Trauma: Who Cares? - National Confidential Enquiry Into .
Trauma: Who cares?A report of the National Confidential Enquiry into Patient Outcome and Death (2007)
Trauma: Who cares?A report of the National Confidential Enquiry into Patient Outcome and Death (2007)Compiled by:G Findlay MB ChB FRCAN Smith BSc PhDI C Martin LLM FRCS FDSRCSD Weyman BScS Carter MBBS FRCS FRCS(G) RCPSM Mason PhD11
Contents2Acknowledgements4Foreword8Summary of findings10Principal 7Chapter 1 – Data overview21Chapter 2 – Organisational data25Key findings33Recommendations33Chapter 3 – Overall assessment34Key findings36Chapter 4 – Prehospital care37Introduction37Organisational aspects of care37Clinical aspects of care42Airway and ventilation43Key findings48Recommendations48References49Chapter 5 – Hospital reception50Introduction50Results50Trauma team response51Trauma team response – individual cases52Primary survey and overall assessment59Key findings60Recommendations61References61
Chapter 6 – Airway and breathing62Chapter 10 – Results119Case study 168Case study 6123Key findings68Case study 7123Recommendations68Key s125Chapter 7 – Management of circulation70Introduction70Chapter 11 – Incidence of traumaResults71and organisation of trauma services126Case study 272Introduction126Case study 376Results126Key findings81Discussion128Recommendations82Key s132Chapter 8 – Head injury management85Introduction85Appendix A – Glossary133Results85Prehospital data86Appendix B – Injury severity score134Hospital data91Case study 497Case study 5104Appendix C – Adult and paediatricGlasgow Coma Scale135Key findings108Recommendations109Appendix D – An example of an excellentReferences109Patient Report Form (PRF)138Chapter 9 – Paediatric care112Appendix E – Level 1 trauma care140Organisational data112Clinical data114Appendix F – Participation141Key findings116Appendix G – Corporate structure148Recommendations116References1173
AcknowledgementsThis is the twenty first report published by NCEPOD and, as always, could not have beenachieved without the support of a wide range of individuals and organisations.Our particular thanks go to:The Expert Group who advised NCEPOD:Dr A NicholsonConsultant Vascular Radiologist,Dr B WinterClinical Director of RadiologyConsultant in Adult Critical CareDr I DoughtyDr C CarneyConsultant PaediatricianChief Executive East Anglian Ambulance NHS TrustThe Advisors who reviewed the cases:Mr D GilroyConsultant General SurgeonDr A WilsonConsultant in Emergency MedicineMr K PorterConsultant Orthopaedic SurgeonMiss A HutchingsTrauma Nurse Specialist / Trauma Co-ordinatorProfessor P GiannoudisProfessor of Trauma and OrthopaedicsDr A FeazeyConsultant in Emergency MedicineMr S DaviesTrauma Nurse Co-ordinatorDr A BlackConsultant PaediatricianProfessor T CoatsProfessor of Emergency MedicineMiss A McGinleyNurse Consultant Critical Care Outreach TeamMr T PigottConsultant Spinal SurgeonDr A SutcliffeConsultant in Intensive CareMs E SymondsLay RepresentativeMr A ArmstrongConsultant Plastic SurgeonDr A GrayConsultant AnaesthetistMr B WhiteConsultant Neurosurgeon4
AcknowledgementsMr M PerryDr C StevensonConsultant Oral and Maxillofacial SurgeonSpecialist Registrar in AnaesthesiaMr M McMonagleDr C GomezSpecialist Registrar in General SurgeryConsultant in Intensive CareMr N TaiDr C DeakinConsultant Vascular SurgeonConsultant AnaesthetistDr O BagshawDr D GardinerConsultant PaediatricianConsultant in Intensive CareDr R LandauDr D BrydenConsultant in Emergency MedicineConsultant in Intensive CareDr R BanksMr D TeanbySpecialist Registrar in Maxillofacial SurgeryConsultant Orthopaedic SurgeonMr S MarksDr D EsbergerConsultant NeurosurgeonConsultant in Emergency MedicineDr S SmithDr E AbrahamsonConsultant in Emergency MedicineConsultant in Emergency MedicineDr S LuneyMiss H CattermoleConsultant AnaesthetistConsultant Orthopaedic SurgeonDr J BerridgeConsultant AnaesthetistMr K BrohiConsultant General SurgeonMajor M ButlerSpecialist Registrar in Trauma and Orthopaedics5
