Transcript SIP Presentation all - National Confidential Enquiry

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 Score
Injury
1
Minor
2
Moderate
3
Serious
4
Severe
5
Critical
6
Unsurvivable
•
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
ISS - example calculation
Region
Injury Description
AIS
Head &
Neck
Cerebral Contusion
3
Face
No Injury
0
Chest
Flail Chest
4
16
Abdomen
Minor Contusion of Liver
Complex Rupture Spleen
2
5
25
Extremity
Fractured femur
3
External
No Injury
0
Injury Severity Score:
Square Top
Three
9
50
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
Patient sample
31
No notes returned
ISS < 16
468
ISS ≥ 16
ISS ≥ 16 but excluded
795
909
• 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
Mechanism of injury
Mode of arrival
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
Patient report form (PRF)
Response times from emergency call to
arrival at scene
Response time and survival
Mode of arrival
Mode of transport during day and night
Length of time spent at scene
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
Helicopters
Intubation at scene
• Helicopter transfer
35/56 (41%)
• Ambulance transfer
32/440 (7.3%)
Airway obstruction
Noisy or blocked airways
• Helicopter
3/54 (5.6%)
• Ambulance
52/380 (13.7%)
Mode of transport by ISS
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
Primary and secondary surveys
Airway status
Airway and ventilatory management
Adequacy of airway
Adequacy of ventilation
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
Control of haemorrhage
Fluid therapy
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%)
– Weekends168/265 (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
Key findings (1)
• A pre-alert from the ambulance crew to the receiving
emergency department was documented for only 50.1%
of patients in this study
• One in five hospitals admitting severely injured patients
did not have a formal trauma team
• A trauma team response was documented for only
59.7% of patients in this study
• A consultant was the team leader/ first reviewer in only
169/419 (40.3%) of cases
• 176/419 (42%) patients were not seen by a consultant in
the emergency department
Key findings (2)
• If no trauma response was activated, then it was more
likely that an SHO was the first reviewer or team leader
for the severely injured patient
• Advisors felt that the patient’s initial management was
inappropriate in 23.5% of cases where an SHO was the
team leader/ first reviewer compared to 3.1% of cases
where a consultant was the team leader/ first reviewer
• The initial management of the patient was thought to be
inappropriate in 94/699 cases (13.4%)
Recommendations
• Trusts should ensure that a trauma team is available 24
hours a day, seven days a week. This is an essential
part of an organised trauma response system
• A consultant must be the team leader for the
management of the severely injured patient. Trusts and
consultants should work together to provide job plans
that will lead to better consultant presence in the
emergency department at all times
Airway
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)
Airway status on arrival at hospital
• 85 patients arrived at hospital with obstructed/partially
obstructed airway (85/676 – 12.6%)
• Higher mortality in these groups compared to patients with a
patent airway on arrival at hospital
• Problems with airway patency exist despite prehospital care
Timing of tracheal intubation
• 74 patients were intubated in the prehospital phase
• 11/85 of attempted intubations in the prehospital phase
were unsuccessful (13% failed intubation rate)
• 362 patients were subsequently intubated in hospital
Timing of intubation in hospital
• Approximately 50% intubated within 30 minutes of arrival
and almost 25% intubated immediately
Grade and specialty involved with
intubation
•
•
•
•
Grade poorly recorded
Mainly SpRs, low consultant involvement
Specialty better recorded
Primarily anaesthesia, surprisingly low contribution from
emergency medicine
Overall assessment of in hospital airway
management
• Unsatisfactory management in 52 cases
• But remember
– Incidence of failed intubation (prehospital)
– Number of patients arriving with obstructed/partially
obstructed airway
– Number of patients intubated immediately after admission
Key findings
• One in eight patients arrived at hospital with either a
