1. Audit of the Quality of Inter-Hospital Transfers of Patients with Acute Brain Injury in South Wales Dr Nigel Jenkins, Dr Gethin Pugh and Dr Tom West South West Wales Transfer Network Meeting July 2013

2. Why this?

3. Because this….

4. Has become this….

5. Distances Distance in miles to nearest neuro centre (Time) MorristonUHW Morriston041.4 (0hr 50mins) Glangwili26.7 (0hr 41mins)66.9 (1hr 20mins) Withybush55.2 (1hr 19mins)95.5 (1hr 58mins) Bronglais76 (2hr 4mins)108.6 (2hr 30mins)

6. Aims Audit ofAudit of Quality of care receivedQuality of care received Inter-hospital transfers to UHWInter-hospital transfers to UHW Level 3 patientsLevel 3 patients Diagnosis of acute brain injuryDiagnosis of acute brain injury Calendar year of 2011.Calendar year of 2011.

7. Definitions Acute Brain Injury (ABI) – Traumatic brain injury and spontaneous subarachnoid haemorrhage.

8. Gold Standards

9. Objectives P RIMARY O UTCOMES P RIMARY O UTCOMES  Determine the composition of transfer team and mode of transfer  Evaluate the quality of preparation for transfer  ABG documented  Adequate IV access  Minimum monitoring standards met  GCS recorded before sedation

10. Objectives S ECONDARY O UTCOMES S ECONDARY O UTCOMES  Assess the quality of neuro-protective care administered during transfer and therefore prevention of secondary brain injury  PaO2 ≥ 13kPa  ETCO2 ≤ 5 kPa  MAP ≥ 80mmHg  Pupils: Size & Reaction

11. Data Collection South Wales Critical Care Network.South Wales Critical Care Network. UHW ICU admissions database.UHW ICU admissions database. 84 neurosurgical transfers between 1/1/2011 and 31/12/2011.84 neurosurgical transfers between 1/1/2011 and 31/12/2011. 71 were level 3 patients.71 were level 3 patients. Transfer documentation interrogated for the 71 relevant patients.Transfer documentation interrogated for the 71 relevant patients.

12. 71 transfers with ABI to UHW in 2011 Results: Mode of Transport 69 road transfers69 road transfers 2 air transfers2 air transfers

13. Results: Transfer Team Designed for Life: Welsh guidelines for the transfer of critically ill adult. 2009

14. Results: Transfer Team 6% 4% 41% 32% 17%

15. Results: Transfer Team 4% 24% 57% 11%

16. Results: Transfer Preparation Preparation and stabilisation for transfer Venous access must be secured before departure. These must be at least 2 wide bore peripheral cannulae or central venous cannula. Minimal monitoring standards for the level of the patient are mandatory Designed for Life: Welsh guidelines for the transfer of critically ill adult. 2009

17. Results: Transfer preparation 79% 14% 4% 3%

18. Results: Transfer Preparation Preparation and stabilisation for transfer Arterial blood gas analysis should be performed prior to departure after the patient has been on the ventilator for at least 15 minutes. Designed for Life: Welsh guidelines for the transfer of critically ill adult. 2009

19. Results: Transfer Preparation 63% 37% 72% 28%

20. Results: During Transfer Management during transfer All patients must receive the same level of care during transfer as they would get at their base intensive care unit. The patient must be monitored continuously throughout the transfer and observations recorded on the transfer chart. Designed for Life: Welsh guidelines for the transfer of critically ill adult. 2009

21. Results: Neuro- protection 62% 25% 13% 58% 39% 3%

22. Results: Pupils 73% 27%

23. Discussion Large percentage of transfers performed by CTs.Large percentage of transfers performed by CTs. Failure to undertake neuro-protective management in ~40% of transfers.Failure to undertake neuro-protective management in ~40% of transfers. General problem with inaccurate documentation of transfersGeneral problem with inaccurate documentation of transfers

24. Recommendations Present at local transfer network meetings and departmental audits to increase knowledge of problem.Present at local transfer network meetings and departmental audits to increase knowledge of problem. Create poster for display in emergency departments (requested by SEW transfer network).Create poster for display in emergency departments (requested by SEW transfer network). Educational programme for CTs.Educational programme for CTs. Re-audit 10-15 cases October / January / April to hopefully show improvement with above programmeRe-audit 10-15 cases October / January / April to hopefully show improvement with above programme

25. Acknowledgements Ms. Julia Jayne, Welsh Critical Care NetworkMs. Julia Jayne, Welsh Critical Care Network Michael Ware, Critical Care data collection, UHWMichael Ware, Critical Care data collection, UHW

26. References 1.Designed for Life: Welsh guidelines for the transfer of critically ill adult. 2009 2.Head Injury. National Institute for Health and Clinical Excellence. 2007. 3.Transferring the Critically Ill Adult. South East Wales Critical Care Network. April 2011.

27. Questions?