National Planning Forum Major Trauma Sub Group. A Quality Framework for Major Trauma Services Report to NPF September 2013 (v1.0)

Transcription

1 National Planning Forum Major Trauma Sub Group A Quality Framework for Major Trauma Services Report to NPF September 2013 (v1.0) Table of Contents Page 1 Executive Summary 2 2 Introduction 4 3 Current Context 6 4 Background and methodology 10 5 Epidemiology 11 6 Evidence 12 7 Current major trauma service provision in Scotland 16 8 Major Trauma Data 21 9 Quality Framework for Major Trauma Pre Hospital Care Acute Care Ongoing Care Rehabilitation Performance Implications, Challenges & Opportunities Options and Conclusion References & Appendices 72

2 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Executive Summary The National Planning Forum has been asked to look at possible ways to enhance existing major trauma services (for all ages) in Scotland. Trauma remains the fourth leading cause of death in western countries and the leading cause of death for people under 40. Each year in Scotland, around 5000 people are seriously injured, with around cases being defined as major trauma. It is estimated that each year, there are also 100 cases of major trauma in children under 16. For each trauma fatality, there are two survivors with serious or permanent disability that will have significant impact on quality of life. Trauma is not only a leading cause of death but also a large socio-economic burden; Major trauma patients comprise only 0.2% of the emergency medicine workload, resulting in many hospitals and hospital staff being unable to maintain optimal skills in major trauma care. It can commonly exceed the capacity of local healthcare services, and there is currently no supporting infrastructure, or consistent use of appropriate triage and tasking tools and protocols across Scotland; People who sustain major trauma have better outcomes if they are quickly delivered to definitive care from a specialist multi-disciplinary team. Definitive major trauma care should be consultant led and be available on a single site, 24 hours a day. Time from injury to definitive care is a primary determinant of outcome in major trauma, not time to arrival in the nearest emergency department; The Scottish Health Technologies Group (SHTG) has found that there is limited published secondary evidence on the clinical effectiveness of major trauma centre (MTC) care compared with usual care and did not identify relevant cost-effectiveness evidence generalisable to the UK. However, clinicians on the MT Subgroup point out that many of the early studies on MTCs did not consider patients who did not survive to transfer and a systematic review the primary literature is infeasible. There is however, compelling published primary literature, and recent evidence from England, which demonstrates that MTC care reduces mortality and improves outcomes, including better functional outcomes. There is also some evidence that suggests MTC care is not only effective, but also cost-effective; In addition, there is no evidence to suggest major trauma outcomes and treatment are superior in hospitals lacking in experienced and appropriately qualified personnel. It is highly unlikely that patients badly injured in Scotland are somehow different to those elsewhere in the world; The chance of patients surviving major trauma in England has increased by 20% (1 in 5) in the year since the Major Trauma Networks went live (in April 2012). The Quality Strategy makes it clear that services should be safe, effective and person centred and the overwhelming view of clinicians is that MTCs improve outcomes and provide safer care. One third of major trauma patients are currently transferred to more definitive care and there is evidence which shows that the outcomes for patients who are transferred, is worse than those who access definitive care. Ensuring major trauma patients access definitive care first time, wherever possible is clearly best for patients; Consequently, the NPF Major Trauma Subgroup recommends that major trauma services at the Southern General Hospital Glasgow, Aberdeen Royal Infirmary, Ninewells hospital and the Royal Infirmary Edinburgh are enhanced to become major trauma centres and operate as 4 hubs within a national major trauma network which will improve major trauma care across the entire network, not just in the proposed MTCs, but in all hospitals, that continue to receive major trauma; The NPF Major Trauma Subgroup also recommends that major trauma services for children are aligned as far as possible within the national major trauma network. All major trauma patients that are able to reach one of the 4 proposed centres should be taken there. The proposed changes will mean diversion of a small number of complex patients to centres better equipped to deal with them; Local hospitals will still deal with 2

3 some major trauma cases, where patients are unable to access definitive care within 45 minutes; There should also be an opportunity for clinicians with an interest in major trauma to carry out sessions at an MTC as part of their job plan. This will help ensure that they are able to deliver definitive care and received appropriate major trauma training that will benefit the wider network; A national quality framework that will support the safe, effective and person centred delivery of major trauma care has therefore been developed; There will be resource and capacity implications for NHS Boards and the Scottish Ambulance Service, associated with implementing the Major Trauma Quality Framework, should NPF and NHS Board Chief Executives support the recommendations set out in this report; Implementation of the Major Trauma Quality Framework might require access to additional capacity in terms of critical care. Further additional investment in the consultant workforce (including interventional radiology) for the acute phase of the pathway may also be required. Similarly, additional investment in rehabilitation staffing, both for the rehabilitation services at each MTC, as well as within local NHS Boards might be required, including additional psychological support for both major trauma patients and potentially their families. Nevertheless, the NPF Major Trauma Subgroup expects that implementation of the quality framework will help NHSScotland to deliver world class major trauma services, ensure definitive trauma care is provided across Scotland and importantly, better outcomes for people who experience major trauma.

4 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Introduction 2.1 Background 1. Major trauma describes serious and often multiple injuries where there is a strong possibility of death or disability. It is the most common cause of death in young people in the UK. 2. Road traffic incidents, falls, sporting injuries, occupational hazards and violence can all result in major trauma. 3. Each year in Scotland around 5000 people are seriously injured, with around cases being defined as major trauma (injury severity score>15) 1. Major trauma generally includes such injuries as: Traumatic injury requiring amputation of a limb; Severe knife and gunshot wounds; Major head injury; Multiple injuries to different parts of the body e.g. chest and abdominal injury with a fractured pelvis; Spinal injury; and, Severe burns. 4. Some patients with an ISS <15 are also at risk of death and disability. For example, the elderly or very young may be more likely to die from a more moderate injury than a young adult. 5. Following developments in England, the Royal College of Surgeons Edinburgh (RCSE) published the Trauma Care in Scotland report (May 2012), which recommends that a coherent, integrated and inclusive national trauma service is developed, and that further work takes place to determine the optimal configuration of major trauma care in Scotland. 6. The Cabinet Secretary agreed that work should be carried out under the auspices of the National Planning Forum (NPF), to explore possible ways to enhance existing major trauma services in Scotland, and in June 2012, the NPF agreed that a subgroup should be established to take this work forward. 2.2 Remit 7. The remit of the NPF Major Trauma subgroup has been: To explore possible ways of enhancing current major trauma services in Scotland. The group will report to the NPF on its recommendations for enhancing major trauma services in Scotland by spring The NPF Subgroup has therefore developed a national quality framework to support delivery of major trauma care across Scotland, and improve outcomes for 1 Scottish Trauma Audit Group ( 4

5 the adult and 100 children seriously injured in Scotland each year. This work has included: Describing the current configuration of trauma services in Scotland; Setting out the inter-dependencies and co-located services which are required for treating major trauma patients including workforce and training issues; Assessing current data collection for major trauma in Scotland and advise on any further audit requirements; and, Defining and describing a quality framework for major trauma services including a model of care which will help ensure that there are clear patient pathways which span: pre-hospital care; acute trauma care; ongoing care; and, rehabilitation. 9. In developing this framework, consideration has been given to the involvement of multidisciplinary teams, the use of telehealth and the challenge posed by Scotland s geography. 10. The NPF Major Trauma Subgroup was also asked to make recommendations on the configuration and location of major trauma services. This work was not to involve closure of existing A&E units, and any recommended enhancements were to be carried out in conjunction with the wider national strategic quality improvement work on unscheduled care.

6 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Current Context 3.1 UK Perspective 11. There have been a number of recent English-focused reports that have identified serious failings in trauma care delivery with the 2007 NCEPOD report identifying that almost 60% of patients in the study, received a standard of care that was less than good practice Making a comparison with outcomes in the US, the NAO estimated that mortality for patients admitted to major trauma in England was 20% higher. 13. While the above evidence has been cited it has also been contested and comparisons with the US are potentially risky as there is a significantly higher incidence of major trauma in the US. Nevertheless, plans have been implemented in England to improve major trauma services. Trauma networks that include the 4 existing major trauma centres (MTCs) in London, and 22 new MTCs specialising in treating patients who experience major trauma opened across England on 2 April Scotland Perspective 14. Scotland has a population of around 5.2 million, and around major trauma patients per year. Distribution of major trauma cases across 30 hospitals with varying capabilities makes it unlikely that any one hospital can accumulate sufficient experience to optimally manage patients with major trauma at this time. 15. Major trauma occurs at low frequency but with high acuity and is inherently unpredictable. It can commonly exceed the capacity of local healthcare services, and there is currently no supporting infrastructure, or consistent use of appropriate triage and tasking tools and protocols Workforce and training issues 16. Major trauma patients comprise only 0.2% of the emergency medicine workload 3, resulting in many hospitals and hospital staff being unable to maintain optimal skills in major trauma care. 17. Although some hospitals in Scotland participate in the Scottish Trauma Audit Group (STAG) audit, there is currently no clinical governance framework or implementation assurance for major trauma care in NHS Scotland, and participation in the STAG audit is not mandatory. 18. Major trauma care should be consultant led although trainees have an important role in the delivery of safe and effective care. The European Working Time Directive and New Deal regulations have had a significant effect on the number of 2 The National Confidential Enquiry into Patient Outcome and Death. Trauma, who cares? National Audit Office, Major Trauma Care in England, National Audit Office,

7 hours trainees have available for rotas and it will become more difficult to maintain provision of major trauma services at multiple sites from junior staff present at hospital with on-call consultant cover. The delivery of major trauma care from a smaller number of sites should help ensure they are properly equipped and resourced. 3.3 Why change is necessary Vision 19. Fundamentally, we should seek to optimise outcomes for people who experience major trauma in Scotland. 20. The Scottish Government's 2020 Vision is that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting and, that we will have a healthcare system where: We have integrated health and social care; There is a focus on prevention, anticipation and supported self-management Hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm; Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions; and, There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of readmission. 21. In order to deliver safe, effective and person centred care for major trauma patients and achieve the best outcomes, we need to reduce mortality and disability and ensure they continue to be supported to help maximise their quality of life Improving patient care and outcomes 22. Currently, patients who suffer major trauma are taken to the nearest hospital, regardless of whether it has the skills, facilities or equipment to deal with such serious injuries. This often means patients end up being transferred, causing delays in people receiving the right treatment. 23. Many deaths could be prevented and better outcomes and quality of life achieved with systematic improvements to the delivery of major trauma care. It is worth noting that major trauma patients (ISS>15) who are treated initially in local hospitals are times more likely to die than those treated in a major trauma centre 4 (see section for the definition of a major trauma centre). 24. Time from injury to definitive care is also a primary determinant of outcome in major trauma, not time to arrival in the nearest emergency department. 4 London: Modernising major trauma services in London. London severe injuries working group 2001 LSIWG; 2001.

8 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Major trauma patients require definitive care from a multidisciplinary group of professionals, and survival is improved when clinicians can maintain their skills by treating a high volume of trauma patients. Clinicians involved in the NPF subgroup also point out that specialist trauma care can result in better functional outcomes. 26. People with major trauma therefore require urgent and definitive care from a specialist multi-disciplinary team in order to optimise the outcome of their treatment. Definitive major trauma care should be available 24 hours a day, from those with particular expertise, for example vascular, plastic, neuro, orthopaedic, and cardiothoracic surgeons among others, who are co-located on a single site. Definitive care must also be led by clinicians with a particular interest, and training, in the management of patients with severe injuries not just on arrival in hospital, but throughout their inpatient stay. In summary, people who sustain serious injuries have better outcomes if they are delivered to definitive care quickly Benefits of Trauma Networks and Major Trauma Centres 27. A trauma network includes major trauma centres (MTCs) that provide consultant-led specialist teams with access to appropriate diagnostic and treatment facilities round-the-clock and provide life-saving treatment for seriously injured patients. 28. The MTC has a clinical culture and management systems that reflect the importance of integrated trauma care. The centre has a regional leadership role with responsibility for optimising the pathways and care of major trauma patients wherever they are injured in the region. It has senior clinical and executive commitment to the care of major trauma patients and an integrated trauma service responsible for the ongoing care of all major trauma patients in the hospital. 29. The MTC has all surgical specialties and support services (i.e. general surgery, emergency medicine, vascular, orthopaedic, plastic, spinal, maxillofacial, cardiothoracic and neurological surgery and interventional radiology, along with appropriate services such as critical care and anaesthesia) to provide consultant led care, 24 hours a day, for major trauma patients, regardless of their pattern of injury. It supports other hospitals, (pre-hospital care and rehabilitation providers) in the region in optimising the major trauma patient pathway. 30. A major trauma network provides clinical leadership, both within the MTC and the wider trauma system not just in the emergency department, but throughout the entire patient journey. 31. The MTC should have its own robust trauma clinical governance and performance improvement programmes and assists in delivering quality assurance and quality improvement across the major trauma network. The MTC should also have active and relevant research, education and injury prevention programmes that support major trauma care across the region. 32. The MTCs form the core of the network, and work alongside hospitals in the region to ensure that patients reach and receive definitive care quickly. The network approach means ambulances will often take seriously injured patients directly to a 8

9 specialist centre where they will be assessed immediately and treated by a full specialist trauma team. 33. England has recently introduced the trauma network approach and expects that the major trauma system will save up to 600 lives a year. There is a clearly a case for change to implement nationally planned service delivery enhancements in order to provide high quality major trauma services, and optimise patient outcomes. The quality framework for major trauma services set out later in this report describes the model of care which, if implemented, will help to achieve this.

10 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Background and methodology 4.1 Methods 34. The NPF Major Trauma Subgroup met for the first time on 16 November 2012, and having approved the recommended major trauma care pathway set out in the NHS Clinical Advisory Groups Report 2010 and the Trauma Care in Scotland report from the Royal College of Surgeons Edinburgh, focused its initial efforts on identifying current major trauma service provision across Scotland, to assess how it compares with the recommended care pathway. 35. The NPF Major Trauma Subgroup membership is included as appendix A service mapping questionnaire was completed by NHS Boards, to establish current major trauma service provision. Members of the Major Trauma Subgroup have particular expertise that has also helped inform the group s recommendations to NPF and the questionnaire was also sent to members of the Subgroup to capture their views. The resulting information was analysed by the Subgroup at its meetings on 12 February, 28 March 20 May, and has helped identify gaps in current service provision, and informed the Quality Framework set out later in this report. 37. A smaller working group of the NPF Major Trauma Subgroup then met on 20 June to discuss the emerging recommendations on enhancing major trauma care in Scotland. The membership of the smaller working group on major trauma is included as appendix 2. This group met for the final time on 29 August to agree the Major Trauma Subgroup s draft report to NPF. 38. The quality framework and supporting recommendations contained in this report should be considered by NPF at its meeting on 26 September, and following that, by Scottish Ministers. 39. If its Quality Framework and recommendations are approved, NHS Boards will be asked to implement the framework and its supporting recommendations to begin to enhance major trauma services across Scotland. 10

11 5. Epidemiology 5.1 Incidence 40. The exact incidence of major trauma in Scotland cannot be determined as not all hospitals currently participate in the Scottish Trauma Audit Group (STAG) audit. STAG data suggests that around 5000 people sustain significant injuries in Scotland each year, with around 1000 to 1100 of these incidents being defined as major trauma (injury severity score>15) It is also estimated that each year, 100 children under 16 sustain major trauma in Scotland. 5.2 Mortality/ Survival 42. Trauma remains the fourth leading cause of death in western countries and the leading cause of death in the first four decades of life. As the incidence of trauma is particularly high in the younger population; an average of 36 life years are lost per trauma death There are only historical limited data regarding mortality from major trauma in Scotland, although the return of STAG to trauma audit in 2011 is beginning to provide good quality information, where hospitals participate in STAG. 44. The situation in Scotland is likely to be similar to that in England as described by the 2010 NAO report 2. This report highlighted significant deficiencies in the delivery of major trauma care and that survival rates for major trauma vary significantly between hospitals, reflecting variations in the quality of care. The evidence cited suggests that major trauma patients managed initially in local hospitals are times more likely to die than patients transported directly to trauma centres Survival 45. For each trauma fatality, there are two survivors with serious or permanent disability 8 that will have significant impact on quality of life. Trauma is, therefore, not only a leading cause of death but also a large socio-economic burden. Ensuring survivors of major trauma have access to person centred rehabilitation is therefore extremely important. 5 Scottish Trauma Audit Group ( 6 The National Confidential Enquiry into Patient Outcome and Death. Trauma, who cares? National Audit Office, London Severe Injuries Working Group: Modernising major trauma services in London, 2001; McGuffie et al., Scottish urban versus rural trauma outcome study. J Trauma 2005; 59(3): The National Confidential Enquiry into Patient Outcome and Death. Trauma, who cares? National Audit Office, 2007

12 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Evidence 6.1 SHTG Scoping report and Advice statement 46. NPF asked the Scottish Health Technologies Group (SHTG) to review the available evidence for the clinical and cost effectiveness of major trauma centres as the core component of a trauma service, compared with standard care for adults with major trauma. 47. The SHTG Advice Statement was published alongside the Technologies scoping report on Healthcare Improvement Scotland s website on 19 July Review of the literature 48. The technologies scoping report reviewed the available secondary evidence and economic evaluations. SHTG did not review the primary literature Clinical effectiveness 49. SHTG found that there is limited published secondary evidence on the clinical effectiveness of major trauma centre care compared with usual care. However, two systematic reviews of observational studies showed that there is some evidence that major trauma centre care reduces mortality. 50. A systematic review of the impact of inter-hospital transfer on mortality after major trauma showed no difference in in-hospital/ 30-day mortality between direct transport to a MTC and secondary transfer from an outlying hospital, but the authors advised caution in drawing definitive conclusions given the high level of heterogeneity among the observational studies that were included. 51. Most of the primary studies included in the systematic reviews originated in the USA, and marked variation was evident in the trauma centres and systems, comparators and trauma patient populations evaluated. 52. The technologies scoping report did not identify secondary evidence for morbidity or functional outcomes, or service impact outcomes, comparing major trauma centre care with usual care. It also did not identify secondary evidence on the impact of MTC volume on mortality finding only a lack of consensus in key reports Cost effectiveness 53. The technologies scoping report did not identify relevant cost-effectiveness evidence generalisable to the UK SHTG Advice Statement 54. Based on technologies scoping report, SHTG advise that: There is insufficient published evidence from existing systematic reviews to determine whether or not major trauma centres, as the core component of a trauma service, are clinically and cost effective compared with usual care for 12

13 adults with major trauma. The few systematic reviews that have been published show a lack of high quality evidence, marked heterogeneity among primary studies, reliance on mortality as the sole measure of the effectiveness of major trauma centre care, and that most studies have been conducted in settings that may not be generalisable to Scotland. No relevant cost-effectiveness evidence generalisable to the United Kingdom was identified. 6.2 Other considerations 55. The way health services are organised can lead to better outcomes in three main ways. Services can get better results for patients when doctors, nurses and therapists specialise in particular procedures - practice makes perfect. Services can also get better outcomes for patients when clinical teams and facilities (hospital, community and primary care) are organised to meet best practice clinical guidelines, standards or key performance indicators. For communities as a whole, outcomes can be improved when services are organised efficiently, so that resources are used to treat more patients safely and effectively such that the patient is consistently treated by the right person in the right environment Do trauma systems improve outcomes? 56. The recommendations of NCEPOD, the Intercollegiate Group of the Royal Colleges and the NAO reports have all recommended trauma systems, with the development of major trauma centres as the way forward. This is supported by a systematic review which concluded that treating major trauma patients in higher level trauma centres can achieve a reduction of 10-20% of in-hospital mortality 9. SHTG note however, that both of these reports do not report using systematic methods to review the literature, as well as the limitations of the Celso systematic review cited. 57. There is, however, a consensus from within the NPF major trauma subgroup that achieving better outcomes requires more than simply designating a major trauma centre - it requires effective organisation and strong clinical leadership to ensure that higher level trauma centre standards are met and strong triage to ensure patients are transferred to the most appropriate centre. 6.3 Conclusion 58. The NPF Major Trauma Subgroup acknowledges that the existing secondary evidence for improved outcomes and cost effectiveness of major trauma centres is limited. A trauma system is a complex, multi-layered public health intervention. Techniques for synthesising evidence gained from prospective trials do not tend to work well for this type of data. 9 Celso et al, A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems; Journal of Trauma 2006

