North West Children s Major Trauma Centres and Network

North West Children s Major Trauma Centres and Network Operational Policy June 2016 nwchildrenstrauma.nhs.uk Page 1 of 21

Classification: General Organisation North West Children s Major Trauma Network Document Purpose Guidance Title Operational Policy Author Michael Wafer Date and Version June 2016 version 2 22.6.16 Linkages NWChMTN Network Guidelines NWChMTN Annual Report NWChMTN Forward Plan To be read in conjunction with Circulation Description Points of Contact Alder Hey and Royal Manchester Children s Hospitals Clinical Guidelines Operational Delivery Networks All members of the North West Children s Major Trauma Network. This document outlines the key operating principles of the Children s Major Trauma Centres in the North West Children s Major Trauma Networks michael.wafer@cmft.nhs.uk naomi.davis@cmft.nhs.uk bimal.mehta@alderhey.nhs.uk Page 2 of 21

CONTENTS Measure Page 1 Introduction 5 2 Purpose of the Operational Policy 5 3 Purpose of the Children s Major Trauma Centres and Network 5 4 Network Governance 5 Network Configuration T16-1C-101 5 Network Governance Structure T16-1C-102 8 Network Protocol for Transfer from Trauma Units to MTC T16-1C-104 9 Tele-radiology Facilities T16-1C-105 10 Network Imaging Protocol for Children 10 Trauma Management Guidelines T16-1C-107 10 Management of Spinal Injuries T16-1C-109 10 Emergency Planning T16-1C-110 11 The Trauma Network Director of Rehabilitation T16-1C-111 11 Directory of Rehabilitation Services T16-1C-112 11 Referral Guidelines to Rehabilitation Services T16-1C-113 11 Rehabilitation Education Programme T16-1C-114 11 Network Patient Repatriation Policy T16-1C-115 11 5 Reception and Resuscitation 12 Reception Trauma Team Leader T16-2B-201 12 Emergency Trauma Nurse /AHP T16-2B-203 12 Trauma Team Activation Protocol T16-2B-204 12 24/7 Surgical and Resuscitative Thoracotomy Capability T16-2B-205 12 Radiology 24/7 CT Scanner Facilities and On Site Radiographer T16-2B-206 12 CT Reporting T16-2B-207 12 24/7 MRI Scanning Facilities T16-2B-208 13 24/7 Interventional Radiology T16-2B-209 13 Interventional Radiology Facilities 13 Surgery 24/7 Access to Emergency Theatre and Surgery T16-2B-210 13 Damage Control Training T16-2B-211 13 24/7 Access to Consultant Specialists T16-2B-212 13 Provision Surgeons and Facilities Fixation of Pelvic Ring Injuries T16-2B-213 14 Trauma Management Guidelines T16-2B-214 14 Critical Care Critical Care Provision T16-2B-215 14 Pain management Pain Management 24/7 Acute Pain Service T16-2B-216 14 Transfusion Transfusion Lead Clinician 14 24/7 Specialist Transfusion Advice 15 Massive Transfusion Protocol 15 6 Definitive care 15 Major Trauma Centre Lead Clinician T16-2C-201 15 Major Trauma Service 15 Major Trauma Coordinator Service T16-2C-202 15 Major Trauma MDT Meeting T16-2C-203 15 Identification of Social and Welfare Needs T16-2C-204 16 Formal Tertiary Survey T16-2C-205 16 Management of Neurosurgical Trauma T16-2C-206 16 Craniofacial Trauma T16-2C-207 16 Management of Spinal Injuries T16-2C-208 16 Management Muscoskeletal Trauma T16-2C-209 17 Management of Hand Trauma T16-2C-210 17 Management of Complex Peripheral Nerve Injuries T16-2C-211 17 Page 3 of 21

Management of Maxillofacial Trauma T16-2C-212 17 Designated Specialist Burns Care T16-2C-213 18 Patient Transfer T16-2C-214 18 Specialist Dietetic Support T16-2C-215 18 24/7 Access to Psychiatric Advice T16-2C-216 18 Patient Information T16-2C-217 18 Discharge Summary T16-2C-219 18 7 Rehabilitation 18 Clinical Lead for Acute Trauma Rehabilitation Services T16-2D-201 18 Specialist Rehabilitation Team T16-2D-202 19 Rehabilitation Coordinator Post T16-2D-203 19 Specialist Rehabilitation Pathways T16-2D-204 20 Key Worker T16-2D-205 20 Rehabilitation for Traumatic Amputation T16-2D-207 20 Referral Guidelines to Rehabilitation Services T16-2D-208 20 Clinical Psychologist for Trauma Rehabilitation T16-2D-209 21 List of Tables and Diagrams Tables Page Table 1 Population covered by the NWChMTN Ref.2011 Census 5 Table 2 Designated Trauma Units in North West England 6 Table 3 North Wales /Local Emergency Hospitals Within the NWChMTN 7 Figures Figure 1 Map of ChMTCs and Trauma Units in North West England 7 Figure 2 Diagrammatic representation of Clinical Governance Arrangements for the North West Children s Major Trauma Network 9 Page 4 of 21

