1999-2000

Report of the Working Party on the Management of Patients with Head Injuries

1999

2007

2008

2009

2009

?

2010

MAJOR TRAUMA IMPROVEMENT SUMMITimproving treatment and rehabilitation for major trauma patients

May 2010

Paramedic in Control Room

Clinical advice and support Enhanced care teams

Major trauma to major centre 45-minute isochrones

Clinical Advisory Group Recommendations to the

Department of Health

Pre-Hospital Care

The New RulesAll major trauma patients go to a major trauma centre:

– If journey < 45 minutes, directly

– If journey > 45 minutes, they still go to the major trauma centre – indirectly or directly

– If deteriorating, they still go to the major trauma centre – indirectly or directly

Exceptions– If treated immediately at trauma unit and no longer at risk– If immediate trauma unit assessment excludes major trauma

Advisory Group on Pre-Hospital Care 2010

Stoke-on-Trent

Birmingham

Coventry

60 miles

Stoke-on-Trent

Birmingham

Coventry

60 miles

45 minutes by land ambulance

45 minutes by helicopter

ACS 2006

Physiology

Anatomy

Mechanism

Special features

Accuracy of ACS Triage Criteria

Trauma Team and activation

Trauma Team Leader

Emergency Radiology

Emergency Surgery

Clinical Advisory Group Recommendations to the

Department of Health

Acute Care and Surgery

Care should be led by consultants experienced in major trauma

Major trauma is most likely to occur at night-time or at weekends

National Audit Office 2010

Resident Consultant Trauma Team Leaders in Major Trauma Centres

• 24-hour consultant presence in emergency departments treating major trauma patients

• Resident consultant team leader in major trauma centre and ≥ ST4 in trauma unit

• Other consultants available within 30 minutes

Trauma Team Leader

• Often but not necessarily emergency medicine

• Resident status or immediately available

• No conflicting duties – dedicated role

• 1-4 PA per hour versus 1 PA per week

Patient-centred care

Dedicated trauma wards and theatres

Intensive care

Repatriation

Clinical Advisory Group Recommendations to the

Department of Health

Ongoing Care and Reconstruction

Head Injury ‘Scandal’ 1

Time to decompression

Mendelow AD, et al.Extradural haematoma: effect of delayed treatment.

British Medical Journal 1979;1:1240-1241

Acute extradural haematomas have a better outcome if evacuated promptly

A delay of more than 2 hours from clinical deterioration to haematoma evacuation led to significantly worse outcome

59.0% (59*)GOS 5 (good recovery)

7.2%7.7%GOS 2 & 3 (PVS or severe disability)

54.8% (34**)23.1%GOS 4 (moderate disability)

38.1% (57**)10.3% (17*)GOS 1 (death)

6.0 h5.25 hOverall transfer time

0.75 h0.75 hArrival to surgery

2.38 h2.5 hCT to arrival

2.25 h2.0 hDeterioration or injury to CT

4239Number of patients

Acute Subdural Haematoma

Acute Extradural Haematoma

Leach P, et al. Transfer times for patients with extradural and subdural haematomas to neurosurgery in Greater Manchester

British Journal of Neurosurgery 2007; 21:11-15

* Mendelow 1979 ** Seelig 1981

Number of patients 23

Isolated extradural 9

Mixed extradural and subdural 1

Isolated subdural 7

Intracerebral 4

Mixed subdural and intracerebral 2

Number operated < 4 hours of injury 0

GOS 1 (death) 21.7%

GOS 2 & 3 (PVS or severe disability) 13.0%

GOS 4 (moderate disability) 21.7%

GOS 5 (good recovery) 43.5%

Sergides IG, et al. Is the recommended target of 4 hours from head injury to emergency craniotomy achievable?

British Journal of Neurosurgery 2006;20:301-305

Head Injury ‘Scandal’ 2

Refusing non-operable cases

Old and New Rules

• Closed door to non-operable head injuries

• Gatekeeper protectionism

• Open door to life-threatening intracranial haematomas

• Immediate transfer of responsibility to neurosurgeons

NHS East Midlands

NHS North West

Head Injury ‘Scandal’ 3

Inappropriate repatriation

Appointments

• Director/Clinical Lead in Major Trauma Care• Trauma Nurse Coordinator(s)

To oversee and review early trauma careTo deliver ‘real-time’ clinical governanceTo serve as a bridge between the immediate

care and rehabilitation teams

Early start

Director of Rehabilitation

Coordination

Country-wide review

Clinical Advisory Group Recommendations to the

Department of Health

Rehabilitation

Appointments

• Clinical Lead in Acute Trauma Rehabilitation• Trauma Rehabilitation Coordinator(s)

To coordinate and deliver early trauma rehabilitation

To serve as a single point of contact for patients, family and other support

Journal of Rehabilitation Medicine 2010;42:(in press)

Uncoupling Acute Care from Rehabilitation

• As soon as appropriate after injury

• Converts a ‘push’ system to a ‘pull’ one

Professor Keith Willett (in development)

The costs of major trauma are not fully understood, and there is no national tariff to underpin the commissioning of services

Funding arrangements do not reflect the true costs

National Audit Office 2010

HRG Grid for Major Trauma

Professor Keith Willett (in development)

Definitions and designation

Boundaries based on needs

Responsibility for transfer

TARN mandatory

Performance frameworkClinical Advisory Group

Recommendations to theDepartment of Health

Network Organisation

Primary care trusts should use their commissioning powers to require all acute and foundations trusts with emergency departments that receive trauma patients to submit data to TARN

National Audit Office 2010

By September 2011: TARN Compliance

Incidence of Major Trauma

• 200 per million per year NCEPOD

• 300 per million per year admitted to hospital Intercollegiate Group

Avery B. Nathens; Gregory J. Jurkovich; Ronald V. Maier; et al.Relationship Between Trauma Center Volume and OutcomesJAMA. 2001;285(9):1164-1171

Penetrating Abdominal Injury

Multisystem Blunt Trauma