A Major Problem for the Health Service

1. A Major Problem for the Health Service • Worldwide injury is a major public health problem • The commonest cause of death between the ages of 1 and 40 years is injury • For every fatality there are 2 survivors with serious and permanent disability • There appears to be a strong relationship between social deprivation and injury • Facilities for treatment of the injured and their effectiveness varies across the UK

2. Our Healthier Nation Quotes from this document indicate the importance of ‘injury’ and its consequences: “ It is clearly important that we continue to reduce the number of deaths from accidents.” “… many people suffer prolonged distress and poor quality of life as the result of a serious accident ”

3. Is there potential for improvement in the care of injured patients? Working Party on the Management of Patients with Major Injury, Royal College of Surgeons 1988 “….this report reveals significant deficiencies in the management of seriously injured patients.” “Standards of hospital care of the injured should be monitored through a national audit scheme…..”

4. Improvements in systems of trauma care may be achieved by :- • Enhancing pre-hospital care, ensuring • appropriate medical intervention • rapid transfer to best local facility • Assessing the use of helicopters • Adopting ATLS principles • Integrating trauma care services within and between hospitals • Investing in rehabilitation services and • Auditing and Researching injury and systems of care

5. Trauma NetworkBackground • 1988 the Major Trauma Outcome Study was established • 1992 1st REPORT published in BMJ: - UK mortality rate higher than US - large interhospital variation - slow response time - lack of senior input • 1994 Statistical analysis was improved and modified • 1996 New funding system1998 • 104 hospitals in Europe audited their trauma services through the Network

6. Annual new Attendances at A &E Departments < 30,000 30,001 - 40,000 40,001 - 50,000 50,000 - 60,000 60,001 - 70,000 70,001 - 80,000 >80,000 Total Active members October 1998 13 18 31 15 8 7 10 104 Widespread Participation

7. Trauma NetworkObjectives • collect and analyse clinical and epidemiological data • provide a statistical base to support clinical audit • aid the development of trauma services and inform the research agenda

8. Quality Cycle Health Care Systems Measurement ACTION Analysis

9. MeasurementData collection should be: • Accurate • Complete • Comprehensive

10. Measurement / Data Collection Simple vs Complex Accurate, complete, comprehensive

11. Patient Inclusion Criteria • Admission > 72 hours • Admission to an intensive care area • Transfers for continuing care > 72 hours • All deaths • Excluding: Fractures of the femoral neck or single pubic rami (age > 65yrs) OR SIMPLE isolated injuries

12. The Trauma NetworkAnalysis INPUT PROCESS OUTPUT • Common standards for severity measurement • Common measures for performance assessment

13. Assessment of Trauma Severity Physiological Measurements Anatomical Injury Age Blunt/Penetrating Probability of survival of individual patients Hospital Comparisons

14. Physiological - Revised Trauma Score • Is a physiological measurement and • by convention, recorded on arrival at hospital The RTSincludes: • Respiratory rate • Systolic blood pressure • Glasgow Coma Scale

15. Abbreviated Injury Scale (AIS 90) 1 injury = 1 code with a range of 0 - 6 Injury Severity Score (ISS) Uses a formula to represent multiple injuries in 1 number with a range of 0 - 75

16. INJURY SEVERITY SCORE Example Abbreviated Injury Scale Small subdural haematoma 4 Parietal lobe swelling 3 Major liver laceration 4 Upper tibial fracture (displaced) 3 ISS = 42 + 42 + 32 = 41

17. Ps cannot be applied to individuals If the Probability of Survival (Ps) of an injured patient = 0.4 Then, on average, 6 out of 10 patients will die

18. The Trauma Network Reports Monthly: Clinical activities Quarterly: Outcome statistics (anonymous) Process filters Ad Hoc Reports Formatted data

19. Process Measures • Time intervals • injury and arrival at A&E • arrival in A&E and 1st doctor seeing the patient • transfer to another hospital • Seniority of staff • Haemo/pneumothorax • evidence of chest drains • # skull, brain & spinal injury (AIS3+ ) • evidence of CT scan • immobilisation of spine • recorded GCS

20. Hospital comparisons 1994 - 1998Summary Ws scores and 95%CI. Blunt injuries, excl. referrals

21. Morbidity • Wider variation than with mortality • Inadequate scoring systems • What to estimate? • temporary • permanent

22. Trauma Audit - Closing the loop D Yates, J Bancewicz, M Woodford, P Driscoll, RAC Jones, R Kishen, D Marsh, S Hollis. Injury (1994) 25:511

23. Conclusions and lessons learnt • Close inter-disciplinary cooperation and clinical improvement at a senior level. • Application of protocols to provide continuity of care from the scene of the accident through to the hospital ward. • Frequent statistical analysis of performance at audit meetings to ‘close the loop’ is an essential part of the strategy to improve trauma care.

24. Setting quality standards National Institute for Clinical Excellence Clinical Governance Commission for Health Improvement National Service Frameworks