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Emergency Admissions: A journey in the right direction?

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.

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Emergency Admissions: A journey in the right direction?

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  1. 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)

  2. Study aim To examine the process of care for severely injured patients and identify variations that affect the achievement of agreed endpoints.

  3. 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)

  4. 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

  5. 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

  6. 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

  7. ISS - example calculation

  8. Data collected • Casenotes (anonymised) • Advisor assessment form (peer review of casenotes) • A&E clinician questionnaire • Admitting Consultant questionnaire • Organisational questionnaire

  9. Case assessment • Good practice • Room for improvement – clinical care • Room for improvement – organisational care • Room for improvement – clinical and organisational care • Less than satisfactory

  10. Data returned • 1735/2203 (79%) potential patients scored • 909/1735 (51%) ISS < 16 • 826 patients ISS ≥ 16, 31 excluded

  11. 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

  12. Mechanism of injury

  13. Mode of arrival

  14. Outcome at 72 hours • 2/3 of patients on critical care or specialist ward • 1/6 deceased

  15. Overall assessment of care • In more than half of cases there was room for improvement • Greater room for improvement in organisational factors

  16. 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)

  17. 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

  18. 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

  19. Patient report form (PRF)

  20. Response times from emergency call to arrival at scene

  21. Response time and survival

  22. Mode of arrival

  23. Mode of transport during day and night

  24. Length of time spent at scene

  25. 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

  26. Helicopters

  27. Intubation at scene • Helicopter transfer 35/56 (41%) • Ambulance transfer 32/440 (7.3%)

  28. Airway obstructionNoisy or blocked airways • Helicopter 3/54 (5.6%) • Ambulance 52/380 (13.7%)

  29. Mode of transport by ISS

  30. 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

  31. Primary and secondary surveys

  32. Airway status

  33. Airway and ventilatory management

  34. Adequacy of airway

  35. Adequacy of ventilation

  36. 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

  37. Control of haemorrhage

  38. Fluid therapy

  39. 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

  40. 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

  41. 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

  42. 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)

  43. 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

  44. 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

  45. 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

  46. 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%)

  47. 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

  48. 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

  49. 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

  50. 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

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