Glan Clywd Hospital Trauma Unit Peer Review Thursday 3 rd November 2016 Final Report Overview of Service Glan Clwyd Hospital has been designated as a Trauma Unit within the North West Midlands and North Wales Trauma Network since February 2012. It receives both adult and paediatric patients and serves the semi-rural population of central North Wales, including parts of Conwy, Denbighshire and the Vale of Clwyd, Flintshire. Within its catchment area are high-speed rural roads, and a major trunk road connecting the English road network to North Wales and the ferry ports to Ireland. The stunning scenery of the coast as well as Snowdonia and its surrounding area attracts a large tourist population all year around. The population is older, more frail, and more deprived than the neighbouring regions, and this is reflected in the trauma patients derived from that population. Agricultural and equine related injuries are not uncommon. As part of the network Glan Clwyd transfers patients to the Major Trauma Centre at Royal Stoke University Hospital (RSUH). Glan Clwyd Hospital is 90 miles from RSUH MTC by road and as such receives trauma patients not directly transferred from scene by EMRTS (WAST do not operate a triage tool by-pass system, and therefore this needs to be considered for any comparisons of trauma data with similar hospitals that do have bypass triage tools). In addition, YGC receives those with conveyed by EMRTS with immediately life-threatening injuries who require stabilisation prior to onward transfer to the trauma centre. The management and governance of major trauma within BCUHB is overseen by the Health Board s Trauma Board. Reception & Resuscitation Trauma Team Leader of ST3 or above or equivalent NCCG, with an agreed list of responsibilities available within 5mins, 24/7. There should also be a consultant available in 30 minutes. The trauma team leader should have been trained in Advanced Trauma Life Support (ATLS) or equivalent. There should be a clinician trained in advanced paediatric life support available for children s major trauma. The TU is compliant. The reviewers were provided with completed training schedules and were reassured that TTL are ST3 or above. The TU screens the locums for up to date training whenever possible. Emergency Trauma Nurse/AHP There should be a nurse/ahp available for major trauma 24/7 who has successfully attained or is working towards the adult competency and educational standard of level 2 as described in the 1
National Major Trauma Nursing Group guidance. In unit s which accept children; there should be a paediatric registered nurse/ahp available for paediatric major trauma 24/7 who has successfully attained or is working towards the paediatric competency and educational standard of level 2 as described in the National Major Trauma Nursing Group guidance. All nursing/ahp staff caring for a trauma patients should have attained the competency and educational standard of level 1. In units that accept paediatric major trauma, this should include the paediatric trauma competencies (as described in the National Major Trauma Nursing Group guidance). The TU is not compliant. They do not fulfill the measure for L1 or L2 nurse training. They expressed concerns about being able to release staff and having access to available courses. They showed good commitment however to try to become compliant. The reviewers mentioned that they may need to look further afield for courses. Trauma team activation protocol There should be a trauma team activation protocol. The TU is compliant, they provided their policy as evidence however, the reviewers highlighted a comment in their protocol about unsalvageable patients that they feel needs further discussion as a team as to the need and relevance of this comment. Agreement to Network Transfer Protocol from Trauma Units to Major Trauma Centres The trauma unit should agree the network protocol for the transfer of patients from trauma unit to major trauma centre. The TU is compliant. They adhere to the Designed for Life guidelines for Transferring the Critically Ill Adult in Wales. Radiology 24/7 CT Scanning Facilities There should be CT scanning available within 60 minutes of the trauma team activation. The TU is compliant. They have CT Scanning facilities. CT reporting There should be a protocol for trauma CT reporting that specifies there should be a provisional report within 60 minutes. The TU is not compliant. The RRO service provider contract stipulates a report will be available within 90 minutes from the last image being sent, this sits outside of the trauma/national recommendations of 60 minutes. Teleradiology facilities The trauma unit should have an image exchange portal that enables immediate image transfer to the MTC 24/7. 2
