National Peer Review Programme - TQuINS

National Peer Review Programme:

Major Trauma Measures

VERSION CONTROL SHEET Date Nov 2014 Nov 2014

Trauma Measures

Version 1.0 1.1

Changes Initial version Measure 2D-101 title correction

NOVEMBER

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Update by Julia Hill Julia Hill

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TRAUMA SPECIFIC MEASURES Contents Section 1 - Measures Network Governance Measures T14-1C-101

Network Configuration

T14-1C-102

Network Governance Structure

T14-1C-103

Network Audit of the Pre-Hospital Phase of Trauma

T14-1C-104

Individual Pre-Hospital Provider Feedback

T14-1C-105

Network Transfer Protocol from Trauma Units to Major Trauma Centres

T14-1C-106

Network Transfusion Protocols for Trauma Units

T14-1C-107

Teleradiology Facilities

T14-1C-108

Network CT Protocol for Adults

T14-1C-109

Network Imaging Protocol for Children

T14-1C-110

The Trauma Audit and Research Network (TARN)

T14-1C-111

Trauma Management Guidelines

T14-1C-112

Management of Severe Head Injury

T14-1C-113

Management of Spinal Injuries

T14-1C-114

Emergency Planning

T14-1C-115

The Trauma Network Director of Rehabilitation

T14-1C-116

Directory of Rehabilitation Services

T14-1C-117

Referral Guidelines to Rehabilitation Services

T14-1C-118

Patient Transfer

T14-1C-119

Network Patient Repatriation Policy

Pre-Hospital Care Measures T14-2A-101

Pre-Hospital Care Clinical Governance

T14-2A-102

Trauma Triage Tool and Immediate Transfer Policy

T14-2A-103

24/7 Consultant Medical Advice for the Ambulance Control Room

T14-2A-104

24/7 Paramedic Advice in the Control Room

T14-2A-105

Enhanced Care Teams available 24/7

T14-2A-106

Pain Management Protocol for Adult Patients

T14-2A-107

Pain Management Protocol for Children

T14-2A-108

Pre-Hospital Administration of Tranexamic Acid for Adult Patients

T14-2A-109

Application of Pelvic Binders

T14-2A-110

Hospital pre-alert and handover

TRAUMA SPECIFIC MEASURES

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Reception and Resuscitation Measures for Adult Major Trauma T14-2B-101

Trauma Team Leader

T14-2B-102

Trauma Team Leader Training

T14-2B-103

Trauma Team Activation Protocol

T14-2B-104

24/7 Surgical and Resuscitative Thoracotomy Capability

T14-2B-105

24/7 CT Scanner Facilities and on-site Radiographer

T14-2B-106

CT Reporting

T14-2B-107

24/7 MRI Scanning Facilities

T14-2B-108

24/7 Interventional Radiology

T14-2B-109

Interventional Radiology Facilities

T14-2B-110

24/7 Access to Emergency Theatre and Surgery

T14-2B-111

Damage Control Training for Emergency Trauma Consultant Surgeons

T14-2B-112

24/7 Access to On-site Surgical Staff

T14-2B-113

24/7 Access to Consultant Specialists

T14-2B-114

Dedicated Orthopaedic Trauma Operating Theatre

T14-2B-115

Provision of Surgeons and Facilities for Fixation of Pelvic Ring Injuries

T14-2B-116


T14-2B-117

On-site Intensive Care Unit

T14-2B-118

Audit of the Intensive Care Unit

T14-2B-119

24/7 Specialist Acute Pain Service

T14-2B-120

Transfusion Lead Clinician

T14-2B-121

24/7 Specialist Transfusion Advice

T14-2B-122

Massive Transfusion Protocol for the Major Trauma Centre

T14-2B-123

Administration of Tranexamic Acid

Definitive Care Measures for Adult Major Trauma T14-2C-101

Major Trauma Centre Lead Clinician

T14-2C-102

Major Trauma Service

T14-2C-103

Major Trauma Coordinator Service

T14-2C-104

Major Trauma MDT Meeting

T14-2C-105

MDT Conference Facilities

T14-2C-106

Dedicated Major Trauma Ward or Clinical Area

T14-2C-107

Protocol for Formal Tertiary Survey

T14-2C-108

Management of Neurosurgical Trauma

T14-2C-109

Management of Craniofacial Trauma

T14-2C-110


T14-2C-111

Management of Musculoskeletal Trauma

T14-2C-112

Management of Hand Trauma

T14-2C-113

Management of Complex Peripheral Nerve Injuries


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T14-2C-114

Management of Maxillofacial Trauma

T14-2C-115

Vascular and Endovascular Surgery

T14-2C-116

Designated Specialist Burns Care

T14-2C-117

Nutritional Management Policy

T14-2C-118

Discharge Summary

Rehabilitation Measures for Adult Major Trauma T14-2D-101

Clinical Lead for Acute Trauma Rehabilitation Services

T14-2D-102

Rehabilitation Coordinator Post

T14-2D-103

Specialist Rehabilitation Service

T14-2D-104

Key Worker

T14-2D-105

Rehabilitation Prescriptions

T14-2D-106

Rehabilitation for Traumatic Amputation

T14-2D-107

Facilities for Family / Carers

T14-2D-108

Patient Information

T14-2D-109


T14-2D-110

Patient Transfer

T14-2D-111


T14-2D-112

Clinical Psychologist for Trauma Rehabilitation

T14-2D-113

24/7 Access to Psychiatric Advice

Reception and Resuscitation Measures for Children's Major Trauma T14-2B-201

Trauma Team Leader

T14-2B-202


T14-2B-203


T14-2B-204


T14-2B-205


T14-2B-206

CT Reporting

T14-2B-207

24/7 MRI Scanning Facilities

T14-2B-208


T14-2B-209


T14-2B-210

24/7 access to Emergency Theatre and Surgery

T14-2B-211


T14-2B-212


T14-2B-213


T14-2B-214


T14-2B-215


T14-2B-216


T14-2B-217


T14-2B-218



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T14-2B-219


T14-2B-220


T14-2B-221


Definitive Care Measures for Children's Major Trauma T14-2C-201


T14-2C-202


T14-2C-203


T14-2C-204


T14-2C-205


T14-2C-206


T14-2C-207


T14-2C-208


T14-2C-209


T14-2C-210


T14-2C-211


T14-2C-212


T14-2C-213


T14-2C-214


T14-2C-215


T14-2C-216


T14-2C-217

Discharge Summary

Rehabilitation Measures for Children's Major Trauma T14-2D-201


T14-2D-202


T14-2D-203


T14-2D-204

Key Worker

T14-2D-205


T14-2D-206


T14-2D-207

Facilities for Family/Carers

T14-2D-208

Patient Information

T14-2D-209


T14-2D-210

Patient Transfer

T14-2D-211


T14-2D-212


T14-2D-213


Reception and Resuscitation Measures for Trauma Units T14-2B-301

Trauma Team Leader

T14-2B-302



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T14-2B-303

Agreement to Network Transfer Protocol from Trauma Units to Major Trauma Centres

T14-2B-304

24/7 CT Scanner Facilities

T14-2B-305

CT Reporting

T14-2B-306

Network CT Protocols

T14-2B-307


T14-2B-308

24/7 Access to Surgical Staff

T14-2B-309


T14-2B-310


T14-2B-311


T14-2B-312


T14-2B-313

Network Transfusion Protocol

T14-2B-314


Definitive Care Measures for Trauma Units T14-2C-301

Major Trauma Lead Clinician

T14-2C-302

Designated Specialty

T14-2C-303

Trauma Coordinator Service

T14-2C-304


T14-2C-305

Management of Multiple Rib Fractures

T14-2C-306


T14-2C-307

Facilities for Fixation of Fractures

T14-2C-308


T14-2C-309

Discharge Summary

T14-2C-310


Rehabilitation Measures for Trauma Units T14-2D-301

Rehabilitation Coordinator

T14-2D-302

Trauma Unit Agreement to the Network Repatriation Policy

T14-2D-303

Physiotherapy Services

T14-2D-304

Access to Rehabilitation Specialists

T14-2D-305



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Section 2 – Clinical Indicators / Lines of Enquiry TARN DATA