partially or completely obstructed airway
• Prehospital intubation failed on 11/85 attempts (12.9%)
• 131 patients were intubated either on admission or
within the first 30 minutes after admission to hospital
• Data on grade of medical staff performing tracheal
intubation was poorly documented and not available in
223/362 cases (61.6%)
• Management of the airway was considered
unsatisfactory in 52/741 cases (7%)
Recommendation
• The current structure of prehospital management is
insufficient to meet the needs of the severely injured
patient. Change is urgently required to provide a system
that reliably provides a clear airway with good
oxygenation and control of ventilation. This may be
through the provision of personnel with the ability to
provide anaesthesia and intubation in the prehospital
phase or the use of alternative airway devices
Circulation
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)
Management of circulation
• Published evidence suggests that 30-40% of early
trauma deaths are directly attributable to haemorrhage
• It is estimated that 62% of all in-hospital trauma deaths
occur within the first four hours, of which haemorrhage is
either the primary cause or a major contributing factor
Management of circulation
• Early haemorrhage control, whether it occurs naturally or
after iatrogenic intervention such as embolisation or
intraoperatively by a surgeon, is paramount in achieving
good patient outcomes
• Effective and timely haemorrhage recognition and
control may be the single most important step in the
emergency management of the severely injured patient
Cardiovascular measurements
• In hospital measurements
- 95% blood pressure
- 95% pulse
- 31% capillary refill
- 54% temperature
Appropriateness of fluid therapy
• Fluid therapy was assessed to be appropriate in 93%
of cases and inappropriate in 7%
Case study
20 year old back seat passenger involved in a high speed
RTA. CT head excluded significant head injury.
Haemoglobin fell from 12 to six over 3 hours. The eventual
injuries identified were; pelvic fracture, splenic and renal
lacerations and mediastinal haematoma. There was only
one blood pressure measurement within the first hour of
admission and there was no I/V access. When the blood
loss was recognised the patient was over transfused with 6
litres of crystalloid and 3 units of blood.
Messages from case study
• Young otherwise fit patients can appear stable with little
change in heart rate or blood pressure despite
significant blood loss
• The pattern of injury should raise the index of suspicion
of serious injuries
• An opportunity to perform a whole body CT would
probably have identified the missed injuries
• Repeated assessment of perfusion and haemodynamic
status is required in the early resuscitation and
stabilisation phase
• Unless these assessments continue there is a danger of
inappropriate administration of therapy
Investigation of haemorrhage
• 483/795 (61%) patients had a CT scan for haemorrhage
- 393 CT alone
- 90 other scan (e.g. FAST) + CT
• In addition 66 patients had a FAST or similar scan, alone
Reasons why it was believed that a CT
scan was unnecessary
• The patient was shocked with obvious intraperitoneal
haemorrhage and it was felt that immediate surgery,
rather than imaging, was required (5 cases)
• FAST had revealed free fluid and it was felt that no
further imaging should have been required prior to
surgery (5 cases)
• No indication for imaging (6 cases)
Case study
An elderly patient was involved in a RTC, on arrival at the ED
they were speaking, pulse 120 but BP was unrecordable. The
patient became agitated and was intubated. A chest x-ray,
pelvic x-ray and abdominal ultrasound (US) were performed.
US revealed a splenic injury and free fluid in the peritoneal
space.
The patient was then transferred to CT for chest, abdomen,
head and spine imaging. The patient was unstable and
received seven litres of fluid and five units of blood. Following
CT scanning, the patient was transferred to critical care to be
stabilised prior to laparotomy and thoracotomy. At surgery
splenic and liver injuries were packed and a diaphragmatic
tear repaired. The patient returned from theatre and
subsequently arrested and died. The casenotes did not
document any consultant involvement in the management of
this patient and the advisors believed that this was an
avoidable death.