The TU is compliant. Surgery 24/7 access to surgical staff The following staff should be available within 30 minutes 24/7: a general surgeon ST3 or above, or equivalent NCCG; a trauma and orthopaedic surgeon ST3 or above or equivalent NCCG; an anaesthetist ST3 or above or equivalent NCCG. The TU is compliant. Examples of each rota were provided as evidence and further discussions with staff provided reassurance that the staff were available as required. Dedicated orthopaedic trauma operating theatre There should be dedicated trauma operating theatre lists with appropriate staffing available 7 days a week. The lists must be separate from other emergency operating. The TU is compliant. Evidence provided. 24/7 access to Emergency Theatre and Surgery There should be 24/7 access to a fully staffed and equipped emergency theatre. Patients requiring acute intervention for haemorrhage control should be in an operating room or intervention suite within 60 minutes. The TU is compliant. The reviewers were reassured by the evidence provided in their reports. Trauma management guidelines The trauma unit should agree the network clinical guidelines specified in T16-1C-107. The trauma unit should include relevant local details. The TU are not compliant. The Network is currently unable to meet the full list of guidelines mentioned against this measure. Transfusion Transfusion Protocol There should be a protocol for the management of massive transfusion in patients with significant haemorrhage. The TU is compliant. The protocol was provided as evidence. Administration of Tranexamic Acid There should be a protocol for the management of massive transfusion in patients with significant haemorrhage. Patients with significant haemorrhage should be administered Tranexamic Acid within 3 hours of injury and receive a second dose according to CRASH-2 protocol. The TU is compliant. The TU have 100% compliance in TARN and they regularly review their data. 3
Good Practice/Significant Achievements 1. The reviewers praised the TU for the excellent level of engagement with this process, which is largely down to the leadership roles within the TU. 2. The reviewers reported that the paperwork and evidence was exemplary and the best they had seen in all 14 visits. Immediate Risks Serious Concerns 1. CT Reporting - The TU is not compliant. The RRO service provider contract stipulates a report will be available within 90 minutes from the last image being sent, this sits outside of the trauma/national recommendations of 60 minutes. Concerns 1. Emergency Trauma Nurse/AHP - The TU is not compliant. They do not fulfill the measure for L1 or L2 nurse training. They expressed concerns about being able to release staff and having access to available courses. The reviewers mentioned that they may need to look further afield for courses. 4
Definitive Care Major Trauma Lead Clinician There should be a lead clinician for major trauma, who should be a consultant with managerial responsibility for the service and a minimum of 1 programmed activity specified in their job plan. The TU is not compliant. It was noted that whilst there is an MT Lead, with managerial responsibility for the service, he does not have 1 programmed activity specified for this role in the job plan and is something undertaken in his free time and days off. The additional work easily equates to 1 programmed activity, which is something that inevitably gets absorbed into his current job plan. Should an additional programmed activity be job planned and remunerated, this would need to be in addition to the Leads current remuneration rather than a substitution of Direct Clinical Care for Supporting Professional Activity. Trauma Group The TU should have a trauma group that meets at least quarterly. The membership should include: major trauma lead clinician; executive board representation; ED medical consultant; ED nurse; representation from: radiology, surgery, anaesthetics, critical care, trauma orthopaedic surgeons The TU is compliant. However, the reviewers would like to see evidence at the next review of executive representation at future meetings that helps strengthen the decision-making process and is necessary for well-functioning trauma group. Trauma coordinator service There should be a trauma coordinator service available Monday to Friday for the co-ordination of patients. The coordinator service should be provided by nurse or allied health professionals. The TU is not compliant. They do not have a true trauma coordination service in place, they are currently only identifying T&O patients. The reviewers provided the TU with some ideas about how they may take this forward in the future. Management of spinal injuries The trauma unit should agree the network protocol for protecting and assessing the whole spine in adults and children with major trauma. There should be a linked Spinal Cord Injury Centre (SCIC) for the MTC which provides an out-reach nursing and/or therapy service for patients with spinal cord injury within 5 days of referral. The TU is compliant. The protocol was provided including details of their linked SCIC. Management of multiple rib fractures There should be network agreed local management guidelines for the management of multiple rib fractures including: pain management including early access to epidural; access to surgical advice. The TU is compliant. The reviewers were happy with the current protocol that included the relevant information about their pain management team. Management of musculo-skeletal trauma 5
There should be guidelines for: isolated long bone fractures; early management of isolated pelvic acetabular fractures; peri-articular fractures; open fractures. The guidelines should include: accessing specialist advice from the MTC; imaging and image transfer; indications for managing on site or transfer to the MTC. The TU is compliant. The TU could provide evidence of all from the list above. Designated Specialist Burns Care Burns care should be managed through a designated specialist burns network. There should be a clinical guideline for the treatment of burns. This should include the referral pathway to the specialist burns centre. The TU is compliant. The evidence provided was adequate to meet this measure and included the pathway for paediatric patients. TU agreement to the Network Repatriation Policy The trauma unit should agree the network repatriation