NHS GRAMPIAN
Development of a Major Trauma Network
1.Actions Recommended
The NHS Grampian Board received a report on the development of major trauma centres (MTCs) in Scotland in the context of a national major trauma network at its meeting in June 2014. A programme of work has been taken forward in the north of Scotland since then to develop a major trauma network and to establish Aberdeen Royal Infirmary and the Royal Aberdeen Children’s Hospital as a MTC.
The Board is asked to note progress and support the approach to improve the major trauma system in the north of Scotland.
2.Strategic Context
Major trauma constitutes injuries which could result in permanent disability or death and/or combinations of injuries with an injury severity score exceeding 15’. (RoyalCollege of Surgeons of Edinburgh 2012)
Each year in Scotland around 5,000 people are seriously injured with approximately 1,000-1,100 cases being defined as major trauma. It is estimated that there are approximately 100 children seriously injured each year in Scotland. Major trauma is the most common cause of death under 40 years of age in the UK.
For each trauma death there are two survivors with serious or permanent disability which significantly impacts on their quality of life. In addition to the human costs, trauma also poses a large socio-economic burden. Although major trauma is low in frequency and high acuity, it is also by nature unpredictable which can create challenges in delivering the necessary capacity in relation to responsive and sustainable definitive care.
A number of studies and reports have highlighted deficiencies in trauma care within the NHS in the UK. International evidence shows that a regionalised network approach to major trauma care improves mortality and functional outcomes, and is cost-effective. Following the development and implementation of a major trauma change programme in England the Royal College of Surgeons of Edinburgh published a report in May 2012 recommending the optimal reconfiguration of major trauma care for Scotland focusing on the general principles of a holistic, inclusive, tiered system which reduces mortality and improves functional outcomes.
In November 2013, the NHS Chief Executives Group of the NHS in Scotland endorsed the National Quality Framework for Major Trauma Services together with recommendations to establish a single national major trauma system to include four regional trauma networks, each with a MTC i.e. in Aberdeen, Dundee, Edinburgh and Glasgow. The report setting out the proposals indicated that this was an interim position and that therewould be a further review of the number of MTCs in Scotland. These recommendations were approved by the Cabinet Secretary in April 2014with the aim of regional networks and MTCs being operational by the end of 2016. In December 2014 it was proposed that there should be three paediatric MTCs in Scotland based in Aberdeen, Edinburgh and Glasgow.
The fundamental aim of the national major trauma system is to deliver timely, safe, effective and person centred care for those who suffer major trauma which achieves the best outcomes by reducing mortality and disability and ensuring individuals are supported to help maximise their quality of life.
- Key Matters Relevant to Recommendation
Major Trauma Event – 13 May 2015
More than 110 clinicians and managers from all participating Boards in the north of Scotland came together in Aberdeen on 13 May to debate and develop the emerging plans for the regional major trauma network in the north. The event considered the vision and model for the network, together with the proposed pathway of care from pre-hospital to recovery/ongoing care and emerging key actions to deliver this. Delegates also heard about the approach in NHS England which has undergone a re-organisation of major trauma over the past 3-5 years.
A significant feature of the event was the use of patient, carer and staff stories to illustrate the issues and the impact that major trauma has on individuals and families. One of the patient stories used at the event will be considered at the Board meeting on 4 June 2015.
North of Scotland Approach
Following the approval of the plans for the improvement of major trauma by the Cabinet Secretary in April 2014 a structure to facilitate the full participation of the NHS Boards (Grampian, Highland, Orkney, Shetland and the Western Isles) and clinicians in the north was established.
This structure is led by the North of Scotland Major Trauma Programme Group which oversees the development of the major trauma network in the north and the preparation of the detailed plans for the north region in the context of the national network. Clinicians and managers from all north Boards participate in this group.
Reporting to the Programme Group are a number of task and finish groups focused on the main elements of the major trauma pathway i.e.
- Pre-hospital care, transfer and retrieval
- Development of Aberdeen Royal Infirmary and Royal Aberdeen Children’s Hospital as a MTC
- Rehabilitation and repatriation of patients
- Patient, carer and staff experience
The regional Programme Group reports to the North of Scotland Planning Group and the national Major Trauma Oversight Group.
Appendix 1 provides further detail on the programme structure.
Vision for Major Trauma
The North of Scotland Major Trauma Programme Group has developed a vision for major trauma in the region. This vision has been the subject of wide consultation with clinicians and managers in the region. It was approved by the North of Scotland Planning Group in February 2014 and further endorsed at the regional major trauma event on 13 May. The vision is set out in Appendix 2.