Time to CT scan for haemorrhage
• Average time to CT scan from arrival in ED
- CT scan alone: 2.3 hours
- Other scan + CT: 3 hours
Reasons for delay in CT scan
• Data from the A&E questionnaire
- 55/254 delays to CT reported
- 35 of these delays were organisational factors
Procedures for control of haemorrhage
Grade of surgeon
Time to laparotomy
• Mean time to laparotomy
- No CT scan: 1.8 hours
- CT scan: 8.3 hours
Timeliness of surgery
The interventions performed were considered untimely in 24/87
(28%) cases
Key findings (1)
• In 61/671 cases it was felt that the possibility of
haemorrhage was not investigated satisfactorily (9%)
• 110/795 patients underwent surgery or further
procedures for the control of haemorrhage (14%)
• 57/73 operations were performed by consultants (78%)
• In 37/110 poor documentation prevented the grade of
the surgeon being determined (34%)
Key findings (2)
• The interventions performed were considered untimely
in 28% of patients
• Where operative intervention for haemorrhage was
considered timely the 72 hour mortality was 24%
compared to 33% where the intervention was
considered delayed
• 19% patients from whom data were available and who
required surgery for management of haemorrhage had
unsatisfactory overall management
Recommendations (1)
• Rapid identification of patients who require immediate
surgery for control of haemorrhage is essential. Ongoing
fluid requirements and instability identify a group of
patients who require immediate intervention rather than
further investigation. Local protocols should clearly
identify the patient population for whom it is
inappropriate to delay the surgery/intervention for
reasons of ‘stabilisation’ or further investigation
• Trauma laparotomy is potentially extremely challenging
and requires consultant presence within the operating
theatre
Recommendations (2)
• CT scanning will have an increasing role in the investigation
and management of trauma patients. In major centres, CT
facilities should be co-located with the emergency
department to provide a combined investigation/resuscitation
area
• If CT scanning is to be performed, all necessary images
should be obtained at the same time. Routine use of ‘top to
toe’ scanning is recommended in the adult trauma patient if
no indication for immediate intervention exists
Recommendations (3)
• Timely access to CT scanning is essential. CT radiographers
should be available within 30 minutes of the patient arriving
in hospital. In larger trauma centres, with a higher workload,
CT radiographers should be immediately available at all
times
• In the setting of remote radiology facilities and/or lack of
timely access to CT scanning, unstable patients should not
be taken to the CT scanner. These unstable patients should
have immediate surgery
Secondary transfers
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)
Association of Anaesthetists of GB and I
transfer guidelines (1996)
• Designated consultant at both the referring and receiving
hospitals
• Local guidelines should be in existence and should be
consistent with national guidelines
• Resuscitation and stabilisation achieved before transfer.
• Only in exceptional circumstances should a patient with
altered conscious level be transferred unintubated
• The accompanying doctor must be of sufficient
experience and have received supervised training in the
transfer of patients with head injuries
• There must be a means of communication to both the
dispatching hospital and the receiving hospital
Number of secondary transfers
• 194/795 (24.4%) patients admitted to hospitals with
severe injuries underwent a secondary transfer.
• Only eight of these were retrievals. The remaining 186
were transfers conducted by the original admitting
hospital.
Protocols for secondary transfer
• Only 126/183 (69%) hospitals had protocols for
secondary transfers
Effect of mode of initial transport system
on secondary transfers
• Initial arrival at hospital by helicopter was associated
with a decreased requirement for secondary transfer
(12% vs. 25.5%)
Arrangement of transfers
Data from the A&E questionnaire identified that the transfer was
arranged by a consultant in only 49/137 (36%) cases
Accompanying staff
• Recommendations state that a minimum of two
attendants should be present for the transfer.
• Of the 194 transfers only 35 (18%) had a documented
second attendant and 3 (1.5%) a third attendant.
• In 155/194 transfers notified to NCEPOD, the grade of
the accompanying person was not documented (80%).
• In the 39 transfers where specialty of the accompanying
clinician was documented, an anaesthetist or critical
care specialist accompanied 36 of the cases.
Grade of clinician receiving patient
• Only 14/76 (18%) of patients were received by a consultant
• In 118/194 patients the grade of the clinician receiving the
patient could not be determined
Specialty to which the patient was transferred
• 172/194 (89%) patients were transferred for specialist treatment
• 106/172 (62%) patients transferred for specialist treatment
required neurosurgical input
Delays and appropriateness of transfer
• Where it could be assessed there were delays in 26.4%
(34/129) of transfers and 50% (4/8) of retrievals.
