Trauma: Who cares? NCEPOD 2007 Barrie D White Trauma: Who cares? - PDF document

Society of British Neurological Surgeons Trauma: Who cares? NCEPOD 2007 Barrie D White

Trauma: Who cares? Headlines Headlines Less than half of patients with trauma have a good Less than half of patients with trauma have a good standard of care standard of care Poor airway and ventilation before hospital Poor airway and ventilation before hospital Failure to recognise injuries Failure to recognise injuries Delay to investigate and treat Delay to investigate and treat Lack of co Lack of co- -ordination and senior input ordination and senior input Barrie D White

Trauma: Who cares? Headlines Headlines Head Injury is major cause of long Head Injury is major cause of long- -term disability term disability Head Injury present in 62% of severely injured Head Injury present in 62% of severely injured H lf H lf Half of these in coma (GCS<9) Half of these in coma (GCS<9) f th f th i i (GCS 9) (GCS 9) 50% GCS3 dead by 72hrs 50% GCS3 dead by 72hrs Majority (54%) taken to non Majority (54%) taken to non- -specialist unit first specialist unit first Most common need for transfer is HI Most common need for transfer is HI Two Two- -fold mortality if stay in DGH fold mortality if stay in DGH Mean time for transfer 6hrs Mean time for transfer 6hrs Direct admission seems sensible but Direct admission seems sensible but pre pre-hospital ABC poor and priority pre pre-hospital ABC poor and priority hospital ABC poor and priority hospital ABC poor and priority Barrie D White

Trauma: Who cares? Saddening but not surprising! Saddening but not surprising! Recognise the difficulties and deficiencies Recognise the difficulties and deficiencies Timely, in tune with, and builds on NICE guidance Timely, in tune with, and builds on NICE guidance Trauma unpredictable, uncommon, high demand, Trauma unpredictable, uncommon, high demand, High resource, low reward (clinical and tariff) High resource, low reward (clinical and tariff) Trauma is only 5 Trauma is only 5- y -10% neurosurgical workload 10% neurosurgical workload g Barrie D White

Trauma: Who cares? Head injury Head injury Come a long way in a life Come a long way in a life- g g y y -time time 1950s 1950s Head injury care rudimentary Head injury care rudimentary 1960s 1960s Appreciation importance of surgery for clots Appreciation importance of surgery for clots Angiography at 6+hrs, delayed operations Angiography at 6+hrs, delayed operations 1970s 1970s Real beginnings of head injury management Real beginnings of head injury management GCS, Skull Xray (few CTs), ICP, rule based mgt GCS, Skull Xray (few CTs), ICP, rule based mgt 1980s 1980s National head injury recommendations National head injury recommendations some improvements, recognition residual problems some improvements, recognition residual problems cross cutting collaboration, step investments required cross cutting collaboration, step investments required out of hospital care, regional reorganisation out of hospital care, regional reorganisation resources, facilities to match resources, facilities to match , Barrie D White

Trauma: Who cares? NICE Says NICE Says NCEPOD Shows NCEPOD Shows ABC/GCS ABC/GCS A 85%, B 90%, C 91%, GCS 97% A 85%, B 90%, C 91%, GCS 97% GCS<9. Standby call GCS<9. Standby call GCS<9 Standby call GCS<9 Standby call 60% only 27% intubated pre-hosp 60% only 27% intubated pre 60%, only 27% intubated pre 60%, only 27% intubated pre hosp hosp hosp GCS<13. CT within 1hr GCS<13. CT within 1hr 30% , 75% in 2hrs, 10% not at all 30% , 75% in 2hrs, 10% not at all GCS<13. discuss with NS GCS<13. discuss with NS 82%, 10% in 1hr, 60% in 4hrs 82%, 10% in 1hr, 60% in 4hrs GCS<9. Transfer to NS GCS<9 T GCS<9. Transfer to NS GCS<9 T f f t t NS NS Not analysed but occurred, and not Not analysed but occurred, and not N t N t l l d b t d b t d d d d t t Operation within 4hrs Operation within 4hrs 66% on site, 14% off site, 84% ok 66% on site, 14% off site, 84% ok but 10/13 delayed ops were for ICH but 10/13 delayed ops were for ICH Consultant involvement Consultant involvement 19% EDH, SDH, Contusions (all ok) 19% EDH, SDH, Contusions (all ok) , , , , ( ( ) ) Barrie D White