Model for Major Trauma in the North of Scotland
A triage protocol for major trauma has been formulated by the Scottish Ambulance Services with the support of the national Major Trauma Oversight Group. The triage protocol, included at Appendix 3, is based on the approach to triage in many countries and in NHS England. The protocol requires patients in need of major trauma care to receive definitive care within 45 minutes - if this cannot be provided within this time at a MTC then arrangements need to be made within a region for the best possible care to be available as soon as possible, and for there to be subsequent transfer to a MTC (secondary transfer).
The response to the protocol requires the designation of facilities based on the level of service that can be provided in a sustainable way. This is a challenge in the north of Scotland given the geographical distribution of the population and services compared to urban areas where a large proportion of the population is within 45 minutes of a MTC. In order to assist the task of clarifying the role of facilities in the coming year a model for major trauma in the north has been developed (see appendix 4) which includes the following levels of care for both the initial part of the pathway and the latter part in terms of rehabilitation and ongoing care/support:
- Major Trauma Centre
- Major Trauma Unit
- Local Emergency Hospital
- Community Hospital
- Community Services
Key Issues and Challenges
Considerable progress has been made in the development of the vision and model for major trauma services in the north of Scotland. Work has also been done to prepare an initial implementation plan which covers all aspects of the major trauma pathway. The initial draft of this plan was submitted in March and a further developed draft version will be submitted for consideration by the Scottish Government in June alongside the plans of the other regions.
The development of the plan has highlighted a number of issues and challenges for consideration by the Board:
- The number of people who experience major trauma is small but resource intensive. It is clear that the focus on major trauma services will have implications for a wide range of patients and services i.e. the implementation of plans for major trauma will result in a broad improvement of care and services for all critically ill and injured patients in the north and transform the way that acute services are organised.
- The approach to the development of major trauma in the north is proving to be a significant focus for enhancing care andimproving clinical support through coordination and integration across the participating Boards. Given the range of services and facilities being considered the process will go some way towards the development of a clinical model for the whole of the region.
- The designation of facilities will require consideration by the Boards and will need to take account of critical mass, distance/unique geography, potential clinical outcomes and sustainability. This will require consultation within the relevant Boards with a focus on what the facilities can provide on a continuous and sustainable basis in relation to competencies and facilities for initial stabilisation until transfer.
- Major trauma care is often regarded as the very acute care provided at the scene of an incident or on arrival at an Emergency Department. However it is important to recognise that the major trauma quality framework requires the improvement of all aspects of the pathway including rehabilitation. Advice received from major trauma centresin England on recent visits by clinicians and managers from Scotland emphasised the need to give due consideration to rehabilitation at an early stage. A considerable amount of early work has been done in the north network on rehabilitation and this will, in due course, require the input of the Integrated Joint Boards (IJBs).
- Retrieval and patient transport is a significant issue in the north of Scotland and a review is being undertaken under the auspices of the North of Scotland Planning Group (NoSPG). The work of the major trauma pre-hospital care, transfer and retrieval task and finish group is informing this. It is likely that there will need to be significant improvements in the transport services in order to ensure that the time taken to definitive care is reduced. This was also highlighted in Mr Jan Jansen’s (National Adviser on Major Trauma) Four MTC Reconfiguration Report produced for the national Major Trauma Oversight Group.
- In ARI and RACH there is a requirement to re-organise the response provided by services to major trauma cases e.g. in relation to the attendance of specialties on the arrival of major trauma cases, access to radiology services 24 hours per day, the development of trauma coordination and leadership, access to ITU and HDU facilities and early goal focussed rehabilitation. The Clinical Director for the MTC and Programme Manager have met with clinical leads and operational managers to ascertain any challenges and the potential improvements/actions required. A draft MTC Implementation Plan has been produced and will be further developed based on the output of the event on the 13May. Many of the emerging improvements/actions highlighted will enhance care, outcomes and processes for all patients andimprove sustainability.
- When the national recommendations regarding major trauma were approved by the Cabinet Secretary in 2014 it was advised that there would be a further review of the number of major trauma centres in Scotland. This review will be informed by a geo-spatial study undertaken by Mr Jan Jansen, Consultant Surgeon/Intensivist at ARI who is also the National Adviser on Major Trauma. A subgroup of the national Major Trauma Oversight Group will be established to undertake the review which should be complete by the end of 2015.
- There will be a requirement for additional resources to meet the requirements of the quality framework for major trauma and the specific requirements for the north of Scotland are currently being formulated. The Scottish Government have advised that specific funding may be available and they will consider the plans submitted by the regions in due course. It is important to recognise, however, that treating and managing major trauma cases is not a new requirement, and that many of the actions necessary to meet the quality framework will be necessary across the pathway in any case over the next five to ten years if high standards of care are to be provided for critically injured and ill patients. In relation to ARI the focus on major trauma will also highlight a number of areas which require to be addressed to ensure sustainability as a major teaching and tertiary centre, and be consistent with the needs of other initiatives including the provision of seven day services.