AcknowledgementsThe organisations that provided funding to cover theThe professional organisations that support our workcost of this study:and who constitute our Steering Group:National Patient Safety AgencyAssociation of Anaesthetists of Great Britain and IrelandDepartment of Health, Social Services and Public SafetyAssociation of Surgeons of Great Britain and Ireland(Northern Ireland)Coroners’ Society of England and WalesAspen HealthcareFaculty of Dental Surgery of the Royal CollegeBenenden Hospitalof Surgeons of EnglandBMI HealthcareFaculty of Public Health of the Royal CollegeBUPAof Physicians of the UKCapio GroupInstitute of Healthcare ManagementCovenant HealthcareRoyal College of AnaesthetistsCromwell HospitalRoyal College of Child Health and PaediatricsIsle of Man Health and Social Security DepartmentRoyal College of General PractitionersFairfield Independent HospitalRoyal College of NursingHCA InternationalRoyal College of Obstetricians and GynaecologistsHorder CentreRoyal College of OphthalmologistsHospital Management TrustRoyal College of PathologistsHospital of St John and St ElizabethRoyal College of Physicians of LondonKing Edward VII HospitalRoyal College of RadiologistsKing Edward VIIs Hospital Sister AgnesRoyal College of Surgeons of EnglandLondon ClinicMcIndoe Surgical CentreMount Alvernia HospitalNetcare HealthcareNew Victoria HospitalNorth Wales Medical CentreNuffield HospitalsOrchard HospitalSt Anthony’s HospitalSt Joseph’s HospitalSpencer Wing, Queen Elizabeth theQueen Mother HospitalStates of Guernsey, Health and Social ServicesStates of Jersey, Health and Social ServicesUlster Independent Clinic6
AcknowledgementsThe authors and Trustees of NCEPOD wouldparticularly like to thank the NCEPOD staff for theirhard work in collecting and analysing the data forthis study:Robert Alleway, Sabah Begg, Philip Brown, HeatherCooper, Karen Protopapa, Sidhaarth Gobin, Clare Holtby,Dolores Jarman, Viki Pepper, and Saba Raza.In addition we thank our scientific advisors Dr Martin Utleyand Professor Steve Gallivan for all their assistance.DISCLAIMERThis work was undertaken by NCEPOD, which receivedfunding for this report from the National Patient SafetyAgency. The views expressed in this publication are thoseof the authors and not necessarily those of the Agency.7
ForewordSevere injury - a car crash, a fall froma height - accidents such as these arethe commonest causes of loss of life inthe young. The chance of survival andthe completeness of recovery are highlydependent on the care that follows. Someare killed outright but those who survivethe initial impact may still die in the hours,days or weeks that follow. The speedwith which lethal processes are identifiedand halted makes the difference betweenlife and death. The injury sets in trainlife threatening effects of injury on thecirculation, tissue oxygenation and thebrain. The sooner we can halt and reversethese processes, the more likely andcomplete will be the return to health.8
ForewordAs a junior in the emergency and neurosurgical departmentsTo be effective, all processes, including ATLS and otherin Cambridge in the early 1970s we were trained in thesecomponents of care of severely injured patients, must berather obvious principles. To use a current catch phrase - it’sembedded in practice at every stage: the scene of thenot rocket science or another, nearer the point - it doesn’taccident; alerts to the hospital; the journey from the scenetake a brain surgeon to work that out! And yet somehow theto the emergency department; preparations made there;apparently obvious - or we might see it as “common sense”expertise accessible on arrival and at all subsequent stages,- was not so commonplace. Then in 1976 an orthopaedicincluding transfer to specialist services. This NCEPOD reportsurgeon James Styner crashed his plane in Nebraska. Hishas studied how well we do - and where we sometimeswife was dead and there he was in a field with three of hisfail. It is by sympathetically, and analytically, studying wherefour children critically injured. He flagged down a car to getthings go wrong that we can learn most.to the nearest hospital - which was closed. Once opened itbecame clear to him that the care available was inadequateand inappropriate.The minutes and first hours after an accident are not thetime to be working out care from first principles. We missthe obvious under pressure; we cannot hope to makeconsistently inspired diagnoses. It is not the time to benegotiating a hierarchy, debating priorities and searchingProfessor T. Treasureshelves and drawers for equipment. We need a well workedChairmanout process based on getting most things right and very fewthings wrong. Realising this, Styner started to work out asystem of care. From his initial efforts came Acute TraumaLife Support (ATLS) and with it a new philosophy of careof the severely injured patient based around well thoughtthrough processes and teams trained in them - all adheringto the same workshop manual.9