1. Introduction 1.1 This document is the Operational Policy of the North West Children s Major Trauma Centres and the Children s Major Trauma Network (NWChMTN). The document should be read in conjunction with NWChMTN Annual Report, Forward Plan and the network guidelines and local policies where applicable. 2. Purpose of the Operational Policy 2.1 The purpose of this Operational Policy is to provide a summary of the management of children with major trauma or those triaged onto the major trauma pathway within the North West Children s Major Trauma Network. 2.2 Specific clinical guidance is given in the documented standard operating procedures/guidelines of the MTCs and the Clinical Guidelines for the Network. 3. Purpose of the North West Children s Major Trauma Centres and Network 3.1 The purpose of the North West Children s Major Trauma network is to provide excellent high quality care in all parts of the pathway and network in the North West of England, North Wales and the Isle of Man to ensure the best possible outcome, reducing mortality and morbidity, for all Children who have experienced Major Trauma. 3.2 The injury severity data nationally demonstrates a consistently low incidence of severely injured children annually due to major trauma compared with adult data. As a result, organisation of trauma networks for children requires a different approach. Maintenance of high-quality paediatric trauma resuscitation, imaging, and emergency decision-making and surgical skills specific to trauma must not be compromised. While expertise will naturally be concentrated in the Children s Major Trauma Centres, skills need to be maintained throughout the network. On-going education and support for practitioners to maintain skills in the management of Children s Major Trauma is vital. 3.3 In addition to ensuring that the pathway for major trauma in children is supported the Network is also committed to supporting accident prevention for children. This includes working with partner agencies to support local and national initiatives. 4. Network Governance Network Configuration (Ref T16-1C-101) 4.1 The North West Children s Major Trauma Network provides a service to the conurbations of Merseyside and Greater Manchester, Cheshire, Lancashire and South Cumbria, North Wales and the Isle of Man. Population Served 4.2 The approximate current population for children aged less than 16 years old served by the North West Children s Major Trauma Network (NWChMTN) is 1.4 million. North Wales and the Isle of Man have a separate health system to NHS England and have separate commissioning arrangements. Total Population Population under 16 years old North West England 7,052,177 1,324,548 Betsy Cadwaladar 772,434 138,389 University Board Area and Isle of Man Total 7,824,611 1,462,937 Table 1: Population covered by the NWChMTN Ref.2011 Census Page 5 of 21

4.3 The population of children in North West England is expected to rise by an additional c.250,000 by 2035. (Source: Population Projections Unit, ONS.) 4.4 The central hubs of NWChMTN are the two Children s Major Trauma Centres of Alder Hey Children s Hospital and Royal Manchester Children s Hospitals. 4.5 The network facilitates the pathway of care that ensures that all children who are suspected of having a major trauma are brought as soon as possible to a Children s Major Trauma Centre. Pre Hospital Services 4.6 Pre-Hospital Care is provided by the North West Ambulance and the North West Air Ambulance Service. In addition on the borders of the Network other providers are the East Midlands Ambulance Service, Royal Air Force, Welsh Ambulance Service and the Great North Air Ambulance. 4.7 NWAS has an established clinical leadership structure which allows senior clinicians i.e. Senior Paramedics, Advanced Paramedics, Consultant Paramedic and NWAS Assistant Medical Directors to provide advice and scene support where required. This is usually through the Trauma cell or on the request of the crew. This is also supported by the BASICS Doctors. Children s Trauma Units 4.8 There are 16 Trauma Units (TU s) for Children which are shown in the table below which transfer to either Alder Hey or Royal Manchester Children s Hospital. Cheshire and Mersey ( AHCH) Greater Manchester (RMCH) Lancashire and South Cumbria Countess of Chester Salford Royal FT Trust Royal Preston Hospital.LTHT (RMCH) Southport and Ormskirk Stockport NHS Trust Furness General, Barrow UHMBT(AHCH) Whiston Hospital Royal Oldham PAT Royal Lancaster Infirmary (AHCH) UHMBT Warrington Hospital Royal Albert and Edward (Wigan) Infirmary Blackpool Victoria Hospital (AHCH) Wirral Hospital University Hospital South Manchester Blackburn Royal Infirmary (ELHT RMCH) Leighton Hospital,(Mid Cheshire NHS Trust) Table 2: Designated Trauma Units in North West England 4.9 The pathway stipulates that children involved in incidents and are suspected of having had a major trauma are taken directly to the ChMTCs if within the 60 minute isochrone. If the child requires immediate stabilisation due to serious compromise of airway, breathing or circulation he/she will be taken to the nearest Trauma Unit and then transferred to the Major Trauma Centre. Children involved in incidents that occur in locations more than 60 minutes travelling time away from the ChMTCs will be taken to the nearest Trauma Unit and then transferred on to the ChMTCs. 4.10 Each Trauma Unit/Local Emergency Hospital has a designated Major Trauma Centre. This is shown in the diagram below. Trauma Units to the left of the line are transferred to Alder Hey Children s Hospital and those to the right RMCH. There is flexibility as required. 4.11 There are Network Guidelines for Trauma Units/ Local Emergency Hospitals about onward transfer to the Children s MTC. Page 6 of 21