• 91/194 (46.9%) transfers were considered appropriate
by the advisors and 17 (8.8%) transfers were considered
inappropriate. There were insufficient or incomplete data
to comment and classify the remainder of the transfers.
• Inappropriateness transfers
- unsurvivable injuries
- failure of closer centre to accept the patient
- failures in effective communication between
hospitals
- missed injuries
Case study
A young patient had a severe brain injury following a fall.
The patient had a GCS of 3 at presentation with
unresponsive pupils and a compound skull fracture with
brain matter exuding from the ear. The patient was
transferred to a neurosurgical unit but certified brain dead
shortly after arrival.
There were some concerns over the transfer of a number of
patients who had sustained a head injury. Six patients with
a Glasgow Coma Score of less than 10 were transferred
without intubation.
Key findings
• There was a lack of adherence to the numerous
recommendations and guidelines that exist regarding the
transfer of critically ill and severely injured patients
• The arrangements for the secondary transfer of severely
injured patients were haphazard
• The use of a helicopter system reduced the need for
secondary transfers compared to a road ambulance
system
• The documentation of transfers was almost uniformly poor
• Despite the limited information available from the poor
documentation, there was an apparent lack of consultant
input into the arrangement and conduct of secondary
transfers
Recommendations (1)
• A clear record of the grade and specialty of all
accompanying staff involved in the transfer or retrieval of
severely injured patients should be made and this
documentation should accompany the patient on
transfer.
• There should be standardised transfer documentation of
the patients’ details, injuries, results of investigations
and management with records kept at the dispatching
and receiving hospitals.
Recommendations (2)
• Published guidelines must be adhered to and audits
performed of the transfers and protocols
• Local networks should develop protocols for the transfer
of severely injured patients suitable for regional
requirements
• The number of transfers may be decreased if
appropriate arrangements are made for cross cover in
specialties, e.g. interventional radiology, between trusts
Head injuries
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)
Incidence and severity
•
•
493 patients were classified as having suffered a head injury
(493/795 – 62%)
PRF only available for 320 out of 493 patients
Prehospital oxygenation
• Only 250/320 patients (78%) had oxygen administered
in the prehospital phase
Prehospital airway management
• Of 265 not intubated in prehospital phase 162 were
subsequently intubated in hospital
– 72 Of these 162 were intubated on admission to hospital or
within 30 minutes
Prehospital airway management and outcome
• Small numbers
• Patients intubated prior to arrival at hospital have higher
mortality (in keeping with literature)
• Note very high mortality in group of patients where there
was attempted but failed intubation
GCS and prehospital intubation
• More likely to be intubated if GCS lower
• 103 patients with GCS less than 9 not intubated prior to
hospital
Advisor opinion
• Concerns over airway and ventilatory management in
14.3% and 10.6%
– But remember 103 patients with GCS less than 9 not
intubated prior to hospital
– ? Advisors aware of constraints of current system
Advisor opinion and outcome
• Mortality rate more than doubled in group where
management of airway or ventilation was inadequate
• Importance of hypoxia and hypercapnia in head injuries
well known
Some consistent messages
• Many patients arrived at hospital with an obstructed or
partially obstructed airway
• There was a high rate of failed intubation in the prehospital
phase
• Most patients with acute severe head injury were
transported to hospital unintubated
• There was a high incidence of hypoxia and hypercapnia
on admission to hospital
• Many patients were intubated in the immediate period after
admission to hospital
Pre-alerts
• Use of pre-alerts variable
• Even in group with severe head injury 59/160 (37%) did
not have a pre-alert
• Not in keeping with NICE guidance
Hospital data
•
•
•
•
Minor
Mild
Moderate
Severe
91
99
63
215
(100 GCS = 3)
GCS and timing of intubation
• High number of patients with severe head injury
transported to hospital unintubated
• Previous data shows high incidence of:
– advisor concerns over adequacy of airway and ventilation
– hypoxia and hypercapnia on admission to hospital
• Potential for secondary insults and adverse effect on
outcome
• Structure of prehospital care?
