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This report examines the care process for severely injured patients and identifies variations that affect the achievement of agreed endpoints. It covers topics such as timeliness of events, prehospital care, resuscitation, secondary transfers, communication, and more.
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Trauma: Who cares? Emergency Admissions:A journey in the right direction? A report of the National Confidential Enquiry into Patient Outcome and Death (2007) A report of the National Confidential Enquiry into Patient Outcome and Death (2007)
Study aim To examine the process of care for severely injured patients and identify variations that affect the achievement of agreed endpoints.
Study thematics • Timeliness of events making up the clinical management process • Issues associated with prehospital care at the site of injury and transfer to hospital • Issues associated with the care team that performs the initial resuscitation • Processes and procedures associated with secondary transfers • Issues associated with pathways, handovers and communication • Membership of the Trauma Audit Research Network (TARN)
Patient inclusion/identification • Patients of all ages with an injury severity score of 16 or more • February 1st 2006 to April 30th 2006 • Prospective identification in ED based on clinical judgement • Patient identifier spreadsheet and the casenotes for the first 72 hours of care in hospital
Abbreviated Injury Scale (AIS) • AIS is an anatomical scoring system • Injuries are ranked on a scale of 1 to 6 • This represents the 'threat to life' associated with an injury and is not meant to represent a comprehensive measure of severity
Injury Severity Score (ISS) • Provides an overall score for patients with multiple injuries • Each injury is assigned an AIS score and is allocated to one of six body regions • Only the highest AIS score in each region is used • The 3 most severely injured body regions have their score squared and added together • The ISS score correlates linearly with mortality, morbidity, hospital stay and other measures of severity
Data collected • Casenotes (anonymised) • Advisor assessment form (peer review of casenotes) • A&E clinician questionnaire • Admitting Consultant questionnaire • Organisational questionnaire
Case assessment • Good practice • Room for improvement – clinical care • Room for improvement – organisational care • Room for improvement – clinical and organisational care • Less than satisfactory
Data returned • 1735/2203 (79%) potential patients scored • 909/1735 (51%) ISS < 16 • 826 patients ISS ≥ 16, 31 excluded
Age range • 75% of the population were male • Mean age of 39.6 years • Mode age 18 with ~ 1 in 3 patients 16 - 25 years old
Outcome at 72 hours • 2/3 of patients on critical care or specialist ward • 1/6 deceased
Overall assessment of care • In more than half of cases there was room for improvement • Greater room for improvement in organisational factors
Prehospital care Emergency Admissions:A journey in the right direction? A report of the National Confidential Enquiry into Patient Outcome and Death (2007) A report of the National Confidential Enquiry into Patient Outcome and Death (2007)
Objectives of prehospital care • Prioritisation and management of life threatening injuries • Rapid transfer for definitive care in appropriate unit • International variations in emphasis between on site care against rapid transfer
Prehospital documentation • The ambulance patient report form (PRF) was unavailable in: 245/749 (33%) of cases • Data in this section is therefore based upon the remaining 504 cases • PRF provides vital information on prehospital care and potentially a structure which can help to ensure that relevant protocols are adhered to • There was lack of standardisation and variable quality both in form design and content
Length of time spent at scene • Excluding 71 entrapments, 278/504 cases (55%) exceeded the recommended maximum of 10 minutes at scene • Intubation and/or cannulation was attempted in 105 cases • The 10 minute recommendation applies where a doctor is not present on the prehospital team
Intubation at scene • Helicopter transfer 35/56 (41%) • Ambulance transfer 32/440 (7.3%)
Airway obstructionNoisy or blocked airways • Helicopter 3/54 (5.6%) • Ambulance 52/380 (13.7%)
Transport and secondary transfer Secondary transfer required: • Helicopter 7/50 (11.9%) • Ambulance 112/440 (25.5%) Appropriateness of first hospital: • Helicopter All taken to appropriate first hospital • Ambulance 31/440 (7%) taken to an inappropriate first hospital
Cardiovascular management - guidelines • National Institute for Health and Clinical Excellence (NICE) • Joint Royal Colleges Ambulance Liaison Committee (JRCALC) • IV Fluids should only be administered if radial or central pulse not palpable. • Blood pressure measurement not recommended • Repeat boluses of 250ml crystaloid until pulse palpable • Do not delay transport to definitive care
Head injury and intubation • In 25 cases neither GCS nor AVPU recorded • GCS < 9 - only 46/170 (27%) intubated • Recording of other airway and ventilatory support was poor
Analgesia • There was evidence of administration of analgesia in 110/504 (21.8%) cases • In 7/110 the analgesia was felt to be inappropriate • In 3 cases with significant chest trauma Entonox was used • There was one overdose • There was one case of respiratory depression which was inadequately managed • Overall advisor’s questioned why there were so few cases where the administration of analgesia had been documented
Recommendations • There should be multi-agency clinical governance arrangements for regional trauma services • There should be a standardised PRF and this should be securely retained in the patient’s medical record • Appropriate guidelines should be widely disseminated, and compliance monitored • An early primary survey together with resuscitation of Airway, Breathing and Circulation with C-Spine control should be undertaken, reviewed, and recorded • The prehospital team should include someone with the skills to secure the airway including rapid sequence induction
Hospital reception Emergency Admissions:A journey in the right direction? A report of the National Confidential Enquiry into Patient Outcome and Death (2007) A report of the National Confidential Enquiry into Patient Outcome and Death (2007)
Pre-alerts • Only 375/749 patients arrived at hospital with a pre-alert (50%) • No clear influence of time of day or day of week on use of pre-alerts • Lack of pre-alerts may slow appropriate hospital response
Trauma team - organisational • 143/183 hospitals stated they had a formal trauma team (78%) • Table 39 – respondents to request for trauma call at 0200 on a Sunday morning • 65% stated consultant would not be present • Only 60% had resident SpR or above in emergency medicine and anaesthesia • Only 47% had resident SpR or above in surgery • 21%, 32% and 34% stated they would not have SpR or above in emergency medicine, anaesthesia and surgery respectively
Trauma team – individual cases • Trauma team response in 460/770 cases (60%) • Trauma team response varied by: • Day 137/259 (53%) • Night 100/163 (61%) • Weekends 168/265 (66%) • ? less needed during the day (consultants immediately available) or busy with other duties and so not available
First reviewer/team leader • Overall • Consultant 136/502 (27%) SHO 54/502 (10%) • Trauma call • Consultant 111/307 (36%) SHO 14/307 (4%) • No trauma call • Consultant 25/195 (13%) SHO 40/195 (21%)
Consultant involvement • Self reported data • 40% seen on admission • 42% not seen by any consultant in the emergency department • No influence of ISS on consultant involvement
Influence of time of day on team leader/first reviewer • Day • Consultants 4 in 10 SHOs 1 in 10 • Night • Consultants 1 in 10 SHOs 2 in 10 • Less senior involvement at night • Poorer standard of care
Grade of reviewer and appropriateness of initial care • Not possible to analyse in 318 cases due to poor documentation of grades • 51/477 cases considered inappropriate initial care (11%) • Relationship between seniority of reviewer and appropriateness of care
Appropriateness of initial response • 94/699 cases inappropriate initial response (13%) • These 94 cases scored poorly on overall assessment • Good practice 8/94 (9%) • Less than satisfactory 17/94 (18%) • Highlights importance of initial assessment • Senior staff and better initial assessment