Figure 1: Map of ChMTCs and Trauma Units in North West England Local Emergency Hospitals 4.12 Children from North Wales Hospitals (Betsi Cadwaladr University Health Board - Bangor, Rhyl and Wrexham), and Nobles Hospital also transfer children with major trauma into the North West Children s MTCs. These hospitals are part of the network governance arrangements. 4.13 Hospitals within the NWChMTN area which have emergency departments and are not Trauma Units do on occasion have children presenting to them with Major Trauma (e.g. selfpresenting / brought in by parents or guardians ) These hospitals are engaged with the Network and are also represented at the Children s Major Trauma Governance Board. Greater Manchester Lancashire and South Cumbria North Wales and Isle of Man /Cheshire Fairfield Hospital, Bury Chorley and South Ribble LTHT Nobles Hospital, IOM North Manchester Burnley General Hospital ELHT Wrexham Maelor Hospital General Hospital Royal Bolton Hospital Ysbyty Gwynedd, Bangor Tameside Hospital, Glan Clwyd Hospital, Rhyl Ashton Under Lyne Macclesfield General Hospital (East Cheshire Trust) Table 3: Local Emergency Hospitals within the NWChMTN Page 7 of 21

Rehabilitation Services 4.14 Hyperacute Rehabilitation after major trauma is available in the Children s Major Trauma Centres. There is a rehabilitation consultant in each of the MTCs supported by a full multidisciplinary team. Rehabilitation is directed by the child s lead consultant supported by a full range of therapy services including physiotherapy, occupational therapy, speech and language, psychology, dieticians and education. 4.15 The Rehabilitation Co-ordinators in the ChMTCs provide a key role in ensuring that the rehabilitation of children is planned by implementing the use of a rehabilitation prescription. This is used to ensure that a co-ordinated discharge with comprehensive arrangements for the continuation of care in the community is achieved. Reintegration into education is facilitated by the Rehabilitation Co-ordinators and wider MDT. Network Governance Structure (Ref T16-1C-102) Leads for Clinical Governance within the Network 4.16 The Network is led jointly by Clinical Network Directors who are responsible for clinical governance within the Network they are Miss Naomi Davis: Consultant Paediatric Orthopaedic Surgeon, Royal Manchester Children s Hospital Dr Bimal Mehta: Consultant in Emergency Paediatric Medicine, Alder Hey Children s Hospital 4.17 The Leads for Governance for Major Trauma within each of the ChMTCs are Miss Davis for Royal Manchester Children s Hospital and Dr Mehta for Alder Hey Children s Hospital. Both Lead Consultants job plans include adequate time for their management roles within the Major Trauma Service. 4.18 The host provider of the Children s North West Major Children s Major Network is Royal Manchester Children s Hospital Details of the Governance Structure and Governance Meetings (Ref T16-1C-102) 4.19 The North West Children s Major Trauma Governance Network Board meets every 3 months - representation is from all of the Trauma Units, Local Emergency Hospitals, NWTS and Pre Hospital Care. The meeting is chaired by a Network Clinical lead. 4.20 The NWChMTN Governance Board is accountable to the Executive Boards of Alder Hey and Royal Manchester Children s Hospital. 4.21 The clinical leads of the NWChMTN are members of the Operational Delivery Networks Major Trauma (All Ages) of Cheshire and Mersey, Lancashire and South Cumbria and Greater Manchester. 4.22 In each of the Major Trauma Centres there are minuted regular meetings of the Trauma Committee chaired by the Major Trauma Clinical Leads at which clinical governance issues are discussed. Page 8 of 21

