British Orthopaedic Association Prof Keith Willett John Radcliffe - - PowerPoint PPT Presentation

British Orthopaedic Association

Prof Keith Willett John Radcliffe Hospital, Oxford

Chairman BOA Trauma Group Chairman BOA Trauma Group

• Standards of Care for

index injuries against hi h t dit h it l which to audit hospital performance

• Regional system of

trauma organisation to audit that trauma care audit that trauma care performance and develop local access, t t t b d treatment, bypass and transfer protocols to achieve those standards

RCSoE 1988, BOA 1992

International road death rate comparative statistics

25 15 20

Pedestrian deaths per 100K population

10 15 5

Road deaths per 100K population

S w U K N e G e A u I r i C a U S F r J a S p P

• K
• G

S w e d e n U K N e t h e r l a n d s G e r m a n y A u s t r a l i a I r i s h R e p C a n a d a U S A F r a n c e J a p a n S p a i n P

• r

t u g a l K

• r

e a G r e e c e

Population density: UK 243, USA 30, Sweden 20 sqkm-1

Decline in UK road crash deaths and Decline in UK road crash deaths and serious injury rate serious injury rate the last decade the last decade - 1994 1994-2004 2004 the last decade the last decade 1994 1994 2004 2004

60000

K illed and seriously

50000

seriously injured K illed

40000

ed

30000 20000 10000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

My response to this NCEPOD report My response to this NCEPOD report

• Strongly support findings, conclusion and

recommendations: further data and expert p

• pinion
• Sadly not new . . . . .

even sadder little progress . . . . . . . . even sadder little progress and in some areas worse than previous reports

– Senior input in trauma team – Head injury management R l f th l l h it l – Role of the local hospital – Timeliness and transfers – Limitations of the report p – Key solutions, implementations and commissioning

Off i iti ti d ti Off i iti ti d ti Offer prioritisation and pragmatism Offer prioritisation and pragmatism

• Airway - pre-hospital solution
• Local trauma team decisive - senior input
• Rapid triage – transfer

– CT scan availability R i i i l it/ t ibilit – Receiving regional unit/system responsibility – Over-riding clinical priority – Transfer/retrieval expertise

• Repatriation – rehabilitation

What are the key recommendations? What are the key recommendations? y . . . . . . . strategy for commissioning . . . . . . . strategy for commissioning gy g gy g

A consultant must be the trauma team leader A consultant must be the trauma team leader d i th l ki k (?) . . . . . . . . during the normal working week (?)

140 120 80 100 60 80 Tot al

Working Day

20 40 20

00.00hrs 24.00hrs 00.00hrs 24.00hrs

(85% of surgery is musculoskeletal)

Timing of Trauma Care Timing of Trauma Care Timing of Trauma Care Timing of Trauma Care

Arrivals and discharges/admission data for sameday Trauma Service referrals from JR Emergency Department in 6 months from 01/05/2003-31/10/2003 g y p 140 100 120 No of Arrivals No of discharges 60 80

• f patients

Working Day

40 60 no o 20 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hour of day

. . . . . a popular change? . . . . . a popular change?

The thin end of a very damaging wedge . . . the most outlandish idea yet !

BMA NEWS 1994

. . . the most outlandish idea yet ! BMA NEWS 1994

So what is the standard? So what is the standard? So what is the standard? So what is the standard?

1. 1. There must be a Consultant to lead There must be a Consultant to lead the trauma team in all units receiving the trauma team in all units receiving g seriously injured patients seriously injured patients

Head injury management j y g

• 62% had neurotrauma

I thi t 493 f 795 (ISS 16) h d h d i j

• In this report 493 of 795 (ISS >16) had head injury
• 114 had neuro-critical intervention

66 surgery – 66 surgery – 48 intracranial pressure monitoring

. . . . so what should the standard of care be? . . . . so what should the standard of care be? All patients with severe head injury should be All patients with severe head injury should be transferred to a neurosurgical/critical care transferred to a neurosurgical/critical care transferred to a neurosurgical/critical care transferred to a neurosurgical/critical care centre irrespective of the requirement for centre irrespective of the requirement for surgical intervention surgical intervention g

. . . . so what should the standard of care be? . . . . so what should the standard of care be?

• All patients with severe head injury should be transferred

to a neurosurgical/critical care centre irrespective of the to a neurosurgical/critical care centre irrespective of the requirement for surgical intervention

• 20 – 25% (114) had neuro-critical intervention

– 66 surgery – 48 intracranial pressure monitoring 48 intracranial pressure monitoring

• 278 had GCS on arrival <12 but less than half

needed neuro-critical care (other injuries)

• NCEPOD excluded all patients with isolated

moderate head injury (AIS 3: ISS 9) moderate head injury (AIS 3: ISS 9) . . . . . . . . overwhelmed

. . . so what should the standards of care be? . . . so what should the standards of care be?