14 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September There is however a strong view from clinicians on the NPF major trauma sub group that: the secondary evidence reviewed is not up to date; there are several recent key studies, which were not included in the scope of the scoping exercise; synthesising the evidence is difficult, due to heterogeneity of injuries and treatment; there are few prospective studies; most trauma systems that have been researched grew, rather than researching a fully implemented system; early findings from England make a compelling case for the introduction of major trauma networks/ centres; and, that survival from paediatric major trauma is also improved when organised in conjunction with MTC services. 60. Many of the early studies on MTCs did not consider patients who did not survive to transfer. SHTG was not initially asked to review the primary literature and a subsequent full systematic review of the primary literature was agreed to be infeasible. Although the primary literature as a whole has not been systematically reviewed, there is some published primary literature which demonstrates that major trauma centre care reduces mortality 1011, and improves outcomes 12, including better functional outcomes There is also some evidence that regionalisation of trauma care (MTCs) is not only effective, but also cost-effective 14. This needs to be interpreted with caution as the scoping report (which reviewed this US study) did not identify cost-effectiveness evidence relevant to the UK. 62. The most current evidence and perhaps the most appropriate to Scottish circumstances is the emerging evidence from England that supports the introduction of trauma networks. 63. The report by the National Audit Office on Major Trauma Care in England, published in February 2010, found that current services for people with major trauma are not good enough. Only 35% of patients with severe injury were seen by a consultant immediately on arrival at hospital In response to this report, the NHS in England has completely redesigned the system of care for patients with severe injuries. Regional Trauma Networks now 10 MacKenzie et al, A National Evaluation of the Effect of Trauma-Center Care on Mortality, N Engl J Med Moore et al, Evaluation of the Long-term Trend in Mortality from Injuryin a Mature Inclusive Trauma System, World J Surg (2010) 12 Davenport et al, A major trauma centre is a specialty hospital not a hospital of specialties, British Journal of Surgery Gabbe et al, Improved Functional Outcomes for Major Trauma Patients in a Regionalized, Inclusive Trauma System, Ann Surg MacKenzie et al, The Value of Trauma Center Care, J Trauma Major Trauma Care in England. National Audit Office. HC213, 5 Feb Trauma: Who cares? Report of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD)

15 allow the rapid and safe transfer of these patients to designated Major Trauma Centres throughout the country. These provide 24-hour consultant-led care. Expertise has been concentrated in 22 Major Trauma Centres with a further 4 Centres providing care for children alone. The development of these networks has been clinically led by doctors, nurses and allied health professionals including paramedics and physiotherapists, to ensure that the patient receives the best possible care from the scene of the accident through to their rehabilitation at home. The aim is to get the right patient to the right hospital at the right time 17. The system went live for the whole of England in April England recognises that changes in such a complex system might take up to five years to see the full benefits, but the early results show that there has been a tremendous improvement in trauma care throughout England. Communication, from paramedics at the accident scene or in the ambulance, has greatly improved so that the hospital can be alerted in advance and the patient met by a Trauma Team led by a consultant 18. With this pre-alert, 95% of patients are now met by a consultant-led trauma team. Once they arrive at the Major Trauma Centre, patients now receive much more rapid care with faster times to key tests, such as a CT scan 19. This allows the trauma team to identify life-threatening injuries much quicker and so patients are having life-saving operations at an earlier stage. Although patients are spending slightly longer in the ambulance or helicopter, the more rapid and efficient care provided by an expert team at the Major Trauma Centre means that the total time to these key operations is now shorter. 66. Patients who suffer complex fractures and soft tissue injuries are also benefiting from the new system. These injuries often cause permanent disability and require specialist surgery. Previously, these patients could wait up to 7-10 days before being transferred to specialist units. Changes in the system now mean that over 90% of these patients are transferred to the right hospital within two days of injury Results from an independent national audit (Trauma Audit and Research Network) for the first 12 months confirm that these changes have greatly benefitted patients and the chance of a patient surviving severe trauma in England has increased by 20% (1 in 5) in the year since the Major Trauma Networks went live Recovery from severe injury takes up to two years. As well as improving survival, a key aim of the Major Trauma Networks is to improve the quality of life in 17 In % of patients with severe injury in England were taken directly to a Major Trauma Centre. In this increased to 85% - C Moran, National Clinical Director for Trauma NHS England, September % of patients identified by paramedics with major trauma are now met by a consultant-led trauma team when they arrive at the Major Trauma Centre. In , 43% of patients in England with severe injury were met by a consultant-led team. - C Moran, National Clinical Director for Trauma NHS England, September % of patient with a significant head injury now have a CT scan within 1 hour of arrival at hospital. 58% of adults with multiple injuries now have a whole-body CT scan within 1 hour of arrival at the Major Trauma Centre. - C Moran, National Clinical Director for Trauma NHS England, September months ago 75% of patients were transferred to a for complex trauma surgery within 2 days. Now, 92% are transferred to a Major Trauma Centre within the same time frame. - C Moran, National Clinical Director for Trauma NHS England, September C Moran, National Clinical Director for Trauma NHS England, September 2013

16 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 the survivors. The Networks in England have also redesigned the rehabilitation pathways to give the patients the best chance of recovery following surgery. It is predicted that for every additional survivor, 3 further patients will make an enhanced recovery, which hopefully will allow them to return to their families and to work In summary, the NPF major trauma subgroup agrees that the available published evidence is in favour of better outcomes when patients with major trauma are treated in MTCs. There is no evidence to suggest major trauma outcomes and treatment are superior in hospitals lacking in experienced and appropriately qualified personnel. The notion that badly injured Scottish patients are somehow different to those elsewhere is not plausible C Moran, National Clinical Director for Trauma NHS England, September

17 7. Current major trauma service provision in Scotland 7.1 Board questionnaires 70. The NPF Major Trauma Subgroup wrote to NHS Boards on 14 January seeking their help with the work to enhance major trauma services in Scotland. NHS Boards completed a questionnaire which captured current service provision in each board and the Scottish Ambulance Service (SAS). Views on the service redesign Boards and the SAS thought necessary to deliver the major trauma pathway set out in the NHS Clinical Advisory Groups Report 2010 and the Royal College of Surgeons Edinburgh, Trauma Care in Scotland report were also sought. 71. A partial analysis of NHS Board returns was discussed at the NPF Major Trauma Subgroup meeting on 12 February, and the group s feedback taken into account when producing the final analysis set out at appendix 3. It includes a comparison of existing pre-hospital, acute, ongoing and rehabilitation care provision for major trauma across Scotland with the recommended care pathway (set out in the RCSE report) and attempts to identify the gaps. 72. This analysis has helped the NPF Major Trauma Subgroup to highlight a number of issues and informed the subgroup s Quality Framework and supporting recommendations. 7.2 Summary 73. NHS Boards questionnaire returns confirm that there is currently no formal service delivery framework for major trauma care in Scotland. There is no clear system of referral pathways in place across Scotland, nor are there consistent protocols in place, such as a consistent trauma triage tool in use across Scotland, which can result in delays to patients being transferred to definitive care and could lead to poorer outcomes. 74. The exercise confirmed there are currently 30 hospitals across NHS Scotland with A&E receiving units that accept major trauma patients, delivered by the Scottish Ambulance Service (SAS) (table 1 below). However, there is evidence of some regionalisation of trauma care with local protocols in place in two regions to determine the circumstances in which the SAS should bypass certain A&E units. 23 Table 1: NHS Scotland Hospitals with A&E unit Hospital Ayr Hospital Crosshouse Hospital Borders General Hospital Dumfries & Galloway Royal Infirmary Galloway Community Hospital Queen Margaret Hospital Victoria Hospital Health Board A&A A&A Borders D&G D&G Fife Fife 23 In NHS Lothian, St John s Hospital can be bypassed in order to transport a patient directly to the Royal Infirmary of Edinburgh. In NHS Tayside, patients with serious injuries can be taken directly to Ninewells Hospital.

18 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 Forth Valley Royal Hospital Aberdeen Royal Infirmary Dr Gray's Hospital Royal Aberdeen Children's Hospital Glasgow Royal Infirmary Inverclyde Royal Hospital Royal Alexandra Hospital Royal Hospital for Sick Children (Glasgow) Southern General Hospital Victoria Infirmary Western Infirmary / Gartnavel General Lorn and Isles Oban Raigmore Hospital Caithness General Belford hospital Wick Hairmyres Hospital Monklands District General Hospital Wishaw General Hospital Royal Hospital for Sick Children (Edinburgh) Royal Infirmary of Edinburgh St John's Hospital Balfour Hospital Gilbert Bain Hospital Ninewells Hospital Perth Royal Infirmary Western Isles Hospital FV Grampian Grampian Grampian GG&C GG&C GG&C GG&C GG&C GG&C GG&C GG&C Highland Highland Highland Highland Lanarkshire Lanarkshire Lanarkshire Lothian Lothian Lothian Orkney Shetland Tayside Tayside Western Isles 75. No Children s hospital in Scotland has all the required facilities on site, but Aberdeen and Dundee have access to these services on the same site. 76. None of these 30 hospitals meet the requirements for a major trauma centre or even a trauma unit (as defined by the NHS Clinical Advisory Groups Report 24 ). Aberdeen Royal Infirmary has most of the required specialties on site. The Royal Infirmary of Edinburgh (RIE) does not currently have neurological services on site, although these are planned to move from the Western General Hospital to RIE in Ninewells Hospital does not have a cardiothoracic service. Services in Glasgow are fragmented across several hospitals and sites, although some of these will be consolidated at the new Southern General Hospital by around The following table sets out which major trauma services are, or will be missing these 4 sites: Table 2: Major trauma services missing from 4 regional centre hospitals Hospital Missing Major Trauma Services Aberdeen Royal Infirmary No missing services every required specialty on site Royal Infirmary of Edinburgh Burns, Maxillofacial Ninewells Hospital Cardiothoracics New Southern General Hospital Glasgow Plastics, Cardiothoracics 24 Regional Networks for Major Trauma. NHS Clinical Advisory Groups Report. Department of Health,

19 77. The SAS provides pre-hospital care delivery, and is supported by a number of specialist clinical teams, for example Emergency Medical Retrieval Service, Tayside Trauma Team, Medic 1, BASICS doctors and a physician-delivered pre-hospital service in Grampian, as well as other ad hoc hospital teams. 78. Despite the two local protocols referred to above, the service provision survey has confirmed that current practice across NHS Scotland is fragmented, and injured patients are generally taken to the nearest hospital with an Emergency Department. This does not take into account either the severity of the injuries or the facilities and staffing of the receiving unit. Triage of patients and tasking of SAS assets is essential to ensure patients are taken to a hospital capable of caring for their injuries. 7.3 Conclusion & Recommendations 79. Scotland has a population of around 5.2 million, and around major trauma patients per year. The sporadic distribution of major trauma cases across a large number of hospitals with varying capabilities makes it unlikely that any hospital can accumulate sufficient experience to optimally manage patients with major trauma. 80. Mapping current major trauma service provision across Scotland has been helpful in clearly demonstrating the case for change to implement nationally planned service delivery enhancements in order to provide high quality major trauma services, and optimise patient outcomes. To achieve this, the NPF Subgroup recommends that NHS Scotland develops and implements a major trauma network that consists of regional major trauma centres that link with hospitals in their region to provide timely access to definitive care. Recommendation 1: NHS Scotland should develop and implement a national major trauma network to provide timely access to definitive care for all ages across Scotland. 81. The Royal College of Surgeons of England and Edinburgh cite research advising that Major Trauma Centres should admit a minimum of 250 critically injured patients per year 25. There is other valid evidence that suggests that the minimum number of cases should be at least 400, or further evidence to suggest that MTCs should admit more than 650 cases per year. Although services can achieve better results for patients when doctors, nurses and therapists specialise in particular procedures, high volume should not be the only concern. The best outcomes for people who experience major trauma will undoubtedly come from the enhanced services (that ensure all relevant specialties work together on a single site and are available 24/7), that a major trauma centre can provide, although this will require effective organisation and strong clinical leadership to drive improvements. This investment in resources is better justified with high volume caseloads. 82. There are conflicting views on whether having very few, large-volume major trauma centres, and reasonable access times, can be balanced across Scotland. Based on the available evidence and data on major trauma, it has proved difficult to 25 RCSEngland 2009, Interim guidance for commissioners.

20 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 establish precisely, how many high volume MTCs Scotland needs and where they should be located. 83. The ongoing GEOS study described in chapter 8 will help determine the optimal configuration of trauma system for Scotland, to ensure that the majority of injured patients reach definitive care in the shortest possible time. 84. In the interim, any move towards enhancing existing major trauma services in Scotland should however, be incremental. Given that there are 40 hospitals in Scotland that potentially see cases of major trauma, and 30 hospitals with A&E departments, the MT Subgroup s key recommendation is that services at 4 sites should be enhanced to be able to provide definitive major trauma care to everyone who can reach one of these locations within 45 minutes. Recommendation 2: As a first step, services at 4 sites should be enhanced to provide definitive major trauma care to everyone who can reach one of these locations within 45 minutes. This will lead to the creation of 4 major trauma centres at Aberdeen Royal Infirmary, Ninewells Hospital Dundee, Royal Infirmary of Edinburgh and the Southern General Hospital Glasgow, which will work with, and provide the necessary advice and support to, acute hospitals within each region to ensure definitive trauma care is provided across Scotland. 85. It is for NHS Boards to recommend the location of the 4 proposed MTCs, although the Southern General Hospital Glasgow, the RIE Edinburgh, Aberdeen Royal Infirmary and Ninewells Hospital Dundee, are likely locations, given that these hospitals are existing regional centres and already have, or will have, the majority of the key specialties required on site. 86. It is envisaged that the majority of major trauma cases will be cared for at one of these 4 enhanced sites, however acute hospitals in each region will still receive some major cases those which are outwith 45 minutes travel time to any of the 4 MTCs. The existing capability within acute hospitals will remain the same, however they will benefit from the enhanced advice and support provided by the MTC within their area. 87. Appendix 4 includes 2 maps which provide estimates of the number and location of major trauma cases that would be able to reach definitive MTC care within 45 minutes, and an estimate of the number and location of major trauma cases that might require to be taken to hospitals outwith the 45 minute radii. 88. The case for enhancing 4 MTCs is set out in more detail in section Implementation of this recommendation should be viewed as a first step to enhancing major trauma services across Scotland. Further service reconfiguration will be required at some point in the future if major trauma centres are to receive the recommended volume of cases, (a minimum of 250 cases a year in each centre and more likely to be around 400 cases a year), in order to build and maintain multidisciplinary team skills. 20

21 89. The enhancements in care, dedicated leadership and effective organisation required in major trauma centres on 4 sites will be brought about through implementation of the agreed major trauma pathway set out in the RCSE Major Trauma report. Recommendation 3: NHS Boards should implement the agreed major trauma pathway set out in the RCSE Trauma Care in Scotland report. 90. The next chapter on major trauma data aims to support NHS boards with their decision-making. In addition, the quality framework set out later in this report will assist NHS Boards in developing a major trauma network for Scotland.

22 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Major Trauma Data 8.1 Background 91. A small data working group of the NPF Major Trauma Sub-group has gathered the best possible available information on major trauma in Scotland in order to inform development of the a major trauma network. 92. The data group firstly agreed that although there is currently no single accepted definition or agreed list of constituting criteria, the Injury Severity Score (ISS) appears to be the most clearly accepted way of identifying and defining major trauma. 93. The group considered possible sources of data on major trauma including SMR01, Scottish Ambulance Service (SAS) and Scottish Trauma Audit Group (STAG). The strengths and weaknesses of each of these data sources was summarised as follows: SMR01 can provide information on NHS Board of admission and treatment but does not capture geographical location of incidents and the quality of injury coding is difficult to ascertain. There is no severity stratification and the system does not capture ISS. The SAS data system is very inclusive and can provide good geographical data on incident location. It captures all incidents dealt with by SAS irrespective of outcome and destination. However, it does not provide detail of the nature of injuries so cannot be easily cross referenced to ISS. This limited diagnostic information and lack of severity stratification means that assessing the number of major trauma cases from this source is problematic. STAG data groups trauma patients into sub-groups of minor (ISS <8), moderate (ISS 8-15) and major trauma (ISS >15). The STAG also provides information on the cause of injury e.g. assault, fall, RTA, and on category of location of incident e.g. sports venue, home, construction site, transport site. Data on outcome (hospital mortality) is also included. There is no detail of the exact location of retrieval although a two-fold urban-rural classification of incident is recorded. The data is currently incomplete with 20 receiving hospitals in Scotland of 30 participating and not all submitting a full year of data. Pro-rata assessment of Emergency Department attendances suggests that STAG data gives more than 70% coverage of Scotland. This is likely to rise for more significant trauma if there is an onward transfer to a hospital contributing to STAG. 94. The data group concluded that taking into account the strengths and weaknesses of each of these sources, STAG would offer the best current data to inform and provide a basis for NPF sub-group discussions. 22

23 8.2 Current Major Trauma Activity STAG 95. The aim of the STAG Audit is to Improve the Emergency Management of Seriously Injured Trauma Patients in Scotland. The inclusion/ exclusion criteria follow: STAG Audit Inclusion Criteria All trauma patients who enter the hospital via an emergency department and remain in hospital for at least 3 consecutive days, excluding day of attendance; All trauma patients who die in hospital within 3 days of attendance; All trauma patients transferred into ED from another hospital, who remain in hospital for at least 3 consecutive days following attendance at initial hospital All trauma patients transferred out of the hospital within 3 days of attendance, e.g. patients transferred for regional care or localised specialist care, provided they have a total combined inpatient stay of at least 3 consecutive days. All trauma patients managed in resus who meet the above inclusion criteria should be reviewed to determine the presence of exclusion criteria. Exclusion Criteria < 13 years Injuries older than 1 week. Isolated burn injuries Isolated smoke inhalation Isolated lacerations, puncture wounds and bites, with no underlying injury Isolated minor head injuries: no fracture and GCS >13 Isolated Colles fractures Isolated reduction of dislocations Isolated facial injuries Isolated hip fracture in patients aged 65 years or older (Any femur # that is classed as subcapital, intracapsular, intertrochanteric or basal. If the injury is described as proximal shaft of femur confirmation from clinical staff should be gained on whether the injury is being treated as subtrochanteric (exclude) or proximal shaft of femur (include)). Isolated periprosthetic or pathological fractures Isolated dislocation of prosthesis Isolated fractured Pubic Rami in patients aged 65 years or over Patients admitted to medical wards under the care of a physician only should be excluded. However if the patient was admitted to a medical ward as a surgical boarder, or if they were under shared care of a physician and surgeon then they should be included. Patients entering ED with no recordable observations and declared dead within 15 minutes. Patients with no documented Systolic B/P, RR and GCS in ED or on a patient report form (PRF) Patients whose initial reason for admission is social ( specifically documented or from information gained following discussion with clinical staff) Deaths or injury caused exclusively by asphyxia with no anatomical injuries such as hanging, drowning, carbon monoxide poisoning Patients for whom the only reason they are managed in resus is to carry out a procedure such as reduction of fracture etc, should not be included Please note: Any patient with a combination of any of the above isolated injuries are excluded

24 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Volume 96. The most recent available STAG data from 2011 shows the following volume and distribution of major trauma cases in adults (age >16). Paediatric trauma is considered later in this section. Total number of trauma cases aged > Total number and % of these with major trauma (ISS>16) 749 (15.1%) 97. These 749 major trauma cases break down by the 4 STAG regions as follows: Central 86 (11.5%) North 45 (6.0%) South East 196 (26.2%) South West 422 (56.3%) And by NHS Board and Hospital as follows: Table 2: Number and percentage of major trauma cases in 2011 by NHS Board NHS Board Hospital Number and % of MT Cases Ayrshire and Arran Ayr 24 (3.2%) Crosshouse 50 (6.7%) Dumfries & Galloway DGRI 17 (2.3%) Fife Queen Margaret s 36 (4.8%) Forth Valley FV Royal 40 (5.3%) GGC Glasgow RI 78 (10.4%) Inverclyde Royal 17 (2.3%) Royal Alexandra 15 (2.0%) Southern General 49 (6.5%) Victoria Infirmary 35 (4.7%) Western Infirmary 59 (7.9%) Grampian Aberdeen RI 15 (2%) Highland Raigmore 30 (4%) Lanarkshire Hairmyres 28 (3.7%) Monklands 15 (2.0%) Wishaw General 35 (4.7%) Lothian ERI 120 (16%) Tayside Ninewells 82 (10.9%) Perth RI 4 (0.5%) TOTAL 749 (100%) Note: only hospitals that participate in the STAG audit and data available are included in this table 98. A key point to note in relation to these figures is that STAG data is incomplete. Only 20 out of 30 emergency department receiving hospitals currently submit data to STAG and some of these data for the participating hospitals is incomplete. In particular, Aberdeen Royal Infirmary (ARI) only submitted data for 2 out of 12 months. Extrapolating the number of cases from those two months across the year, the total number of major trauma cases for ARI would be around 90. A further estimate using SAS data and the positive predictive value of the Field Triage Decision Scheme estimated a similar number. This represents an additional 75 cases for the North region and would bring the total number of major trauma cases in 2011 to

25 99. Although unable to determine a precise figure, the NPF Major Trauma Subgroup agrees that the number of major trauma cases in Scotland is likely to be between Geographic Distribution 100. In terms of geographical distribution, the STAG data (by Region, NHS Board and Hospital) above gives some indication of the geographic spread of trauma incidents Further information on geographic distribution can also be found through analysis of SAS data, although this data does not provide information on the nature or severity of injuries. A recent study (Morrison et al 2012), on the rural and urban distribution of trauma, used SAS data to examine incidents over one year. This provided useful information described in the map and figure 1 below: Geospatial distribution of trauma incidents attended by Scottish Ambulance Service, Nov 2009-Oct 2010 Jan Jansen, Aberdeen

26 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 Figure 1: Number of incidents, by NHS board, Nov 2008-October This information demonstrates that the majority of trauma incidents take place in more densely populated urban areas. This includes across the central belt and to a lesser extent the north and east covering Grampian and Tayside Transfers 103. Of the 749 major trauma cases in 2011, 276 (36.8%) required transfer to another hospital either directly from the Emergency Department or at a later point in their care. It is interesting to note this transfer rate is virtually identical to the NAO report in 2010 from England Of these 276 transfers, 200 (72.5%) were to either Western General Edinburgh, or Southern General Glasgow, for neurosurgical care. A further 37 (13.4%) were to 26 Rural and urban distribution of trauma incidents in Scotland, Morrison et al, BJS, February

27 the Southern General s Spinal Injury Unit. There is no accurate data currently available on the transfer of paediatric trauma patients A significant proportion of major trauma cases currently require transfer at some point in their hospital stay and traumatic brain injury and spinal injury are important reasons for transfer. STAG data consistently demonstrates that around one third of major trauma patients undergo a subsequent transfer from the initial receiving site for both clinical and non-clinical reasons and around 75% of these transfers are to neurosurgical care. This increases the time to definitive care for the patient and can significantly deplete the critical care resources of the transporting site TARN data shows patients requiring neurosurgical transfer in England had over double the mortality compared to those taken directly to a centre with a neurosurgical service. The NPF Major Trauma Subgroup agrees that Scotland should aim to virtually abolish transfers in Scotland through the reconfiguration of major trauma services. Evaluation of outcome for all transfers must therefore be compulsory. Recommendation 4: Evaluation of outcome for all major trauma patients (including children) who are transferred must be compulsory. A national KPI should be developed that would seek to help eliminate unnecessary transfers. 8.3 Considerations The number of Major Trauma Centres required 107. In an attempt to inform its recommendation on the number of MTCs that Scotland might require, the NPF subgroup has extrapolated STAG data, to estimate the number of major trauma patients that would be treated in MTCs, depending on the number of sites: Major Trauma Patient numbers per MTC: One MTC, located in the Central Belt 824 patients Two MTCs, located in the Central Belt (582 patients) and North East (242 patients) Three MTCs, located in the Glasgow (422 patients), Edinburgh (196 patients) and North East (206 patients) Four MTCs, located in Glasgow (422 patients), Edinburgh (160 patients), Aberdeen (120 patients) and Tayside (122 patients) 108. The above patient numbers have been calculated using 2012 STAG data, reporting on 2011 activity. An estimated figure for Aberdeen has been included. Numbers may vary due to a potential underestimate of the figures, which might influence NHS Boards thinking on major trauma service reconfiguration and overtriage. It is also important to note that STAG relies on data on the hospital that the patient was taken to, and not the incident location, introducing additional bias.

