24/7 Access to Consultant Specialists. T14-2B-114. Dedicated Orthopaedic Trauma Operating Theatre. T14-2B-115. Provision
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
201 4
Update by Julia Hill Julia Hill
2
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
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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
Trauma Management Guidelines
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
Management of Spinal Injuries
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
Referral Guidelines to Rehabilitation Services
T14-2D-110
Patient Transfer
T14-2D-111
Network Patient Repatriation Policy
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
Trauma Team Leader Training
T14-2B-203
Trauma Team Activation Protocol
T14-2B-204
24/7 Surgical and Resuscitative Thoracotomy Capability
T14-2B-205
24/7 CT Scanner Facilities and on-site Radiographer
T14-2B-206
CT Reporting
T14-2B-207
24/7 MRI Scanning Facilities
T14-2B-208
24/7 Interventional Radiology
T14-2B-209
Interventional Radiology Facilities
T14-2B-210
24/7 access to Emergency Theatre and Surgery
T14-2B-211
Damage Control Training for Emergency Trauma Consultant Surgeons
T14-2B-212
24/7 Access to Consultant Specialists
T14-2B-213
Provision of Surgeons and Facilities for Fixation of Pelvic Ring Injuries
T14-2B-214
Trauma Management Guidelines
T14-2B-215
On-site Intensive Care Unit
T14-2B-216
Audit of the Intensive Care Unit
T14-2B-217
24/7 Specialist Acute Pain Service
T14-2B-218
Transfusion Lead Clinician
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T14-2B-219
24/7 Specialist Transfusion Advice
T14-2B-220
Massive Transfusion Protocol for the Major Trauma Centre
T14-2B-221
Administration of Tranexamic Acid
Definitive Care Measures for Children's Major Trauma T14-2C-201
Major Trauma Centre Lead Clinician
T14-2C-202
Major Trauma Service
T14-2C-203
Major Trauma Coordinator Service
T14-2C-204
Major Trauma MDT Meeting
T14-2C-205
MDT Conference Facilities
T14-2C-206
Dedicated Major Trauma Ward or Clinical Area
T14-2C-207
Protocol for Formal Tertiary Survey
T14-2C-208
Management of Neurosurgical Trauma
T14-2C-209
Management of Craniofacial Trauma
T14-2C-210
Management of Spinal Injuries
T14-2C-211
Management of Musculoskeletal Trauma
T14-2C-212
Management of Hand Trauma
T14-2C-213
Management of Complex Peripheral Nerve Injuries
T14-2C-214
Management of Maxillofacial Trauma
T14-2C-215
Designated Specialist Burns Care
T14-2C-216
Nutritional Management Policy
T14-2C-217
Discharge Summary
Rehabilitation Measures for Children's Major Trauma T14-2D-201
Clinical Lead for Acute Trauma Rehabilitation Services
T14-2D-202
Rehabilitation Coordinator Post
T14-2D-203
Specialist Rehabilitation Service
T14-2D-204
Key Worker
T14-2D-205
Rehabilitation Prescriptions
T14-2D-206
Rehabilitation for Traumatic Amputation
T14-2D-207
Facilities for Family/Carers
T14-2D-208
Patient Information
T14-2D-209
Referral Guidelines to Rehabilitation Services
T14-2D-210
Patient Transfer
T14-2D-211
Network Patient Repatriation Policy
T14-2D-212
Clinical Psychologist for Trauma Rehabilitation
T14-2D-213
24/7 Access to Psychiatric Advice
Reception and Resuscitation Measures for Trauma Units T14-2B-301
Trauma Team Leader
T14-2B-302
Trauma Team Activation Protocol
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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
Teleradiology Facilities
T14-2B-308
24/7 Access to Surgical Staff
T14-2B-309
Dedicated Orthopaedic Trauma Operating Theatre
T14-2B-310
Trauma Management Guidelines
T14-2B-311
Transfusion Lead Clinician
T14-2B-312
24/7 Specialist Transfusion Advice
T14-2B-313
Network Transfusion Protocol
T14-2B-314
Administration of Tranexamic Acid
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
Management of Spinal Injuries
T14-2C-305
Management of Multiple Rib Fractures
T14-2C-306
Management of Musculoskeletal Trauma
T14-2C-307
Facilities for Fixation of Fractures
T14-2C-308
Designated Specialist Burns Care
T14-2C-309
Discharge Summary
T14-2C-310
The Trauma Audit and Research Network (TARN)
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
Rehabilitation Prescriptions
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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: • • • •
Reception and Resuscitation T14-2B-200 Definitive Care Measures T14-2C-200 Rehabilitation Measures T14-2D-200 The responsibility for the measures lies with the major trauma lead clinician for the trust.
Major Trauma Measures for Trauma Units The measures for trauma units are divided into 3 sections: • • • •
Reception and Resuscitation T14-2B-300 Definitive Care Measures T14-2C-300 Rehabilitation Measures T14-2D-300 The responsibility for the measures lies with the major trauma lead clinician for the trust.