• All patients with severe head injury should be transferred

to a neurosurgical/critical care centre irrespective of the to a neurosurgical/critical care centre irrespective of the requirement for surgical intervention

O ti i th l l i i it f t i O ti i th l l i i it f t i

• Optimise the local receiving unit for triage,

Optimise the local receiving unit for triage, critical resuscitation and rapid dispatch critical resuscitation and rapid dispatch – Consultant Consultant-

• led trauma team

led trauma team – Time to CT less than 1 hour (radiographer) – Time to craniotomy/neurosurgery/ICP Time to craniotomy/neurosurgery/ICP monitor of less than 4 hours monitor of less than 4 hours – Vascular injury, interventional radiology, etc. Vascular injury, interventional radiology, etc. Vascular injury, interventional radiology, etc. Vascular injury, interventional radiology, etc. . . . . . the role of the local hospital (trauma team)

Risk of limb amputation with delay to surgery Risk of limb amputation with delay to surgery

meta meta-

• analysis 21 studies 1574 pts

analysis 21 studies 1574 pts Willett et al Willett et al 2006 2006

54 50 60 age % 40 50 percenta 33 30 utated in 13 10 20 bs ampu 3 5 0 to 4 4 to 5 5 to 6 6 to 8 8 to 12 limb 0 to 4 4 to 5 5 to 6 6 to 8 8 to 12 ischaemic time (hours)

. . . so what should the standards of care be? . . . so what should the standards of care be?

Optimise the local receiving unit for triage, critical resuscitation and rapid dispatch

• Transfers

Transfers: NCEPOD (194) major underestimate:

• nly those within 72 hours
• “specialist management” of injuries
• 62% neurosurgery

62% neurosurgery

• 10% burns and plastics
• 4% cardiothoracic
• 3% PICU
• 3% PICU

Omits most Omits most complex pelvis and acetabulum complex pelvis and acetabulum bl i l i j i bl i l i j i unstable spinal injuries unstable spinal injuries

• pen and complex fractures
• pen and complex fractures

need urgent primary not emergency surgery

Quality of reduction – complex t b l (hi k t) f t acetabular (hip socket) fractures %

2 year functional outcome 2 year functional outcome – – complex complex acetabular fractures acetabular fractures complex complex acetabular fractures acetabular fractures

%

. . . so what should the standards of care be? . . . so what should the standards of care be?

Optimise the local receiving unit for triage, critical Optimise the local receiving unit for triage, critical resuscitation and rapid dispatch resuscitation and rapid dispatch

. . . and how should the transfer be secured . . . and how should the transfer be secured? 1 Charge the regional receiving unit with the 1. Charge the regional receiving unit with the responsibility for achieving the definitive standard and the patient placement

• verride their local patient priorities
• facilitate prompt quality transfers
• retrieval teams valid role of helicopter
• retrieval teams, valid role of helicopter
• priority repatriation / rehabilitation pathways

2. Working through regional trauma system g g g y (locally sensitive protocols) developed from auditing of key standards

My response to this NCEPOD report My response to this NCEPOD report

• BOA strongly support findings, conclusion and

recommendations: data and expert opinion recommendations: data and expert opinion

S i i t i t t – Senior input in trauma team – Regional organisation – Role of the local hospital – Timeliness and transfers Timeliness and transfers R t Li it ti NO ACTION PLAN R t Li it ti NO ACTION PLAN – Reports Limitation: NO ACTION PLAN Reports Limitation: NO ACTION PLAN

My response to this NCEPOD report My response to this NCEPOD report Expertly inform commissioning: Regional Trauma System Executive

1 Each acute hospital Trauma Committee 1. Each acute hospital – Trauma Committee 2. Local solutions and service changes 3 Pre hospital protocols (urban rural NHS 3. Pre-hospital protocols (urban, rural, NHS facilities) 4 Inter-hospital and bypass procedures 4. Inter-hospital and bypass procedures 5. Monitoring and development based on analysis

• f TARN returns for commissioned standards

commissioned standards

• f TARN returns for commissioned standards

commissioned standards . . . what are the priorities and which are feasible? . . . what are the priorities and which are feasible?

Wh t t d d f t i i ? Wh t t d d f t i i ? What standards of care to commission? What standards of care to commission? 48 NECPOD recommendations:

5 organisational data 5 organisational data 6 prehospital care 6 hospital reception 2 i b thi 2 airway breathing 6 circulation management 7 (+)head injury ( ) 7 (+) paediatric care 5 (+) transfers 4 service organisation

thank you

Prof Keith Willett ff O f John Radcliffe Hospital, Oxford Chairman BOA Trauma Group