Investigation of head injury
•
•
• NICE guidance not followed?
• 44 patients with GCS < 13 not CT scanned
• effect on treatment?
GCS less than 13
on initial
assessment in
the emergency
department
GCS less than 15
at two hours after
the injury on
assessment in
the emergency
department
Timing of CT scanning
• Significant delays to CT scanning were present across all
grades of head injury
• 32 patients with severe head injury waited more then 2
hours for CT scan
• Delays in recognition and management of potentially
reversible lesions
• NICE guidance
Reason for delays
• Delays primarily organisation
– Radiography and radiology staff not resident
• Patient instability?
– Related to location of CT scanners
– Related to seniority of trauma team leader and
accompanying staff
Advisor opinion
• Advisors felt that 1 in 4 scans were not performed in a
timely fashion (103/412)
• These delays were apparent across all grades of head
injury
• Severe head injuries subject to same degree of
untimeliness
– Most time critical group
• Organisational factors
Neurosurgical consultation
• 44/271 (16%) of patients with moderate/severe head
injury had no evidence of neurosurgical consultation
• 155 cases with no evidence of neurosurgical
consultation
– Advisors believed that this should have happened in 28
cases (18%)
Location of neurosurgical service
• Most patients received off site neurosurgical support
• 197/365 (54%) who required neurosurgical support were
taken to hospitals without this specialty
– Effects on timeliness of treatment?
Time to neurosurgical consultation
• More patients in neurosurgical centres discussed
within first hour
• 35% v 29% (onsite v offsite) discussed within first 2
hours
Neurosurgical procedures
• 114 patients required intervention
• 48 ICP monitor insertion alone
• 66 required more major neurosurgical procedures
Grade of senior surgeon
• Overall consultants performed 12/114 procedures
(15.8%)
• Excluding ICP monitor insertion consultants performed
9/66 more major procedures (18.8%)
• Overall low rate of consultant involvement compared to
other surgical specialities in NCEPOD reports
Time to surgical intervention
• Transfer greatly delayed
time to surgical intervention
• Only 6/43 patients who
required transfer had
surgery within 4 hours
(14% v 67% for nontransfers)
• 13 cases considered
untimely
• 10/13 were evacuation
of intracranial masses
Overall assessment of head injury
management
•
•
•
•
Not good
Almost 6/10 less than good practice
Remediable clinical and organisational factors
1 in 20 cases very poor
Key findings (1)
• The prehospital management of the airway and
ventilation was inadequate in 14.3% and 10.6% of cases
respectively
• One in five patients who required a head CT scan did
not have this performed in a timely fashion
• Delays in CT scanning were primarily due to
organisational factors rather than patient factors
• More than half of the patients who required
neurosurgical advice or input were taken to hospitals
where there was no onsite neurosurgical service
Key findings (2)
• Only 6/43 (14.0%) patients who required a secondary
transfer to access neurosurgical services had an
operation within four hours of injury (cf 22/33 – 66.7%
with no transfer)
• There were delays to neurosurgery in 13/81 (16.0%)
cases. Most of these cases were evacuation of traumatic
space occupying lesions
• Only 9/48 (18.8%) patients who had major neurosurgical
procedures as a result of trauma were operated on by
consultant surgeons
Recommendations (1)
• A pre-alert should be made for all trauma patients with a
GCS less than or equal to 8, to ensure appropriately
experienced professionals are available for their
treatment and to prepare for imaging
• Patients with severe head injury require early definitive
airway control and rapid delivery to a centre with onsite
neurosurgical service. This implies regional planning of
trauma services, including prehospital physician
involvement, and reconfiguration of services
• Patients with severe head injury should have a CT head
scan performed as soon as possible after admission and
within one hour of arrival at hospital
Recommendations (2)
• All patients with severe head injury should be transferred
to a neurosurgical/critical care centre irrespective of the
requirement for surgical intervention
• Consultant presence should be increased at operations
requiring major neurosurgery
Incidence and organisation of trauma
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)
Trauma audit
• TARN
– To highlight individual cases where unexpected outcomes
occur (either good or bad)
– Four times a year the Quarterly Report focuses on a