Trauma: Who cares? NICE Asks NICE Asks NCEPOD Shows NCEPOD Shows NS unit vs DGH NS unit vs DGH Ad Admit direct or transfer Admit direct or transfer Ad i di i di f f Mean transfer time 6hrs M M Mean transfer time 6hrs f f i i 6h 6h Outcomes for “non NS” Outcomes for “non NS” Operations timely in 83% Operations timely in 83% Rx ICH Rx ICH Consensus on significant Consensus on significant g Prediction of decline Prediction of decline Watch, monitor, or do Watch, monitor, or do Transfer 9- Transfer 9 -13/contusions 13/contusions Validate child specific rules V lid t Validate child specific rules V lid t hild hild ifi ifi l l F Few children in study F Few children in study hild hild i i t d t d Predict longterm sequelae Predict longterm sequelae Predict longterm sequelae Predict longterm sequelae Not specifically addressed Not specifically addressed Not specifically addressed Not specifically addressed Barrie D White

Trauma: Who cares? Some UK Official Reports Some UK Official Reports •Harrogate Seminar 1983 Harrogate Seminar 1983 •Royal College of Surgeons 1986, 1999, 2000 Royal College of Surgeons 1986, 1999, 2000 •British Association of A&E Medicine 2000 British Association of A&E Medicine 2000 •Scottish Intercollegiate Guidelines Network 2000 Scottish Intercollegiate Guidelines Network 2000 rd Health Committee Report 2001 rd Health Committee Report 2001 House of Commons 3 rd House of Commons 3 rd •House of Commons 3 •House of Commons 3 Health Committee Report 2001 Health Committee Report 2001 •Department of Health 2001, 2004 Department of Health 2001, 2004 •British Society of Rehabilitation Medicine 2002 British Society of Rehabilitation Medicine 2002 British Society of Rehabilitation Medicine 2002 British Society of Rehabilitation Medicine 2002 •Royal College of Physicians 2002, 2003 Royal College of Physicians 2002, 2003 •NICE 2003, 2007 NICE 2003, 2007 •National Audit Office 2004 National Audit Office 2004 •NSF for Longterm Neurological Conditions 2005 NSF for Longterm Neurological Conditions 2005 •NCEPOD 2007 •NCEPOD 2007 NCEPOD 2007 NCEPOD 2007 Barrie D White

Trauma: Who cares? SBNS has been trying for ~25 years to improve overall SBNS has been trying for ~25 years to improve overall neurosurgical standards neurosurgical standards neurosurgical standards neurosurgical standards 1984, 1993, 2000, 2001, 2003, 2005 1984, 1993, 2000, 2001, 2003, 2005 Largely regarded as self-serving wish lists Largely regarded as self Largely regarded as self serving wish lists Largely regarded as self serving wish lists serving wish lists Best shot so far is standards document 2002 Best shot so far is standards document 2002 Best shot so far is standards document 2002 Best shot so far is standards document 2002 scoring system for national comparison scoring system for national comparison gaps for business case construction gaps for business case construction Barrie D White

Trauma: Who cares? Barrie D White

Trauma: Who cares? General m Pt Centred 61% Organisation 70% C Communication i ti 65% 65% Management 89% Access 43% Neurosurgery 50% Critical care 73% Follow up 62% Rehabilitation 49% Educate / train 77% R&D 72% Audit 73% Specialty Paediatrics 79% Head injury 64% Oncology 74% Vascular 66% Spinal 58% Functional 65% Summary m General General 65% 65% Specialty 68% Overall 67% Barrie D White