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MAJOR TRAUMA MEASURES Introduction These measures were commissioned by the National Clinical Director for Major Trauma Chris Moran. The measures have been developed from the National Service Specification for Major Trauma (NHS England D15/S/a 2013) and the NHS clinical advisory group report on Major Trauma Workforce (CFWI March 2011). They support the National Peer Review quality assurance programme for major trauma services in England enabling quality improvement both in terms of clinical and patient outcomes. The National Peer Review Programme includes expert clinical and lay person representation, and will provide important information about the quality of clinical teams and a national benchmark of major trauma services across the country. The measures cover the whole organisation of adult and children's major trauma services including sections for Major Trauma networks, pre-hospital care via ambulance services, Adult Major Trauma centres, Children's Major Trauma centres and Major Trauma units. In addition outcome data from the Trauma Audit and Research Network (TARN) dataset will be used to review clinical outcomes alongside the measures. The measures draw on the experience and success of the National Peer Review programmes for cancer and children and young people's diabetes along with the early Trauma Peer Review programme run by the Department of Health (DH). Compliance with the measures has not been centrally imposed and adherence to the measures is not mandatory for the NHS but it is used by the National Peer Review Programme as part of the assessment of major trauma services and to provide information for commissioners. Reviewing the Measures The Major Trauma Peer Review Programme aims to improve care for people with major trauma by: • • • • • •

ensuring services are as safe as possible; improving the quality and effectiveness of care; improving the patient and carer experience; undertaking independent, fair reviews of services; providing development and learning for all involved; encouraging the dissemination of good practice.

The benefits of peer review have been found to include the following: • provision of service specific information across the country together with information about individual teams which has been externally validated; • provision of a catalyst for change and service improvement; • identification and resolution of immediate risks to patients and/or staff; • engagement of a substantial number of front line clinicians in reviews; • rapid sharing of learning between clinicians, as well as a better understanding of the key • recommendations in the guidance. Full details of the peer review process are outlined in the handbook for the programme which is on the resource page of the TQuINS website www.tquins.nhs.uk.


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Reviewing the Major Trauma Network Network Governance Measures T14-1C-100 • For review purposes completion of the Network Governance measures is the responsibility of the Network Director and should be applied to both adult and children's services. • Each network will be reviewed once in conjunction with its constituent centres and units. Pre- Hospital Care Measures T14-2A-100 • Integrating the various pre-hospital services for adults and children and the collation of evidence for the peer review is the responsibility of the network director. Evidence documents should include reference to both children and adults. • There are ambulance services which provide pre-hospital care to more than one major trauma network. Where this is the case it is expected the ambulance service will be required to submit only one set of evidence and will participate in one review. This should be the network for which the ambulance service is a major provider of pre-hospital care and that is reviewed earliest in the cycle. The information will be shared with subsequent reviews for networks which the ambulance service covers. This will be agreed prior to the commencement of the review cycle. Adult Major Trauma Centre Measures The measures for major trauma centres are divided into 3 sections: • • • •

Reception and Resuscitation T14-2B-100 Definitive Care Measures T14-2C-100 Rehabilitation Measures T14-2D-100 The responsibility for the measures lies with the major trauma lead clinician for the trust.

Children's Major Trauma Centre Measures The measures for major trauma centres are divided into 3 sections: • • • •


Major Trauma Measures for Trauma Units The measures for trauma units are divided into 3 sections: • • • •


Where there is a combined adult and children's centre it is expected the centre will be reviewed once against both adult and children's measures. This will enable the service to demonstrate how they fulfill both roles. A major trauma centre that is also a trauma unit children's major trauma will only be reviewed against the relevant major trauma centre measures.


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Network Governance Measures Introduction The following measures are the responsibility of the network director and should be applied to both adult and children's services. Evidence documents should include reference to both children and adults.

Measure T14-1C-101

Notes

Evidence

Network Configuration

The network should provide the current population served by the trauma network.

Operational Policy including details of the major trauma network configuration.

If the population covered by the network is undergoing change the expected maximum population should be provided along with the expected timescale for the change. The network configuration should be identified including the following constituent parts: • pre - hospital services including: • ambulance services; • air ambulance services; • enhanced care services; • hospitals including: • major trauma centre(s); • trauma units; • local emergency hospitals; • rehabilitation services including; • specialist centre(s); • local hospital services; • community services. T14-1C-102

Network Governance Structure

The major trauma network should have a clinical governance structure which includes: • the name of the network director; • the name of clinical governance lead, if this is not the network director; • details of the governance structure; (1) • there should be regular clinical governance meetings that have an agenda and recorded minutes. T14-1C-103

(1) The structure should demonstrate links to the governance structure of the host trust.

Operational Policy specifying name of the clinical governance lead and structure.

Network Audit of the Pre-Hospital Phase of Trauma

The network should complete an audit of the pre-hospital phase of trauma. This should include: • the number and proportion of patients transferred directly to MTC; • the number and proportion of patients that have an acute secondary transfer (within 12 hour) from a trauma unit to a major trauma centre; • the number of patients that have an urgent


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Annual Report specifying details of the audit and the feedback.

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transfer (greater than 12 hours ) from a trauma unit to a major trauma centre; • the proportion of urgent transfers that occur within 2 calendar days; • The number of patients with ISS >=15 managed definitively within a trauma unit. Feedback of the audit results should be presented at a major trauma network meeting. T14-1C-104

Individual Pre-Hospital Provider Feedback

The network should provide feedback to each individual pre-hospital provider from the clinical governance system. T14-1C-105

Annual Report with details of the feedback.

Network Transfer Protocol from Trauma Units to Major Trauma Centres

There should be a network protocol for the safe and rapid transfer of patients to specialist care that covers: • transfer of patients with major trauma initially taken to a local trauma unit to a major trauma centre after initial assessment and resuscitation; • urgent transfer (within 2 calendar days) for specialist care within the network e.g. orthoplastics.

(1) Anaesthesia, Intensive Care and Pre-Hospital Emergency Medicine all include transfer training in their curricula.

Operational Policy including the protocol and TARN data.

The transfer protocol should specify the following: • transfer for adults is carried out by a team that have been trained in the transfer of patients; (1) • for time critical conditions, the transfer proceeds without delay; • a structured checklist is completed for the transfer; • standardised documentation should be used by trauma units and major trauma centres. There should be involvement of the regional paediatric critical care transfer service in defining the transfer protocol for children. T14-1C-106

Network Transfusion Protocols for Trauma Units

There should be a network agreed massive transfusion protocol covering both adults and children which is used in all trauma units.