28 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Estimates of over triage of patients considered to have sustained major trauma are as high as 50%. This would need factored into planning logistics. It is worth noting however that over triage is essential in order to minimise under triage, which is associated with excess mortality 110. STAG data has been helpful in estimating the number of major trauma cases that each region deals with and is likely to deal with, however it is incomplete. It has not proved possible to make a recommendation on the number of trauma centres Scotland might need and their ideal location, as available data is insufficient A key point is that NHSScotland should not send major trauma patients to hospitals that cannot provide definitive care. All major trauma patients that are able to reach one of the 4 centres that can provide definitive care within 45 minutes should be taken there. The proposed changes will mean diversion of a small number of complex patients to centres better equipped to deal with them Major trauma services at the Southern General Hospital Glasgow, ARI, RIE and Ninewells hospital should be enhanced to allow them to become major trauma centres (MTCs) and operate as 4 hubs within a national major trauma network In 3 cases (ARI, Ninewells, and RIE) these centres are the regional referral centres for multiple trauma and only modest reorganisation of referrals in these areas should be required. There will however, need to be enhancement of facilities, clinical leadership, staffing, training and processes to allow them to function as MTCs, and make a difference. The west is perhaps a more difficult problem; clearly the new SGH most closely approximates a MTC and is a realistic choice These 4 hospitals already have, or will have, all or most of specialties required to deliver definitive major trauma care on site. And given Scotland s geography, 4 MTCs makes sense as a first step to enhancing major trauma care. These 4 hospitals also have helicopter landing pads Neurosurgical care is a vital component of major trauma care and is available, and will continue to be available, at each of the 4 proposed MTCs. If NHS Scotland was to consider the implementation of fewer than 4 MTCs in the first instance, there may be a risk that the remaining MTCs (3, 2 or 1) would be overwhelmed The NPF Major Trauma subgroup s recommendation is therefore to enhance major trauma services at 4 key sites. This is by no means considered the optimal configuration for a major trauma network in Scotland, but should be viewed as a pragmatic first step, until better data (through GEOS) becomes available Receiving sites 117. Including Community Hospitals, there are around 40 hospitals that can receive major trauma patients and there are currently only 2 bypass protocols in place. This means that at present, the Scottish Ambulance Service normally takes a trauma patient to the nearest receiving hospital, irrespective of the available resources or the volume of trauma episodes it receives. 28

29 118. The NPF Subgroup recommends that individual NHS Boards should assess the preparedness of each of their sites, to deal with major trauma and agree detour procedures with the SAS where appropriate. Process and outcome data must also be reviewed on these sites for each major trauma case received as part of an ongoing quality improvement process. Recommendation 5: NHS Boards should assess the readiness of each major trauma receiving site, including Community and Paediatric Hospitals, and agree detour procedures with the SAS, in line with the Prehospital Quality Framework set out at Recommendation 6: Process and outcome data must also be reviewed at these sites for each major trauma case as part of an ongoing quality improvement process The following table demonstrates the possible impact of these recommendations in terms of the estimated reduction and increase in numbers of cases seen across the current sites. STAG data is not complete and does not record the exact location of trauma incidents. As a result, this information will not be completely accurate. The table should be interpreted with caution. Not all major trauma patients who currently go to local hospitals can be taken to one of the proposed 4 MTCs within 45 minutes, even by helicopter. Scotland will not have a perfect trauma system, with no undertriage. Nevertheless, it does provide a useful indicator of the possible impact on existing emergency department services. Table 3: estimated number of major trauma cases by NHS Board and individual hospital NHS Board Hospital Current No. of MT Cases per year No. of MT Cases and increase / decrease (+/-) per year under proposed framework Ayrshire & Arran Ayr 24 0 (-24) Crosshouse 50 0 (-50) Dumfries & Galloway DGRI 17 0 (-17) Fife Queen Margaret s 36 0 (-36) Forth Valley FV Royal 40 0 (-40) Glasgow RI 78 0 (-78) GG&C Inverclyde Royal 17 0 (-17) Royal Alexandra 15 0 (-15) Southern General (+373) Victoria Infirmary 35 0 (-35) Western Infirmary 59 0 (-59) Grampian Aberdeen RI 90 (estimate) 120 (+30) Highland Raigmore 30 0 (-30) Lanarkshire Hairmyres 28 0 (-28) Monklands 15 0 (-15) Wishaw General 35 (-35) Lothian ERI (+40) Tayside Ninewells (+40) Perth RI 4 0 (-4) Shetland Gilbert Bain n/k n/k TOTAL Note: only hospitals that participate in the STAG audit and data available are included in this table

30 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September The greatest impact in terms of numbers of cases seen annually would appear to be the reduction of cases currently dealt with at Glasgow Royal Infirmary that would be treated by the Southern General Glasgow Column 4 of the above table assumes that every person that experiences major trauma is taken to an MTC. It is accepted that if projected travel time is more than 45 minutes, patients should be diverted to the nearest hospital. This means that a proportion of these patients (depending on the location of their incidents, and availability of helicopters) will still be taken to non-mtc hospitals Pre-Hospital 122. Enhanced pre-hospital expertise is available in certain areas with Medic 1 in Edinburgh, Tayside Trauma Team based in Dundee and Emergency Medical Retrieval Service based in Glasgow. Co-ordination and enhancement of these services, working collaboratively with the SAS, is ongoing Pilots evaluating enhanced triage decision making support have been very positive. Recommendation 7: Work to progress pre-hospital triage and decision making should continue. Protocols for all ages should be developed that give clear guidance in line with the Prehospital Quality Framework set out at Recommendation 8: A network of enhanced care medical teams should also be established within Scotland capable of delivering critical care interventions and operating under a single Governance Structure Assurance 124. In England, the National Audit Office Report from 2010 set in motion a series of events to establish trauma networks. The report detailed the explicit requirement that all sites receiving trauma patients must submit data to the national Trauma Audit and Research Network (TARN STAG s equivalent in England) and that this information should be used for quality improvement At the time of this report, 114 hospitals (59% of hospitals delivering trauma care) voluntarily submitted data for analysis and comparison. As further enhancements to trauma care are implemented, this must be assured via STAG Paediatric Trauma 126. There is currently no single audit or data source for capturing specific information on paediatric trauma in Scotland. Injury Severity Score (ISS) cannot be directly translated retrospectively from SMR01 data and in addition, this scoring is not specifically validated for children In an attempt to estimate the number of paediatric major trauma cases in Scotland, a proxy indication was used - All cases that required a stay of 3 days or more, or died on day 1 or 2, or who were transferred indicated major trauma. Other 30

31 caveats to note concerning this approach are that quality of coding and appropriateness of all the codes used is difficult to ascertain and is likely to be over inclusive, rather than exclusive and not robust The NPF Major Trauma Subgroup agrees that the geographic distribution of paediatric major trauma is likely to have a similar pattern to that in adults aligned with population density. However, based on extrapolation from data from England, there would only be approximately 100 Paediatric Major Trauma cases in Scotland per year. This estimate is supported by the personal knowledge and experience of paediatric colleagues involved in the NPF Major Trauma Subgroup Two sites (SGH and RIE) will have paediatric services and paediatric ICU on site in the foreseeable future Following discussion with both STAG and paediatric colleagues the overall conclusion is that there is an urgent need for mandatory collection of paediatric trauma data and this should be developed via STAG Geospatial Evaluation of Systems of Trauma Care for Scotland (GEOS) 131. The GEOS study aims to identify whether the conflicting objectives of largevolume major trauma centres, and reasonable access times, can be balanced, and what the cost of such a system would be. The study will determine the optimal configuration of trauma system for Scotland, to ensure that the majority of injured patients reach definitive care in the shortest time possible Phase 1 of the GEOS study comprises the prospective application of a validated triage decision scheme, to determine which trauma patients, attended to by the Scottish Ambulance Service and the Emergency Medical Retrieval Service, require high-level trauma care. Geographical and triage data will be collected for 15 months, as of April Phase 2 comprises the calculation of travel times from incident locations to possible destination health care facilities, using different modes of transport, by geospatial information services software. This phase has been successfully tested Phase 3 involves the modeling of different configurations of trauma system. England has adopted a three-tier approach to stratifying capability, comprising major trauma centres, trauma units, and local emergency hospitals. The same system will be used for GEOS. Each hypothetical configuration will consist of a number of major trauma centres and trauma units. The algorithm will determine the number of patients who would have gone to each centre, given its hypothetical designation, and the access times, helicopter usage, etc. The development and testing of the decision making and modelling algorithms has been completed Phase 4 comprises the selection of the optimal configuration of trauma system, from the large number of possible configurations investigated in phase 3, using multiobjective optimisation methodology. The development of the optimisation algorithm has also been completed Phase 5 will determine the cost and cost-effectiveness of the trauma systems selected by phase 4. This phase is in planning.

32 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September The GEOS study is currently accruing data, and is expected to be completed in July Data summary 138. In relation to major trauma data, NPF will wish to note the following key points: While the GEOS study will undoubtedly provide a far more comprehensive and valid picture of the effect of different configurations of trauma network in Scotland, it is not expected to be completed until July The NPF Subgroup has agreed that Scotland should not postpone work on enhancing major trauma services until then. Taking into account the various caveats STAG has been acknowledged to currently provide the best available data. An accurate figure cannot be provided but a best estimate of numbers of major trauma cases in Scotland would be between per year. Accurate data on geographic distribution of major trauma is also not currently available but the indication is that the numbers are greatest in line with overall population i.e. across the central belt and the north east. More than a third of MT cases currently require transfer and neurosurgery appears to be particularly important. Currently available data on paediatric trauma is more complex to obtain and likely to be less reliable. This requires further work. The broad indication is that in Scotland we would expect to see around 100 paediatric major trauma cases annually. The geographic distribution of paediatric trauma is likely to have a similar pattern to that in adults aligned with population density. 8.5 Recommendations for Future Trauma Data Collection 139. The NPF Major Trauma Sub-group has agreed the following recommendations to improving future data: Recommendation 9: STAG should continue and all hospitals must participate in STAG the audit. This will ensure more complete data collection. The STAG audit should be extended to include patient-centred outcomes. Enhancing local level support will be crucial to implementing this recommendation. Recommendation 10: Data linkage work between STAG, SAS and, EMRS/ ScotSTAR should be progressed. This will allow for full patient journey data to be collected including more precise incident location and pre-hospital care. Recommendation 11: Data linkage work between STAG and SMR01 data should be progressed. This will enable valuable information to be explored in relation to outcomes and survival. It will also allow for links between major trauma outcome and other information, such as deprivation and prior patient morbidity to be explored. Development of a HSMR type measure for trauma should also be considered as a tool for performance improvement. 32

33 Recommendation 12: For paediatric trauma a new specific component of STAG should be developed. The methodology of this will be challenging and there are issues to overcome such as validated scoring for injury severity, however this should not preclude collecting injury data. This work should be prioritised. As an interim measure, a crosswalk exercise from Children s SMR01 to AIS should be considered to in order to identify some more accurate estimates of paediatric trauma activity, although it is clear that the mandatory prospective collection of paediatric trauma data is essential to permit accurate planning of paediatric trauma services. Recommendation 13: Once published, the findings of the GEOS study should be taken into account when considering future configurations of a trauma network in Scotland, including whether the number of major trauma centres can and should be reduced further from 4 MTCs and where the optimal location(s) might be.

34 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Quality Framework for Major Trauma Services 9.1 Introduction 140. The NPF Subgroup has developed a national quality framework to support delivery of enhanced major trauma care across Scotland The following sections of this report describe a model of major trauma care which includes the recommended patient pathway set out in the NHS Clinical Advisory Groups Report 2010 and the RCSE Major Trauma report and supporting recommendations which span: pre-hospital care; acute trauma care; ongoing care; and, rehabilitation In developing this Framework, consideration has been given to the involvement of multidisciplinary teams, the use of telehealth and the challenge posed by Scotland s geography The NPF Subgroup envisage that by implementing the Quality Framework and recommendations above on data, configuration and the location of major trauma services, a coherent, integrated and inclusive major trauma network will be established across NHS Scotland - A network that will be well placed to optimise outcomes for people who experience major trauma. 34

35 9.2 Pre Hospital Care Introduction/ background 144. Pre-hospital care encompasses the response from the call alerting the emergency services, to on-scene care, triage, primary transfer and (if required) interhospital transfer Major trauma patients managed initially in local hospitals are times more likely to die than patients transported directly to trauma centres, and the average delay in transferring patients from a local hospital to a major centre in the UK is 6 hours 27. In contrast, longer pre-hospital times have a minimal effect on trauma mortality or morbidity, even in rural areas such as the west of Scotland. It is probable that there is a critical time after which some hospital care may be better than no hospital care, but this time is not known, and almost certainly varies from patient to patient. Many trauma systems use a cut-off of 45 minutes The NPF major trauma subgroup therefore recommends that all major trauma patients should be taken to a MTC directly, bypassing other hospitals within 45 minutes. If a casualty cannot be delivered to definitive care within this timeframe, they should be taken to the nearest facility capable of receiving trauma patients Implementation of the major trauma pre hospital quality framework set out below will help to ensure that people who experience major trauma access definitive care quickly. 27 A C McGuffie, C A Graham, D Beard, J M Henry, M O Fitzpatrick, S C Wilkie, G W Kerr and T R J Parke. Scottish urban versus rural trauma outcome study. The Journal of Trauma 2005;59(3):632

36 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Pre-Hospital Major Trauma Quality Framework PATHWAY STANDARD A Trauma Triage Tool should be used to identify major trauma WHAT ARE THE RECOMMENDED NEXT STEPS? A triage tool is essential for identifying patients who require specialist care, and to determine how such optimal care can be delivered. A triage tool must be developed and implemented to help identify patients who might benefit from critical care resources at the scene. The Scottish Ambulance Service should introduce a trauma triage tool to aid ambulance clinicians in early identification of patients with serious injuries. This triage tool will be based on the mechanism of injury, the presence of obvious injuries and the patient s vital signs. A number of examples of trauma triage tools have been in use in England as part of their trauma system over the past four years. Validated examples of best practice from these services will be adopted. If required these will be adapted to address Scotland s geography. The triage tool adopted must be rigorously validated during its first 12 months of use. Following this, it should be modified to improve its sensitivity, specificity and applicability to local circumstances. A paediatric version of the tool will also be required. The London Ambulance Service already operates a paediatric trauma triage tool. For reasons of patient safety it is important that the triage tool adopted identifies as many major trauma patients as possible. Implementation of Trauma Triage Tool should support tests of change in relation to emergency department pre alert. Triage must be linked to tasking (see below). This is a national system-wide issue. It requires national leadership and oversight. HOW MIGHT ANY RISKS BE MITIGATED? Triage attempts to identify patients who would benefit from specialist care usually defined as those with an injury severity score (ISS) >15, or those deemed to be at high risk of death or disability (irrespective of their injury severity score). Triage is therefore a diagnostic test, and like any diagnostic test has a sensitivity, specificity, and positive and negative predictive values. In the context of triage, these are more commonly referred to as over triage (a patient taken to a level of facility which was ultimately not required) and under triage (a patient taken to a level of facility lower what was ultimately required). Over triage and under triage cannot both be minimised. Triage tools are generally designed to err on the side of caution, as it is recognised that under triage is associated with excess mortality, whereas overtriage is only associated with increased cost. Most triage tools, aim for an under triage rate of <5%, which usually corresponds to an over triage rate of about 50%. Experience from London has shown that for every case of major trauma identified there are two cases with minor or moderate injuries that trigger the tool and are taken to a MTC. Other regions, such as Newcastle, have experienced less over triage, underlining that performance depends on many factors. Over triage needs to be taken into consideration when modeling centre volumes; projections should therefore be based on triage categories, rather than injury severity score. The performance of the triage tool should be formally evaluated, as is currently being done as part of the GEOS study. The application of a triage tool can be optimised through training of all providers, and continuous audit. 36

37 A paramedic should be available 24/7 in the ACC to identify and co-ordinate the response to MT A consultant level doctor with extensive pre-hospital experience of the management of Major Trauma should be available 24/7 to advise medically on the best care provision of each patient. MT patients should be taken to a MT centre directly if within 45 minutes travel time In cases where the decision to transport directly from scene to a MTC is difficult due to location or the patient s clinical condition, specialised clinical decision making support must be available. A specially trained advanced paramedic must be available in ambulance control 24 hours a day. Paramedics at incident scenes should discuss individual patients with them and jointly make decisions about triage and transport. If appropriate the specialist paramedic should also deploy a trauma team to the scene, or a helicopter ambulance. If a decision is made to transport an unstable patient to a non-mtc hospital, the specialist paramedic should activate a retrieval team to meet the patient at that hospital to allow safe onward transfer to an MTC as quickly as possible. A consultant in pre-hospital and retrieval medicine must also be available 24 hours a day to provide expert telephone advice when required. MTCs should be able to provide such advice. Each of the four health boards where MTCs are proposed already operate pre-hospital trauma teams. These are consultant delivered services capable of delivering lifesaving critical care at the scene of the patient s accident and during the journey to hospital. Interventions include emergency anaesthesia to maintain airways, ventilation for chest and brain injuries, chest surgical procedures, fracture and dislocation reduction and blood transfusion. These teams also are capable of providing advanced pain relieving and sedative medication. Patients with suspected major trauma will be taken directly from the scene of their injury to a major trauma centre (MTC) by the ambulance service. Hospitals not designated as MTCs will be bypassed. This direct transfer rule will not apply in the following circumstances: a. Direct transfer time exceeds 45 minutes. b. Airway, severe respiratory The development of 24/7 cover. This work requires judgment, and therefore experienced paramedics, who will be taken away from clinical duties. This loss will have to be mitigated against with increased training and recruitment. Running a national trauma system without this type of decision support would not be possible, this aspect of the service therefore must be adequately resourced and supported. 24/7 cover should be provided. For most of the Scottish population the instigation of diversion protocols will not produce significantly increased transfer times. For remote locations the transfer times are already longer than desirable. Although the majority of major trauma patients should be able to reach an MTC, ultimately, the entire population cannot be brought into a 45 minute transfer time by any practical and affordable solution. Determination of the optimal destination

