The impact of trauma networks and the importance of data: A year of - PowerPoint PPT Presentation

The impact of trauma networks and the importance of data: A year of trauma audit in Northern Ireland Northern Ireland Major Trauma Network Conference 8 th March 2019 Antoinette Edwards: Executive Director Laura White: Operations Director Twitter account: @TARNaudit www.facebook.com/TARNaudit www.tarn.ac.uk

The Trauma Audit & Research Network  National Clinical Audit for trauma care Monitoring processes of care & outcome 29 years  Data submitted by all trauma receiving hospitals (England, Wales, Ireland & other parts of Europe) >200 hospitals submitting data  Largest European trauma registry >800,0000 injured patients >1,500 cases per week - approx. 75,000 cases per year  Based at Salford Royal NHS Foundation Trust, part of the University of Manchester  Clinically led, Academic and Independent

Output  Themed Clinical Reports  Produced 3 times per year  Standards & guidelines (RCS, BOA, NICE)  Comparative Outcome Analysis/Rates of Survival  Major Trauma Dashboards  Benchmarking against peers  Clinical & quality indicators  Produced Quarterly  Major Trauma PROMs (English MTCs)  Best Practice Tariff (Support flow of £60-80 million per annum)  TARN Research

 Data Analytical tool accessible to each hospital • Dynamic way of reporting • Flexible and ‘real-time’ • Better data visualisations LAUNCH SUMMER 2019

NETWORK MANAGER SPECIALITY THEMED 2-3 measures

Trauma Networks

What has changed? On scene patient triage: Positive TARN Direct to MTC TARN Indirect Transfer • < 45 mins travel • >45 mins • time critical intervention MAJOR TRAUMA CENTRE  Consultant led trauma team Trauma Unit  Immediate operating theatre Trauma team  All specialties: neurosciences Immediate CT Resuscitate,  Immediate CT scan Assess & ? Transfer  Interventional radiology  Specialist critical care

Trauma Networks Can they make a difference?...

Impact of Trauma Networks MJA 2008; 189: 546–550 Conclusions: Introduction of a statewide trauma system was associated with a significant reduction in risk-adjusted mortality. Such inclusive systems of trauma care should be regarded as a minimum standard for health jurisdictions.

Impact of Trauma Networks EClinicalMedicine 2-3 (2018): 13-21 Major Trauma networks were associated with significant changes in: • Patient flow (with increased numbers treated in Major Trauma Centres) • Treatment systems (more consultant led care and more rapid imaging) • Patient factors (an increase in older trauma) • Clinical care (new massive transfusion policies and use of tranexamic acid). Demonstrated a 19% increase in the case mix adjusted odds of survival from severe injury for patients who reach hospital alive

Major Trauma Centre: Best Practice Tariff (18-19) Level 1 (Moderate Trauma): ISS >8 £1,500  TARN data is completed and dispatched within 25 days of discharge/death  Rehabilitation prescription completed for each patient & recorded on TARN  Tranexamic acid (TXA) administered within 3 hours of injury for any patient receiving blood within 6 hours of injury  Non-emergency transfers: Patient must be admitted to MTC within 2 calendar days of referral from Trauma Unit Level 2: (Major Trauma) ISS>15 £3,000 Level 1 criteria and following additional criteria met:  Direct admissions or emergency (<12 hour) transfers: Patient must be seen by Consultant within 5 minutes of arrival  Direct admissions: Head CT performed within 1 hour of arrival for patients with SeeAIS1+ Head injury & GCS <13 in ED (or intubated pre-hospital)

Impact of Trauma Networks Case Ascertainment Year Trauma Units Major Trauma Centres 2010/11 48% 55% 2012 59% 81% 2013 56% - 68% 84% - 100% 2014 60% - 73% 88% - 102% 2015 69% - 80% 96% - 110% 2016 70% - 84% 98% - 112% 2017 76% - 91% 98% - 114%

Supporting Service Improvement  Clinical Leads & Network Managers ”Understanding the data is key”  Motivates data coordinators  Drives funding  Peer Review  Share ideas and best practice between hospitals  Network meetings  Discussing data (reports/Dashboards/data quality)=Drive improvement  Encourage inclusiveness & support  Data Coordinators “feel valued”  Data Coordinators “developed from a clinical perspective”  Understanding the data that’s sent to TARN  How it impacts on patient care

Importance of Data Quality data can produce powerful information Potential to influence change!