Summary of findingsThis study shows a rounded picture ofcurrent trauma care provision in England,Wales, Northern Ireland and the OffshoreIslands. It draws on data provided by theclinicians involved in the care of thesepatients (from questionnaires) and dataextracted from the casenotes. However,these data are accompanied by peerreview, by practising clinicians involved inthe day-to-day care of trauma patients, togive a much richer picture than a purelyquantitative assessment would allow.Almost 60% of the patients in this study received a standardof care that was less than good practice. Deficiencies inboth organisational and clinical aspects of care occurredfrequently.There were difficulties in identifying those patients with aninjury severity score (ISS) 16. With large costs involved inboth the provision of care and resources for the managementof these patients it is surprising that that there is no currentmethod of identifying the demand for the management ofthese patients.10
Summary of findingsThe organisation of prehospital care, the trauma teamresponse, seniority of staff involvement and immediate inhospital care was found to be deficient in many cases.Lack of appreciation of severity of illness, of urgency ofclinical scenario and incorrect clinical decision making wereapparent. Many of these clinical issues were related to thelack of seniority and experience of the staff involved in theimmediate management of these patients.It was clear that the provision of suitably experienced staffduring evenings and nights was much lower than at othertimes. In the management of trauma, which very oftenpresents at night, this is a major concern. NHS Trustsshould be open about the differences in care by day andnight and look to address this as a matter of urgency. Publicawareness of these differences may be useful in any debateabout the future configuration of trauma services.Severe trauma is not common and many hospitals see lessthan one severely injured patient per week. This has a directbearing on experience and ability to manage these challengingpatients. Not only does this relate to clinical skills but also tothe feasibility of providing the entire infrastructure required tomanage the trauma patient definitively in all centres.11
Principal recommendationsOrganisational dataThere is a need for designated Level 1 trauma centresand a verification process needs to be developedto quality assure the delivery of trauma care (as hasbeen developed in the USA by the American Collegeof Surgeons). (Royal College of Surgeons of England,College of Emergency Medicine)Prehospital careAll agencies involved in trauma management, includingemergency medical services, should be integrated intothe clinical governance programmes of a regional traumaservice. (All healthcare providers)Airway management in trauma patients is oftenchallenging. The prehospital response for these patientsshould include someone with the skill to secure theairway, (including the use of rapid sequence intubation),and maintain adequate ventilation. (Ambulance andhospital trusts)Hospital receptionTrusts should ensure that a trauma team is available 24hours a day, seven days a week. This is an essential partof an organised trauma response system. (Hospital trusts)A consultant must be the team leader for the managementof the severely injured patient. There should be no reasonfor this not to happen during the normal working week.Trusts and consultants should work together to providejob plans that will lead to better consultant presence in theemergency department at all times to provide more uniformconsultant leadership for all severely injured patients.(Hospital trusts and clinical directors)12
Principal recommendationsAirway and breathingAll patients with severe head injury should be transferredto a neurosurgical/critical care centre irrespective of theThe current structure of prehospital management isrequirement for surgical intervention. (Strategic healthinsufficient to meet the needs of the severely injuredauthorities, hospital trusts, trauma team leaders)patient. There is a high incidence of failed intubationand a high incidence of patients arriving at hospital witha partially or completely obstructed airway. ChangePaediatric careis urgently required to provide a system that reliablyprovides a clear airway with good oxygenation andEach receiving unit should have up to date guidelines forcontrol of ventilation. This may be through the provisionchildren which recognise the paediatric skills available onof personnel with the ability to provide anaesthesiasite and their limitations and include agreed guidelinesand intubation in the prehospital phase or the use offor communication and transfer with specialisedalternative airway devices. (Ambulance trusts)paediatric services within the local clinical network.