38 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 compromise or catastrophic haemorrhage, which cannot be adequately managed, is present. Tasking requires rapid informationsharing between paramedics on the ground, ambulance control, paramedic and medical decision support, and hospitals. A national tasking strategy should be developed and should be a priority for the national clinical major trauma lead in close collaboration with SAS and hospitals. With the challenges of Scotland s geography it is acknowledged that a number of remote and rural areas are outwith a 45 minute travel time to one of the four MTCs. In such circumstances a Trauma Team will be deployed to the scene to allow optimal management before transfer to the nearest MTC or the patient will be retrieved by the ScotSTAR retrieval service from the local receiving hospital. Responsibility for implementing and governing the new triage system will lie with the ambulance service. An ambulance service trauma lead clinician with responsibility for training and quality will need to be appointed on a permanent full time basis. The effective operation of this component of the new Scottish trauma network is essential for its success. A robust clinical governance system will be necessary. This will include ongoing training, standard operating procedures, significant event management, incident debriefs, regional clinical governance meetings and an annual national ambulance service major trauma meeting. A set of key performance indictors will be introduced and closely monitored. facility, for an individual patient, requires not only identification of their needs (by triage, see above), but also consideration of their specific circumstances (location of incident, distance to nearest trauma centre, projected drive- and flight-times, helicopter availability, weather, etc). This is referred to as tasking. Patients who are triaged to major trauma centre care may, nevertheless, not be able to reach such a centre in a reasonable time, necessitating a diversion to a local hospital. Such decisions can be straightforward (e.g. in Tayside), but can also be very complex (e.g. in the Highlands), and therefore require support. Tasking requires a high degree of integration of information from a variety of sources. It would probably be best provided by the trauma desk within the SAS, who could perform this role in addition to their decision support functions. Much of this work could be automated, using computerised drive-time and flight-time analysis, similar to that used by the GEOS study. Without tasking support, the benefit of designating MTCs would be lessened, as it would be difficult for paramedics to decide where patients should be taken. It is therefore crucial that this aspect of the service is adequately supported and resourced. A number of air ambulance services in England now respond by helicopter to pre-hospital trauma scenes at night. The risks and benefits of night HEMS operations in Scotland should be investigated. Appropriate tasking of specialised trauma teams to major trauma cases is vital. Building on the success of recent 38

39 When necessary MT patients should be transferred without delay to definitive care after initial assessment and optimisation in the ED at the receiving hospital A structured pre-alert should be given to the receiving hospital as early as possible. On arrival at the hospital, a structured handover should be given to the receiving team. A structured checklist and standardised documentation should be used and included in the patient s clinical record. Scottish Ambulance Service s trauma desk pilot, the specialist trauma decision paramedic in ambulance control must also have responsibility for identifying cases of potential serious trauma at the time of the initial 999 call and tasking teams to the scene. Some patients with major trauma will not be taken directly to an MTC. This happens due a number of reasons including prolonged distance from scene to MTC, unstable clinical condition, failure to recognise severity of injury and patients arriving at local hospitals by private transport. In such cases a mechanism to rapidly and safely retrieve these patients to a MTC must be in place. Scottish Trauma Audit Group data has shown that only 50% of patients with major trauma are called in en-route to hospital by ambulance crews. Prealerting the emergency department about these patients considerably improves the care they receive in the initial stages of their hospital journey, especially when immediately lifesaving interventions are necessary. The trauma triage tool will improve identification of these patients by ambulance crews and mandate the provision of a hospital pre-alert call. In addition to this, a system should be introduced to standardise the structure of patient handovers to receiving hospital clinicians on arrival in the Emergency Department. The ATMIST Tool follows the same flow as SBAR allowing for a consistent approach across NHS Scotland even where SBAR is the tool of choice. Modifications to enhance E-PRF for major trauma should be made. These are being incorporated into the next version of the e-prf. Development by SAS underway. Paediatric specific documentation is also required. There is a risk that patients who have been triaged to MTC care, but had to be diverted to a lower level facility, cannot be received by a major trauma centre in reasonable time. Diverted patients should be rapidly assessed, and if necessary undergo rapid, life-saving surgery, before onward movement to an MTC. This requires a service which has both the facilities (ambulances/helicopters) and staffing (critical-care trained personnel) to transfer such patients. Triage and (particularly) tasking will simplify pre-alerting, which could be done by the trauma desk. Even if this is not possible or available, the use of a triage tool will facilitate pre-alerts. No risks identified.

40 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 Secondary Emergency Department transfer to a Major Trauma Centre should be provided by an appropriately trained team. Pre-hospital services should submit to a national trauma dataset and be included in regular audit For remote and rural Scotland the Emergency Medical Retrieval Service and paediatric retrieval services already perform this role. This work should continue as part of the new ScotSTAR project. Retrieval services require to be established for the non-remote and rural hospitals which are non-mtcs. This would most cost effectively be done by enhancement of existing services. Currently the SAS and individual trauma teams collect considerable amounts of data relating to trauma patients. Unfortunately this information is not currently shared or linked with Scottish Trauma Audit Group (STAG) data. All hospitals that deal with major trauma, including paediatric major trauma, must participate in STAG the audit. Data linkage work between STAG and SAS should be progressed. This will allow for full patient journey data to be collected including more precise incident location and pre-hospital care. Data linkage work between STAG and SMR01 data should be progressed. This will enable valuable information to be explored in relation to outcomes and survival. It will also allow for links between major trauma outcome and other information, such as deprivation and prior patient morbidity to be explored. Development of a HSMR type measure for trauma should also be considered as a tool for performance improvement. For paediatric trauma a new specific component of STAG should be developed. This work should be prioritised. As an interim measure, a crosswalk exercise from Children s SMR01 to AIS should be considered to in order to identify some more accurate estimates of paediatric trauma activity, although it is clear that the mandatory prospective collection of paediatric trauma data is essential to permit accurate planning of paediatric trauma services. A national pre-hospital trauma data manager should be appointed who will have responsibility for linking the existing data sources and reporting the necessary performance and outcome data. There is a risk that patients who have been triaged to MTC care, but had to be diverted to a lower level facility, cannot be retrieved to a major trauma centre in reasonable time. Diverted patients should be rapidly assessed, and if necessary undergo rapid, life-saving surgery, before onward movement to an MTC. This requires a service which has both the facilities (ambulances/ helicopters) and staffing (critical-care trained personnel) to transfer such patients. At present, STAG is not staffed to fulfill this role. There is a risk that performance evaluation of the system would not be possible. Data collection, linkage, and analysis resources will be required. 40

41 9.2.3 Prehospital Workforce & Training 148. Ambulance clinicians require to be supplied with the most up to date, evidence based trauma equipment and intervention capabilities. The JRCALC 2013 guidelines advise that paramedics are supplied with the following additional equipment for trauma care: tranexamic acid for serious bleeding, limb tourniquets for limb haemorrhage, blast and haemostatic dressings, intra-osseous fluid administration equipment and paediatric splints Regular additional training in trauma patient assessment and management will also be required These improvements will help to minimise on scene time and allow patients to be transferred safely for more prolonged periods, directly to definitive care Measuring success 151. Adult and paediatric Key Performance Indicators (KPIs) for prehospital care should be developed that include: outcomes (for major trauma network as a whole - mortality, functional outcome, quality of life, morbidity, preventable deaths); National system and performance KPIs for prehospital care including; Secondary transfer rates and timings from hospitals within the proposed MTC catchment areas; and, process measures (over triage, under triage, other measures of triage performance, pre-alerts, tasking, access times, number of patients requiring helicopter transport, number of helicopter transfers not possible); KPIs also require a verification system Audit and Data Collection 152. All hospitals must participate in an enhanced STAG audit. Audit and data collection should also include SAS, EMRS/ ScotSTAR and the different data sets should be linked.

42 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Acute Care Introduction/ background 153. The Acute Care phase of management of major trauma refers to the following: initial reception and rapid evaluation of the patient in the Emergency Department. treatment of any immediate life-threatening condition(s) rapid access to diagnostic imaging, including interventional radiological expertise rapid access to trauma operating theatres subsequent access to a critical care in-patient bed Implementation of the major trauma acute care quality framework set out below will help to ensure that people who experience major trauma receive definitive care Acute Major Trauma Care Quality Framework RCSE PATHWAY STANDARD Reception: Trained trauma team available 24/7 Radiology: Emergency radiology available 24/7. MRI available 24/7 at MTCs. WHAT ARE THE RECOMMENDED NEXT STEPS? Establish Consultant-led trauma teams in designated MTC s. The Trauma Team Lead should be a Consultant trained in Trauma Resuscitation to prioritise damagecontrol elements of trauma resuscitation. For the most part this Consultant will be an Emergency Medicine specialist but could also be a Consultant in Acute Care General Surgery or Critical Care. Ensure 24/7 access to emergency radiology (including CT scanning) at all hospitals receiving trauma patients (to include Trauma Units and MTC s) Develop protocols for obtaining MRI scans 24/7 at MTC s. HOW MIGHT ANY RISKS BE MITIGATED? 24/7 Consultant presence: this is a challenging recommendation. MTC s will form part of existing regional centres in Scotland which will already have Consultants in Emergency Medicine working on-site 0800 midnight. General/acute surgeons also work on shift rotas in some regional centres. Consultant numbers are gradually increasing and 24 hour cover becoming more common. For example, RIE have 24 hour cover on site in general surgery and cover in A/E progressing towards that. With accumulation of more multiple trauma cases in a smaller number of specified locations it will be practical to extend duration of consultant cover across relevant specialities. This is an essential component and is already available in most big centers that are candidate MTC s. This is also essential, but again, most centers that could be MTC s already have MR on site. 42

43 Radiology reporting. Teleradiology facilities. Interventional radiology (IR). Emergency Trauma Surgery General Ensure robust reporting for trauma radiology in remote/rural areas. It should be agreed which local hospitals will receive major trauma cases and those hospitals should have radiologists available 24/7 for rapid reporting. Ensure compatibility of systems to allow transmission of images between trauma units and MTC s. 24/7 access to IR is essential for MTCs as part of the array of haemorrhage control facilities. Boards will need to ensure that IR services can be reliably provided 24/7 to the MTC. Whilst the majority of Boards can provide 24/7 access to on call Consultant General Surgeons there is a recognised need for additional training for surgeons in the management of serious torso trauma. It is recommended that General Surgeons providing acute care in local hospitals and MTCs should be formally credentialed in trauma surgery. The national PACS system can be used Advisory service can be run from designated MTCs for multiple trauma patients taken to local hospitals due to adverse circumstances. This should not be an issue as Scotland has a national PACS system. These services are available at the proposed 4 designated centres. They also complement the service needs of collocated specialties such as Vascular Surgery. The main risks relate to the provision of trauma training and a sustainable 24/7 rota. Formal fellowship level training is currently available in a number of overseas centers (US, Canada, Australia, and South Africa) and would be considered the preferable route of accreditation. However, overseas fellowships are not possible or feasible for all interested surgeons, either preor post- completion of training. A further near-term option includes training in an English MTC or the establishment of a local mentoring program. The latter would require a baseline set of qualifications (post- CCT plus courses such as DSTS) and a period of paralleled working with an accredited colleague. In the longer-term, the aim would be for Scotland to train a proportion of its Trauma Surgeons within Scottish MTCs, which in combination with those trained via overseas fellowships, would lead to a sustainable workforce. The need for 24/7 care will undoubtedly drive centralisation/ regionalisation of trauma care in order to maximise workforce efficiency.

44 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 Orthopaedics Vascular Plastic surgery, Maxillo-facial surgery, Urological surgery, and ENT surgery. Any centre designated as having MTC status will require a consultant led team of orthopaedic trauma surgeons with a subspecialist interest in trauma management. The number of consultants required would depend on predicted volume but not less than 8 would be required to populate the on-call rota. An additional on-call service for spinal trauma would be desirable although it is recognised that most spinal reconstructive surgery for trauma would be carried out on a scheduled urgent basis. Access to at least one orthopaedic trauma theatre would be required on a 24 hour basis 365 days/year. Additional theatre access during daytime hours for scheduled urgent reconstructive surgery would be necessary during daytime hours 5 7 days per week depending on centre volume. Vascular surgeons must be available to treat major trauma patients 24/7. Endovascular trained surgeons may also be able to contribute to the IR component, although it is recognized that the range of IR techniques required to support this service will certainly extend beyond endovascular stent grafting and it is essential that centres provide a full complement of haemorrhage control techniques (more commonly required) staffed by personnel with appropriate competencies of a Trauma Service. Specialist surgeons in all these fields must be available to attend a MTC to provide emergency care for seriously injured patients. Subspecialist training in the field of orthopaedic trauma is now widely available in the UK and in North American centres. This training option is now popular in the field of orthopaedics and it is therefore anticipated that finding suitably qualified surgeons for these posts would not be difficult. Clinical risk will be minimised by appointing an adequate number of orthopaedic trauma surgeons to any centre designated as an MTC. Ideally any such centre would have a number of spinal surgeons available to supplement the trauma service. Vascular surgical emergencies are currently treated in designated vascular surgical centres. Effective pre-hospital triage ought to ensure that seriously injured patients are taken to a centre that has 24/7 access to a vascular surgeon. In regions where not all surgical specialties are available on-site arrangements must exist whereby such surgeons can provide care at a MTC in a peripatetic fashion. 44

45 Cardiothoracic (CT) surgery. 4. Senior trainees available on site 24/7 and Consultants within 30mins. 5. Neurosurgery and spinal cord injury. Data from STAG strongly suggests that specialist cardiothoracic surgical interventions are rarely required in the management of trauma in Scotland as the incidence of penetrating trauma and gun-shot wounds is particularly low. Non-operatively managed thoracic injury is much more common, and much of this workload could be dealt with by general surgeons with additional training. Recommended for the following specialties in local hospitals/mtcs: Emergency Medicine, General Surgery, Anaesthesia, Critical care, and Orthopaedic Surgery. In addition to the above: for MTCs there should be senior trainees in neurosurgery and vascular surgery available on-site 24/7 and Consultant within 30mins. Given the preponderance of significant head injury in seriously injured trauma victims in Scotland it is recommended that such patients be transported primarily to a Neurosurgery Unit collocated with an MTC. Currently, there are 3 Neurosurgical units on-site at recommended MTC locations (Aberdeen, Dundee, and at the SGH in Glasgow.) Plans are afoot for the transfer of the Neurosurgical Unit at the Western General in Edinburgh to the Royal Infirmary of Edinburgh acute hospital site Implementation of this recommendation will have the beneficial effect of significantly reducing the current high percentage of secondary transfer of head injured patients in Scotland. Spinal cord injury. The Scottish Regional Spinal Injuries Unit is located at the Southern General Hospital, Glasgow. The national trauma network must ensure that robust referral pathways exist for the transfer of patients with spinal cord injury. There should be formal referral pathways between MTCs without onsite CT surgery and the supra-regional cardiothoracic centres. There are certain acute cardiothoracic intervention such as resuscitative thoracotomy and urgent thoracic hemorrhage control that require specific provision. There are established courses for both EM and General Surgery that can provide training for such maneuvers without the need for on-site CT surgery. As most severe head injuries are already managed at a Neurosurgical Unit via secondary transfer, it is unlikely that primary admission would overwhelm resources. A modest increase in workload should be expected and planned for, especially as survival increases. It is also important that there are robust mechanisms for onward repatriation and rehabilitation of patients who reach the end of their MTC phase of care. This will maximize outcomes while ensuring suitable unit turn-over.

46 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Critical Care MTCs must provide 24/7 access to a Critical Care specialist and critical care bed. There exists the potential for a major increase in workload for the Critical Care Units sited on a MTC. This will require appropriate planning for both staffing and resources. Accordingly there must be robust mechanisms in place within the National Critical Care network to identify an available bed and facilitate safe inter-hospital transfer when and where required. 7. Blood transfusion. MTCs must have a written Massive Haemorrhage protocol which ensures the rapid and safe delivery of blood and blood products 24/7 to the Emergency Department/Trauma Operating Theatre/ Interventional Radiology Suite. MTCs must have a Hospital Transfusion Committee together with strict clinical governance procedures relating to the use of blood and blood products. There must be a designated lead clinician in Transfusion Medicine/ Haematology who will oversee the laboratory involvement in the massive haemorrhage protocol Acute Care Workforce & Training 155. Any recommendation relating to the establishment of a major trauma network and major trauma centres must take into account the current and projected difficulties in recruitment to specialties required to operate them 24/ The Acute Care Quality Framework (Section 9.3.2) sets out some of the challenges of maintaining a significant consultant grade presence in an MTC 24/7. This will necessitate the centralisation of major trauma services to deliver enhanced and definitive care for that patient group The required consultant workforce can be met from two sources. One, from a cadre of consultants whose job plan is based in the MTCs and includes specific service responsibilities (for example, Regional Clinical Leads or similar). Second, from a pool of non-mtc consultants who have an interest in major trauma and who have/ or could have, job plans affiliated with and provide clinical sessions in an MTC The second model would provide for a core of consultants that can develop the major trauma service, as well as deliver clinical care, but without being overwhelmed by an unsustainable rota. Equally, the delivery of and experience in major trauma care remains accessible to non-mtc appointed consultants on a sessional basis. As well as the MTCs it is envisaged that sessional consultants will work in other tiers of the trauma network which would strengthen communications and links between local hospitals and MTCs. 46

47 159. In terms of any additional training required to work within an MTC, this will largely be specialty specific. As a minimum, all medical staff will be required to have successfully completed an Advanced Trauma Life Support (ATLS) course. Subsequently, each acute specialty will have other trauma specific courses as a prerequisite to practice in an MTC Any hospital managing major injuries in children should ideally have staff accredited in ATLS For doctors in training grades, experience in MTCs as a prelude to consultant practice will be essential. It is anticipated that a Scottish trauma network would become capable of delivering a significant portion of that training, although due to the low volume, outside experience might still be required. Each specialty group will need to establish what it considers a standard with which to accredit a major trauma consultant Measuring success 162. Central to the assessment of the trauma network performance will be the use of a continuous audit, based around a set of key performance indicators (KPI s). These would include markers of both clinical and non-clinical performance. Such parameters ideally need to be system specific, evidence based and subject to regular review. Scotland is in a strong position with large elements of this framework already in place in the form of the Scottish Trauma Audit Group (STAG) STAG is well placed to lead the development and audit of appropriate KPI s. As such, it will be important that the National Clinical Lead and Clinical Leads of the MTCs have representation on the STAG National Steering Committee. Submission of data by all tiers of the trauma system should be mandatory in order to permit the identification of important trends relevant to system process and outcome. Data and KPI s should be examined at both regional and national levels as a matter of routine process Audit and Data Collection 164. Some of the recommended KPIs are already measured by STAG, for example, attendance by consultant, time to CT, in-hospital mortality. STAG will need to be enhanced and other KPIs developed to ensure that success can be measured across the entire major trauma pathway Resource should be in place at the 4 MTCs to facilitate data collection for acute care KPIs and outcome KPIs Resources to extend STAG data collection to the paediatric population will also be required.

48 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Ongoing Care Introduction/ background 167. A national trauma network for Scotland will help deliver improvements in process and outcomes for people who experience major trauma. A key component of this is the ongoing care of the patient. This can be defined as the period of time following the initial assessment and resuscitation/ intervention phase until commencement of rehabilitation. The RCSE Trauma Care in Scotland report (2012), based on the NHS Clinical Advisory Groups Report 2010, provides an overview of this phase within the potential Major Trauma Network model. There are several issues to consider in this context. Geographical location ongoing care may continue in local hospitals for patients with a less severe trauma (ISS<15). More significant and complex major trauma patients should be admitted directly to the nearest MTC, or transferred there for ongoing care following an initial period of stabilisation at the nearest hospital, if the patient is outwith the 45 minute recommended time to definitive treatment. Major Trauma Network and personnel regardless of geography, there should be a clinical lead for trauma with an appropriate team of senior clinicians in each MTC and local hospital. This team may comprise consultants from a variety of specialties including general surgery, orthopaedics, anaesthesia, critical care and emergency medicine. An interest in trauma with a drive to pursue improvements in the process of ongoing care and outcome for injured patients is probably of more importance than a specific subspecialty. One model evolving in North American trauma systems is the concept of the acute care surgeon. This is a general surgeon with an interest in both trauma surgery, and emergency non trauma general surgery. Allied and supporting specialties these must be adequately resourced and staffed and viewed as an essential component of the multi-disciplinary major trauma team. This may include other surgical specialties. For example, neurosurgery, diagnostic services (e.g. radiology and clinical laboratories), and other key disciplines (e.g. critical care and anaesthesia, interventional radiology) Implementation of the major trauma ongoing care quality framework set out below will help provide definitive ongoing care. 48

49 Ongoing Major Trauma Care Quality Framework PATHWAY STANDARD Focus on person centred services and the role of family and friends MT patients should be admitted under the care of designated responsible trauma consultants and the service should include a care and rehabilitation coordinator to coordinate current and future care and rehabilitation Cross specialty supporting services Nursing: Co-locate patients with multiple injuries in dedicated trauma wards. Radiology: 24/7 access to CT, U/S, MRI, angiography, interventional radiology. Access to PACS WHAT ARE THE RECOMMENDED NEXT STEPS? Clear pathways and protocols are needed to support patients as they move from MT services to ongoing care through rehabilitation to discharge. Good rehabilitation triage is essential to ensure that complex trauma is properly identified and proper on-going care is provided. Whatever configuration, there needs to be a repatriation to a local ward (surgical /rehabilitation (IP rehab) or home (OP rehab). The rehabilitation coordinator role is viewed as essential to ensuring patients get all the elements of on-going care that they need. This happens for severe head injuries at the moment but not for other major trauma. MTCs (and local hospitals) need to be resourced to deliver all appropriate elements of the MDT that major trauma (MTC) and trauma patients need, including the rehabilitation coordinator role. The appropriate skill mix in consultant led MDT teams is essential. MTCs need consultants with training and experience in the management of major trauma patients, who can provide clinical leadership for major trauma patients. Dedicated major trauma wards should be introduced at MTCs. Further examination of the Lanarkshire model to determine whether it might inform good practice is recommended. Strong links are required between the MDT in MTC and local hospital teams are crucial and need leadership. Comprehensive radiology services and investment in staff training within a national trauma network should to be developed. Lanarkshire and Tayside report being able to provide all services 24/7. Further examination of these models to determine whether they might inform good practice is recommended. The CEM Unscheduled Care Workforce group could be asked whether it might consider any workforce issues. Local management teams should monitor access times to key radiological investigations. HOW MIGHT ANY RISKS BE MITIGATED? Ensure clarity regarding repatriation arrangements. Standardised ICP for trauma in Scotland will mitigate risk by minimising variation and facilitating interfacility transfer. Each NHS Board to clearly identify the nominated lead trauma consultant and named trauma rehabilitation coordinator. A named consultant is essential to ensure responsibility for definitive patient care. Local Management teams to monitor ward stays. Designated trauma ward will concentrate expertise. Ensure robust pathways are in place for access to diagnostics. Access to diagnostic and interventional radiology support as part of an MDT is key to a successful trauma system.