Executive Boards of Alder Hey and Royal Manchester Children s Hospital Cheshire and Mersey ODN (all ages ) Greater Manchester ODN ( all ages) North West Children s Major Trauma Governance Board Lancashire and South Cumbria ODN ( all ages) Figure 2: Diagrammatic representation of Clinical Governance Arrangements for the North West Children s Major Trauma Network Network Protocol for Transfer from Trauma Units to MTC (Ref T16-1C-104) 4.23 Procedures to facilitate timely forward transfers are co-ordinated via the NWAS Trauma Cell. These have been refined in partnership with the Children s Major Trauma Centres. 4.24 The Network Transfer in Document is used for guidance for all children requiring secondary transfer from a TU or LEH into the MTC. (See NWChMTN Pathway for Transferring a Major Trauma Child in to the MTC). Children requiring secondary transfer from Trauma Unit to the ChMTC are transported quickly by a Trauma Blue call. (Response by NWAS within 8 minutes) 4.25 The TU/LEH is responsible for providing appropriately experienced and trained transfer team for secondary transfer to the ChMTCs as part of the TU standards. Advice is available if required 24/7 from Trauma Team Leader in the ChMTC and if required the regional paediatric critical care transfer service team (NWTS) 4.26 A transfer checklist is used to support safe transfer of patients of patients from TU/LEH to MTC. 4.27 The regional paediatric critical care transfer service (NWTS) provide advice to TU/LEH on stabilisation of critically ill child prior to transfer if required as well as critical care transport training to all acute receiving Trusts in the network. The Time Critical Trauma Transfer protocol was produced by NWTS in conjunction the NWChMTN. Page 9 of 21

Teleradiology Facilities (Ref T16-1C-105) 4.28 Tele-radiology facilities are available throughout the Major Trauma Network via the NHS Image Portal. 4.29 There are designated PACs managers in the Children s Major Trauma Centres who provide support for any image transfer issues. 4.30 There is a facility for Radiologists, and other staff, to review images taken at other hospitals for children transferred to Children s Major Trauma Centres from Trauma Units. IEP is set to download images straight into PACS so that all clinicians can view them as soon as they arrive. Network Imaging Protocol for Children 4.31 The Network has agreed to follow the Royal College of Radiologists Guidelines (2014) on Imaging in Paediatric Trauma (http://www.rcr.ac.uk/docs/radiology/pdf/bfcr(14)8_paeds_trauma.pdf) Trauma Management Guidelines (Ref T16-1C-107) 4.32 There are Network guidelines; these include guidelines on emergency anaesthesia within the emergency emergency surgical airway resuscitative thoracotomy abdominal injuries severe traumatic brain injury open fractures compartment syndrome vascular injuries penetrating cardiac injuries spinal cord injury severe pelvic fractures including urethral injury chest drain insertion analgesia for chest trauma with rib fractures Management of Severe Head Injury (Ref T16-1C-108) 4.33 All children with a severe head injury (AIS3+) are managed in the Children s Major Trauma Centres (Alder Hey or Royal Manchester Children s Hospitals) according to NICE guidance for Head Injury. Management of Spinal Injuries (Ref T16-1C-109) 4.34 Both ChMTCs are designated as neurosciences centres. At the ChMTCs acute head and spinal trauma with resuscitation is dealt with initially in the emergency department. Spinal cord injury guidelines are available covering acute and post-acute management. (Please see Clinical Guidelines) There is 24 hours, 7 days a week cover from paediatric neurosurgical, spinal and orthopaedic teams. 4.35 Initial management of the patient will be on the paediatric intensive care unit, high dependency unit or neurosurgical ward led by the relevant consultant. Initial contact is made during the acute phase of management with the Northwest Spinal Injuries Centre at Southport and Ormskirk NHS Trust. 4.36 Severe spinal injuries are referred early to the spinal unit at Southport and Ormskirk ideally within 4 hours of the event. A Consultant from the Spinal Unit will attend and review the child in the ChMTC and provide outreach within 4 days. Page 10 of 21