(Strategic health authorities and hospital trusts)Management of circulationTransfersTrauma laparotomy is potentially extremely challengingand requires consultant presence within the operatingThere should be standardised transfer documentation oftheatre. (Clinical directors)the patients’ details, injuries, results of investigations andmanagement with records kept at the dispatching andIf CT scanning is to be performed, all necessary imagesreceiving hospitals. (Trauma team leader, Departmentshould be obtained at the same time. Routine use ofof Health)‘top to toe’ scanning is recommended in the adulttrauma patient if no indication for immediate interventionPublished guidelines must be adhered to and audits per-exists. (Royal College of Radiology and radiologyformed of the transfers and protocols. (Hospital trusts)department heads)Head injury managementIncidence of trauma and organisationof trauma servicesPatients with severe head injury should have a CT headGiven the relatively low incidence of severe traumascan of the head performed as soon as possible afterin the UK, it is unlikely that each individual hospitaladmission and within one hour of arrival at hospital.can deliver optimum care to this challenging group of(Trauma team leader and radiology heads)patients. Regional planning for the effective delivery oftrauma services is therefore essential. (Strategic healthauthorities, hospital trusts)13
IntroductionTrauma remains the fourth leading cause of death in westerncountries and the leading cause of death in the first fourdecades of life. The incidence of trauma is particularly highin the younger population; an average of 36 life years arelost per trauma death1. Furthermore, trauma is also a majorcause of debilitating long-term injuries. For each traumafatality there are two survivors with serious or permanentdisability2. Trauma is, therefore, not only a leading causeof death but also a large socio-economic burden. In 1998,the estimated cost to the NHS, of treating all injuries, was 1.2 billion per annum3. Reducing injuries is, therefore, a keygovernment objective. By 2010, the Department of Healthaims to have reduced the incidence of accidents by at least20% from the baseline that was set in 19963.Road trauma accounts for over a third of all deaths due toinjury4. In 2001-2003, there were (on average) 3,460 trafficrelated fatalities per annum in Great Britain5. The incidenceof severe trauma, defined as an Injury Severity Score (ISS) of16 or greater, is estimated to be four per million per week6.Given that the UK population in mid-2003 was in the regionof 59.5 million7, there are approximately 240 severely injuredpatients in the UK each week.In 1988, the working party report by the Royal College ofSurgeons of England highlighted ‘serious deficiencies in themanagement of severely injured patients’8. Following thisreport, there was increased focus on the care of traumapatients in the UK and consequently the fatality rate oftrauma patients reduced. However, most of the improvementin the outcome of these patients occurred prior to 1995, withno further significant change occurring between 1994 and20009.In 2000, a joint report from the Royal College of Surgeonsof England and the British Orthopaedic Associationrecommended that standards of care for the severelyinjured patient should be nationally co-ordinated and14
Introductionsystematically audited6. It was also recommended thatwho were involved in the care of particular patients. Togetherstandards and outcome measures be developed, againstwith national evaluations of trauma care, in particular headwhich institutions can audit the outcome of treatment. Theinjury, processes of trauma care are also analysed andstandards of care recommended in the report include theprovide a factual basis for system review.use of advance warning systems by the ambulance service,the establishment of trauma teams, the involvement ofA lack of continued improvement in outcome is coupleda senior anaesthetist from the outset and criteria for thewith concern that the quality of care in hospital is not ofactivation of the trauma team. The overall purpose of thesea consistently