Operational Policy including the protocol.

The protocol should include the administration of tranexamic acid and blood products including plasma, cryoprecipitate and platelets in the early stages of transfusion. T14-1C-107


There should be teleradiology facilities between the major trauma centre and all the trauma units in the network allowing immediate image transfer 24/7.


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Operational Policy.

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T14-1C-108

Network CT Protocol for Adults

There should be a network agreed trauma CT protocol which is used in all trauma units.

T14-1C-109


Network Imaging Protocol for Children

There should be a network agreed imaging protocol for Where there are national Operational Policy children which is used in all trauma units. The protocol guidelines it is expected these including the should include imaging of: are included in the protocol. protocol. • • • •

head; neck and spine; abdomen; pelvis.

T14-1C-110


All constituent services of the network including pre-hospital services should participate in the TARN audit.

Annual Report including details of TARN data completeness and data quality for all services in the network.

The results of the audit should be discussed at the network audit meeting at least annually and distributed to all constituent teams in the network, the CCGs and area teams. T14-1C-111


There should be network agreed clinical guidelines for the management of: • emergency anaesthesia within the emergency department; • emergency surgical airway; • resuscitative thoracotomy; • abdominal injuries; • severe traumatic brain injury; • open fractures; • compartment syndrome; • vascular injuries; • penetrating cardiac injuries; • spinal cord injury; • severe pelvic fractures including urethral injury; • chest drain insertion; • analgesia for chest trauma with rib fractures. T14-1C-112

Where there are national Operational Policy guidelines it is expected these including the are included in the protocol. guidelines.

Management of Severe Head Injury

All patients with a severe head injury (AIS3+) within the trauma network should be managed within a neurosciences centre as specified in the NICE guidance Head injury: Triage, assessment, investigation and early management of head injury in children, young people and adults (CG176 -January 2014).


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Annual Report including details of TARN data.

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T14-1C-113


There should be a network protocol for protecting and assessing the whole spine in adults and children with major trauma. (1)

This may be a single protocol Operational Policy or separate protocols for including the adults and children. protocol.

The protocol should be used at the MTC and all TUs within the network and should specify that: • all spinal imaging should be reviewed and reported by an appropriate expert within 24 hours of admission; • all patients with spinal cord injury have their neurology, including any changes over time, documented on an ASIA chart;

Annual Report including audit data showing time from X-rays/CT/MRI to definitive report.

There should be protocols for resuscitation and acute management including skin care, gastric, bowel and bladder care and neuro-protection agreed with the linked Spinal Cord Injury Centre(SCIC) and available in all emergency departments that may receive patients with spinal cord injury. T14-1C-114

Emergency Planning

The network should have an emergency plan for dealing with a mass casualty event that is reviewed and updated annually. T14-1C-115

Operational Policy including the emergency plan.

The Trauma Network Director of Rehabilitation

There should be a network director for rehabilitation with experience in trauma rehabilitation. The director should have an agreed list of responsibilities and time specified for the role.

T14-1C-116

Directory of Rehabilitation Services

There should be a network directory of rehabilitation services which should include: • a list of services; • a list of the rehabilitation resources. T14-1C-117

Operational Policy including the directory of rehabilitation services.


The should be network agreed referral guidelines for access to rehabilitation services.

T14-1C-118

Operational Policy including the name and agreed list of responsibilities of the trauma network director of rehabilitation.

Operational Policy including referral guidelines.

Patient Transfer

There should be a network agreed protocol for patient transfer from specialist medical care in either the MTC or a TU to a rehabilitation service.


The protocol should include details of available resources to meet ongoing care and rehabilitation needs. TRAUMA SPECIFIC MEASURES

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T14-1C-119


There should be a network agreed policy for the repatriation of patients transferred to the MTC which should include:

Operational Policy including the policy.

• patients are accepted by the trauma units within 48 hours of being identified ready for repatriation; • local contact details for each trauma unit; • the provision of ongoing care and non-specialised rehabilitation by the trauma units.


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Pre-Hospital Care Measures Introduction Integrating the various pre-hospital services for adults and children and the collation of evidence for the peer review is the responsibility of the network director. Evidence documents should include reference to both children and adults.

Measure T14-2A-101

Notes

Pre-Hospital Care Clinical Governance

There should be a clinical governance structure for the This should enable two way ambulance service(s) that enables integration with the feedback and learning MTN and MTC. between services.

T14-2A-102

Evidence

Operational Policy containing details of the clinical governance structure and interface with the network and MTC.

Trauma Triage Tool and Immediate Transfer Policy

A trauma triage tool should be used to identify patients The triage tool for adults and with major trauma. children may be combined or separate. There should be a policy whereby:

Operational Policy with details of the trauma triage tool.

• all major trauma patients within 45 minutes travelling time are taken directly to the major trauma centre bypassing other units; • major trauma patients outside of 45 minutes travelling time or critically unstable should be taken to the nearest trauma unit for assessment and immediate resuscitation and then transferred to the MTC if needed. T14-2A-103

24/7 Consultant Medical Advice for the Ambulance Control Room

These should be 24/7 consultant medical advice available for the ambulance control room. T14-2A-104

Operational Policy.

24/7 Paramedic Advice in the Control Room

There should be a critical care paramedic or paramedic with experience of air ambulance operations present in the ambulance control room 24 hours a day to advise and support the on scene team and coordinate the transfer pathway to a MTC.


Paramedics in this role should Operational Policy. have significant experience of pre hospital trauma care.

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T14-2A-105

Enhanced Care Teams available 24/7

Enhanced care teams should be available in the pre-hospital phase 24/7 to provide care to the major trauma patient. The enhanced care team should be one or more of the following: • • • •

Operational Policy including details of enhanced care provision.

Advanced paramedic; BASICS GP; HEMS team with doctor on board; A Merit Service.

T14-2A-106

Pain Management Protocol for Adult Patients

There should be a pre-hospital pain management protocol for adult major trauma patients. This should include details of pain management by:


• Paramedic; • Pre-hospital doctor. T14-2A-107

Pain Management Protocol for Children

There should be a pre-hospital pain management protocol for children. This should include details of pain management by:


• Paramedic; • Pre-hospital doctor. T14-2A-108

Pre-Hospital Administration of Tranexamic Acid for Adult Patients

There should be a protocol for the administration of Tranexamic Acid in pre-hospital care by trained paramedics.

T14-2A-109

Operational Policy. Annual Report showing training details of paramedics.

Application of Pelvic Binders

There should be a protocol for the application of Pelvic binders as pre-hospital care by trained paramedics.

T14-2A-110

Operational Policy. Annual Report showing training details of paramedics.

Hospital pre-alert and handover

There should be a network wide agreed pre-alert system with effective communication between pre-hospital and in-hospital teams.

Operational Policy including the details of the pre-alert system and documentation.

This should include documented criteria for trauma team activation and patient handover.


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ADULT MAJOR TRAUMA CENTRE MEASURES Reception and Resuscitation Measures Introduction The responsibility for the following measures lies with the lead clinician of the major trauma centre.

RECEPTION

Measure T14-2B-101

Notes

Evidence

Trauma Team Leader

There should be a consultant trauma team leader with an agreed list of responsibilities who should be leading the trauma team and available 24/7.

Operational Policy including agreed responsibilities.

The trauma team leader should be available in 5 minutes. There should be a nurse trained in ATNC or equivalent available for major trauma 24/7. T14-2B-102


All trauma team leaders should have attended trauma team leader training.