Emergency Planning (Ref T16-1C-110) 4.37 Emergency plans are documented for each of the Children s Major Trauma Centres and are tested regularly.(these include preparation for a mass casualty event) The Trauma Network Director of Rehabilitation (Ref T16-1C-111) 4.38 The joint rehabilitation clinical leads of the Children s Major Trauma Centres Network provide strategic leadership for the rehabilitation element of the pathway. There are Network Directors for Rehabilitation all ages in each of the Operational Delivery Networks Major Trauma All Ages (Cheshire and Mersey, Lancashire and South Cumbria, Greater Manchester). Directory of Rehabilitation Services (Ref T16-1C-112) 4.39 There is a directory of services for rehabilitation across the network. There are challenges as outside the ChMTCs there is variability in provision for specialist children s rehabilitation. Rehabilitation services are a key priority in the future strategic plan of the network. Referral Guidelines to Rehabilitation Services (Ref T16-1C-113) 4.40 Referrals to community services are made via referral letter, forms or telephone. Spinal Injuries are referred via the National Spinal Cord Injury Database System with direct liaison with Southport SIC. 4.41 For children who require specialist commissioning the Continuing Care documentation is completed and the case is taken to the local area specialist commissioning panel for health, social and education. Cases for additional therapy support, care package or specialist rehabilitation placement will all go to the Specialist Commissioning Panel. Rehabilitation Education Programme (Ref T16-1C-114) 4.42 A number of rehabilitation education courses are available within the North West Children s major trauma network for community and hospital AHPs and other health professions these include: Taylor Spatial Frame Training Paediatric Hip Course Ponseti Teaching Orthopaedic Competency Hospital AHP In-service Training Programme has including paediatric shoulder development, spinal surgery for physiotherapists, Osteogenesis Imperfecta, OBBP, Paediatric Foot Training, and Torticollis. Network Patient Repatriation Policy (Ref T16-1C-115) 4.43 Reverse transfer from ChMTC to Trauma Units is infrequent, this is in part due to lack of services at the DGHs, primarily availability of AHPs with paediatric expertise. Therefore specialist rehabilitation services for injured children are currently provided within ChMTCs. 4.44 A small number of children have had reverse transfer to their local hospital the reasons being: Safeguarding investigations to be competed For local teams to review patient before discharge home and to plan for local service follow up Completion of acute, non-specialist treatment. 4.45 The NWChMTN is establishing links with DGH s to identify gaps in service provision. The network has a named lead consultant for major trauma patients in each area who will be a point of contact for the Rehabilitation Co-ordinator s for referrals and information sharing. 4.46 Some children have been transferred out to other specialist centres to continue specialist treatment or for specialist rehabilitation. (Please see Transfer Guidelines) Page 11 of 21

5. Reception and Resuscitation Reception Trauma Team Leader (Ref T16-2B-201) 5.1 As per NHS England Service Specification a Consultant Trauma Team Leader is immediately available in the Paediatric Emergency Department between the hours of 08.00 24.00 hrs. Outside of these hours (0.00 to 8.00hrs) there is a middle grade doctor available in the PED department and an ED consultant is available on-call to attend the PED within half an hour. The responsibilities of the Trauma Team Leader are specified in the network guidelines. Emergency Trauma Nurse / AHP (Ref T16-2B-203) 5.2 The Nursing and Allied Health Professionals Trauma Competencies in the Emergency Department Children and Young People Level 2 (April 2016) are available within the Network and the network is working towards meeting the standards. Trauma Team Activation Protocol (Ref T16-2B-204) 5.3 There are trauma team activation protocols on both ChMTC sites and regular audits of this protocol are undertaken. Test calls by switchboard are made of the major trauma call system. 5.4 There are regular simulation exercises in the Emergency Department of the Major Trauma Team activation. The traumas team consists of medical, nursing, ODP and radiography staff with specific training in paediatrics. The medical staff are paediatric trained and the nursing staff are registered sick children s nurses. (RN Child) 24/7 Surgical and Resuscitative Thoracotomy Capability (Ref T16-2B-205) 5.5 Resuscitative Thoracotomy is a rare occurrence in paediatric trauma. If required, emergency thoracotomy would be undertaken by a cardiothoracic surgeon or the clinician with most experience on the trauma team. This could be a cardiothoracic or general surgeon, both of whom would be called in on pre-alert of a shocked patient with penetrating torso injury. 5.6 There is a thoracotomy tray with appropriate instruments in the resuscitation room. Radiology 24/7 CT Scanner Facilities and On Site Radiographer (Ref T16-2B-206) 5.7 The MTCs adhere to the Royal College of Radiologists Guidelines (2014) on Imaging in Paediatric Trauma (http://www.rcr.ac.uk/docs/radiology/pdf/bfcr(14)8_paeds_trauma.pdf) 5.8 Emergency radiology facilities are collocated to the Emergency Departments. Whole body CT is not the diagnostic modality of choice in children. 5.8 Radiography services are available 24/7 including availability to prepare the CT scanner. CT Reporting (Ref T16 2B 207) 5.10 The following is the protocol for Major Trauma CT reporting There will be hot report within 5 minutes A detailed radiological report will be documented within one hour Scans are reported on by a Consultant radiologist within one hour Page 12 of 21