50 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 Anaesthesia and theatres: Access to fully resourced separate dedicated theatres Critical care: 24/7 care from dedicated intensive care consultants. ICU subject to national audit Rehabilitation: MTCs to provide enhanced rehabilitation services to meet the needs of complex trauma patients. Trauma Units to have skills and capacity to deliver rehabilitation. MTCs located at major hospitals that are geared up to deliver all aspects of major trauma surgery are recommended. It is thought that there are dedicated theatres are in place, however further work is required to determine the number of theatres required based on volume of MT cases. 24/7 ICU care should be available to all major trauma patients who require it. ICU consultants should be an integral part of the MT multidisciplinary team. ICU resourcing may or may not need to be enhanced depending on the location of any future MTCs The universal view is that specialist rehabilitation services reach only a proportion of those who could benefit from them. The proportion is highest in diagnostic groups with established rehabilitation pathways, such as major brain injury and spinal cord injury. It is recognised that a variety of factors may reduce access to rehabilitation, e.g. challenging behaviour, the need to clear acute beds quickly, and failure to recognise a brain injury in major trauma patients who are managed without neurosurgical involvement. Good rehabilitation triage is essential to ensure that complex trauma is properly identified and proper on-going care is provided. Need fewer sins of omission MDT will help ensure the right thing is done at the right time. This is where large volume is likely to bring real advantage. Good communication between the MT service rehabilitation co-ordinator and local NHS services is viewed as essential need to ensure MT patients get back to their host board as quickly as appropriate and good communications are maintained to ensure that patient receive the appropriate on-going rehabilitation care as locally as possible. The model of communication used by the military is a salutary model that should be explored to see whether it might be adapted for NHS Scotland. Rehabilitation teams needs to be multi-professional and to work as locally as possible. Patients cannot be expected to travel to a major trauma centres that might be several hundred miles away, for their ongoing rehab care. Ensure robust theatre management arrangements are in place. A compromise to the dedicated trauma theatre in smaller units may be access to a general surgical emergency theatre. Ensure adequate provision of ITU and management is in place along with escalation arrangements. Arrangements should be put in place to monitor the effectiveness of MDT arrangements The 4 existing centres will already have large physiotherapy and occupational therapy services and in addition will have liaison psychiatry consultants. Staffing levels may need to be increased, but in some centres the increase required will be modest. 50

51 Pain management: All hospitals taking trauma patients to have a specialist acute pain service. Neuropsychology and neuropsychiatry: Post-traumatic amnesia screening and monitoring to be routine in all major trauma patients. Psychosocial and mental health care Equipment: Appropriate equipment to be available routinely. Care teams to be skilled in using and maintaining equipment. Injury specific care: Individual specialties required to manage injuries will exist in some local hospitals. Where they do not, or where there are multiple injuries, clear referral pathways to MTCs must be defined. Technological solutions to help ensure that specialist rehabilitation care is delivered locally should be explored. For example, virtual meetings for difficult cases. Central / Remote specialist rehabilitation advice, perhaps from MTCs that supports local rehabilitation services should be available. Rehabilitation medicine Consultants in MTCs, are well placed to lead on this work. The appropriate local chronic pain improvement groups in NHS Boards should be involved in the development of any future major trauma services to ensure appropriate pain management of major trauma patients and have input to Rehabilitation prescriptions. Post-traumatic amnesia screening and monitoring should be routine in all major trauma patients. Clearly there are examples of good practice (e.g. Grampian, GG&C and Tayside) that should inform the development and delivery of screening tools, protocols and appropriate training. NHS Boards should ensure appropriate staff and tools are available to complete the screening. Specialist psychosocial and mental health care pathways for trauma patients should be developed. Examples of good practice in AA, Fife and Grampian might inform this work. NHS Boards should develop/ adapt referral pathways for this patient cohort to mental health services. NHS Boards should implement to ensure equipment is in place and can be used and maintained. A Scottish trauma network should develop referral pathways to ensure people with major trauma access the care and support they need quickly. The established referral networks might be able to help identify good practice and help clearly define and formalise referral pathways. All MTCs should have pain management services. Monitor case notes to ensure completion. Local monitoring of referral rates. Local checks are made. Ensure referral pathways are in place. Monitor referrals. One consultant (perhaps the admitting consultant) should have overarching responsibility for the ongoing care of the patient regardless of the other specialties involved.

52 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 Facilities should exist that allow early definitive fixation of pelvic and long-bone injuries. Treatment planning and surgery for complex intraarticular injuries should both be performed by an orthopaedic trauma specialist. Compliance with published standards for the management of open fractures relies on daily access to appropriate theatres that can be staffed simultaneously with both senior orthopaedic and plastic surgeons with the requisite skills to treat these challenging cases. Definitive planned surgery for amputations should be performed in consultation with rehabilitation and prosthetic services. NHS Boards should review current arrangements for when developing and implementing MTCs and ensure access. This should be implemented however, how it is implemented might be a question for a Major Trauma Service implementation group. NHS GG&C, Grampian, Lothian and Tayside provide this service and should help inform good practice Implementation group to consider how best to implement. Agree that a Scottish major trauma network should ensure integrated care for amputations that includes involvement of rehabilitation and prosthetic services from the start. The NHS Boards already doing this may be able to inform good practice. Implementation group to consider how best to implement. This responsibility may need to be formally handed on to another consultant if inter facility transfer required. Monitor access. The 4 proposed MTCs have adequate orthopaedic facilities to provide the relevant surgical interventions. Monitor access. The 4 proposed MTCs have adequate orthopaedic facilities to provide the relevant surgical interventions. Monitor access. The 4 proposed MTCs have adequate orthopaedic facilities to provide the relevant surgical interventions. Monitor treatment planning arrangements. 52

53 The prevention of complications arising from spinal instability or neurological compromise involves all members of the multi-disciplinary team and must begin immediately. If there is significant spinal cord injury, early contact should be made with a spinal cord injury centre for advice and to plan strategy. Burn care should be managed through the designation of specialist centres, supporting burns units and some local burns services. Multiprofessional outpatient burns services are essential to ensure optimum ongoing management and outcomes after discharge. For hand injuries, there must be expertise in microvascular surgery and the management of tissue loss. MTCs should have a combination of plastic surgeons and orthopaedic surgeons in the hand surgery team. A hand therapy unit, manned by specialist therapists, is fundamental to achieving a good result following hand trauma. The Neurosurgery MSN should be involved in discussions about any major trauma service implementation plans to help ensure this recommendation is met. Implementation group to consider how best to implement. A Scottish major trauma network should provide burns services through a network of designated specialist unit(s) and local supporting services. The specialist burns services provided by NHS GGC, Grampian, Lothian and Tayside will be able to inform good practice. Burns services already provided through specialist units/local supporting services. National MCN (Cobis) established standards and is collecting data for a national database. All burns units take part in Cobis. NHS Fife, GG& C, Grampian, Highland, Lanarkshire and Lothian hand injury services should inform good practice. Implementation group to consider how best to implement. Monitor treatment planning arrangements. Monitor effectiveness of referral and treatment arrangements. Monitor treatment planning arrangements.

54 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 For maxillofacial injuries, there is a requirement for both TUs and MTCs to provide round-the-clock consultant-led care with immediate specialist maxillofacial technical support. Craniofacial trauma should be concentrated in MTCs, usually colocated with neurosurgical units. Traumatic brain injuries should be managed as per published recommendations. Opinions should be sought from neurology and neuroradiology departments, with a clear definition of areas of clinical responsibility among the various neurological specialties. Complex peripheral nerve, such as brachial plexus injuries, should be managed in specialist units. Facilities should be in place in MTCs to provide major vascular and endovascular surgery. NHS Fife, GG&C, Grampian, Lanarkshire, Lothian and Tayside provide maxillofacial services and should help inform good practice. Implementation group to consider how best to implement. NHS GG&C, Grampian, Lothian and Tayside provide Craniofacial services and should help inform good practice. Implementation group to consider how best to implement. The Acquired Brain Injury (ABI) Network, and GG&C, Grampian, Lothian and Tayside provide specialist brain injury services should help inform good practice. Implementation group to consider how best to implement. NHS GG&C s specialist services should help inform good practice. The regional planning groups are in the process of implementing the vascular quality frameworks developed following the vascular services review. The Regional Planning Groups should help inform best practice. Monitor treatment planning arrangements. Monitor treatment planning arrangements. Monitor treatment planning arrangements. Monitor agreed model. Monitor agreed configuration. 54

55 Pneumothoraces, chest drains and tracheostomies should be managed in line with published guidelines. There should be 24-hour access to respiratory physiotherapy, including an outof-hours on-call service. Injuries to the kidney and urinary tract are often complex, and should be identified early and managed in conjunction with urologists, as per published recommendations. Other care considerations: In addition to the treatment of injuries, children and older people require specific age-related considerations. Joint care with paediatric or ortho-geriatric support is important. Pre-existing medical conditions should be considered, and other specialists involved in care as appropriate. Organisations and network structures should facilitate follow-up appointments to take place in the most appropriate setting, be this in the MTC, hospital or community. NHS Boards should review current practice at Board level against guidelines. Urology services should be represented on any Major trauma Implementation Group that is be set up to implement NPF recommendations and review current practice against guidelines. Links between major trauma and geriatric / paediatric services need to be clearly established and these services should be represented on any Major trauma Implementation Group that is set up to implement the NPF recommendations. Services for rehabilitating injured children are sparse in Scotland, with none at all for children with brain or spinal cord injuries. No link between paediatric and adult rehabilitation services. Services for the inpatient rehabilitation of older adults who survive multiple trauma tend to form part of generic elderly rehabilitation services. NHS Boards should ensure that these specialties are represented on any implementation group. Pre existing comorbidity will be a significant issue in certain age groups and must be managed in conjunction with the appropriate specialty. Mechanisms should be put in place to allow joint follow-up, including the expansion of telemedicine. Local arrangements to be put in place wherever possible. Monitor compliance. Monitor compliance. Monitor representation. Monitor pathway and referral arrangements. Monitor arrangements.

56 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 Policies, Protocols and Standards: A discharge summary describing the patient s injuries, care received and ongoing needs and plans should be provided at the time of discharge or transfer from a MTC or hospital. This should include a rehabilitation prescription. There should be cross-network agreements and adequate resources to ensure that once specialist medical care has been completed, patients can be transferred to the care of a service which is able to meet their ongoing care and rehabilitation needs. Nutritional management: Effective nutritional management is crucial to recovery and rehabilitation following traumatic injury. Policies for nutritional management should be in place in MTCs and local hospitals. Governance: Any hospital receiving trauma patients should have associated governance structures in place. Standardised documentation and processes for rehabilitation should be developed within a Scottish major trauma system/ service to support patients as they move from MT service to ongoing care through rehabilitation to discharge and beyond. ICPs and network arrangements should be formalised to ensure appropriate transfer and repatriation from Major trauma services to local rehabilitation services. Policies for nutritional management of major trauma patients should be in place. NHS Boards have established dietetic service policies and protocols to help them do this. A Scottish major trauma network should establish a specific trauma governance framework with mandatory and consistent participation in national audit for adults and children. Highland and AA are well placed to help inform good practice. Monitor availability and use of documentation. Ensure standard repatriation protocols are developed. Monitor availability and use of protocols and numbers of patients effectively repatriated within defined timescales. Monitor nutritional arrangements. Many nutrition programmes are over stretched there should be clear guidelines for early establishment of nutritional support where indicated pending formal review by the nutrition team. Monitor participation in audit. In house quality control programmes should link in to national trauma audit process. 56

57 Ongoing Care Workforce & Training 169. There are significant workforce and training implications, which whilst not insurmountable for NHS Scotland, may require a paradigm shift in the delivery of ongoing care for trauma patients One clinician must have over-arching responsibility for the ongoing care of the patient regardless of the involvement of other disciplines. This is most likely to be the admitting consultant surgeon if models of care in other countries with mature trauma systems are to be emulated. This consultant will liaise with other specialties but will take ultimate responsibility for the patient care and decision making. There are probably two options for NHS Scotland One is to have small teams of dedicated trauma surgeons on a separate rota from the non-trauma emergency general surgeons. This is unlikely to be attractive to either the health boards (increased resource utilisation and financial implications with two on call teams) or the surgeons (relatively low volume of major trauma, a proportion of which is increasingly managed non-operatively) The second option may suit Scotland s particular needs better developing the concept of the acute care surgeon responsible for all emergency surgical workload including trauma. These surgeons may continue to have an elective subspecialty interest which would be a useful additional resource for health boards, and would maintain their surgical skills. This option should still concentrate the relatively small volume of major trauma in the hands of interested parties an area of significant concern with the current model of care The EWTD imposes very definite limitations on training in any surgical specialty, but this is more pronounced in the relatively low volume areas such as major trauma. Training for short intense periods is likely to improve technical surgical skills and facilitate non-technical skills, such as pattern recognition and decision making capability, by concentrating the learning experience. These could take the form of short focussed blocks where repetition is the key during the training period. These blocks could perhaps be undertaken once at junior trainee level, and again as a senior trainee prior to consultant appointment Measuring success 174. There are several phases in measuring success of the recommendations in the ongoing care of the trauma patient which would be viewed as a dynamic and evolving process: development of Key Performance Indicators (KPIs), initial implementation of a small subset of these KPIs, in house peer review of KPIs, feedback to a Scottish Trauma Review Board, implementation of further agreed KPIs or modification of existing indicators.

58 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September One potential excellent resource for this process is the American College of Surgeons Committee on Trauma Blue Book 28 which defines quality in trauma care through its Performance Improvement and Patients Safety (PIPS) programme. This programme facilitates individual institutional tracking and also national bench marking referred to above Key Performance Indicators for ongoing care would be peer reviewed and could include: protocol violation preventable and potentially preventable mortality missed injuries inter hospital transfer to a higher level within a specified time frame procedural complications DVT prophylaxis surgical site infection Audit and Data Collection 177. Data collection should occur as close to real time in ongoing care as possible, preferably as part of an Electronic Patient Record. This would be a searchable data base and could be used to generate weekly reports for discussion at peer review meetings. 28 The American College of Surgeons Committee on Trauma Blue Book 2007Evaluating trauma center process performance in an integrated trauma system with registry data Year : 2013 Volume : 6 Issue : 2 Page : Journal of Emergencies, Trauma and Shock 58

59 9.5. Rehabilitation 9.1. Introduction 178. The effective rehabilitation of major trauma patients is crucial to ensuring good long-term outcomes and in supporting people to return to work as quickly as possible Implementation of the major trauma rehabilitation quality framework set out below will ensure that rehabilitation experts play an active part in the decisionmaking process, and manage patients transition from acute care into local rehabilitation services as soon as it is clinically appropriate to do so. This approach will tailor the rehabilitation to the needs of the individual patient and aims to make sure patients receive the care they require throughout the rehabilitation process, from the right people at the right time, and as close to home as possible Rehabilitation for Major Trauma Quality Framework RCSE PATHWAY STANDARD Rehabilitation should start as soon as is appropriate after admission, typically in the critical care setting, and continue at the intensity required, and for as long as is necessary, to enable patients to achieve their functional potential. WHAT ARE THE RECOMMENDED NEXT STEPS? Good rehabilitation triage is essential to ensure that complex trauma is properly identified and proper on-going care is provided. Need fewer sins of omission MDT will help ensure the right thing is done at the right time. This is where large volume is likely to bring real advantage. Comprehensive and enhanced rehabilitation care pathways for trauma patients must be developed including early intervention, to help enable patients to recover as best they can. This should include repatriation guidance. AHPs are expert in rehabilitation at the point of registration and bring a different perspective to the planning and delivery of services. They are uniquely placed to exploit their expertise in enabling approaches through providing rehabilitation/ reablement and leadership across health and social care as well as driving integrated approaches at the point of care. AHP Directors in NHS Boards are expected to lead on implementation of the Scottish Government s National Delivery Plan for the Allied Health Professions in Scotland, pdf. HOW MIGHT ANY RISKS BE MITIGATED? Most Boards have adequate community rehab facilities for patients with orthopaedic trauma, but some MT patients are still too unwell or disabled to be discharged home at the end of acute care, and need inpatient rehab first. Consideration should be given as to whether this will be in local acute orthopaedic wards or in rehab units. Plans should be put in place to ensure: Recruitment and retention of sufficient consultants in rehabilitation medicine; Sufficient bed capacity to deliver major trauma rehab in rehab units Criteria for the rehabilitation pathway need to be agreed and monitored. This could be done through a national rehabilitation network.

60 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 The action plan contains a number of recommendations that seeks to improve rehabilitation and reablement services across the patient pathway. Patients who have not been admitted to a MTC should not be disadvantaged in accessing the level of rehabilitation they require. All stages of care, including the rehabilitation and transfer aspects of the patient s pathway, should be the responsibility of the network. There should be an appointment of a Trauma Network Director of Rehabilitation Services. AHP Directors must support the development of rehabilitation services for major trauma patients and should be included in any future major trauma service implementation group(s). Any major trauma patient not admitted to a MTC should nevertheless be able to receive major trauma rehabilitation care appropriate to their needs. This should be built into the major trauma rehabilitation pathway. NHS Boards will wish to consider their progress with implementation of the AHP national delivery plan (June 2012). Progress should be monitored through an implementation group(s) / a national major trauma rehabilitation network. The rehabilitation co-ordinator role is viewed as essential to ensuring that patients get all elements of ongoing care that they need and that the ball doesn t get dropped. There is a rehabilitation co-ordinator for severe head injuries but not for most other types of major trauma. Inclusion of rehabilitation specialists in the MDT early on in patient care will ensure people receive the care they need. This should be built into the rehab care pathway. Delivery of good rehabilitation services requires leadership, communication/ coordination, and resources. This does not necessarily need to be provided through a new post of Director of Rehab Services, but could use existing people with the necessary attributes. This might include AHP Directors of Boards, but it should not be assumed that they have the right clinical skills to direct major trauma rehabilitation services. Local rehabilitation medicine consultant(s) are likely to be suitable for this role. The rehabilitation co-ordinator role is viewed as essential to ensuring patients get all the elements of on-going care that they need. They should also have a role in liaising with paediatric trauma rehabilitation. NHS Boards need to ensure appropriate MDT rehabilitation resources (especially specialist AHPs) to support ongoing care locally. This standard should be monitored through a national rehabilitation network. Separate conclusions listed for paediatric medicine. Standardised documentation is crucial. This standard should be monitored through a national rehabilitation network which should include paediatric major trauma. Each Board, whether or not it hosts a MTC, needs to have a nominated lead in place for major trauma rehabilitation. That person s professional background may vary. Ensuring a relevant skills mix in the major trauma rehabilitation team is important. There are workforce gaps across Scotland that need to be considered. In rehabilitation the number of treating clinicians is more important than the number of beds, and is more difficult to change quickly. Putting plans in place to recruit/ retain RM consultants is a good strategy but a long-term one, given the current job market and training structure. 60

61 There should be an appointment of a Clinical Lead for Acute Trauma Rehabilitation Services in every MTC (Consultant in Rehabilitation Medicine). There should be adequately skilled and resourced multi-disciplinary rehabilitation teams in all of a network s services. There should be rehabilitation and care coordinator posts throughout the network. Patients should have an identified key worker to be a point of contact for them, their carers or family doctor, and to ensure delivery of their personal prescription for rehabilitation. Every MT patient should receive routine screening of rehabilitation needs. A Lead Consultant in Rehabilitation Medicine (RM) should be included in any major trauma service MDT, and may well be the right person to lead it. Strong clinical links will be needed between the MTC and local rehab services for MT patients, as ultimately when/ where to transfer a patient must be a clinical decision and not an administrative one. Rehab teams across the major trauma network must be multi-disciplinary and work as locally as possible. Patients cannot be expected to travel to a major trauma centre that might be over 100 miles away for ongoing rehabilitation. AHP Directors should help shape future major trauma rehabilitation services from admission, through acute care and beyond into the community. The rehabilitation co-ordinator role is seen as essential to ensuring patients get all elements of ongoing care they need. AHP directors should help shape this role. It may be part of an existing role. Trauma rehabilitation coordinators should be identified in each Board area. Routine screening of rehabilitation needs should be developed as part of a care pathway within a major trauma network. An expert group should consider and agree the core content of a screening tool and its piloting and implementation. Only Glasgow, Edinburgh, and Aberdeen currently have more than one RM consultant (though Dundee is about to recruit a second consultant), so the baseline is low. It is also important to have plans for increasing the number of specialist AHPs and others. This standard should be monitored through a national rehabilitation network. Plans should be put in place to ensure recruitment and retention of sufficient consultants in rehabilitation medicine. Implementation of the AHP national delivery plan should help all patients who need rehabilitation, not just MT patients. Dialogue between MTC team and local MDT can identify and resolve problems in order to improve individual rehab outcomes. This standard should be monitored through a national rehabilitation network/ implementation group(s). This standard should be monitored through a national rehabilitation network. This standard should be monitored through a national rehabilitation network.

