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 which to audit hospital hi h t dit h it l performance • Regional system of trauma organisation to audit that trauma care audit that trauma care performance and develop local access, t treatment, bypass and t t b d transfer protocols to achieve those standards RCSoE 1988, BOA 1992
International road death rate comparative statistics 25 20 Pedestrian deaths per 100K population 15 15 10 Road deaths per 5 100K population 0 S S U U N N G G A A I I U U F F J J S S P P K K C C G G r r r r a a w w K K e e u u i i S S p p o o o o e e a a r s a p t a r e r s n A r e h h n m a t e i e t d a u n e r c n a R c d e a a g e r e e n l n l a a a i a p y l n d s 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 the last decade the last decade 1994 1994-2004 1994 2004 2004 2004 60000 K illed and seriously seriously injured 50000 K illed ed 40000 30000 20000 10000 0 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 opinion • 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 – Role of the local hospital R l f th l l h it l – Timeliness and transfers – Limitations of the report p – Key solutions, implementations and commissioning
Off Off Offer prioritisation and pragmatism Offer prioritisation and pragmatism i i iti iti ti ti d d ti ti • Airway - pre-hospital solution • Local trauma team decisive - senior input • Rapid triage – transfer – CT scan availability – Receiving regional unit/system responsibility R i i i l it/ t ibilit – 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 gy g g
A consultant must be the trauma team leader A consultant must be the trauma team leader . . . . . . . . during the normal working week (?) d i th l ki k (?) 140 120 100 80 80 Tot al 60 40 Working Day 20 20 0 00.00hrs 00.00hrs 24.00hrs 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 140 120 No of Arrivals No of discharges 100 of patients 80 60 60 no o Working Day 40 20 0 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 • In this report 493 of 795 (ISS >16) had head injury I thi t 493 f 795 (ISS 16) h d h d i j • 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 Optimise the local receiving unit for triage, Optimise the local receiving unit for triage, O ti i i th th l l l l i i i i it f it f t i t i 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 60 age % 54 50 50 percenta 40 utated in 33 30 bs ampu 20 13 10 limb 5 3 0 0 0 0 to 4 0 to 4 4 to 5 4 to 5 5 to 6 5 to 6 6 to 8 6 to 8 8 to 12 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: • only 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 unstable spinal injuries unstable spinal injuries bl bl i i l i j l i j i i open and complex fractures open and complex fractures need urgent primary not emergency surgery
Quality of reduction – complex acetabular (hip socket) fractures t b l (hi k t) f t %
2 year functional outcome 2 year functional outcome – – complex complex acetabular fractures complex complex acetabular fractures 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 1. Charge the regional receiving unit with the Charge the regional receiving unit with the responsibility for achieving the definitive standard and the patient placement • override 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 – Senior input in trauma team S i i t i t t – Regional organisation – Role of the local hospital – Timeliness and transfers Timeliness and transfers – Reports Limitation: NO ACTION PLAN R R Reports Limitation: NO ACTION PLAN t t Li Li it ti it ti NO ACTION PLAN NO ACTION PLAN
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