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
TRAUMA SPECIFIC MEASURES
NOVEMBER 2014
Annual Report specifying details of the audit and the feedback.
11
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
Teleradiology Facilities
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.
12
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
Operational Policy including the protocol.
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
The Trauma Audit and Research Network (TARN)
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
Trauma Management Guidelines
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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NOVEMBER 2014
Annual Report including details of TARN data.
13
T14-1C-113
Management of Spinal Injuries
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.
Referral Guidelines to 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.
Operational Policy including the protocol.
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
Network Patient Repatriation Policy
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.
TRAUMA SPECIFIC MEASURES
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:
Operational Policy including the protocol.
• 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:
Operational Policy including the protocol.
• 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
Trauma Team Leader Training
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.
Trauma Team Activation Protocol
There should be a Trauma Team Activation Protocol.
T14-2B-104
Operational Policy including the protocol.
24/7 Surgical and Resuscitative Thoracotomy Capability
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
24/7 CT Scanner Facilities and on-site Radiographer
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.
24/7 Interventional Radiology
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 Facilities
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
Damage Control Training for Emergency Trauma Consultant Surgeons
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
24/7 Access to Consultant Specialists
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.
Dedicated Orthopaedic Trauma Operating Theatre
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
TRAUMA SPECIFIC MEASURES
NOVEMBER 2014
20
timetable should be available for PR visit. T14-2B-115
Provision of Surgeons and Facilities for Fixation of Pelvic Ring Injuries
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.
Trauma Management Guidelines
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
On-site Intensive Care Unit
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.
Audit of the Intensive Care Unit
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
24/7 Specialist Acute Pain Service
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
NOVEMBER 2014
21
injuries (AIS3+), who were not ventilated and who received epidural analgesia.
TRANSFUSION
Measure T14-2B-120
Notes
Transfusion Lead Clinician
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.
Massive Transfusion Protocol for the Major Trauma Centre
There should be a protocol for the management of massive transfusion in patients with significant haemorrhage. T14-2B-123
Operational Policy.
24/7 Specialist Transfusion Advice
There should be transfusion advice available 24/7 from a clinical consultant with appropriate experience.
T14-2B-122
Evidence
Operational Policy including the protocol.
Administration of Tranexamic Acid
Patients with significant haemorrhage should be administered Tranexamic Acid within 3 hours of injury and receive a second dose according to CRASH-2 protocol.
TRAUMA SPECIFIC MEASURES
NOVEMBER 2014
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
Major Trauma Centre Lead Clinician
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.
Major Trauma Service
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.
Major Trauma MDT Meeting
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.
Major Trauma Coordinator Service
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.
MDT Conference Facilities
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
Dedicated Major Trauma Ward or Clinical Area
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.
Protocol for Formal Tertiary Survey
There should be a protocol specifying that all major trauma patients should have a formal tertiary survey to identify missed injuries.
TRAUMA SPECIFIC MEASURES
NOVEMBER 2014
Operational Policy including the protocol.
23
The major trauma service should audit the implementation of the protocol.
T14-2C-108
Annual report including results of the audit.
Management of Neurosurgical Trauma
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.
Management of Craniofacial Trauma
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
Management of Spinal Injuries
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.
Management of Musculoskeletal Trauma
There should be trauma orthopaedic surgeons who spend a minimum of 50% of their programmed activities in trauma.
Operational Policy. Annual Report including TARN data.
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
Management of Hand Trauma
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
Management of Complex Peripheral Nerve Injuries
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.
Designated Specialist Burns Care
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.
Management of Maxillofacial Trauma
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.
Nutritional Management Policy
There should be a policy for nutritional management following trauma.
TRAUMA SPECIFIC MEASURES
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.
TRAUMA SPECIFIC MEASURES
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
Clinical Lead for Acute Trauma Rehabilitation Services
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.
Rehabilitation Coordinator Post
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
Specialist Rehabilitation Service
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
Rehabilitation Prescriptions
All Major Trauma patients at the MTC should receive a rehabilitation prescription within 72 hours.
TRAUMA SPECIFIC MEASURES
NOVEMBER 2014
Annual Report including TARN dash board data for rehabilitation prescription.
27
T14-2D-106
Rehabilitation for Traumatic Amputation
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.
Referral Guidelines to Rehabilitation Services
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.
Network Patient Repatriation Policy
The MTC should agree the network policy for the repatriation of patients. measure T14-1C-119. T14-2D-112
Operational Policy.
Clinical Psychologist for Trauma Rehabilitation
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.
TRAUMA SPECIFIC MEASURES
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
24/7 Access to Psychiatric Advice
There should be 24/7 access to urgent psychiatric advice for patients with significant mental health problems.
TRAUMA SPECIFIC MEASURES
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.
Operational Policy including agreed responsibilities.
The trauma team leader should be available in 5 minutes. T14-2B-202
Trauma Team Leader Training
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.
Trauma Team Activation Protocol
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
Operational Policy including the protocol.
24/7 Surgical and Resuscitative Thoracotomy Capability
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
24/7 CT Scanner Facilities and on-site Radiographer
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.
24/7 Interventional Radiology
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 Facilities
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.