24/7 MRI Scanning Facilities (Ref T16-2B-208) 5.11 A dedicated paediatric MRI is available 24 hours a day, 7 days a week via a daytime and oncall service at the ChMTC s 24/7 Interventional Radiology (Ref T16-2B-209) 5.12 The requirement for interventional radiology is rare in children. Interventional Radiology is available on both ChMTC sites. At RMCH, Interventional Radiology is available 24/7 through a consultant based service covering Greater Manchester, and which can be accessed via Switchboard. At Alder Hey there is not 24/7 Interventional Radiology provision. If an Interventional Radiologist is required, the Trauma Team Leader will liaise with the on call diagnostic radiologist who can contact one of the Trust Interventional Radiologists. If none is available, support can be sought from the Interventional Radiologists across the adult Major Trauma Centre Collaborative. Interventional Radiology Facilities 5.13 The Interventional Radiology room is located in Theatre at Alder Hey Children s Hospital. At Royal Manchester Children s Hospital the Interventional radiology room is in the Radiology Department next to CT which is collocated to PED. When patient are transferred within the MTC, the Trust Patient Transfer policy will be adhered to. Surgery 24/7 Access to Emergency Theatre and Surgery (Ref T16-2B-210) 5.14 There is 24 hour access to fully staffed and equipped theatres. Haemorrhage control is started in the resuscitation room and definitive control undertaken in the operating room. 5.15 There is a 24/7 emergency operating theatre available with a resident middle grade (ST3 or above) anaesthetist resident on site 24/7. In the event of a trauma call, either the resident anaesthetist or the trauma team leader in the ED will escalate the call to the consultant anaesthetist on call if required who will be able to attend within 30min. In the event of the emergency theatre being occupied, during normal working hours theatre space will be immediately created by stopping a trauma list or an elective surgical list. Out of hours a second on-call theatre team (including that nominally on-call for cardiac surgery at AHCH) can be utilised along with a designated consultant anaesthetist. The hospital switch board and theatre coordinator hold a copy of the on-call rota and contact details to ensure the relevant staff are contactable. 5.16 Patients requiring acute intervention for haemorrhage control have access to an operating room or intervention suite within 60 minutes Damage Control Training for Emergency Trauma Consultant Surgeons (Ref T16-2B-211) 5.17 Emergency Trauma Surgery is performed by a consultant surgeon with appropriate skills and experience. All surgeons have been trained in trauma surgery. All specialities have a 24 hour on call system. On call consultant for trauma surgery is available 24 hours a day. Depending on speciality thoracic and abdominal surgery is covered by general surgeons. All Consultants are APLS trained and trauma surgery trained. Consultants attend damage control surgery training as appropriate for their speciality 24/7 Access to Consultant Specialists (Ref T16-2B-212) 5.18 There is 24/7 access to key consultants who are available to attend an emergency case within 30 minutes including (Paediatric) Neurosurgeon, Anaesthetist, Orthopaedic Surgeon General Surgeon, Plastic and Reconstructive Surgeon and Paediatric Intensivist. Page 13 of 21

