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

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

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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

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The impact of trauma networks and the importance of data: A year of trauma audit in Northern Ireland

Northern Ireland Major Trauma Network Conference 8th March 2019

Antoinette Edwards: Executive Director Laura White: Operations Director

Twitter account: @TARNaudit www.facebook.com/TARNaudit www.tarn.ac.uk

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

LAUNCH SUMMER 2019

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NETWORK MANAGER

SPECIALITY THEMED 2-3 measures

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Trauma Networks

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What has changed?

On scene patient triage: Positive

Direct to MTC

  • < 45 mins travel

Indirect Transfer

  • >45 mins
  • time critical intervention

MAJOR TRAUMA CENTRE Consultant led trauma team Immediate operating theatre All specialties: neurosciences Immediate CT scan Interventional radiology Specialist critical care Trauma Unit Trauma team Immediate CT Resuscitate, Assess & ? Transfer

TARN TARN

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Trauma Networks Can they make a difference?...

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Impact of Trauma Networks

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.

MJA 2008; 189: 546–550

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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

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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)

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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%

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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
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Importance of Data

Quality data can produce powerful information Potential to influence change!

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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)
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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

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Comparison: QUANTITY (Case ascertainment)

Comment:

  • NI % marginally higher than English Pre MTN configuration
  • Case ascertainment target = 80%+

Network Cases submitted 2018 Northern Ireland 58% of expected

Network Cases submitted English combined Pre Major Trauma Network configuration 2011 Post Major Trauma Network configuration 2013 55% of expected 65% of expected

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Comparison: QUALITY (Data Accreditation)

Comment:

  • NI % marginally higher than English Pre MTN configuration
  • Data Accreditation target = 95%+

Network Accreditation Northern Ireland 91% key fields completed

Network Accreditation English combined Pre Major Trauma Network configuration 2011 Post Major Trauma Network configuration 2013 85% 91%

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Comparison: NI Data Accreditation breakdown Target: 95%+

GCS Arrival Incident Transfer s CT Operatio n ED doctors PMCs Pupil reactivity Injuries Overall No of 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

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System indicators

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

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Comparison: Median Time to CT: All cases

Comment:

  • NI time lower than both pre & post English MTN configuration

Network 2018 Time to CT (minutes) Northern Ireland 108

Network Time to CT (minutes) English combined Pre Major Trauma Network configuration 2011 Post Major Trauma Network configuration 2013 134 110

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Comparison: Median Time to CT: NICE Head injuries

GCS<13 and Head injury present

Comment:

  • NI Time to CT lower than both pre & post English MTN configuration

Network 2018 Time to CT (minutes) Northern Ireland 33

Network Time to CT (minutes) English combined Pre Major Trauma Network configuration 2011 Post Major Trauma Network configuration 2013 47 35

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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 configuration 2011 Post Major Trauma Network configuration 2013 English combined ISS 1-8 ISS 9-15 ISS >15 ISS 1-8 ISS 9-15 ISS >15 20% 44% 36% 20% 44% 36% Comment:

  • NI ISS breakdown very similar to England
  • Marginally fewer ISS >15 cases
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Comparison: ISS>15 Consultant & ST3+ presence

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

Network 5 mins 30 mins In ED

NI Consultant

15% 17% 24%

Network Pre Major Trauma Network configuration 2011 Post Major Trauma Network configuration 2013 English Consultant 5 mins 30 mins In ED 5 mins 30 mins In ED 19% 21% 29% 26% 29% 34%

NI ST3+

42% 51% 83%

English ST3+ 5 mins 30 mins In ED 5 mins 30 mins In ED 39% 46% 69% 41% 47% 61%

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Outcome

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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

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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 2nd Network on database
  • Caveat: Case ascertainment needs to be 80%+ to validate this
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Improving Data Quality

Case ascertainment

  • Validate denominator: Document ineligible cases: feedback to TARN
  • Suggest using TARN SQL script to identify cases where possible

Data Accreditation

  • Data Quality report available on TARN website
  • Shows breakdown
  • Amendments submitted to TARN
  • Increased report accuracy

Time to CT

  • Ensure Time of arrival and Time of CT both recorded

Ps/Ws accuracy

  • All Pre-existing medical conditions must be recorded
  • GCS ED and Pre hospital recorded
  • Injuries complete: ISS accurate
  • Result: Accurate Ps/Ws
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Questions?