62 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 A rehabilitation prescription should be provided to all trauma patients with identified needs. Trauma patients should receive appropriate levels of care and rehabilitation at all points along their care pathway. Many trauma patients are of working age, so vocational rehabilitation should therefore be a key component of rehabilitation. A directory of services and resources should be developed relating to rehabilitation and ongoing care to facilitate referral and access to these services. A rehabilitation prescription should be developed as part of a care pathway within a major trauma network. The Major Trauma Rehabilitation MDT should take this forward. An expert group should consider and agree the core content of a rehab prescription and its piloting and implementation. A major trauma network should establish a specific MT governance framework with mandatory and consistent participation in national audit for adults and children. NHS GG&C is well placed to help inform good practice. MT patients should return to their home as soon as is clinically appropriate. Good clinical communication is needed to ensure that all patients receive ongoing rehabilitation care that is appropriate to their needs as locally as possible. An expert group should consider and agree arrangements for audit. Major Trauma rehabilitation advice should be included at all stages of care, through the MDT. In Scotland vocational rehabilitation following major trauma is patchy, often absent, and almost never specifically geared to major trauma patients. Sometimes it is done as an extension of a clinical rehabilitation programme, or through referral to NHS or independent providers. Only a few major trauma patients access these services, and the systematic approach to vocational rehabilitation that is routine in most other advanced countries is lacking in Scotland. An expert group should consider and agree a model for delivering vocational rehabilitation services to MT patients. There is no directory of services other than one prepared in Glasgow by a brain injury charity (and confined to services relevant to brain injury). A directory would be useful, but its usefulness might be limited unless it can provide information about spare capacity and waiting times. This should include services available for children. NHS Boards should review how best to integrate this with existing local directories of services. This standard should be monitored through a national rehabilitation network. This standard should be monitored through a national rehabilitation network. This standard should be monitored through a national rehabilitation network. This standard should be monitored through a national rehabilitation network. 62

63 Appropriate funding structures should be developed to ensure timely and comprehensive rehabilitation. There should be coordinated development of rehabilitation services and longterm support in the community which can deliver comprehensive and effective rehabilitation to meet the needs of trauma patients irrespective of age. NHS Boards should ensure there are adequate resources for the rehabilitation MDT to allow major trauma patients to access the rehabilitation services they need as locally as possible. NHS Boards should review their existing services and resources. The Major Trauma Network should develop rehabilitation services for major trauma patients across all age groups and specialties. AHP Directors have been tasked with overseeing implementation of the AHP national delivery plan (June 2012) and should help take this forward. Good communication between the MTC rehabilitation service and local NHS rehabilitation services is essential. Major Trauma patients should be able to return to their home NHS board as soon as is clinically appropriate. Communication must be good enough to ensure that patients receive appropriate ongoing rehabilitation as locally as possible. Nationally agreed KPIs would be helpful, but detailed implementation needs to take account of local circumstances. This standard should be monitored through a national rehabilitation network. This standard should be monitored through a national rehabilitation network Rehabilitation Workforce & Training 180. NHS Boards need to ensure appropriate MDT rehabilitation resources (especially specialist AHPs) to support ongoing care as locally as possible There are rehabilitation workforce gaps across Scotland that need to be considered. In rehabilitation the number of treating clinicians is more important than the number of beds, and is more difficult to change quickly. Putting plans in place to recruit and retain Rehabilitation Medicine (RM) consultants is a good strategy, but a long-term one, given the current job market and training structure. Only Glasgow, Edinburgh, and Aberdeen currently have more than one RM consultant, though Dundee is about to recruit a second consultant. It is also important to have plans for increasing the number of specialist AHPs and others AHP Directors should support the development of major trauma rehabilitation services from admission, through acute care and beyond into the community.ahp Directors should also be included in any future major trauma service implementation group(s) Major Trauma rehabilitation advice should be included at all stages of care. A Lead Consultant in Rehabilitation Medicine (RM) should therefore be included in any major trauma service MDT.

64 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September In Scotland vocational rehabilitation following major trauma is patchy. The systematic approach to vocational rehabilitation that is routine in most other advanced countries is lacking in Scotland.An expert group should consider and agree a model for delivering vocational rehabilitation services to MT patients The rehabilitation co-ordinator role is viewed as essential to ensuring patients get all the elements of on-going care that they need Measuring success 186. Some of the recommended KPIs are already, or can be, measured by STAG, for example, return to work, complications, functional outcome and quality of life measures at (GOS-E; SF-36; EQ-5D). STAG will need to be enhanced and other KPIs developed to ensure that success can be measured across the entire major trauma pathway Resource should be in place at the 4 MTCs and the Children s Hospitals receiving trauma, to facilitate data collection for acute care KPIs and outcome KPIs Audit and Data Collection 188. In addition to mandatory participation in an enhanced STAG audit, all hospitals in Scotland responsible for major trauma patients rehabilitation, regardless of age, should also participate in UKROC for audit purposes. 64

65 10. Performance 189. Performance across the entire major trauma network must be measured in order to evaluate success and identify and drive improvements in both service delivery and outcomes Together with mandatory participation in an enhanced STAG audit, MTCs will need to demonstrate robust clinical governance procedures. This should be led by the establishment of MTC/ hospital major trauma committees which will include senior members of the major trauma multidisciplinary team (from all specialties). This committee should meet monthly to review STAG monthly returns Major trauma service Key Performance Indicators (KPIs) should be developed that include: outcomes (for major trauma network as a whole - mortality, functional outcome, quality of life, morbidity, preventable deaths); National system and performance KPIs for prehospital care including: Secondary transfer rates and timings from hospitals within the proposed MTC catchment areas; process measures (over triage, under triage, other measures of triage performance, pre-alerts, tasking, access times, number of patients requiring helicopter transport, number of helicopter transfers not possible); KPIs also require a verification system Some KPIs are already measured by STAG, for example, attendance by consultant, time to CT, and in-hospital mortality. Some other KPIs to be considered include 24h mortality, 30-day, 90-day, 1 year mortality, duration of hospital stay, quality of life (e.g. by SF-36, EQ-5D, up to 2 years post-injury, perhaps by telephone interviews); return to work; complications and functional outcome (using GOS-E, also assessable by telephone interview). Some new KPIs will also need to be developed. Recommendation 14 National system and performance KPIs should be agreed and measured to help monitor success of the major trauma network and drive improvements Clinical leadership at national, MTC and hospital level will be vital in order to help get the major trauma network up and running effectively and drive improvements in outcomes by acting on KPI data. This will include the development of overarching structures and processes, such as triage and tasking, which cross traditional professional boundaries. Prehospital leadership is also vital and it is recommended that a dedicated paramedic is needed to work across the network to identify and help resolve any prehospital care issues. Recommendation 15 Clinical leadership at national, prehospital, MTC and hospital level should be put in place to help develop and improve the major trauma network and optimise patient outcomes.

66 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September All unexpected outcomes should be reviewed and failure to meet agreed major trauma KPIs should also be discussed and appropriate action taken. A forum will be required to allow Major Trauma Centres to compare outcomes nationally and perhaps the STAG National Steering Committee might fulfill this role. This work will require appropriately resources dedicated to data collection Audit of performance in both process and outcome should therefore be a key component of in house review at institutional level and at national level. Progress and issues should be discussed, perhaps as part of an annual major trauma audit meeting, with scope for identifying areas for improvement and also outliers who may have innovations to share with the aim of promoting improvements in the definitive care of major trauma patients in Scotland. 66

67 11. Implications, Challenges & Opportunities Recommendation Implications Challenges Opportunities 1 NHS Scotland should develop and implement a national Service redesign required at national, regional and local Sporadic distribution of major trauma cases currently across a large Opportunity to develop World class major trauma major trauma levels to deliver number of hospitals with services that help network. definitive major varying capabilities. realise the 2020 trauma care. vision. The investment in resources that is required is better justified with high volume caseloads in a small number of MTCs. Coordination needed to develop and implement a cohesive major trauma network that links together regional major trauma centres (MTCs) and hospitals in their region. Excellent planning, organisation and strong clinical leadership locally, regionally, and nationally will be required to drive improvements. Introducing a major trauma network will enhance major trauma care across the entire network, not just in MTCs but all hospitals that continue to receive major trauma. 2 As a first step, services at 4 sites should be enhanced to provide definitive major trauma care to everyone who can reach one of these locations within 45 minutes. 3 NHS Boards should implement the agreed major trauma pathway set out in the RCSE Trauma Care in Scotland report. 4 Compulsory evaluation of outcome for all major trauma patients, including children who are transferred. This will lead to the creation of 4 major trauma centres at Aberdeen Royal Infirmary, Ninewells Hospital Dundee, Royal Infirmary of Edinburgh and the Southern General Hospital Glasgow, which will work with, and provide the necessary advice and support to, hospitals within each region. Significant resources may be required to fully implement the pathway. A national KPI should be developed These 4 centres are already the regional referral centres for multiple trauma. Modest reorganisation of referrals in these areas will be required. There will however, be a need to enhance facilities, staffing, training and processes to allow them to function as MTCs, and make a difference. NHS Boards may need to enhance facilities, staffing, training and processes across NHS Scotland to ensure that the recommended pathway is implemented. Around one third of major trauma patients are currently going to the wrong place. This needs to be resolved. Will help to ensure definitive trauma care is provided across Scotland, improve patient safety, and optimise outcomes for people who experience major trauma. By implementing the Major Trauma Quality Framework, a coherent, integrated and inclusive major trauma network will be established across NHS Scotland Opportunity to help eliminate unnecessary transfers, improve safety and outcomes and save lives.

68 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September NHS Boards should assess the readiness of each major trauma receiving site, including community hospitals, and agree bypass procedures with the SAS (in line with the Prehospital Quality Framework set out at 9.2.2). 6 Process and outcome data must also be reviewed for each major trauma case regardless of receiving site, as part of an ongoing quality improvement process. 7 Work to progress prehospital triage and decision making should continue. 8 A national strategy for the tasking of prehospital services, linked to triage, should be developed. NHS Board and SAS staff resources will be required to carry out this work. Evaluation requires NHS Board resources Experience from London has shown that for every case of major trauma identified there are two cases with minor or moderate injuries that trigger the tool and are taken to a MTC. Other regions, such as Newcastle, have experienced less over triage, underlining that performance depends on many factors. Requires assimilation of information from several sources, such as patients triage category, incident location, access time to appropriate facility, helicopter availability, weather conditions, need for specialist prehospital intervention. There are currently only 2 bypass protocols in place in Scotland. Others will need to be developed and implemented. Areas for improvement will require to be identified and acted upon. For reasons of patient safety it is important that the triage tool adopted identifies as many major trauma patients as possible. Implementation of Trauma Triage Tool should support tests of change in relation to emergency department pre alert. Over triage needs to be taken into consideration when modelling centre volumes; Availability of technological (communication between pre-hospital care providers and ambulance control; drive/flight time analysis) and decision support capability. Associated resource implications. Implementation of bypass protocols will ensure that the majority of people who experience major trauma in Scotland will access definitive care quickly. Opportunity to develop and gather first rate data that will fully inform and help drive service and outcome improvements Opportunity to develop and implement triage protocols that give clear guidance and help major trauma patients access definitive care quickly. Opportunity to deliver individualised, person-centred care, in the context of a population dispersed across a wide geographical area. Opportunity to develop a truly integrated service. 68

69 9 A network of enhanced care medical teams should be established within Scotland. 10 All hospitals must participate in STAG the audit. The STAG audit should be extended to include patient-centred outcomes. Co-ordination and enhancement prehospital teams including Medic 1, Tayside Trauma Team, and Emergency Medical Retrieval Service (EMRS) to allow them to continue to work collaboratively with the SAS, will be required. STAG will require to be enhanced. Pilots evaluating enhanced triage decision making support have been very positive and will require to be resourced. STAG will require to be resourced at local, regional and national levels Opportunity to develop and deliver a co-ordinated, pan Scotland prehospital critical care interventions that operating under a single Governance Structure. This will help ensure more complete data collection, inform decision making and drive improvements in services and outcomes. 11 Data linkage work between STAG, SAS and, EMRS/ ScotSTAR should be progressed. 12 Data linkage work between STAG and SMR01 data should be progressed. STAG will require to be enhanced. STAG will require to be enhanced. This work will require adequate resources. This work will require adequate resources. Development of a HSMR type measure for trauma should also be considered as a tool for performance improvement. This will allow for full patient journey data to be collected including more precise incident location and prehospital care and inform decision making and improvements. This will enable valuable information to be explored in relation to outcomes and survival. It will also allow for links between major trauma outcome and other information, such as deprivation and prior patient morbidity to be explored.

70 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September A new specific component of STAG for paediatric trauma should be developed. 14 Once published, the findings of the GEOS study should be taken into account. 15 National system and performance KPIs for the major trauma network should be agreed and measured to help monitor success and drive improvements for major trauma patients of all ages. 16 Clinical leadership at national, prehospital, MTC and hospital level should be put in place STAG will require to be enhanced. A review of the proposed network structure should take place once GEOS is published. Time and resource will be required to develop KPIs. Clinical Leadership at all levels vital to success of the major trauma network The methodology of this will be challenging and there are issues to overcome such as validated scoring for injury severity, but this shouldn t preclude prospective data collection. This work should be prioritised. GEOS not expected to report until July 2014 at the earliest. Without appropriate KPIs, it will prove difficult if not impossible to measure the success of the major trauma network and its component parts Effective leadership will be required to be identified and have the ability to drive and implement change. Opportunity to improve paediatric data and inform decision making and outcomes. As an interim measure, a crosswalk exercise from Children s SMR01 to AIS should be considered to in order to identify some more accurate estimates of paediatric trauma activity. GEOS is expected to be invaluable when considering future configurations of a trauma network in Scotland, including whether the number of major trauma centres can and should be reduced further from 4 MTCs and where the optimal location(s) might be. A range of measurable KPIs will be crucial to informing and driving improvements in both major trauma services and outcomes Opportunity to help develop and improve the major trauma network and optimise patient outcomes through effective leadership. 70

71 12. Options and Conclusion 196. The remit of the NPF Major Trauma subgroup was therefore to explore possible ways of enhancing current major trauma services in Scotland The limitations of the published secondary evidence in support of major trauma centres needs to be considered. A full systematic review of the primary literature is infeasible. Although the primary literature as a whole has not been systematically reviewed, there is some published primary literature which demonstrates that major trauma centre care reduces mortality 2930, and improves outcomes 31, including better functional outcomes There is also some emerging evidence that regionalisation of trauma care (MTCs) is not only effective, but also cost-effective 33, although the SHTG scoping report found that it was not generalisable to the UK Fundamentally, Scotland must aim to optimise outcomes for people who experience major trauma. Taking all evidence into account and possible opportunities, the following options are available: Option 1 - Maintain the status quo Pros: People who experience major trauma will continue to be able to access care at over 30 sites across Scotland. Cons: There are professional and ethical reasons against maintaining the status quo. There is no clear system of referral pathways in place across Scotland, nor are there consistent protocols in place, such as a consistent trauma triage tool in use across Scotland, which can result in delays to patients being transferred to definitive care and can lead to poorer outcomes. One third of major trauma patients are currently transferred to more definitive care. A third of patients will therefore continue to go to the wrong place; The outcomes for patients that are transferred are worse than those who access definitive care. People who experience major trauma will not be able to access urgent and definitive care from a specialist multi-disciplinary team in order to optimise outcomes. Major trauma patients comprise only 0.2% of the emergency medicine workload. The status quo will mean that many hospitals and hospital staff will 29 MacKenzie et al, A National Evaluation of the Effect of Trauma-Center Care on Mortality, N Engl J Med Moore et al, Evaluation of the Long-term Trend in Mortality from Injuryin a Mature Inclusive Trauma System, World J Surg (2010) 31 Davenport et al, A major trauma centre is a specialty hospital not a hospital of specialties, British Journal of Surgery Gabbe et al, Improved Functional Outcomes for Major Trauma Patients in a Regionalized, Inclusive Trauma System, Ann Surg MacKenzie et al, The Value of Trauma Center Care, J Trauma. 2010

72 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 remain unable to maintain the resources and skills required to deliver optimal major trauma care; Major trauma will continue to be a leading cause of death and a large socioeconomic burden in Scotland. There is no evidence to suggest major trauma outcomes and treatment are superior in hospitals lacking in experienced and appropriately qualified personnel. The notion that badly injured patients in Scotland are somehow different to those elsewhere is not plausible. There is a cogent and compelling case for change. Definitive major trauma care improves outcomes. Maintaining the status quo will be an opportunity missed; Option 2 - Develop and implement a major trauma network and quality framework across NHS Scotland Pros: Delivery of World class major trauma services that help realise the 2020 vision by ensuring definitive trauma care is provided across Scotland; A coherent, integrated and inclusive major trauma network will be established across NHS Scotland, which will help optimise outcomes and provide safer care. Recent data from England supports the case for change; A major trauma network will enhance major trauma care across the entire network, not just in MTCs but all hospitals that continue to receive major trauma; The network will help ensure that the majority of people who experience major trauma in Scotland will access definitive care quickly, eliminate unnecessary transfers, improve safety and save lives; Strong clinical leadership and improved data collection and analysis will fully inform and help drive service improvements and improvements in outcomes for all ages. The network approach would provide the opportunity for non MTC clinicians with an interest in major trauma to carry out sessions at an MTC as part of their job plan, improving skills and further improving the quality of care at non MTCs. Cons: The reconfiguration and enhancements required to establish a major trauma network in Scotland will take time; Enhancing major trauma services across Scotland will require reconfiguration to ensure they are resourced and organised efficiently, and able to treat more patients safely and effectively by the right person in the right environment. Scotland s geography presents challenges which contribute to the difficulties in providing optimal major trauma care. Although a major trauma network will help ensure that the vast majority of major trauma patients can access definitive care, a minority of patients will be unable to reach an MTC within 45 minutes. The published secondary clinical and cost effectiveness evidence in support of MTCs is not strong. 72

73 12.1 Conclusion 200. Should NPF choose to recommend option 2, NHS Boards will be asked to implement the major trauma quality framework and supporting recommendations to enhance major trauma services across Scotland It is envisaged that the 4 NHS Boards that are proposed to host the MTCs will need to scope access and understand the implications of the subgroup s recommendations on capacity and resources, including the implications of overtriage This work is beyond the scope of the NPF Major Trauma Subgroup. A national implementation group and supporting local groups should be formed to take this work forward.