T14-2B-103

For 2015 reviews if not all Annual Report. have attended but are booked and have a date to attend this will be considered as compliant.


There should be a Trauma Team Activation Protocol.

T14-2B-104



There should be a surgical and resuscitative thoracotomy capability within the trauma team and available 24/7.

Operational Policy including a list of all appropriate trained consultants.

The thoracotomy tray with appropriate instruments should be in the resuscitation room.

The consultant rota and equipment should be available for peer review visit.


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RADIOLOGY

Measure T14-2B-105

Notes


There should be CT scanning located in the emergency department and available 24/7.

Trauma CT is the diagnostic modality of choice where patients are stable enough for transfer to CT.

There should be an on-site radiographer available 24/7.to prepare the CT scanner for use.

Where the CT scanner is located outside of the department there should be a protocol for the safe transfer of major trauma patients to and from the scanner. T14-2B-106

Annual Report including TARN data on times to CT.

The protocol. Annual Report containing audit of reporting times.

• there should be a 'hot' report available within 5 minutes; • there should be detailed radiological report available within 1 hour; • scans should be reported by a consultant radiologist within 24 hours. 24/7 MRI Scanning Facilities

MRI scanning should be available 24/7. T14-2B-108

Operational Policy.

CT Reporting

There should be a protocol for trauma CT reporting that specifies:

T14-2B-107

Evidence

Operational Policy.


Interventional radiology should be available 24/7 within Ideally this should be within Operational Policy. 60 minutes of a request. 30-minutes and MTCs should highlight where this is achieved. T14-2B-109


Interventional radiology should be located within operating rooms and / or resuscitation areas.

Operational Policy.

Where interventional radiology suites are located outside the emergency department or operating department there should be a protocol for safe transfer and management and should include anaesthetic and resuscitation equipment.


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SURGERY

Measure T14-2B-110

Notes

24/7 Access to Emergency Theatre and Surgery

There should be 24/7 access to a fully staffed and equipped emergency theatre.

Operational Policy. Annual Report including TARN data.

Patients requiring acute intervention for haemorrhage control should be in an operating room or intervention suite within 60 minutes. T14-2B-111


All general surgeons (including colorectal, hepatobiliary and breast surgery sub-specialists) who are on the emergency surgery rota should be trained in the principles and techniques of damage control surgery.

T14-2B-112

Operational Policy including list of surgeons trained. Annual Report with details of the training.

24/7 Access to On-site Surgical Staff

The following staff should be available on site 24/7:

Operational Policy. Medical staffing rotas should be available for PR visit.

• a general surgeon ST4 or above; • a trauma and orthopaedic surgeon ST4 or above; • an anaesthetist ST4 or above.

T14-2B-113


There following consultants should be available to attend an emergency case within 30 minutes of a trauma activation alert: • • • • • • • • • • • • • •

An individual may fulfil more than one of the roles on the list, compatible with their discipline and status.

emergency department physicians; a general surgeon; an anaesthetist; an intensivist; a trauma and orthopaedic surgeon; a neurosurgeon; an interventional radiologist; a radiologist; a plastic surgeon; a cardiothoracic surgeon; a vascular surgeon; a urology surgeon; a maxillofacial surgeon; an ENT surgeon.

T14-2B-114

Evidence

There should be written pathways for the safe management of patients in place for any specialties that do not meet the requirement.

Operational Policy. Consultant rotas should be available for PR visit.


There should be dedicated trauma operating theatre lists with appropriate staffing available 7 days a week. The lists must be separate from other emergency operating.

Operational Policy. Including the specified number of hours per week. The theatre


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timetable should be available for PR visit. T14-2B-115


There should be specialist surgeons and facilities (theatre/equipment) to provide fixation of pelvic ring injuries within 24 hours.

Operational Policy including the names of the surgeons.

There should be cover arrangements in place for holidays and planned absences.

T14-2B-116

Reviewers to enquire of facilities.


The MTC should agree the network trauma management guidelines as specified in measure T14-1C-111.

Operational Policy.

The MTC should include relevant local details.

INTENSIVE CARE

Measure T14-2B-117

Notes


The major trauma centre should have an on-site-intensive care unit, with sufficient flexible capacity for managing the major trauma demand.

Operational Policy including details of the number and level of beds.

The unit should be part of a critical care network and should comply with the minimum standards of the intensive care society. T14-2B-118

Evidence

Reviewers to enquire.


The Intensive care unit should participate in the national audit (ICNARC).

Annual Report with details of the audit.

The results of the audit should be reviewed at a major trauma centre audit / governance meeting.

PAIN MANAGEMENT

Measure T14-2B-119

Notes

Evidence


There should be a 24/7 specialist acute pain service available for major trauma patients. The MTC should have pain management pathways for: • patients with severe chest injury and rib fractures; • early access to epidural pain management (within 6 hours).

Operational Policy. Including pain management pathways. Annual Report with details of the audit.

The MTC should audit the pain management of major trauma patients including patients with severe chest TRAUMA SPECIFIC MEASURES

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injuries (AIS3+), who were not ventilated and who received epidural analgesia.

TRANSFUSION

Measure T14-2B-120

Notes


There should be a named clinical Lead for transfusion. T14-2B-121

Operational Policy. The rota for transfusion specialist / Haematologists should be available for PR visit.


There should be a protocol for the management of massive transfusion in patients with significant haemorrhage. T14-2B-123

Operational Policy.


There should be transfusion advice available 24/7 from a clinical consultant with appropriate experience.

T14-2B-122

Evidence



Patients with significant haemorrhage should be administered Tranexamic Acid within 3 hours of injury and receive a second dose according to CRASH-2 protocol.


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TARN data.

22

Definitive Care Measures for Adult Major Trauma Introduction The responsibility for the first measure lies with the trust medical director; the subsequent measures are the responsibility of the lead clinician of the major trauma centre.

Measure T14-2C-101

Notes


There should be a lead clinician for the Major Trauma Centre (MTC) who should be a consultant with managerial responsibility for the service and time specified in their job plan. T14-2C-102

Operational Policy.


There should be a major trauma service led by This may be on a daily or consultants who take responsibility for the holistic care weekly basis. and co-ordination of management of every individual major trauma patient on a daily basis. T14-2C-103

This post can be shared with the rehabilitation coordinator.

The coordinator service should be provided by nurse or allied health professionals of band 7 or above.

Including names of the consultants.

Operational Policy. Including the names of the coordinators.


There should be a single daily MDT meeting for the presentation and discussion of all new major trauma patients following admission. T14-2C-105

Operational Policy.


There should be a major trauma coordinator service available 7 days a week for the coordination of care of major trauma patients.

T14-2C-104

Evidence

Operational Policy.


The MDT meeting should have access to adequate physical space and appropriate equipment. This should include:

Operational Policy. Reviewers should enquire at PR visit.

• Audio Visual Equipment; • Information Technology; • PACS. T14-2C-106


There should be a separate major trauma ward or clearly identified clinical area where major trauma patients are managed as a cohort. T14-2C-107

Operational Policy.


There should be a protocol specifying that all major trauma patients should have a formal tertiary survey to identify missed injuries.


NOVEMBER 2014


23

The major trauma service should audit the implementation of the protocol.

T14-2C-108

Annual report including results of the audit.