TRAUMA SPECIFIC MEASURES
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.
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-211
Evidence
Damage Control Training for Emergency Trauma Consultant Surgeons
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
24/7 Access to Consultant Specialists
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
Provision of Surgeons and Facilities for Fixation of Pelvic Ring Injuries
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.
Trauma Management Guidelines
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
On-site Intensive Care Unit
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
Audit of the Intensive Care Unit
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
24/7 Specialist Acute Pain Service
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
TRAUMA SPECIFIC MEASURES
NOVEMBER 2014
33
received epidural analgesia.
TRANSFUSION
Measure T14-2B-218
Notes
Transfusion Lead Clinician
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.
Massive Transfusion Protocol for the Major Trauma Centre
There should be a protocol for the management of massive transfusion in children with significant haemorrhage. T14-2B-221
Operational Policy.
24/7 Specialist Transfusion Advice
There should be transfusion advice available 24/7 from a clinical consultant with appropriate experience.
T14-2B-220
Evidence
Operational Policy including the protocol.
Administration of Tranexamic Acid
Patients with significant haemorrhage should be administered Tranexamic Acid within 3 hours of injury as specified in CRASH-2 protocol.
TRAUMA SPECIFIC MEASURES
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
Major Trauma Centre Lead Clinician
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.
Major Trauma Service
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.
Major Trauma MDT Meeting
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.
Major Trauma Coordinator Service
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.
MDT Conference Facilities
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
Dedicated Major Trauma Ward or Clinical Area
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.
Protocol for Formal Tertiary Survey
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
TRAUMA SPECIFIC MEASURES
NOVEMBER 2014
35
implementation of the protocol. T14-2C-208
Management of Neurosurgical Trauma
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.
Management of Craniofacial Trauma
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
Management of Spinal Injuries
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
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.
Management of Musculoskeletal Trauma
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
Management of Hand Trauma
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
Management of Complex Peripheral Nerve Injuries
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.
The clinical guideline for treatment of burns including the referral pathway.
Nutritional Management Policy
There should be a policy for nutritional management following trauma. T14-2C-217
Operational Policy.
Designated Specialist Burns Care
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.
Management of Maxillofacial Trauma
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
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.
TRAUMA SPECIFIC MEASURES
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
Clinical Lead for Acute Trauma Rehabilitation Services
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.
Rehabilitation Coordinator Post
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
Specialist Rehabilitation Service
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
Rehabilitation Prescriptions
All Major Trauma patients at the MTC should receive a rehabilitation prescription within 72 hours.
T14-2D-206
Annual Report including TARN dash board data for rehabilitation prescription.
Rehabilitation for Traumatic Amputation
The MTC should have a rehabilitation program which
TRAUMA SPECIFIC MEASURES
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.
Referral Guidelines to Rehabilitation Services
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.
Network Patient Repatriation Policy
The MTC should agree the network policy for the repatriation of patients measure T14-1C-119. T14-2D-212
Operational Policy.
Clinical Psychologist for Trauma Rehabilitation
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.
TRAUMA SPECIFIC MEASURES
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.
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T14-2D-213
24/7 Access to Psychiatric Advice
There should be 24/7 access to urgent psychiatric advice for patients with significant mental health problems.
TRAUMA SPECIFIC MEASURES
Operational Policy. The psychiatric on call rota should be available for PR visit.
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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.
Operational Policy including agreed responsibilities.
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
Trauma Team Activation Protocol
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
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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.
Teleradiology Facilities
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
Dedicated Orthopaedic Trauma Operating Theatre
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
Trauma Management Guidelines
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
Transfusion Lead Clinician
There should be a named clinical Lead for transfusion.
TRAUMA SPECIFIC MEASURES
NOVEMBER 2014
Operational Policy.
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T14-2B-312
24/7 Specialist Transfusion Advice
There should be transfusion advice available 24/7 from a clinical consultant with appropriate experience.
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.
Operational Policy including the protocol.
Administration of Tranexamic Acid
Patients with significant haemorrhage should be administered Tranexamic Acid within 3 hours of injury and receive a second dose according to CRASH-2 protocol.
TRAUMA SPECIFIC MEASURES
NOVEMBER 2014
TARN data.
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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.
Management of Spinal Injuries
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
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.
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.
TRAUMA SPECIFIC MEASURES
NOVEMBER 2014
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T14-2C-306
Management of Musculoskeletal Trauma
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.
Designated Specialist Burns Care
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
The clinical guideline for treatment of burns including the referral pathway.
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.
T14-2C-310
The Trauma Audit and Research Network (TARN)
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.
TRAUMA SPECIFIC MEASURES
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
Rehabilitation Prescriptions
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.
TRAUMA SPECIFIC MEASURES
NOVEMBER 2014
Annual Report including TARN dash board data for 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?
TRAUMA SPECIFIC MEASURES
NOVEMBER 2014
47
Appendix 1
TRAUMA SPECIFIC MEASURES
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TRAUMA SPECIFIC MEASURES
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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
TRAUMA SPECIFIC MEASURES
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