policy T16-1C-115. There should be a protocol in place for identifying a specialty team to accept the patient. The protocol should include the escalation process in the event of there not being access to a specialty team. The TU is compliant. The evidence provided was adequate to meet this measure. Patient Experience N/A for TU s this year. Discharge summary There should be a discharge summary which includes: A list of all injuries Details of operations (with dates) Instructions for next stage rehabilitation for each injury (including specialist equipment such as; wheel chairs, braces and casts) Follow-up clinic appointments Contact details for ongoing enquiries. The TU is not compliant. The examples provided to the reviewers did not meet the requirements of the measure, there were no instructions for next stage rehabilitation, it was also noted that some patients still receive written discharge letters, this process requires further work especially as the TU receives a high number of visitors to the area who end up in the hospital and robust discharge information is extremely important for ongoing care when they return home. TARN The trauma unit should participate in the TARN audit. The results of the audit should be discussed at the network audit meeting at least annually and distributed to all constituent teams in the network, the CCGs and area teams. 6
The TU is compliant. The TU need to provide resilience for the TARN Clerk role as currently this is only person dependent. Rate of survival The TU is compliant. The rate of survival is poor, they have a negative Ws figure however the reviewers were reassured by the robust data and death review process they have in place, there is a sense that they own their data and are working hard to establish why there is a negative Ws figure. Good Practice/Significant Achievements 1. The reviewers commended the TU on their governance and data review process, it was clear that the TU take this seriously and have a real sense of their data and what they need to do to try and improve it. 2. The TU provided the reviewers with an excellent example of their STAG lesson and action register which provides high level information and feedback from their case review meetings. Immediate Risks Serious Concerns Concerns 1. Trauma Group - The TU is compliant. However, the reviewers would like to see evidence at the next review of executive representation at future meetings that helps strengthen the decisionmaking process and is necessary for well-functioning trauma group. 2. Trauma Coordination Service - The TU is not compliant. They do not have a true trauma coordination service in place, they are currently only identifying T&O patients. The reviewers provided the TU with some ideas about how they may take this forward in the future. 3. Discharge Summary - The TU is not compliant. The examples provided to the reviewers did not meet the requirements of the measure, there were no instructions for next stage rehabilitation, it was also noted that some patients still receive written discharge letters, this process requires further work especially as the TU receives a high number of visitors to the area who end up in the hospital and robust discharge information is extremely important for ongoing care when they return home. Rehabilitation Rehabilitation coordinator There should be a rehabilitation coordinator who is responsible for coordination and communication regarding the patient s current and future rehabilitation including oversight of the rehabilitation prescription. This rehabilitation coordinator should be a nurse or allied health professional The TU is not compliant. There is no designated coordinator, the current pan North Wales therapies system has been replaced with a new in-house system which may cause more problems. The reviewers did provide the TU with some ideas about how they could move this role forward. Access to Rehabilitation Specialists There should be the following allied health professionals with dedicated time to support 7
rehabilitation of trauma patients: Physiotherapist, occupational therapist; speech and language therapist, dietician There should be specified referral and access pathways for rehabilitation medicine consultant pain management psychology/neuropsychology assessment (1) mental health/psychiatry specialised rehabilitation specialist vocational rehabilitation surgical appliances orthotics and prosthetics wheel chair services. The TU is compliant. Following discussions with relevant staff members it was agreed that there are pathways in place to meet the requirements of this measure. Rehabilitation prescriptions All patients should receive a rehabilitation assessment including barriers to return to work. Where a prescription is required this should be completed within 72 hours. The prescription should be updated prior to discharge and a copy given to the patient. All patients repatriated from the MTC should have their prescription reviewed and updated at the trauma unit. The TU is not compliant. The TU do not issue rehabilitation prescriptions for all patients, however they could provide examples of the rehabilitation prescription they have been trialling. Good Practice/Significant Achievements Immediate Risks Serious Concerns Concerns 1. Rehabilitation Coordinator - The TU is not compliant. There is no designated coordinator, the current pan North Wales therapies system has been replaced with a new in-house system which may cause more problems. The reviewers did provide the TU with some ideas about how they could move this role forward. End 8