The MTC should have the following neurosurgical provision: • on-site neuroradiology; • on-site neuro critical care; • a neurosurgical consultant available for advice to the trauma network 24/7; • a senior neurosurgical trainee of ST4 or above available on site 24/7; • all neurosurgical patient referrals should be discussed with a consultant; • all decisions to perform emergency neurosurgery for trauma are discussed with a consultant; • facilities available to allow neurosurgical intervention within 4 hours of injury and within 1 hour of arrival at the MTC. T14-2C-109

Referral to neurosurgery can be by telephone consultation or email.

Operational Policy. The consultant rota should be available for PR visit.


There should be an agreed pathway for patients with craniofacial trauma which includes joint management with neurosurgery.

Operational Policy.

Where there are facilities for craniofacial trauma on site they should be co-located with neurosurgery. If craniofacial surgery is not co-located with neurosurgery, there should be arrangements for access to specialist in craniofacial trauma and joint management of these cases. T14-2C-110


The MTC should agree the network protocol for If access to the SCIC protecting and assessing the whole spine in adults and outreach service is identified children with major trauma. as an issue by the MTC, audit data should be made There should be a linked Spinal Cord Injury Centre available indicating the (SCIC) for the MTC which provides an out-reach nursing and/or therapy service for patients with spinal delays. cord injury within 5 days of referral. All patients with spinal injury should have a joint management plan formulated with the SCIC consultant who is contacted within 4 hours of admission. The plan should be written in the medical records. All patients with spinal cord injury should be entered onto the national SCI database.

T14-2C-111

Operational Policy. Examples of ASIA charts and management plans should be available at PR visit. Annual report showing time from X-rays/CT/MRI to definitive report and information from the SCI database.


There should be trauma orthopaedic surgeons who spend a minimum of 50% of their programmed activities in trauma.


The MTC should provide a comprehensive TRAUMA SPECIFIC MEASURES

NOVEMBER 2014

24

musculoskeletal trauma service so that all definitive fracture care is undertaken at the MTC. There should be facilities to allow joint emergency orthoplastic management of severe open fractures as specified in BOAST 4 guidelines. T14-2C-112


There should be facilities for the management of patients with hand trauma which include: • dedicated hand surgery specialists with a combination of plastic and orthopaedic surgeons; • facilities for microsurgery; • a dedicated hand therapist. T14-2C-113


There should be facilities and expertise for the management of complex peripheral nerve injuries, including brachial plexus. Where these are not on site the MTC should name the tertiary referral centre.

T14-2C-114

Operational Policy.


Burns care should be managed through a designated specialist burns network. There should be a clinical guideline for the treatment of burns. This should include the referral pathway to the specialist burns centre where the MTC is not the specialist centre. T14-2C-117

Operational Policy Surgical rotas should be available at PR visit.

Vascular and Endovascular Surgery

There should be facilities for open vascular and endovascular surgery, including EVAR, available 24/7. T14-2C-116

Operational Policy including a list of surgical specialists/name of tertiary referral centre.


There should be on site maxillofacial surgeons with access to theatre for the reconstruction of maxillofacial trauma.

T14-2C-115

Operational Policy including details of hand surgery specialists and therapists.

The clinical guideline for treatment of burns including the referral pathway.


There should be a policy for nutritional management following trauma.


NOVEMBER 2014

The Policy.

25

T14-2C-118

Discharge Summary

There should be a discharge summary which includes:

Operational Policy.

• A list of all injuries; • Details of operations (with dates); • Instructions for next stage rehabilitation for each injury (including braces and casts); • Follow-up clinic appointments.

Examples of the discharge summary should be available for PR visit.


NOVEMBER 2014

26

Rehabilitation Measures for Adult Major Trauma Introduction The responsibility for the first measure lies with the network director; the subsequent measures are the responsibility of the lead clinician of the major trauma centre.

Measure T14-2D-101

Notes


There should be a named lead clinician for acute trauma rehabilitation services who should be a consultant in rehabilitation medicine, and have an agreed list of responsibilities and time specified for the role. T14-2D-102

Evidence

Operational Policy including the name and agreed list of responsibilities.


There should be a rehabilitation coordinator who is responsible for coordination and communication regarding the patient's current and future rehabilitation available 7 days a week.

This post can be shared with Operational Policy the major trauma coordinator. including names of the rehabilitation co-ordinators.

This rehabilitation coordinator should be a nurse or allied health professional at AFC Band 7 or above. The rehabilitation coordinator should be available 7 days a week. T14-2D-103


There should be access to the following specialist rehabilitation for:

Operational Policy including details of the team and the number of specialist rehabilitation beds.

• Traumatic brain injuries; • Musculoskeletal injuries. This should include a skilled and resourced multidisciplinary rehabilitation team. T14-2D-104

Key Worker

Each patient should have an identified key worker to be a point of contact for them, their carer/s or family doctor.

Operational Policy.

The key worker should be a health care professional. The name of the patient's key worker should be recorded in the patient's notes. T14-2D-105


All Major Trauma patients at the MTC should receive a rehabilitation prescription within 72 hours.


NOVEMBER 2014

Annual Report including TARN dash board data for rehabilitation prescription.

27

T14-2D-106


The MTC should have a rehabilitation program which includes:

Operational Policy including the name of the linked centre and outreach service, analgesia guidelines and list of psychologists available.

• a linked prosthetics centre which provides an out-reach service to see patients with amputation; • an analgesia guideline for the management of acute amputation; • psychological support services for patients who suffer acute, traumatic amputation. T14-2D-107

Facilities for Family / Carers

The family / carers of major trauma patients should be provided with:

Operational Policy.

• car parking arrangements; • overnight accommodation; • basic cooking facilities. T14-2D-108

Patient Information

The patient and or their family/carers should be provided with written information about the facilities, care and rehabilitation.

T14-2D-109

Operational Policy. Details and examples of written information should be available for PR visit.


The MTC should agree the network referral guidelines for access to rehabilitation services measure T14-1C-117. T14-2D-110

Operational Policy.

Patient Transfer

The MTC should agree the network protocol for patient transfer measure T14-1C-118. T14-2D-111

Operational Policy.


The MTC should agree the network policy for the repatriation of patients. measure T14-1C-119. T14-2D-112

Operational Policy.


The trauma rehabilitation service should include a clinical psychologist for the assessment and treatment of major trauma patients. Inpatient and outpatient clinical psychology services should be available.


Where there is no clinical psychologist the trauma rehabilitation services should provide detail on how they access advice from a clinical psychologist.

NOVEMBER 2014

Operational Policy including the name and agreed responsibilities of the clinical psychologist.

28

T14-2D-113


There should be 24/7 access to urgent psychiatric advice for patients with significant mental health problems.


Operational Policy. The psychiatric on call rota should be available for PR visit.

NOVEMBER 2014

29

CHILDREN'S MAJOR TRAUMA MEASURES Introduction These measures should be applied to all children's major trauma centres. Where this is combined with an adult service, teams may submit a common set of evidence documentation which includes reference to both adults and children. However they will still be required to assess against both adults and children's measures. Where there is a stand-alone children's major trauma centre the team is only required to assess against this set of measures.

Reception and Resuscitation Measures for Children's Major Trauma Introduction The responsibility for the following measures lies with the lead clinician of the children's major trauma centre.

RECEPTION

Measure T14-2B-201

Notes

Evidence

Trauma Team Leader

There should be a consultant trauma team leader with an agreed list of responsibilities who should be leading the trauma team and available 24/7.