- Risk Mitigation
This paper relates to corporate risk 851 – the delivery of strategies to meet the future needs of the population.The north of Scotland approach and actions being taken forward supports the mitigation of the risk in relation to people who suffer from a critical injury or illness.
5.Responsible Executive Director and contact for further information
If you require any further information please contact:
Responsible Executive DirectorGraeme Smith
Director of Modernisation
Date: 27 May 2015 / Further information is available from:
Lorraine Scott
Programme Manager
Paul Bachoo
Clinical Director, Major Trauma Centre
Pete Williams
Clinical Lead, North of Scotland Major Trauma Network
Appendix 1
Appendix 2
Proposed Vision for Major Trauma Care in the North of Scotland
Background
It is critical that there is a shared vision (and underpinning principles) for the delivery of major trauma care across the North of Scotland (NoS). This document aims to outline the proposed NoS vision and principles (as part of the national network for major trauma care) setting out the collective aspirations for the delivery of high quality, safe and sustainable major trauma care (pre-hospital to ongoing care, generic and specialist) for the population within the NoS.
This document has been shared widely and discussed at a series of meetings across the NoS in order to engage with as many individuals/teams as possible in order to develop a single shared vision for the NoS. The vision was approved at the NoS Major Trauma Programme Group meeting held on the 11th February 2015.
The vision will be reviewed periodically. It will also be underpinned by a NoS Major Trauma Implementation Plan setting out the key actions to effectively and efficiently deliver the agreed vision and principles.
Proposed Vision and Principles for Major Trauma Care in the North of Scotland
Major trauma is a term used to describe injuries that are, or have the potential to be life changing or life threatening. Major trauma patients require specialist care from a wide range of healthcare professionals. There are many causes of major trauma but the most common causes are road traffic accidents, falls and assault.
The proposed vision for major trauma care in the NoS is that every person (regardless of age) who experiences major trauma receives responsive, high quality person-centred care from the point of first contact through to recovery. The delivery of care will be provided through a robust multi-professional/multi-agency network approach (as part of the inclusive national network for major trauma) ensuring that care is co-ordinated around the individual’s needs. The focus of all professionals and agencies contributing to the individual’s care is around maximising the impact of available resources around clinical/health outcomes, ensuring the best possible experience for individuals and their families/carers, whilst minimising the long term impact and maximising quality of life.
Key principles underpinning the proposed vision are outlined below.
Network Approach
- High quality, safe and effective person-centred major trauma care (pre-hospital to discharge/ongoing care) will be underpinned by a network approach across the NoS which is also part of the national network for major trauma. This approach will be supported by timely access to senior decision support, timely communication and the transfer of information/images, agreed standardised communication processes/documentation, agreed pathways of care and in/outreach educational programmes.
- The delivery of the agreed outcomes for the NoS Major Trauma Network is the responsibility of all Boards, agencies and professionals (clinical and non-clinical) who have a direct/in-direct role in the provision of major trauma care. All professionals will respect each other and acknowledge the contribution and the circumstances to which others operate in.
- All population groups will have major trauma care planned on a person-centred basis, including consideration to family/carer issues.
- The provision of major trauma care will not disadvantage other individuals requiring health/clinical care.
Pre-hospital, Transfer & Retrieval Care
- Rapid response will be provided by a suitably trained clinician (or team as appropriate) to provide a timely pre-hospital assessment and initial management to the individual. Clinicians will have immediate access to senior decision support at all times.
- Based on the initial assessment and the nationally agreed triage tool, safe and efficient transfer/retrieval will occur without delay to the most appropriate hospital with the necessary services to manage the individual’s injuries. In some circumstances the local hospital will have appropriate facilities and expertise to provide definitive treatment for the specific individual’s needs.
- If the individual requires to be transferred to a major trauma centre (MTC) but the transfer time is beyond 45 minutes, or if the individuals condition is unstable, they will be transferred to the nearest facility which has the capacity and expertise to resuscitate and stabilise prior to onward transfer or retrieval. Transfer decisions will be supported by agreed bypass protocols and immediate access to senior decision support. For those individuals who are on the boundary of the 45 minute transfer time to a MTC, decisions will be made on a case by case basis to ensure minimum delays to definitive care.
- When individuals cannot be safely transferred due to adverse weather conditions, ongoing virtual support will be provided by the appropriate MTC team based on both the needs of the individual and the team currently providing care.
Major Trauma Centre/Hospital Care