Provision of Surgeons and Facilities for Fixation of Pelvic Ring Injuries (Ref T16-2B-213) 5.19 Facilities are available that allow early definitive fixation of pelvic and long bone injuries. The North West Major Pelvic Injury Pathway is adhered to and complex reconstruction is provided by specialist surgeons throughout this pathway. At both ChMTCs all orthopaedic surgeons have the skills to provide emergency external fixation and skeletal traction for pelvic fractures as required. Trauma Management Guidelines (Ref T16-2B-214) 5.20 There are agreed Network Guidelines (please refer 4.43 section in this document) Critical Care Provision (Ref T16-2B-215) 5.21 Critical Care Units at both ChMTCs sites are members of the North West Critical Care Network and complies with the minimum standards of the Paediatric Intensive Care Society. 5.22 There are onsite Paediatric Critical Care Units. These units are staffed by a multi-disciplinary team compromising paediatric intensivists, paediatric and anaesthetic Registrars and Fellows, plus Advanced Nurse Practitioners and a Nurse Consultant. There are also dedicated physiotherapists, dieticians and pharmacists. 5.23 There are in total 40 paediatric Intensive Care Beds across the two Children s Major Trauma Centres. PICU admits over 1800 children per annum. This enables the ChMTCs to be resilient if there are capacity pressures on PICU on one site. 5.24 The adult units in the network if caring for children temporarily under emergency planning guidelines comply with the minimum standards of the Paediatric Intensive Care Society. 5.25 Safe Transfer/Retrieval is provided if non-time critical by the paediatric transfer service (NWTS). If time critical an anaesthetist from the Trauma Unit/LEH accompanies the child on transfer. 5.26 There is a North West Critical Care Network and there is good liaison with the Major Trauma Network. 24/7 Specialist Acute Pain Service (Ref T16-2B-216) 5.27 There is a 24/7 Specialist Pain service available for major trauma patients. Accident and Emergency/Trauma team initiate pain management treatments as deemed appropriate whilst the patient is in Emergency Department as per hospital protocols and guidelines including placement of Femoral Nerve Catheter if appropriate. If a patient requires further intervention e.g. PCA or NCA or other nerve blocks help and advice can be obtained from the on call anaesthetic team or Pain Team during normal working hours. Further on-going pain issues are dealt by the pain team consisting of Consultant Anaesthetists, Specialist Pain Nurses and on call Anaesthetists. 5.28 For every Major Trauma patient including those with chest injuries and rib fractures the consultant lead speciality team and nursing staff will assess the patient s pain score and if appropriate they will make immediate referrals to the pain services that are available 24/7. Transfusion Transfusion Lead Clinician 5.29 The lead transfusion clinicians for the ChMTC are Dr Mark Caswell: Alder Hey Children s Hospital Dr Andrew Will: Royal Manchester Children s Hospital Page 14 of 21

24/7 Specialist Transfusion Advice 5.30 There is 24/7 transfusion specialist advice. Blood transfusion support and advice is on site 24/7 via the laboratory. Support is also provided via the on call Consultant Haematologist and if required via the Blood Transfusion Specialist. Massive Transfusion Protocol 5.31 There is a massive haemorrhage protocol in place. (please refer to ChMTC SOP/Clinical Guidelines). Tranexamic acid bolus and infusion protocols within guidelines doses are included in the trauma documentation sheet. 6. Definitive Care Major Trauma Centre Lead Clinician (Ref T16-2C-201) 6.1 The Major Trauma Centre Lead clinicians who have managerial responsibility for the service are: Miss Naomi Davis, Consultant Paediatric Orthopaedic Surgeon at Royal Manchester Children s Hospital Dr Bimal Mehta, Consultant in Emergency Paediatric Medicine at Alder Hey Children s Hospital. Major Trauma Service 6.2 All major trauma patients are admitted under the primary care of a Major Trauma Service Consultant (the lead consultant will be that speciality of the major injury of the child). 6.3 On-going trauma care is delivered through collaborative working between the critical care and surgical specialties with responsibilities this is described in the SOP document "Process for Designating Lead Consultant for On-going Care. Major Trauma Coordinator Service (Ref T16-2C-202) 6.4 There are on both ChMTC sites an acute trauma care and rehabilitation trauma care coordinators (Band 7).The names of the major Trauma Coordinators are: Samantha Jones Acute Trauma Coordinator. Royal Manchester Children s Hospital Tracey Shackleton - Acute Trauma Coordinator. Alder Hey Children s Hospital Sharon Charlton Rehabilitation Coordinator. Alder Hey Children s Hospital Helen Blakesley Major Trauma Rehabilitation Coordinator. Royal Manchester Children s Hospital. Supported by Caroline Rushmer Major Trauma Specialist Practitioner (Band 6) at Royal Manchester Children s Hospital. 6.5 Arrangements are made for weekend cover which is provided by AHP s on a rota basis. While this cover is not always at Band 7 level, the weekend cases are reviewed on a Monday morning by the Band 7 Acute Trauma Coordinator/Rehabilitation Coordinator. Major Trauma MDT Meeting (Ref T16-2C-203) 6.6 Both Major Trauma Centres hold regular multi-disciplinary Hot Meetings (AHCH) or Trauma Immediate Case Review meetings (RMCH), at least weekly. Each individual patient s case is presented, reviewed and future plan of care is discussed. The number of children experiencing major trauma fluctuates seasonally and in some weeks there can be no children admitted, and in the summer month s high numbers. Where necessary both Centres are able to facilitate more frequent review meetings to meet increased service demands. The weekly meetings include consultant representatives from all relevant disciplines, Network Manager, PED Clinical Lead for Major Trauma, AHP representatives, Safeguarding Specialist Nurse, Clinical Psychology, the Major Trauma Consultant Paediatrician Lead for Rehabilitation, as well as members of the core Major Trauma Service team. Page 15 of 21