The trauma team leader should be available in 5 minutes. T14-2B-202


All trauma team leaders should have attended trauma team leader training.

T14-2B-203

For 2015 reviews if not all Annual Report. have attended but are booked and have a date to attend this will be considered as compliant.


There should be a trauma team activation protocol. The trauma team should include medical and nursing staff with recognised training in paediatrics. T14-2B-204



There should be a surgical and resuscitative thoracotomy capability within the trauma team and available 24/7.

Operational Policy including a list of all appropriate trained consultants.

The thoracotomy tray with appropriate instruments should be in the resuscitation room.

The consultant rota and equipment should be available for peer review visit. TRAUMA SPECIFIC MEASURES

NOVEMBER 2014

30

RADIOLOGY

Measure T14-2B-205

Notes


The MTC should agree and implement the network imaging protocol for children.

Where the CT scanner is located outside of the department there should be a There should be CT scanning located in the protocol for the safe transfer emergency department and available 24/7. of major trauma patients to There should be an on-site radiographer available 24/7 and from the scanner. to prepare the CT scanner for use.

T14-2B-206

Including the protocol. Annual Report including TARN data on times to CT.

The protocol. Annual Report containing audit of reporting times.

• there should be a 'hot' report available within 5 minutes; • there should be detailed radiological report available within 1 hour; • scans should be reported by a consultant paediatric radiologist within 12 hours. 24/7 MRI Scanning Facilities

MRI scanning should be available 24/7. T14-2B-208

Operational Policy.

CT Reporting

There should be a protocol for trauma CT reporting that specifies:

T14-2B-207

Evidence

Operational Policy.


Interventional radiology should be available 24/7 within Ideally this should be within Operational Policy. 60 minutes of a request. 30-minutes and MTCs should highlight where this is achieved. T14-2B-209


Interventional radiology should be located within operating rooms and/or resuscitation areas.

Operational Policy.

Where interventional radiology suites are located outside the emergency department or operating department there should be a protocol for safe transfer and management and should include anaesthetic and resuscitation equipment.


NOVEMBER 2014

31

SURGERY

Measure T14-2B-210

Notes

24/7 access to Emergency Theatre and Surgery

There should be 24/7 access to a fully staffed and equipped emergency theatre.


Patients requiring acute intervention for haemorrhage control should be in an operating room or intervention suite within 60 minutes. T14-2B-211

Evidence


All paediatric surgeons providing emergency surgery should be trained in the principles and techniques of damage control surgery.

Operational Policy including list of surgeons trained. Annual Report with details of the training.

T14-2B-212


The following consultants should be available to attend An individual may fulfil more an emergency case within 30 minutes of a trauma than one of the roles on the activation alert: list, compatible with their discipline and status. • a general paediatric surgeon; Where general surgeons • a paediatric anaesthetist; provide both paediatric and • a paediatric intensivist. adult emergency surgery, this should be indicated.

Operational Policy. Consultant rotas should be available for PR visit.

There should be written pathways for the safe management of patients in place for any specialties that do not meet the requirement. T14-2B-213


There should be specialist surgeons and facilities (theatre/equipment) to provide fixation of pelvic ring injuries within 24 hours. There should be cover arrangements in place for holidays and planned absences.

T14-2B-214

Operational Policy including the names of the surgeons. Reviewers to enquire of facilities.


The MTC should agree the network clinical guidelines for the management of:

Operational Policy.

• emergency anaesthesia within the emergency department; • emergency surgical airway; • resuscitative thoracotomy; • abdominal injuries; TRAUMA SPECIFIC MEASURES

NOVEMBER 2014

32

• • • • • • • •

severe traumatic brain injury; open fractures; compartment syndrome; vascular injuries; penetrating cardiac injuries; spinal cord injury; severe pelvic fractures including urethral injury; chest drain insertion.

The MTC should include relevant local details.

INTENSIVE CARE

Measure T14-2B-215

Notes

Evidence


The MTC should have a paediatric intensive care unit (PICU).

Operational Policy.

The unit should be part of a paediatric intensive care network and should comply with the minimum standards of the paediatric intensive care society. If children are cared for on an adult ITU prior to transfer to a PICU: • there should be guidelines for the temporary management of children that comply with the minimum standards of the paediatric intensive care society; • there should be safe transfer/retrieval pathways; • the unit should be part of a paediatric intensive care network. T14-2B-216


The Intensive care unit should participate in the national audit (PICANET).

Annual Report with details of the audit.

The results of the audit should be reviewed at a major trauma centre audit/governance meeting.

PAIN MANAGEMENT

Measure T14-2B-217

Notes

Evidence


There should be a 24/7 specialist acute pain service available for major trauma patients. The MTC should have pain management pathways for: • patients with severe chest injury and rib fractures; • early access to epidural pain management (within 6 hours).

Operational Policy. Including pain management pathways. Annual Report with details of the audit.

The MTC should audit the pain management of major trauma patients including patients with severe chest injuries (AIS3+), who were not ventilated and who


NOVEMBER 2014

33

received epidural analgesia.

TRANSFUSION

Measure T14-2B-218

Notes


There should be a named clinical lead for transfusion. T14-2B-219

Operational Policy. The rota for transfusion specialist / haematologists should be available for PR visit.


There should be a protocol for the management of massive transfusion in children with significant haemorrhage. T14-2B-221

Operational Policy.



T14-2B-220

Evidence



Patients with significant haemorrhage should be administered Tranexamic Acid within 3 hours of injury as specified in CRASH-2 protocol.


NOVEMBER 2014

TARN data.

34

Definitive Care Measures for Children's Major Trauma Introduction The responsibility for the following measures lies with the lead clinician of the children's major trauma centre.

Measure T14-2C-201

Notes


There should be a lead clinician for the Major Trauma Centre (MTC) who should be a paediatric consultant with managerial responsibility for the service and time specified in their job plan. T14-2C-202

Operational Policy.


There should be a major trauma service led by This may be on a daily or consultants who take responsibility for the care and weekly basis. co-ordination of management of every individual major trauma patient on a daily basis. T14-2C-203

The coordinator service should be provided by nurse or allied health professionals of band 7 or above.

This post can be shared with the rehabilitation coordinator.

Operational Policy including the For combined adult/children's names of the coordinators. centres, the post may cover both adults and children.


There should be a single daily MDT meeting for the presentation and discussion of all new major trauma patients following admission. T14-2C-205

Operational Policy including names of the consultants.


There should be a major trauma coordinator service available 7 days a week for the coordination of care of major trauma patients.

T14-2C-204

Evidence

Operational Policy.


The MDT meeting should have access to adequate physical space and appropriate equipment. This should include:

Operational Policy. Reviewers should enquire at PR visit.

• Audio Visual Equipment • Information Technology • PACS T14-2C-206


There should be a separate major trauma ward or clearly identified clinical area where major trauma patients are managed as a cohort. T14-2C-207

Operational Policy.


There should be a protocol specifying that all major trauma patients should have a formal tertiary survey to identify missed injuries.

Operational Policy.