74 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September References & Appendices 13.1 References Scottish Trauma Audit Group ( The National Confidential Enquiry into Patient Outcome and Death. Trauma, who cares? National Audit Office, 2007 London: Modernising major trauma services in London. London severe injuries working group 2001 LSIWG; London Severe Injuries Working Group: Modernising major trauma services in London, 2001; McGuffie et al., Scottish urban versus rural trauma outcome study. J Trauma 2005; 59(3):632. Celso et al, A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems; Journal of Trauma 2006 MacKenzie et al, A National Evaluation of the Effect of Trauma-Center Care on Mortality, N Engl J Med 2006 Moore et al, Evaluation of the Long-term Trend in Mortality from Injuryin a Mature Inclusive Trauma System, World J Surg (2010) Davenport et al, A major trauma centre is a specialty hospital not a hospital of specialties, British Journal of Surgery 2010 Gabbe et al, Improved Functional Outcomes for Major Trauma Patients in a Regionalized, Inclusive Trauma System, Ann Surg 2012 MacKenzie et al, The Value of Trauma Center Care, J Trauma Major Trauma Care in England. National Audit Office. HC213, 5 Feb In % of patients with severe injury in England were taken directly to a Major Trauma Centre. In this increased to 85% - Personal report from C Moran, National Clinical Director for Trauma NHS England, September % of patients identified by paramedics with major trauma are now met by a consultant-led trauma team when they arrive at the Major Trauma Centre. In , 43% of patients in England with severe injury were met by a consultant-led team. - Personal report from C Moran, National Clinical Director for Trauma NHS England, September % of patient with a significant head injury now have a CT scan within 1 hour of arrival at hospital. 58% of adults with multiple injuries now have a whole-body CT scan within 1 hour of arrival at the Major Trauma Centre. - Personal report from C Moran, National Clinical Director for Trauma NHS England, September months ago 75% of patients were transferred to a for complex trauma surgery within 2 days. Now, 92% are transferred to a Major Trauma Centre within the same time frame. - Personal report from C Moran, National Clinical Director for Trauma NHS England, September 2013 Regional Networks for Major Trauma. NHS Clinical Advisory Groups Report. Department of Health, Relationship Between Trauma Center Volume and Outcomes. Nathens A et al, JAMA. 2001;285:

75 A C McGuffie, C A Graham, D Beard, J M Henry, M O Fitzpatrick, S C Wilkie, G W Kerr and T R J Parke. Scottish urban versus rural trauma outcome study. The Journal of Trauma 2005;59(3):632 The American College of Surgeons Committee on Trauma Blue Book 2007 Evaluating trauma center process performance in an integrated trauma system with registry data Year : 2013 Volume : 6 Issue : 2 Page : Journal of Emergencies, Trauma and Shock

76 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September Appendices Major Trauma Subgroup Membership Appendix 1 Chair Caroline Selkirk, Deputy Chief Executive, NHS Tayside Members Jennifer Armstrong Gordon Birnie Julie Brittenden Euan Dickson Chris Driver Mike Fried Alasdair Gray Douglas Gentleman Peter Gent Paul Gowens Stephen Hearns Jan Jansen Michael Johnston John Keating Sean Kelly Heather Knox Alistair McGowan Crawford McGuffie Heather McIntosh Gordon McNaughton Daren Mochrie Jonny Morrison Medical Director, NHS Greater Glasgow & Clyde (NHSGGC) Medical Director (Operational Division), NHS Fife Chief Medical Officer (CMO) Advisor for Vascular Surgery General Surgeon, NHSGGC Paediatric Surgeon, NHS Grampian Consultant Anaesthetist, NHS Lothian, and President of the Scottish Intensive Care Society Consultant in Emergency Medicine, Royal Infirmary Glasgow, representing College of Emergency Medicine CMO Advisor for Rehabilitation Medicine Regional Planning, North of Scotland Planning Group Head of Clinical Governance, Patient Safety and Quality Scottish Ambulance Service (SAS) Lead Consultant, Emergency Medical Retrieval Service Consultant in General Surgery and Intensive Care Medicine, NHS Grampian Consultant in Emergency Medicine, NHS Tayside Consultant Orthopaedics Surgeon, NHS Lothian Trauma and Orthopaedics Surgeon, NHS Highland Regional Planning, West of Scotland Planning Group CMO Advisor for Ambulance Services Consultant in Emergency Medicine, representing Scottish Trauma Audit Group (STAG) Healthcare Improvement Scotland, Scottish Health Technologies Group CMO Advisor for Accident and Emergency Medicine Director of Service Delivery, SAS General Surgical Registrar & Research Fellow, NHS Lanarkshire 76

77 Simon Paterson-Brown Fiona Ramsay Iain Robertson Jacqui Simpson Patrick Statham William Walker Stuart Watson General/Upper Gastro-Intestinal Surgeon, NHS Lothian Director of Finance, NHS Forth Valley CMO Advisor for Interventional Radiology Regional Planning, South East And Tayside Planning Group CMO Advisor for Neurosurgery CMO Advisor for Cardiac Surgery Consultant Plastic Surgeon, NHSGGC Justine Westwood Head of Planning and Performance, NHS 24 Ian Ross Scottish Government Chief Executive, NHS Lanarkshire Catherine Calderwood Lucy Denvir Elizabeth Porterfield Craig Bell Chris Roberts Ian Williamson Senior Medical Officer Specialty Registrar in Public Health Head, Planning Team, The Quality Unit National Planning Manager, The Quality Unit Policy Manager, The Quality Unit Performance Manager, SAS & NHS 24, Primary Care Division

78 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 Major Trauma Subgroup Report Writing Group Membership Appendix 2 Chair Caroline Selkirk, Deputy Chief Executive, NHS Tayside Members Euan Dickson Douglas Gentleman Paul Gowens Stephen Hearns Jan Jansen Michael Johnston John Keating Heather Knox Crawford McGuffie Jonny Morrison Heather McIntosh General Surgeon, NHSGGC CMO Advisor for Rehabilitation Medicine Head of Clinical Governance, Patient Safety and Quality Scottish Ambulance Service (SAS) Lead Consultant, Emergency Medical Retrieval Service Consultant in General Surgery and Intensive Care Medicine, NHS Grampian Consultant in Emergency Medicine, NHS Tayside Consultant Orthopaedics Surgeon, NHS Lothian Regional Planning, West of Scotland Planning Group Consultant in Emergency Medicine, representing Scottish Trauma Audit Group (STAG) General Surgical Registrar &Research Fellow, NHS Lanarkshire Healthcare Improvement Scotland, Scottish Health Technologies Group Scottish Government Catherine Calderwood Lucy Denvir Elizabeth Porterfield Craig Bell Chris Roberts Senior Medical Officer Specialty Registrar in Public Health Head, Planning Team, The Quality Unit National Planning Manager, The Quality Unit Policy Manager, The Quality Unit 78

79 Appendix 3 Current Major Trauma Service Provision in Scotland Summary of NHS Board Questionnaire Returns PRE-HOSPITAL CARE RECOMMENDED CURRENT MAJOR TRAUMA SERVICE PATHWAY STANDARD PROVISION ISSUES DISCUSSED BY QUESTIONS NPF MAJOR TRAUMA CONSIDERED SUBGROUP BY NPF SUBGROUP 1 A Trauma Triage Tool should be used to identify major trauma There is no consistent trauma triage tool in use There are numerous across Scotland. examples of trauma 2 A paramedic should be There are currently clinical advisors present in all 3 Ambulance Control Centres (ACCs) 24/7 available 24/7 in but they are not exclusively dedicated to MT the ACC to identify and coordinate the advice and co-ordination. A 6 month MT clinical pathfinder project based in the west ACC but covering all regions from response to MT is in place as part of the ScotSTAR project. triage tools in use across the UK based largely on those developed in the USA and Australia. These should be examined, evaluated and an appropriate tool developed or adopted for use across Scotland. The role of the clinical advisors in the ACCs should be developed, or the role of the single MT clinical pathfinder project expanded and formalised as part of core SAS business. Which tool should be used in Scotland and how should this be implemented? Is there an alternative preferable solution? If so, what is it? 3 A consultant level doctor with extensive pre-hospital experience of the management of Major Trauma should be available 24/7 to advise medically on the best care provision of each patient. Most Emergency Departments can provide consultant advice and support to SAS but across Scotland this is currently inconsistent and infrequent particularly out of hours. In remote rural areas and the islands there are also BASICS trained GPs although again availability may be inconsistent. There are some local specialist teams in place providing primary retrieval with consultant support; Glasgow (EMIRS), Lothian (Medic 1), and Tayside (Tayside Trauma Team). Any such arrangements are not formalised across Scotland and there are currently few adequately trained and experienced doctors available to carry out this role. SAS should work with local retrieval teams to develop a clinical advice function to incorporate consultant level medical advice on the best care provision for each MT case. Workforce development issues should be addressed as part of the project to ensure the sustainability of such a function. Is there an alternative preferable solution? If so, what is it?

80 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 RECOMMENDED CURRENT MAJOR TRAUMA SERVICE PATHWAY STANDARD PROVISION ISSUES DISCUSSED BY QUESTIONS NPF MAJOR TRAUMA CONSIDERED SUBGROUP BY NPF SUBGROUP 4 MT patients should be taken to a MT centre directly if within 45 minutes travel time 5 When necessary MT patients should be transferred without delay to definitive care after initial assessment and optimisation in the ED at the receiving hospital There is no consistent policy in place across Scotland and no designated Major Trauma centres (MTCs) or overall trauma system. Local bypass protocols and arrangements are in place such as those in Grampian, Tayside and Lothian. Some MT cases in the north of Borders will be taken by SAS or Medic 1 straight to ERI but there is no formal arrangement in place. Within Lothian SAS have arrangements with Emergency Departments as to which cases should be taken to specific Emergency Departments at which times. For the islands and remote and rural area populations there is currently no mechanism for primary retrieval of MT cases directly to definitive care. Such cases are currently stabilised at the nearest ED and then served by EMRS for secondary retrieval. NHS Boards currently can request a transfer by SAS with a clinician travelling from the requesting hospital which can impact on local staffing levels. If a transfer is performed by a local retrieval service then clinical support is provided. There is no standardised or consistent policy or service across Scotland to ensure best use of the most appropriate resource. The islands and remote rural areas are served by EMRS. Patients from Western Isles are taken either to Glasgow or Inverness, and from Orkney and Shetland to Aberdeen. Forth Valley transfers patients to Edinburgh for neurosurgery and to Glasgow for spinal injuries. AA has various arrangements and SLAs in place with Greater Glasgow & Clyde (GGC). DG transfers either to Glasgow or Edinburgh. Highland will transfer patients for neurosurgery and cardiothoracics to Aberdeen. Fife will transfer patients to Edinburgh for neurosurgery and Edinburgh or Dundee for cardiothoracics. There is no clear system of referral pathways in place across Scotland which can result in delays to patients being transferred to definitive care. MT services should be developed and designated within a Trauma System in a manner of configuration most likely to provide optimum benefits to patient outcomes across Scotland. A key factor in this will be ensuring the vast majority of the population can reach definitive major trauma care within 45 minutes. Do MT clinical advice, MERT primary and secondary retrieval services need to be enhanced and developed with clear, consistent and standardised policies and protocols across Scotland? How would such services and policies take into account the particular needs of island and remote and rural areas?. Do they also need to be developed in a manner which addresses workforce and training issues for the future? Discuss the key questions and options given to the group. How should this aspect of pre-hospital care be addressed? Is there an alternative preferable solution? If so, what is it? 80

81 RECOMMENDED CURRENT MAJOR TRAUMA SERVICE PATHWAY STANDARD PROVISION 6 A structured pre-alert should be given to the receiving hospital as early as possible. On arrival at the hospital, a structured handover should be given to the receiving team. Pre-alerts are generally given but there is currently no specific structured pre-alert or handover format or policy in use across Scotland so it can be inconsistent. SAS has a SOP in place and in some areas SBAR or MIST is used. Shetland, Orkney, Western Isles, Highland and DG have established pre alert and liaison arrangements in place between ED staff and EMRS. ISSUES DISCUSSED BY QUESTIONS NPF MAJOR TRAUMA CONSIDERED SUBGROUP BY NPF SUBGROUP Should the use of ATMIST be consistently implemented nationally and incorporated with a specifically developed or adopted trauma triage tool? Is there agreement on the use of ATMIST or SBAR? How should this be progressed and a single tool implemented across Scotland? Is there an alternative preferable solution? If so, what is it? 7 A structured checklist and standardised documentation should be used and included in the patient s clinical record. SAS use the E-PRF but this is currently a generic tool and not specifically designed to include MT. Some Emergency Departments have their own checklists but there is no standardised, consistent or agreed documentation across Scotland Should the new E-PRF be developed at national level to ensure robust recording of MT cases? What modifications are required to enhance E- PRF for MT? How should this be progressed? Is there an alternative preferable solution? If so, what is it?

82 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 RECOMMENDED CURRENT MAJOR TRAUMA SERVICE PATHWAY STANDARD PROVISION ISSUES DISCUSSED BY QUESTIONS NPF MAJOR TRAUMA CONSIDERED SUBGROUP BY NPF SUBGROUP 8 Secondary Emergency Department transfer to a Major Trauma Centre should be provided by an appropriately trained team. Most transfers are currently provided by SAS accompanied by clinical staff from the requesting hospital. This impacts on local staffing levels and the training of the staff is not consistent. Borders links with SAS and will provide senior anaesthetic and nursing staff. AA links with SAS for secondary transfers. DG and Highland have access to EMRS but also utilise their own staff for some time dependent transfers. The islands and remote rural areas are served by EMRS. Do MT clinical advice, MERT primary and secondary retrieval services need to be enhanced and developed with clear, consistent and standardised policies and protocols across Scotland? How might such services and policies take into account the particular needs of island and remote and rural areas? Do they also need to be developed in a manner which addresses workforce and training issues for the future? How should this aspect of pre-hospital care be addressed? Is there an alternative preferable solution? If so, what is it? 9 Pre-hospital SAS is involved in STAG but currently the services should databases are not linked. Not all Emergency submit to a Departments are included in or consistently national trauma submit to STAG. dataset and be included in regular audit Should the work already in progress to link SAS and STAG databases continue to be taken forward? What barriers are there to taking this work forward? How can they be overcome? Is there an alternative preferable solution? If so, what is it? 82

83 ACUTE CARE RECOMMENDED PATHWAY STANDARD 1 Reception: Trained trauma team available for reception 24/7 CURRENT MAJOR TRAUMA SERVICE PROVISION Currently there are no formal trauma teams in place in Emergency Departments to receive major trauma cases with consultant on site 24/7. The majority of Emergency Departments have senior level cover 24/7 with consultant available within 30 minutes out of hours. Thoracotomy capability is inconsistent. In some remote and rural areas recruitment is an issue. ISSUES DISCUSSED BY NPF MAJOR TRAUMA SUBGROUP Does training and recruitment of ED consultants need to be addressed across Scotland? Do sustainable rotas within a trauma system need to be planned to ensure 24/7 thoracotomy capability and consultant presence, at major trauma services? QUESTIONS CONSIDERED BY NPF SUBGROUP Should the CEM Unscheduled Care Workforce group be asked to consider/ address these issues? Is there an alternative preferable solution? If so, what is it? 2a Radiology: Emergency radiology available 24/7 The majority of Emergency Departments have emergency radiology available 24/7 and co-located or adjacent within the ED. CT is available at most, but not all, receiving Emergency Departments. Radiology recruitment is an issue in some remote and rural areas. MT cases should have 24/7 access to CT How can we ensure equitable access to CT for MT cases? 2b MRI available The majority of Emergency Departments 24/7 at Major cannot provide access to MRI 24/7. This due Trauma to lack of adequately trained staff. The centres islands do not have any MRI facilities. (MTCs) MT cases should have 24/7 access to MRI How can we ensure equitable access to MRI for MT cases? Is there an alternative preferable solution? If so, what is it? 2c Radiology reporting The majority of Emergency Departments have rigorous reporting mechanisms in place for radiology reporting. Do systems need to be in place to ensure Island Boards have prompt and consistent Orkney and Shetland rely on Grampian, and Radiology reporting Western Isles have an agreement in place to and advice? access remote radiologist advice via Borders. Should this be addressed through NHS Board telehealth colleagues? Is there an alternative preferable solution? If so, what is it?

84 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 RECOMMENDED PATHWAY STANDARD CURRENT MAJOR TRAUMA SERVICE PROVISION ISSUES DISCUSSED BY NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 2d Teleradiology facilities All Boards have access to PACS. However, Greater Glasgow & Clyde (GGC) and Highland have some issues with compatible access across all sites. Local issues in provision of PACS should be addressed within those regions. Should this be addressed through NHS Board telehealth colleagues? 2e Interventional Radiology 3 Emergency Trauma Surgery Only 2 Boards have 24/7 access to interventional radiology. All other mainland Boards can only provide consistently within working hours and not across all sites. OOH provision is not currently consistent or sustainable. Some local arrangements are being explored to try and ensure sustainable rotas on a regional basis e.g. Tayside and Fife. The Islands do not have access to interventional radiology and rely on links to mainland. The majority of Boards can provide 24/7 access to emergency theatres and appropriately trained consultant surgeons. The islands and some smaller Boards (e.g. Borders) can only manage simple cases and would look to stabilise and transfer more complex surgery. This can lead to delays in definitive treatment. Additional specialist training is an issue e.g. DSTS course. Should access to 24/7 interventional radiology for all MT cases be provided? Should a trauma system be put in place that will ensure prompt 24/7 access to the highest quality emergency trauma surgery for all MT cases? Is there an alternative preferable solution? If so, what is it? How should 24/7 access to interventional radiology for MT cases best be sustainably configured and provided? Is there an alternative preferable solution? If so, what is it? Discuss the key questions and options given to the group. 84

85 RECOMMENDED PATHWAY STANDARD CURRENT MAJOR TRAUMA SERVICE PROVISION ISSUES DISCUSSED BY NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 4a General, orthopaedic, vascular and cardiothoracic surgery 24/7 Theatre access 4b Senior trainees available on site 24/7 and consultants 30 minutes All Boards can provide 24/7 access to emergency theatres For general and orthopaedic surgery mainland Boards can provide this although not necessarily on all sites. Lanarkshire has this available for all specialties on all sites. Orkney and Shetland have general surgeons only. Western Isles can provide general and orthopaedic. Otherwise cases will transfer to mainland via EMRS. No further recommendation Should a major trauma system be developed to allow all these services to be configured and provided on a single site(s) to meet the needs of MT cases on a sustainable and consistent basis? No questions to address How should the future configuration of these services be taken forward to meet this objective? For vascular surgery most Boards have regional arrangements: AA on one site. Grampian on one site and takes transfers from Orkney and Shetland Greater Glasgow & Clyde (GGC) on one site Highland vascular cover is currently not 24/7 (awaiting recruitment) Lothian on one site and take transfers from Borders Tayside on one site and take transfers from Fife D+G have a shared rota with Cumbria For cardiothoracic surgery most Boards have regional arrangements: AA only on one site Grampian only on one site and take transfers from Highland, Orkney and Shetland GGC only on one site and take transfers from D+G Lothian on one site and take transfers from Borders and Fife and Tayside.

86 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 RECOMMENDED PATHWAY STANDARD 5 Neurosurgery and spinal cord injury CURRENT MAJOR TRAUMA SERVICE PROVISION Neurosurgery is provided through a network approach at 4 centres: GGC, Grampian, Lothian and Tayside GGC takes referrals from AA, D+G, Lanarkshire Grampian takes referrals from Highland, Shetland and Orkney Lothian takes referrals from Borders, D+G, Fife Tayside may refer spinal cases to GGC Some Boards report a lack of consistency and clarity in referral pathways and protocols. This can result in delays in consultant contact, opinion and decision and patient transfer. 6 Critical Care All mainland Boards have access to ICUs compliant with ICS standards (not necessarily on all sites). ICU/anaesthetic will undertake transfers. GGC has a dedicated transfer team (SHOCK). 7 Blood transfusion and haemorrhage The Island Boards have HDUs and are served by EMRS for transfer to mainland. There are some sustainability issues around recruiting staff in some areas (Fife, Grampian). OOH consultant cover in some areas is provided by anaesthetic staff rather than dedicated ICU consultant. All mainland Boards have protocols in place with 24/7 access to haematology advice and support. Not all have an established transfusion committee and some also need support with 24/7 access to interventional radiology. Orkney and Shetland access services via Grampian and Western Isles via Highland. ISSUES DISCUSSED BY NPF MAJOR TRAUMA SUBGROUP Do Neurosurgery network pathways and referral protocols need to be clarified to provide consistency and avoid delays in transfer and treatment? Should neurosurgery and spinal surgery services be co-located with other key elements of a major trauma service and how might consultant contact and response and secondary retrieval be improved? Are there sustainable recruitment issues for ICU staff that need to be addressed? Should all Boards providing services have clear transfusion governance in place including a transfusion committee? Should any future service reconfiguration should take the needs of Island Boards into account. QUESTIONS CONSIDERED BY NPF SUBGROUP How should quality neurosurgery and spinal injury service be provided within a trauma system. Is there an alternative preferable solution? If so, what is it? Should the CEM Unscheduled Care Workforce group be asked to consider/ address these issues? Is there an alternative preferable solution? If so, what is it? How should future transfusion service governance issues be managed within a trauma system? 86

87 ON-GOING CARE RECOMMENDED CURRENT MAJOR TRAUMA ISSUES DISCUSSED BY PATHWAY STANDARD SERVICE PROVISION NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 1 Focus on person centred services and the role of family and friends All Boards support the Do trauma ICPs need principles of person centred further development to care with most reporting use bridge across specialities of integrated care pathways and from acute care to (ICPs). Some areas of good rehabilitation. practice highlighted e.g. Highland YARU and Lothian brain injury unit providing care bridging the gap from acute to community. There are no specific examples of specific trauma ICPs. Should standardised trauma integrated care pathways be developed for Scotland and how should we go about this? Is there an alternative preferable solution? If so, what is it? 2 MT patients should be admitted under the care of designated responsible trauma consultants and the service should include a care and rehabilitation coordinator to coordinate current and future care and rehabilitation No Boards have specific trauma service consultants or rehabilitation and care coordinators. Patients are admitted under a lead consultant as most appropriate to their injuries and care and rehabilitation is planned on an individual basis. Should specific trauma service consultants or rehabilitation and care coordinators roles be developed within a trauma system for Scotland What are the barriers to establishing these key roles within a trauma system and how can these be overcome? Is there an alternative preferable solution? If so, what is it? 3a Cross speciality supporting services Nursing: Co-locate patients with multiple injuries in dedicated trauma wards. Most mainland Boards have access to ICU and orthopaedic wards but currently only Lanarkshire reports it has a dedicated trauma ward. Do dedicated trauma wards / units need to be developed within a trauma system? What are the barriers to developing such services and how can these be overcome? Is there an alternative preferable solution? If so, what is it?