particular specialist area of trauma management –
comparing performance with standards set by the Royal
College of Surgeons Trauma Committee and also
benchmarking performance of one hospital against the rest
of the UK
– Comparisons of outcome between hospitals can be made,
and are publicly available to purchasers and service users
through the Healthcare Commission website, along with
case mix data by hospital. This allows the identification of
‘outliers’ with either very good or very poor trauma
outcomes, allowing potential causes to be identified
• In this study, 183 hospitals returned an organisational
questionnaire. Of these 183 hospitals, only 77 (42.1%)
participated in, and provided data to, TARN
Incidence of trauma
• 12 week study period
• Only 12 hospitals saw
more than 1 patient per
week over the study
period
•
•
•
•
1-5
6-10
11-20
>20
Patients
243
226
197
129
Overall assessment and volume of cases
• Good practice higher in hospitals with >20 cases in this study
• All other grades of assessment lower in hospitals with >20
cases in this study
• However good practice still only about 60%
Deficiencies and problems (1)
Trauma team and trauma response (page 51-55)
• One in five hospitals did not have a trauma team
• Only three out of five severely injured patients are met
by a trauma team
Deficiencies and problems (2)
Consultant involvement (page 55-58)
• A consultant was the trauma team leader/first reviewer
in only one in four cases
• Consultants were involved in the initial care of four out of
10 patients presenting during daytime but only one out
of 10 patients presenting at night
• One in three patients were not seen by a consultant
whilst in the emergency department
Deficiencies and problems (3)
Neurosurgery (page 102-107)
• One hundred and fourteen patients required
neurosurgery as a result of head trauma
• Fifty eight of these patients (50.9%) were initially taken
to a non-neurosurgical centre. Only one out of seven of
these patients had surgery within four hours
• Two out of three patients taken initially to a
neurosurgical centre had surgery within four hours of
injury
Deficiencies and problems (4)
Availability of interventional radiology (page 25-33 and
page 98-102)
• The use of interventional radiology has an increasing
role in the management of haemorrhage in the trauma
patient
• Only one patient in this study underwent an
interventional radiology technique
• Only six out of 10 hospitals stated that they had 24 hour
access to this therapy and in many of those this is ad
hoc due to the small number of trained individuals
Deficiencies and problems (5)
Secondary transfers (page 118-124)
• One in four severely injured patients required a
secondary transfer to receive definitive care
• This underlines the inability of the original admitting
facility to provide definitive care
• Furthermore, these transfers were conducted in a
haphazard fashion with little consultant oversight
Deficiencies and problems (6)
Prehospital airway management (page 37-48)
• One in 10 patients arrived at hospital with an obstructed
or partially obstructed airway
• Eleven out of 85 attempted prehospital intubations failed
(12.9%) Eight of these patients were dead at 72 hours
post injury (72.7% mortality rate)
Deficiencies and problems
• Previous six slides used for illustrative purposes
• Not every hospital can have the manpower, facilities,
equipment and expertise to provide definitive care for all
severely injured patients
• Many of the problems that exist in trauma management,
including the prehospital phase, are organisational and
do not reflect on the abilities or enthusiasm of clinical
teams
• The infrequent incidence of major trauma compounds
these issues
• Association between the volume of cases and good
outcomes
• Association between direct admission to trauma centre
and good outcomes compared to secondary transfer
Recommendations
• Given the relatively low incidence of severe trauma in
the UK, it is unlikely that each individual hospital can
deliver optimum care to this challenging group of
patients. Regional planning for the effective delivery of
trauma services is therefore essential
• Given the importance of evaluation of processes and
outcomes in the trauma patient, all units providing
treatment for severely injured patients should contribute
to the Trauma Audit Research Network
• There should be a system of designation and verification
of each hospital with regards to their function as a
trauma centre, in a similar fashion to the system
instituted by the American College of Surgeons
www.ncepod.org.uk
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)