The major trauma service should audit the


NOVEMBER 2014

35

implementation of the protocol. T14-2C-208


The MTC should have the following neurosurgical provision: • on-site neuroradiology; • on site neuro critical care; • a neurosurgical consultant available for advice to the trauma network 24/7; • a senior neurosurgical trainee of ST4 or above available on site 24/7; • all neurosurgical patient referrals should be discussed with a consultant; • all decisions to perform emergency neurosurgery for trauma are discussed with a consultant; • facilities available to allow neurosurgical intervention within 4 hours of injury and within 1 hour of arrival at the MTC. T14-2C-209

Referral to neurosurgery can be by telephone consultation or email.

Operational Policy. The consultant rota should be available for PR visit.


There should be an agreed pathway for patients with craniofacial trauma which includes joint management with neurosurgery.

Operational Policy.

Where there are facilities for craniofacial trauma on site they should be co-located with neurosurgery. If craniofacial surgery is not co-located with neurosurgery, there should be arrangements for access to specialist in craniofacial trauma and joint management of these cases. T14-2C-210


The MTC should agree the network protocol for protecting and assessing the whole spine in children with major trauma. There should be a linked Spinal Cord Injury Centre (SCIC) for the MTC which provides an out-reach nursing and/or therapy service for patients with spinal cord injury within 5 days of referral.

If access to the SCIC outreach service is identified as an issue by the MTC, audit data should be made available indicating the delays.

All patients with spinal injury should have a joint management plan formulated with the SCIC consultant who is contacted within 4 hours of admission. The plan should be written in the medical records. All patients with spinal cord injury should be entered onto the national SCI database. T14-2C-211



There should be paediatric orthopaedic surgeons who spend a minimum of 50% of their programmed activities in trauma. The MTC should provide a comprehensive musculoskeletal trauma service so that all definitive fracture care is undertaken at the MTC. TRAUMA SPECIFIC MEASURES

NOVEMBER 2014

Operational Policy. Annual report including TARN data.

36

There should be facilities to allow joint emergency orthoplastic management of severe open fractures as specified in BOAST 4 guidelines. T14-2C-212


There should be facilities for the management of patients with hand trauma which include: • dedicated hand surgery specialists with a combination of plastic and orthopaedic surgeons; • facilities for microsurgery; • a dedicated hand therapist. T14-2C-213


There should be facilities and expertise for the management of complex peripheral nerve injuries, including brachial plexus. Where these are not on site the MTC should name the tertiary referral centre. T14-2C-214

There should be a clinical guideline for the treatment of burns. This should include the referral pathway to the specialist burns centre where the MTC is not the specialist centre.

Surgical rotas should be available at PR visit.



There should be a policy for nutritional management following trauma. T14-2C-217

Operational Policy.


Burns care should be managed through a designated specialist burns network.

T14-2C-216

Operational Policy including a list of surgical specialists /name of tertiary referral centre.


There should be on site maxillofacial surgeons with access to theatre for the reconstruction of maxillofacial trauma.

T14-2C-215

Operational Policy including details of hand surgery specialists and therapists.

The Policy.

Discharge Summary


Operational Policy.




NOVEMBER 2014

37

Rehabilitation Measures for Children's Major Trauma Introduction The responsibility for the following measures lies with the lead clinician of the children's major trauma centre.

Measure T14-2D-201

Notes


There should be a named lead clinician for acute trauma rehabilitation services who should have experience in children's rehabilitation and have an agreed list of responsibilities and time specified for the role. T14-2D-202

Evidence

Operational Policy including the name and agreed list of responsibilities.


There should be a rehabilitation coordinator who is responsible for coordination and communication regarding the patient's current and future rehabilitation available 7 days a week.

This post can be shared with Operational Policy the major trauma coordinator. including names of This can be a combined post the rehabilitation co-ordinators. for adults and children.

This rehabilitation coordinator should be a nurse or allied health professional at AFC Band 7 or above. The rehabilitation coordinator should be available 7 days a week. T14-2D-203


There should be access to the following specialist rehabilitation for:

Operational Policy including details of the team and the number of specialist rehabilitation beds.

• Traumatic brain injuries; • Musculoskeletal injuries. This should include a skilled and resourced multidisciplinary rehabilitation team. T14-2D-204

Key Worker

Each patient should have an identified key worker to be a point of contact for them, their carer/s or family doctor.

Operational Policy.

The key worker should be a health care professional. The name of the patient's key worker should be recorded in the patient's notes. T14-2D-205


All Major Trauma patients at the MTC should receive a rehabilitation prescription within 72 hours.

T14-2D-206



The MTC should have a rehabilitation program which


NOVEMBER 2014

Operational Policy

38

includes:

including the name of the linked centre and outreach service, analgesia guidelines and list of psychologists available.

• a linked prosthetics centre which provides an out-reach service to see patients with amputation; • an analgesia guideline for the management of acute amputation; • psychological support services for patients who suffer acute, traumatic amputation. T14-2D-207

Facilities for Family/Carers

The family/carers of major trauma patients should be provided with:

Operational Policy.

• car parking arrangements; • overnight accommodation; • basic cooking facilities. T14-2D-208

Patient Information

The patient and or their family/carers should be provided with written information about the facilities, care and rehabilitation.

T14-2D-209

Operational Policy. Details and examples of written information should be available for PR visit.


The MTC should agree the network referral guidelines for access to rehabilitation services measure T14-1C-117. T14-2D-210

Operational Policy.

Patient Transfer

The MTC should agree the network protocol for patient transfer measure T14-1C-118. T14-2D-211

Operational Policy.


The MTC should agree the network policy for the repatriation of patients measure T14-1C-119. T14-2D-212

Operational Policy.


The trauma rehabilitation service should include a clinical psychologist for the assessment and treatment of major trauma patients. Inpatient and outpatient clinical psychology services should be available.


Where there is no clinical psychologist the trauma rehabilitation services should provide detail on how they access advice from a clinical psychologist.

NOVEMBER 2014

Operational Policy including the name and agreed responsibilities of the clinical psychologist.

39

T14-2D-213


There should be 24/7 access to urgent psychiatric advice for patients with significant mental health problems.


Operational Policy. The psychiatric on call rota should be available for PR visit.

NOVEMBER 2014

40

MAJOR TRAUMA MEASURES FOR TRAUMA UNITS Reception and Resuscitation Measures for Trauma Units Introduction The responsibility for the following measures lies with the lead clinician of the trauma unit.

RECEPTION

Measure T14-2B-301

Notes

Evidence

Trauma Team Leader

There should be a trauma team leader of ST3 or above with an agreed list of responsibilities available within 5 mins, 24/7.


There should also be a consultant available in 30 minutes. The trauma team leader should have been trained in Advanced Trauma Life Support (ATLS) or equivalent. There should be a nurse trained in ATNC or equivalent available for major trauma 24/7. There should be a clinician trained in advanced paediatric life support available for children's major trauma. T14-2B-302


There should be a trauma team activation protocol. T14-2B-303

The protocol.

Agreement to Network Transfer Protocol from Trauma Units to Major Trauma Centres

The trauma unit should agree the network protocol for the transfer of patients from trauma unit to major trauma centre.

The Policy.

RADIOLOGY

Measure T14-2B-304

Evidence

Whole body CT is the diagnostic modality of choice where patients are stable enough for transfer to CT.

Operational Policy.

24/7 CT Scanner Facilities

There should be CT scanning available within 30 minutes of the request 24/7.

T14-2B-305

Notes

Annual report including TARN dashboard data on times to CT.

CT Reporting

There should be a protocol for trauma CT reporting TRAUMA SPECIFIC MEASURES

The protocol. NOVEMBER 2014

41

that specifies there should be a provisional report available within 60 minutes.