88 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 RECOMMENDED CURRENT MAJOR TRAUMA ISSUES DISCUSSED BY PATHWAY STANDARD SERVICE PROVISION NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 3b Radiology: 24/7 access to CT, U/S, MRI, angiography, interventional radiology. Access to PACS Lanarkshire and Tayside report being able to provide all services 24/7. The majority of Boards cannot provide 24/7 access to MRI and / or interventional radiology. All Boards have access to PACS with Highland addressing some local compatibility issues. Should comprehensive radiology services and investment in staff training within a trauma system be developed? How should radiology services best be developed to meet the needs of a trauma system? How can we ensure equitable access to radiology for MT cases? Should the CEM Unscheduled Care Workforce group be asked to consider/ address any workforce issues? 3c Anaesthesia and theatres: Access to fully resourced separate dedicated theatres All Boards can provide 24/7 access to theatres but no specifically dedicated trauma theatre Should separate dedicated theatres within a trauma system be provided? What would be required to ensure dedicated theatres? Is there an alternative preferable solution? If so, what is it? 3d Critical care: 24/7 care from dedicated intensive care consultants. ICU subject to national audit Most mainland Boards can meet this standard. Grampian and Highland have some issues with OOH cover from anaesthetics. The islands rely on mainland for support with intensive care. Should critical care be enhanced in some areas to provide full 24/7 cover? In any trauma system, the needs of the Islands should be taken into account. How should critical care of major trauma patients best be enhanced across Scotland? 88

89 RECOMMENDED CURRENT MAJOR TRAUMA ISSUES DISCUSSED BY PATHWAY STANDARD SERVICE PROVISION NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 4 Rehabilitation: MTCs to provide enhanced rehabilitation services to meet the needs of complex trauma patients. Trauma Units to have skills and capacity to deliver rehabilitation. All Boards provide generic rehabilitation services across acute and community settings. Specialist provision includes: Neuro Fife, GGC, Grampian, Lothian, Tayside. Spinal GGC Amputee Lothian YARU Highland Should the development of specialist post-graduate training for rehab therapies be supported? Is there a need to develop clear and consistent rehabilitation care and referral pathways? How should rehab services best be developed and configured to meet the needs of major trauma patients? 5 Pain management: All hospitals taking trauma patients to have a specialist acute pain service. There is a lack of clear referral and care pathways. Western Isles have no dedicated pain service. Some smaller Boards have a limited service e.g. nurse only or not OOH. This includes Borders, D+G, Fife, Highland, and Orkney. Do trauma services need to ensure access to specialist pain services? Is there a role here for local chronic pain improvement groups that have recently been set up in NHS Boards? Do we agree? 6 Neuropsychology and neuropsychiatry: Post-traumatic amnesia screening and monitoring to be routine in all major trauma patients. The majority of Boards do not provide routine screening. Grampian, GGC and Tayside provide screening for any patients referred. Would a major trauma service (s) need to ensure development and delivery of screening tools and protocols and appropriate training? Do we agree?

90 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 RECOMMENDED CURRENT MAJOR TRAUMA ISSUES DISCUSSED BY PATHWAY STANDARD SERVICE PROVISION NPF MAJOR TRAUMA SUBGROUP 7 Psychosocial and mental health care All Boards provide generic mental health services across acute and community sectors. In some cases there is a lack of clear pathways and inconsistency in long term follow-up. Do specialist psychosocial and mental health care pathways for trauma patients need to be developed? QUESTIONS CONSIDERED BY NPF SUBGROUP Do we agree? AA, Fife and Grampian provide full psychiatry liaison services. 8 Equipment: Appropriate equipment to be available routinely. Care teams to be skilled in using and maintaining equipment. All Boards have access to appropriate equipment and have governance arrangements in place to ensure training and competency. No further recommendation 9a Injury specific care: Most Boards have established Within a Scottish trauma referral networks and SLAs. In some areas referral pathways are not clearly defined (Fife, Grampian). Individual specialities required to manage injuries will exist in some Trauma Units (TUs). Where they do not, or where there are multiple injuries, clear referral pathways to MTCs must be defined. network/system/service, do referral pathways to ensure people with major trauma access the care and support the need, need to be clearly defined and formalised? What are the key referral pathways that need to be worked on in Scotland? 90

91 RECOMMENDED CURRENT MAJOR TRAUMA ISSUES DISCUSSED BY PATHWAY STANDARD SERVICE PROVISION NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 9b Facilities should exist that allow early definitive fixation of pelvic and long-bone injuries. Most mainland Boards can provide this service. The islands and Borders do not provide. Within a Scottish major trauma service, should access to early definitive fixation of pelvic and longbone injuries be provided? Do we agree? If so, how might it best be implemented? 9c Treatment planning and surgery for complex intraarticular injuries should both be performed by an orthopaedic trauma specialist. Most mainland Boards can provide this service. The islands and Borders do not provide but refer to Grampian or Lothian. Within a Scottish major trauma service, should there be access to orthopaedic trauma specialists? Do we agree? If so, how might it best be implemented? 9d Compliance with published standards for the management of open fractures relies on daily access to appropriate theatres that can be staffed simultaneously with both senior orthopaedic and plastic surgeons with the requisite skills to treat these challenging cases. 9e Definitive planned surgery for amputations should be performed in consultation with rehabilitation and prosthetic services. GGC, Grampian, Lothian and Tayside can provide this service. AA has limited service (2 sessions per week). Borders refers to Lothian Fife refers to Tayside D+G and Lanarkshire refer to GGC Highland and Islands refer to Grampian The Islands have links to mainland for these services. Most mainland Boards provide this service. Lothian and Fife require development and enhancement of referral pathways and links to vascular service. Within a Scottish major trauma service, should there be daily access to services for the management of open fractures that meet published standards? Would a Scottish major trauma service/ system need to ensure integrated care for amputations that includes involvement of rehab and prosthetic services from the start? Do we agree? If so, how might it best be implemented? How would amputation services best be provided within a Scottish major trauma system/ service?

92 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 RECOMMENDED CURRENT MAJOR TRAUMA ISSUES DISCUSSED BY PATHWAY STANDARD SERVICE PROVISION NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 9f The prevention of complications arising from spinal instability or neurological compromise involves all members of the multi-disciplinary team and must begin immediately. If there is significant spinal cord injury, early contact should be made with a spinal cord injury centre for advice and to plan strategy. Most Boards have established links with GGC spinal unit. Lothian has its own service. Tayside has its own service but also links with GGC and takes referrals from Fife. Orkney and Western Isles link with Grampian. A Scottish trauma system should ensure early access to spinal injury specialist services. How would spinal injury services best be provided within a Scottish major trauma system/ service? 9g Burn care should be managed through the designation of specialist centres, supporting burns units and some local burns services. Multiprofessional outpatient burns services are essential to ensure optimum ongoing management and outcomes after discharge. Specialist burns services are provided by GGC, Grampian, Lothian and Tayside. GGC takes referrals from AA, D+G, Forth Valley, and Lanarkshire. Lothian takes referrals from Borders, Fife, Forth Valley and Highland. Grampian takes referrals from the Islands. Should a Scottish major trauma system/ service provide burns services through designated specialist units and local supporting services? How might a Scottish Trauma Service/ System ensure the optimum management of major trauma burns? Is there an alternative preferable solution? If so, what is it? 92

93 RECOMMENDED CURRENT MAJOR TRAUMA ISSUES DISCUSSED BY PATHWAY STANDARD SERVICE PROVISION NPF MAJOR TRAUMA SUBGROUP 9h For hand injuries, there must be expertise in microvascular surgery and the management of tissue loss. MTCs should have a combination of plastic surgeons and orthopaedic surgeons in the hand surgery team. A hand therapy unit, manned by specialist therapists, is fundamental to achieving a good result following hand trauma. Fife, GGC, Grampian, Highland, Lanarkshire and Lothian provide hand injury service and Tayside is developing its service. AA and Forth Valley do some work but will refer to GGC if required. D+G refers to GGC. Borders refers to Lothian. The Islands refer to Grampian. Should a Scottish major trauma system/ service provide full services for hand injury?. QUESTIONS CONSIDERED BY NPF SUBGROUP How should hand injury services best be configured in a Scottish major trauma system/ service? Is there an alternative preferable solution? If so, what is it? 9i For maxillofacial injuries, there is a requirement for both TUs and MTCs to provide roundthe-clock consultant-led care with immediate specialist maxillofacial technical support. Fife, GGC, Grampian, Lanarkshire, Lothian and Tayside provide this service. AA, D+G, Forth Valley and Highland do not have full 24/7 cover. Borders refer to Lothian. The Islands refer to Grampian. Within a Scottish major trauma system or service, should maxillofacial injury care pathways and consultant rotas be provided and configured to provide 24/7 care? s How could maxfac services best be configured and provided within a Scottish trauma system? Is there an alternative preferable solution? If so, what is it 9j Craniofacial trauma should be concentrated in MTCs, usually colocated with neurosurgical units. GGC, Grampian, Lothian (not currently co-located) and Tayside provide this service. D+G and Lanarkshire refer to GGC and AA has a joint rota with GGC. Within a Scottish major trauma system/ service should craniofacial trauma be co-located with neurosurgery? Do we agree? Is there an alternative preferable solution? If so, what is it? Borders and Fife refer to Lothian. The Islands and Highland refer to Grampian.

94 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 RECOMMENDED CURRENT MAJOR TRAUMA ISSUES DISCUSSED BY PATHWAY STANDARD SERVICE PROVISION NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 9k Traumatic brain injuries should be managed as per published recommendations. Opinions should be sought from neurology and neuroradiology departments, with a clear definition of areas of clinical responsibility among the various neurological specialties. GGC, Grampian, Lothian and Tayside provide specialist brain injury services. Other Boards have referral networks with these services. Referral criteria and care pathways are not all clearly formalised and standardised. Within a Scottish major trauma system/ service, should care for traumatic brain injury be provided according to published recommendations and clear standardised care pathways be developed? How would brain injury services best be configured within a Scottish major trauma system/ service? 9l Complex peripheral nerve, such as brachial plexus injuries, should be managed in specialist units. GGC provide a specialist unit and all Boards refer cases. The Islands will refer initially to Grampian. No further comment. Do we agree with this service remaining as a single specialist unit within a Scottish major trauma system/ service? 9m Facilities should be in place in MTCs to provide major vascular and endovascular surgery. Most Boards provide this service. Borders refer to Lothian. D+G refer to Cumbria and GGC. Fife refer to Tayside. The Islands refer to Grampian Should a Scottish major trauma system/ service provide major vascular and endovascular surgery?. Do we agree? Is there an alternative preferable solution? If so, what is it? 9n Pneumothoraces, chest drains and tracheostomies should be managed in line with published guidelines. There should be 24-hour access to respiratory physiotherapy, including an out-ofhours on-call service. All Boards manage according to guidelines and most provide 24/7 respiratory physio. Some smaller Boards (Borders and Islands) can only provide emergency general physio OOH. Within a Scottish major trauma system/service, should 24/7 access to respiratory physio be provided?. Do we agree? Is there an alternative preferable solution? If so, what is it? 94

95 RECOMMENDED CURRENT MAJOR TRAUMA ISSUES DISCUSSED BY PATHWAY STANDARD SERVICE PROVISION NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 9o Injuries to the kidney and urinary tract are often complex, and should be identified early and managed in conjunction with urologists, as per published recommendations. Most Boards provide urology service. The islands refer to Highland or Grampian. Borders refer to Lothian. D+G do not have 24/7 urology cover. Within a Scottish major trauma system/ service, should urology services be accessible for the early management of renal and urinary tract injuries? How should urology services best be configured within a Scottish major trauma system/ service? 10 a 10 b Other care considerations: In addition to the treatment of injuries, children and older people require specific age-related considerations. Joint care with paediatric or orthogeriatric support is important. Pre-existing medical conditions should be considered, and other specialists involved in care as appropriate. Most Boards have good links with geriatric and paediatric services. For some cases this will involve referral e.g. D+G may refer to GGC, Fife to Lothian and Islands to Grampian. In some Boards the links across these services continues to require further development. Within a Scottish major trauma system/ service, do links with geriatric and paediatric services need to be clearly established? All Boards provide access to No further recommendation. generic physician service and referral to appropriate specialist services. Individualised patient care is prioritised and patients will be referred to other consultants on an individual basis. How should geriatric and paediatric services be best linked to major trauma services? 10 c Organisations and network structures should facilitate follow-up appointments to take place in the most appropriate setting, be this in the MTC, TU or community. Most Boards plan follow up on an individual basis. In some areas (Islands, D+G) patients are not necessarily seen closest to home. Within a Scottish major trauma system, should mechanisms to allow joint follow-up, including the expansion of telemedicine, be established? Do we agree? Is there an alternative preferable solution? If so, what is it?

96 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 RECOMMENDED CURRENT MAJOR TRAUMA ISSUES DISCUSSED BY PATHWAY STANDARD SERVICE PROVISION NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 11 a 11 b Policies, Protocols and Standards: A discharge summary describing the patient s injuries, care received and ongoing needs and plans should be provided at the time of discharge or transfer from a MTC or TU. This should include a rehabilitation prescription. There should be cross-network agreements and adequate resources to ensure that once specialist medical care has been completed, patients can be transferred to the care of a service which is able to meet their ongoing care and rehabilitation needs. The majority of Boards have policies in place around provision of discharge summaries. However, the provision of a formalised rehabilitation prescription is rare. Most Boards provide individualised patient care within care pathways. There is a lack of formal protocols for repatriation and transfer Should standardised documentation and processes for rehabilitation be developed within a Scottish major trauma system/ service? In a Scottish major trauma system/ service, should ICPs and network arrangements be formalised to ensure appropriate transfer and repatriation? Do we agree? Is there an alternative preferable solution? If so, what is it? Do we agree? Is there an alternative preferable solution? If so, what is it? 11 c Nutritional management: Effective nutritional management is crucial to recovery and rehabilitation following traumatic injury. Policies for nutritional management should be in place in MTCs and TUs. Most Boards provide In a Scottish major trauma nutritional management system/ service, effective through established dietetic nutritional management is service policies and protocols. crucial to recovery and rehabilitation following traumatic injury. Policies for nutritional management should be in place. Do we agree? 96

97 RECOMMENDED CURRENT MAJOR TRAUMA ISSUES DISCUSSED BY PATHWAY STANDARD SERVICE PROVISION NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 12 Governance: Any hospital receiving trauma patients should have associated governance structures in place. Most Boards have well established clinical governance arrangements. There is a lack of specific governance arrangements for trauma but a number of examples of good practice such as Highland and AA have regular trauma MDT case discussions and reviews. Within a Scottish major trauma system/ service a specific trauma governance framework should be established with consistent participation in national audit for adults and children?. Do we agree? Is there an alternative preferable solution? If so, what is it? REHABILITATION RECOMMENDED PATHWAY STANDARD CURRENT MAJOR TRAUMA SERVICE PROVISION ISSUES DISCUSSED BY NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 1 Rehabilitation should start as soon as is appropriate after admission, typically in the critical care setting, and continue at the intensity required, and for as long as is necessary, to enable patients to achieve their functional potential. In most Boards rehab is initiated in the critical and acute phases. There are good examples of links and in reach across acute and community services. However, there can be some variability in service provision particularly in the community setting. Any clear care pathways are mostly restricted to specific specialities e.g. brain injury or amputation and there is no overall rehab pathway for trauma. Do comprehensive and Do we agree? enhanced rehabilitation care pathways for trauma patients need to be developed including early intervention? Is there an alternative preferable solution? If so, what is it? 2 Patients who have not been admitted to a MTC should not be disadvantaged in accessing the level of rehabilitation they require. Most Boards provide generic rehab services across acute and community settings. The level of service and standard of care pathways etc. can be variable and the Islands and some smaller Boards would find it difficult to sustain provision of longer term care for more major or complex cases. Do comprehensive trauma rehab care pathways need to be developed in the context of a major trauma system/ service? Do we agree? Is there an alternative preferable solution? If so, what is it? 3 All stages of care, including the rehabilitation and transfer aspects of the patient s pathway, should be the responsibility of the network. There are good examples of good Do National and links across acute and community settings. However, there are no formal trauma rehab network arrangements and care is largely determined by individual need within specific specialities. regional trauma rehab networks need to be developed with clearly defined care pathways as part of a Scottish major trauma system/ service? Do we agree? Is there an alternative preferable solution? If so, what is it?

98 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 RECOMMENDED CURRENT MAJOR TRAUMA PATHWAY STANDARD SERVICE PROVISION ISSUES DISCUSSED BY NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 4 There should be an appointment of a Trauma Network Director of Rehabilitation Services. There is currently no Director in place 5 There should be an Some Boards have Rehabilitation appointment of a Consultants some of whom Clinical Lead for specialise e.g. in brain injury. The Acute Trauma majority do not have this in place. Rehabilitation Services in every MTC (Consultant in Rehabilitation Medicine). In the context of a Scottish major trauma system/ service, should a Director of rehabilitation Services should be established at national or regional level? Should a Scottish major trauma system/ service have a lead Consultant in Rehabilitation? Should trauma network rehabilitation leadership be provided at regional or national level? Is there an alternative preferable solution? If so, what is it? Do we agree? Is there an alternative preferable solution? If so, what is it? 6 There should be adequately skilled and resourced multi-disciplinary rehabilitation teams in all of a network s services. 7 There should be rehabilitation and care coordinator posts throughout the network. Patients should have an identified key worker to be a point of contact for them, their carers or family doctor, and to ensure delivery of their personal prescription for rehabilitation. There are good examples of MDTs reaching across acute and community settings e.g. within Highland YARU. The majority of Boards have MDTs but capacity is limited and variable especially in the community. Expertise in trauma rehabilitation is also limited. Should a comprehensive multidisciplinary rehab service be developed within the context of a Scottish major trauma system/ service? In some Boards key workers are Should Care and allocated within rehab services. rehabilitation coordinator role(s) be There is currently no rehab and care co-ordinator posts in place. developed as part of a multidisciplinary approach within a Scottish major trauma system/ service Do we agree? Is there an alternative preferable solution? If so, what is it? Do we agree? Is there an alternative preferable solution? If so, what is it? 98

99 RECOMMENDED CURRENT MAJOR TRAUMA PATHWAY STANDARD SERVICE PROVISION ISSUES DISCUSSED BY NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 8 Every patient should receive routine screening of rehabilitation needs. In most Boards care is based on assessment of individual need by a multidisciplinary team. Currently there are no formal screening protocols in place. Should routine Do we agree? screening of rehabilitation needs be Is there an developed as part of a alternative care pathway within a preferable Scottish major trauma solution? If so, system/ service. what is it? 9 A rehabilitation prescription should be provided to all trauma patients with identified needs. 10 Trauma patients should receive appropriate levels of care and rehabilitation at all points along their care pathway. 11 Many trauma patients are of working age, so vocational rehabilitation should therefore be a key component of rehabilitation. Most Boards provide care and rehabilitation based on individual assessment of need and goal setting. There are currently no formal rehabilitation prescription protocols in place. The majority of Boards have no formal ICPs in place. Grampian services fall below BSR guidelines and redesign is on-going to address this. GGC does have a specific audit of rehab services but the majority of boards have only overall organisational governance processes in place. In the majority of Boards there is no dedicated vocational rehab service. GGC, Grampian, Lothian and Tayside provide a service although for Lothian and Tayside this is limited. Some services are provided by the voluntary sector and not specifically dedicated to trauma cases. Should rehabilitation prescription be developed as part of a care pathway within a Scottish major trauma system/ service? Should governance and audit of rehab services be in place across the care pathway in the context of a Scottish major trauma system/ service? Within a Scottish major trauma system, should vocational rehab services be developed as part of personalised care pathways? Do we agree? Is there an alternative preferable solution? If so, what is it? Do we agree? Is there an alternative preferable solution? If so, what is it? Do we agree? Is there an alternative preferable solution? If so, what is it? 12 A directory of services and resources should be developed relating to rehabilitation and ongoing care to facilitate referral and access to these services. There is no sustainable directory of rehab services in place currently. In some Boards there are examples of locality directories being developed (GGC, D+G). Within a Scottish major trauma system/ service, should a directory of rehab services be provided that covers national, regional and locality levels? Do we agree? Is there an alternative preferable solution? If so, what is it?

100 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 RECOMMENDED PATHWAY STANDARD CURRENT MAJOR TRAUMA SERVICE PROVISION ISSUES DISCUSSED BY NPF MAJOR TRAUMA SUBGROUP QUESTIONS CONSIDERED BY NPF SUBGROUP 13 Appropriate funding structures should be developed to ensure timely and comprehensive rehabilitation. 14 There should be coordinated development of rehabilitation services and longterm Support in the community which can deliver comprehensive and effective rehabilitation to meet the needs of traumaticallyinjured patients irrespective of their age. Currently no Board has a formal Within a Scottish major Do we agree? overall strategic structure for funding trauma system/ service rehab services. Funding allocation is should a funding often related to specific specialities. structure for rehab Is there an alternative There are also examples of joint services be clearly preferable funding with social services and the established?. voluntary sector. solution? If so, what is it? GGC and Grampian have established integrated long term community and rehab frameworks in place with Localities. There are additional examples of specific redesign developments in progress in specific localities or around specific care pathways e.g. AA, Fife, Lothian. In some more remote and rural Boards (Islands, D+G, and Highland) geography and sustainability make such provision particularly problematic. Within a Scottish major trauma system/ service, should development of rehab services across all age group and specialities be co-ordinated?. Do we agree? Is there an alternative preferable solution? If so, what is it? 100

101 a) MAP 1: MTC Road ambulance coverage Appendix 4

102 National Planning Forum Major Trauma Sub Group, A Quality Framework for Major Trauma Services, Report to NPF September 2013 b) MAP 2: MTC Helicopter and Road ambulance coverage 102