The Regional Trauma Network Lincoln Trauma Intermediate Life Support Course Michelle Rudd, April 2012

Learning Outcomes To understand the concept behind the regional trauma network, major trauma centres (MTC) & trauma units (TU) To understand the role of EMAS & ULHT within, and the impact of the regional trauma network Michelle Rudd, April 2012

The Underlying Principals The definition of major trauma is multiple injuries that are, or have the potential to be life threatening. Trauma causes significant mortality and morbidity (It costs the NHS £0.4 billion, and £4 billion in lost economic output). Trauma patients require specialist care from a multidisciplinary group of professionals. Patients do better in high volume systems. 20,000 cases of major trauma in England each year. (Diagnosed retrospectively using Injury Severity Score) 5,400 deaths. There are around a further 28,000 cases which, although not meeting the precise definition of major trauma, would be cared for in the same way. 450-600 lives could be saved in NHS hospitals every year if trauma services were better organised. Evidence from the United States shows that positive outcome for major trauma patients depends on them being delivered to a hospital that has the appropriate range of specialist resources to treat multiple injuries. Survival is greatly improved in such hospitals where clinicians can maintain their skills by treating a greater number of trauma patients and patients have access to specialist resources and equipment. Michelle Rudd, April 2012

The Network Model of Trauma Care Each geographical region should have a centre to treat the most seriously injured. Centralised services covering a population of 3-4 million people/250 major traumas a year. Most EDs see less than one major trauma case per week. Therefore major trauma care is a very small part of an ED work load and all departments cannot deliver cost effective high quality care. • 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. • There is an average delay of 6 hours in transferring patients from a local hospital to a specialist centre. Delays of 12 hours or more are not uncommon. Across the UK, almost all ambulance bypasses can be achieved in <30 minutes. Regionalisation of care to specialist trauma centres reduces mortality by 25% and length of stay by 4 days. • High volume trauma centres reduce death from major injury by up to 50%. • Time from injury to definitive surgery is the primary determinant of outcome in major trauma.6 (Not time to arrival in the nearest emergency department) • Long prehospital times have a minimal effect on trauma mortality or morbidity – even in very rural areas such as the west of Scotland. • Trauma centres have significant improvements in quality and process of care. This effect extends to non-trauma patients managed in these hospitals. Michelle Rudd, April 2012

Good Trauma Care Acute trauma care Prevention Initial contact Pre-hospital assessment Acute trauma care Whole system approach. The model that works is the military model returning injured soldiers from Afghanistan. There will be a new joint MoD and NHS rehab facility opening in the next couple of years in this region, Stanford Hall near Loughborough (the new Headly Court. Acute or specialist rehabilitation Community or general rehabilitation Michelle Rudd, April 2012

Regional Trauma Care Integrated pre-hospital care 24 hour consultant led resuscitative trauma team Dedicated trauma theatres All major trauma specialities on site Interventional radiology Appropriate ITU facilities Each region should have a major trauma plan which defines the pathway of care for severely injured patients, identifies the location and capability of each trust/hospital within the trauma system and outlines ambulance bypass protocols and thresholds for transferring patients to more specialist units. All major surgical specialties on a single site (orthopaedic trauma, general and vascular surgery, neurosurgery, plastic surgery, cardiothoracic surgery, head and neck surgery, urology) Interventional radiology (which uses radiological techniques to place wires, tubes or other instruments inside a patient to diagnose and treat various conditions) Michelle Rudd, April 2012

East Midlands Trauma Network Smaller circle is 25 mile radius, larger circle is a 40 mile radius. Trauma calls for QMC over last 3 months; July 172, August 133, September 131. of those from Lincoln 27, 17, 17. (only 1 from Boston ? Correct) Michelle Rudd, April 2012

Changes In Pre-hospital care Trauma desk in EMAS control. Enhanced care teams (HEMS, BASICS) Trauma training for all staff. Trauma unit bypass tool. Special incident desk; 24/7 support, identifies major trauma calls, ensures the right resources are sent to the scene, liase with receiving hospitals. SCAS trauma training includes; IO access, T-POD, tranexamic acid, CAT tourniquet, ATMIST as standardized handover tool. Trauma unit bypass tool; includes physiology/vital signs, anatomy of injury. Michelle Rudd, April 2012

Trauma Triage Tool Step 1. Physiological. Go to MTC. GCS <14 SBP <90 Step 2. Anatomical. Go to MTC. Penetrating head/neck/torso/limb (proximal to elbow knee) Chest injury with altered physiology Two proximal long bone fractures Crushed/degloved/mangled extremity Step 3. Mechanism. Consider TU or MTC. Falls; >6m/2 floors in adults, >3m/2 times height in child Motor vehicles; intrusion >30cm into occupant side, ejection (partial or complete), death in same passenger compartment. Pedestrian/cyclist vs motor vehicle, thrown/run over with significant impact Entrapment An example of a trauma bypass tool. Recent changes include a reduction in the emphasis on mechanism (cars are getting safer so speed is less relevant). Changes are due to over triage by about 45%, trying to get it down to around 30% which is felt to be the safe figure. Also looking to change time to 60 minutes (from 45) to bring in line with cardiac and stroke guidelines. This would have a big impact on Lincoln and Boston. Basically if A or C need controlling and >45 minutes from MTC, go to TU for A and C control. Michelle Rudd, April 2012

Special Considerations >55yrs old Children Anticoagulation/bleeding disorders Morbidly obese Burns circumferential or 20% BSA Pregnancy >20 weeks Consider previous steps and TU or MTC Michelle Rudd, April 2012

Changes In The Regions Hospitals Likely to see a decrease in major trauma presentations. More secondary transfers to QMC. Networks are likely to generate more audit data and research. National training standards & regional courses. 5.4 major traumas a day in the whole SCAS region. Current ISS 9-15=183, increase to 329, current ISS >15= 247, increase to 493 (total 572) Clinical changes; massive transfusion (1:1:1 PRC:FFP:plts), interventional radiology, tranexamic acid, Logistics; documentation, time to CT. Resus room group. Teamwork & communication; CRM, trauma team roles and positions, leadership, handover. Education & research; TILS, funding for ATNC, ECHO research, massive transfusion research. Michelle Rudd, April 2012

Secondary Transfers If Injury Severity Score is >9 phone for advice If ISS >15 send and phone One point of contact Major Trauma Consultant Always send to the emergency department for reassessment Send copy of trauma documentation, blood results, CT results Michelle Rudd, April 2012

Questions? Michelle Rudd, April 2012

Summary Trauma centres will improve patient care. We will work as a team to ensure we make that difference. The aim of the regional trauma network is to reduce mortality by 20% in 5 years. Since the trauma networks became established there have been 600 unexpected survivors of major trauma. 160 of those unexpected survivors were in the East Midlands Regional major Trauma Network, that is 13% above the national average. Michelle Rudd, April 2012