T14-2B-306

Annual report containing audit of reporting times.

Network CT Protocols

The trauma unit should agree the network protocols for trauma CT for adults and children as specified in T14-1C-108 and T14-1C-109. T14-2B-307

The protocol.


The trauma unit should have an image exchange portal that enables immediate image transfer to the MTC 24/7.

Operational Policy specifying details of portal used.

SURGERY

Measure T14-2B-308

Notes

24/7 Access to Surgical Staff

The following staff should be available within 30 minutes 24/7:

Operational Policy. Medical staffing rotas should be available for PR visit.

• a general surgeon ST3 or above; • a trauma and orthopaedic surgeon ST3 or above; • an anaesthetist ST3 or above. T14-2B-309

Evidence


There should be dedicated trauma operating theatre lists with appropriate staffing available 7 days a week.

Operational Policy. Including the specified number of hours per week.

The lists must be separate from other emergency operating.

The theatre timetable should be available for PR visit. T14-2B-310


The trauma unit should agree the network clinical guidelines specified in T14-1C-111. The trauma unit should include relevant local details.

It is recommended these are The guidelines. network wide guidelines with local variation depending upon services available within the TU.

TRANSFUSION

Measure T14-2B-311

Notes

Evidence


There should be a named clinical Lead for transfusion.


NOVEMBER 2014

Operational Policy.

42

T14-2B-312



T14-2B-313

The rota for transfusion specialist / Haematologists should be available for PR visit.

Network Transfusion Protocol

The trauma unit should agree the network protocol for the management of massive transfusion in patients with significant haemorrhage as specified in T14-1C-106. T14-2B-314

Operational Policy.



Patients with significant haemorrhage should be administered Tranexamic Acid within 3 hours of injury and receive a second dose according to CRASH-2 protocol.


NOVEMBER 2014

TARN data.

43

Definitive Care Measures for Trauma Units Introduction The responsibility for the first measure lies with the trust medical director; the subsequent measures are the responsibility of the lead clinician for major trauma.

Measure T14-2C-301

Notes

Major Trauma Lead Clinician

There should be a lead clinician for major trauma, who should be a consultant with managerial responsibility for the service and a minimum of 1 programmed activity specified in their job plan. T14-2C-302

Operational Policy.

Designated Specialty

There should be a policy that major trauma patients should be admitted under a designated lead specialty consultant who is responsible for the co-ordinating of ongoing care. T14-2C-303

This need not be a single specialty for all patients.

The coordinator service should be provided by nurse or allied health professionals.

Operational Policy. Including the names of the coordinators.


The trauma unit should agree the network protocol for If access to the SCIC protecting and assessing the whole spine in adults and outreach service is identified children with major trauma. as an issue by the MTC, audit data should be made There should be a linked Spinal Cord Injury Centre (SCIC) for the trauma unit which provides an out-reach available indicating the nursing and/or therapy service for patients with spinal delays. cord injury within 5 days of referral. All patients with spinal injury should have a joint management plan formulated with the SCIC consultant who is contacted within 4 hours of admission. The plan should be written in the medical records. All patients with spinal cord injury should be entered onto the national SCI database. T14-2C-305

Operational Policy.

Trauma Coordinator Service

There should be a trauma coordinator service available This post can be shared with Monday to Friday for the co-ordination of patients. the rehabilitation coordinator.

T14-2C-304

Evidence


Management of Multiple Rib Fractures

There should be local management guidelines for the management of multiple rib fractures including:

Operational Policy.

• pain management; • early access to epidural; • access to surgical advice.


NOVEMBER 2014

44

T14-2C-306


There should be local guidelines for: • isolated long bone fractures; • early management of isolated pelvic acetabular fractures; • peri-articular fractures; • open fractures.

Where there are nationally agreed guidelines, e.g.BOAST, it is recommended that these are adopted for use locally.

Operational Policy.

The guidelines should include: • accessing specialist advice from the MTC; • imaging and image transfer; • indications for managing on site or transfer to the MTC. T14-2C-307

Facilities for Fixation of Fractures

There should be facilities for the management of patients with isolated long bone fractures. T14-2C-308

Operational Policy.


Burns care should be managed through a designated specialist burns network. There should be a clinical guideline for the treatment of burns. This should include the referral pathway to the specialist burns centre. T14-2C-309


Discharge Summary


Operational Policy.



T14-2C-310


The trauma unit should participate in the TARN audit. The results of the audit should be discussed at the network audit meeting at least annually and distributed to all constituent teams in the network, the CCGs and area teams.


NOVEMBER 2014

Annual Report including details of TARN data completeness and data quality.

45

Rehabilitation Measures for Trauma Units Introduction The responsibility for the following measures lies with the lead clinician of the major trauma unit.

Measure T14-2D-301

Notes

Rehabilitation Coordinator

There should be a rehabilitation coordinator who is responsible for coordination and communication regarding the patient's current and future rehabilitation. This rehabilitation coordinator should be a nurse or allied health professional. T14-2D-302

Evidence

Operational Policy including name of the rehabilitation co-ordinator.

Trauma Unit Agreement to the Network Repatriation Policy

The trauma unit should agree the network repatriation policy measure T14-1C-119.

The policy.

There should be a protocol in place for identifying a speciality team to accept the patient. The protocol should include the escalation process in the event of there not being access to a specialty team. T14-2D-303

Physiotherapy Services

There should be physiotherapy available for trauma patients 7 days a week and in addition 24/7 for patients immediately following repatriation. T14-2D-304

Operational Policy.

Access to Rehabilitation Specialists

There should be the following allied health professionals with dedicated time to support rehabilitation of trauma patients: • occupational therapist; • speech and language therapist. T14-2D-305


All trauma patients should receive a rehabilitation prescription within 72 hours of admission. Following repatriation patients should have a nominated individual responsible for monitoring their rehabilitation prescription.


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Section 2 Clinical Indicators/Lines of Enquiry Introduction The clinical indicators identified in this section have been identified by clinicians within the service as key aspects that reflect the quality of treatment and care provided. These indicators should form the basis of discussion by teams enabling them to identify areas for improvement. The team should comment on these indicators in their self assessment report and any plans for improvement should be included in their work programme.

Clinical Indicators TARN Audit Data Is the data available by individual MTC?


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Appendix 1


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1.2 Glossary ASIA

American Spinal Injury Association

BASICS

British Association for Immediate Care

BOAST

British Orthopaedic Association Standard for Trauma

CAG

Clinical Advisory Group

CCG

Clinical Commissioning Group

CRASH-2 Trial

Clinical Randomisation of an Antifibrinolytic in Significant Haemmorhage

CT

Computerised Tomography

EVAR

Endovascular Aneurysm Repair

HEMS

Helicopter Emergency Ambulance Service

ICNARC

Intensive Care Audit and Research Centre

ISS

Injury Severity Score

ICU /ITU

Intensive Care Unit

MERIT

Medical Emergency Response Incident Team

MRI

Magnetic Resonance Imaging

MTC

Major Trauma Centre

MTN

Major Trauma Network

PACS

Picture Archiving and Communication System

PICNET

Paediatric Intensive Care Network

PICU

Paediatric Intensive Care Unit

RCPCH

Royal College of Physicians in Child Health

SCI

Spinal Cord Injury

TARN

Trauma Audit and Research Network

TU

Trauma Unit


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