One year of Trauma Audit in Northern Ireland Trauma Audit background: • Major Trauma Networks launched in England in 2012 • Northern Ireland Network joined TARN in November 2016 • NI began submitting data over following months • NI: 2018: First full year of data entry Comparison of data: • Northern Ireland MT Network: 2018 • English MT Networks: 2011 & 2013 (pre & post MT Network configuration)

Data Quality comparison Case ascertainment (quantity measure) No. of cases submitted v expected (based on HES data) Data Accreditation (quality measure) Number of key fields completed

Comparison: QUANTITY (Case ascertainment) Network Cases submitted 2018 Northern Ireland 58% of expected Network Cases submitted Pre Major Trauma Network Post Major Trauma Network configuration configuration English combined 2011 2013 55% of expected 65% of expected Comment:  NI % marginally higher than English Pre MTN configuration  Case ascertainment target = 80%+

Comparison: QUALITY (Data Accreditation) Network Accreditation Northern Ireland 91% key fields completed Network Accreditation Pre Major Trauma Network Post Major Trauma Network configuration configuration English combined 2011 2013 85% 91% Comment:  NI % marginally higher than English Pre MTN configuration  Data Accreditation target = 95%+

Comparison: NI Data Accreditation breakdown Target: 95%+ GCS Arrival Incident Transfer CT Operatio ED PMCs Pupil Injuries Overall No of s n doctors reactivity cases. 83% 99% 80% 83% 99% 95% 96% 92% 86% 94% 91% 1010 Above target Below target: areas for improvement GCS, PMC & Injuries most important – impact on Probability of Survival calculation

System indicators Time to CT Injury Severity Score (ISS) breakdown Consultant presence ST3+ presence

Comparison: Median Time to CT: All cases Network 2018 Time to CT (minutes) Northern Ireland 108 Network Time to CT (minutes) Pre Major Trauma Network Post Major Trauma Network configuration configuration English combined 2011 2013 134 110 Comment:  NI time lower than both pre & post English MTN configuration

Comparison: Median Time to CT: NICE Head injuries GCS<13 and Head injury present Network 2018 Time to CT (minutes) Northern Ireland 33 Network Time to CT (minutes) Pre Major Trauma Network Post Major Trauma Network configuration configuration English combined 2011 2013 47 35 Comment:  NI Time to CT lower than both pre & post English MTN configuration

Comparison: ISS breakdown ISS 1-8: Minor injuries ISS 9-15: Moderate injuries ISS >15: Major Trauma Network ISS 1-8 ISS 9- 15 ISS >15 Northern Ireland 21% 45% 34% Network Pre Major Trauma Network Post Major Trauma Network configuration configuration 2011 2013 ISS 1-8 ISS 9-15 ISS >15 ISS 1-8 ISS 9-15 ISS >15 English combined 20% 44% 36% 20% 44% 36% Comment:  NI ISS breakdown very similar to England  Marginally fewer ISS >15 cases

Comparison: ISS>15 Consultant & ST3+ presence Network 5 mins 30 mins In ED NI Consultant 15% 17% 24% 42% 51% 83% NI ST3+ Network Pre Major Trauma Network Post Major Trauma Network configuration configuration 2011 2013 5 mins 30 mins In ED 5 mins 30 mins In ED English Consultant 19% 21% 29% 26% 29% 34% 5 mins 30 mins In ED 5 mins 30 mins In ED English ST3+ 39% 46% 69% 41% 47% 61% Comment:  NI: Consultant presence lower in ED than England  NI: 76% not seen (or accurately documented) by Consultant in ED  NI: ST3+ presence higher than in England

Outcome

Comparative outcome analysis (Ws) Taken from November 18 Clinical report NI position highlighted in red: + 1.07 additional survivors (CI: -0.11 to +2.26) Compared to English Networks

Summary Case ascertainment (Quantity) • Currently 58% overall • Longer term target of 80%+ Data Accreditation (Quality) Currently 91% • Longer term target of 95%+ • • Key areas to target: GCS, Injury details and PMCs Time to CT • Currently 108 minutes Only calculated if Time of Arrival and CT are both documented • ISS breakdown • Very similar to English Networks Ws (Outcome statistic) Currently 2 nd Network on database • Caveat: Case ascertainment needs to be 80%+ to validate this •