALS

,CC

riSP,ATNC

,TNCCor

equivalentandothereducational

opportunities

Commitmenttoadhereto

aperormance-monitoring

ramew

ork

System

orrapididenticationand

transerounder-triagedpatients

tomajo

rtraumacentre

Commitmenttobeingpartoa

trauma

network

Involve

mentopatientsin

developingservicestomeetpatient

need


53/60

Appendices:optimAlresourcesFordesignAtionoFtrAumAunits50

gloSSarYoFSerVIceleVelS

Lvl

dcripi

Consultantavailableimmediatelyonsite24hours,7

daysa

week;availabletoleadtraum

ateam

Consultant-ledserviceavailableonsite24/7

,withcontinuo

usjuniorpresenceoutohoursandconsultantavailableon

site

within30minutes

Consultantavailablewithin3

0minutes;nocommitmentto

provideongoingcontinuous

care

1.

2.

3.

8.6.2SerVIceaNdproceSS

Cririaam

dcripi

Lv

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