high standard across the UK, despite therecommendations was to improve the care of severely injuredavailability of guidelines that indicate referral pathways forpatients in terms of reduced mortality and unnecessaryoptimum triage, management and access to specialistmorbidity.care6,19,20. Furthermore, owing to the incidence of severetrauma, hospitals are unlikely to treat more than one severelyA number of UK-based single and multi-centre studiesinjured patient per week. It has been suggested, therefore,have addressed specific issues relating to the care ofthat as sufficient trauma experience cannot be achieved at10-15trauma patients. The use of ambulance crews to alertall hospitals, optimal outcomes may be compromised. Onehospitals of severely injured patients, the effect of inter-of the overall recommendations of the 2000 report was thehospital transfers and the determinants affecting outcomeestablishment of a National Trauma Service trauma hub andhave all been studied. One of the largest UK-based studiesspoke network between hospitals in each geographic area6.looked at the treatment of neurosurgical trauma patients innon-neurosurgical units16. There has not, however, been aThe organisation of trauma services in the UK remainsnational study to examine the overall care of trauma patientshighly topical. The recent report from The Royal Collegein the UK to date.of Surgeons of England (2006)6 confirms that high qualitytrauma care is not consistently available within the NHS.Much of the research on trauma care in the UK has beenRecent public debate and government statements reflectcarried out using data from the Trauma Audit and Researchthe continuing controversies regarding the optimum systemNetwork (TARN), which was established in response toof d
A report of the National Confi dential Enquiry into Patient Outcome and Death (2007) Compiled by: G Findlay MB ChB FRCA I C Martin LLM FRCS FDSRCS S Carter MBBS FRCS FRCS(G) RCPS 1 N Smith BSc PhD D Weyman BSc M Mason PhD
Behind the Term: Trauma Prepared in 2016 by Development Services Group, Inc., under contract no. HHSS 2832 0120 0037i/HHSS 2834 2002T, ref. no. 283– 12–3702. 1 Behind the Term: Trauma Related terms: complex trauma, historical trauma, human-caused trauma, naturally caused trauma, trauma,
categories of trauma as a framework for trauma assessment. “Little t” trauma “Big T” trauma Complex trauma “Little t” Trauma “Little t” trauma involves events that we encounter day to day that can make life difficult but are not out of the ord
The assessed content included prima - ry survey, secondary survey, airway and ventilation, circulation, shock, thoracic trauma, head/spinal trauma, abdomen/pelvis trauma, musculoskeletal trauma, paediatric trauma, geriatric trauma, obstetric trauma, trans - fer of care, and other course specific inclusions.
LEVEL I PEDIATRIC TRAUMA CENTER The Level I Regional Pediatric Trauma and Burn Center at Children’s Hospital Colorado is a large, multi-disciplinary program. We provide timely, comprehensive, cost- . Trauma/Burn Medical Director Trauma/Burn Program Manager Trauma Coordinators Trauma Registrars Staff Assi
Historical trauma - Cumulative emotional and psychological wounding from massive group trauma across generations, including lifespan Historical trauma response (HTR) is a constellation of features in reaction to massive group trauma, includes . historical unresolved grief (similar to Child of Survivors Complex re: Jewish Holocaust survivors and
Connie J. Mattera, M.S., R.N., EMT-P I. Epidemiology of chest trauma A. Incidence 1. Chest injuries are common occurrences following blunt and penetrating trauma. 2. Isolated chest trauma is uncommon; the majority of these patients will have additional injuries. 3. Prevention efforts a major key 4. Thoracic trauma accounts for ⅓ all trauma .
Kern County Emergency Medical Services Division 4 Trauma Policies and Procedures Effective Date: 07/01/2015 V. PREHOSPITAL TRAUMA SYSTEM ACTIVATION A. If a trauma patient meets the “Trauma Triage Criteria”, the Kern County Trauma Care System shall be activated as follows: 1. The following personnel are authorized to triage and then activate .
KERN COUNTY EMS Kern 1 Kern County Kern Medical Center 1830 Flower Street Bakersfield, CA 93305 Hospital: (661) 326-2161 (Public) Trauma: (661) 326-5658 11/01/2001 California Designated Trauma Centers as of October 2013 Page 3. Appendix E Level I Trauma Center Level I Trauma Center Level II Trauma Center Level I Trauma .