Identification of Social and Welfare Needs (Ref T16-2C-204) 6.7 As identified above, the weekly review meetings are attended by the Major Trauma Paediatric Consultant Lead for Rehabilitation, a band 7 Safeguarding Nurse Specialist, a Clinical Psychologist and provide a multi-disciplinary approach to ensuring social and welfare needs are identified at an early stage. Protocol for Formal Tertiary Survey (Ref T16-2C-205) 6.8 There is a protocol for Tertiary Survey which is a systematic assessment of major trauma to identify any minor injuries, which may not have been detected in the initial primary and secondary survey. All patients have a formal tertiary survey which is documented on a specific form. Management of Neurosurgical Trauma (Ref T16-2C-206) 6.9 At both ChMTC s sites there are neurosurgical consultants available for consultation by the NWChMTN 24 hours a day. There is a 1:5 middle grade rota. All major trauma referrals that are head injuries will be discussed with the consultant on-call who will attend within 30 minutes if required. 6.10 All acute admissions are appropriately assessed and resuscitated on arrival to PED. All head injured patients are treated as time critical to ensure rapid transfer to the ChMTC. On-going audits for transfer in timings are taking place, with assistance from TARN database. 6.11 The ChMTC s have intensive care services and have skills in treating children with traumatic brain injury. In Alder Hey 4 of the consultants are full time and 2 work at both Alder Hey and the Walton Centre of Neurology and Neurosurgery. All consultants live within 30 minute drive from Alder Hey. All 5 middle grades are based at Alder Hey only. 6.12 At RMCH Paediatric Neurosurgery runs a 1:5 tier Consultant On call rota. Consultant advice is available 24/7. A full, dedicated middle-grade rota is available at RMCH 1:5. 6.13 Neurosurgical Consultants are available for consultation by the network 24/7 via the Trauma Team Leader at the ChMTC. All neurosurgical referrals are discussed with a consultant and any emergency surgery will be undertaken by a consultant. Both ChMTCs are designated neuroscience centres for children. Craniofacial Trauma (Ref T16-2C-207) 6.14 On both ChMTC sites there is 24/7 availability of neurosurgeons, ENT, ophthalmic and maxi facial surgeons. Prior communication via pre- alert takes place on those trauma admissions requiring combined cranio facial treatment. Maxillofacial, ENT and Neurosurgery are colocated in ChMTCs with 24 hour on call consultant and junior doctor cover with availability within 30minutes. All paediatric craniofacial trauma is managed in the ChMTC. Management of Spinal Injuries (Ref T16-2C-208) 6.15 The ChMTCs are designated as neurosciences centres. At the ChMTCs acute head and spinal trauma with resuscitation is dealt with initially in the emergency department. Spinal cord injury guidelines are available covering acute and post-acute management. There is 24 hours, 7 days a week cover from on-site paediatric neurosurgical team and spinal and orthopaedic team. 6.16 Initial management of the patient will be on intensive care or neurosurgical ward high dependency unit led by the responsible neurosurgical consultant. Initial contact is made during the acute phase of management with the Northwest Spinal Injuries Centre at Southport and Ormskirk NHS Trust. The rehabilitation pathway for spinal injury is commenced with ongoing care from the neuro-rehabilitation team for those children remaining at the ChMTC on those cases were neurological deficit has taken place. Page 16 of 21

6.17 The Network has good links with the Regional Spinal Injuries Centre in Southport. Early referral takes place if a spinal cord injury is present. Protocols for the management of children with spinal injury have been circulated through the Network Governance Meetings. 6.18 The Regional Spinal Unit has a total of 20 beds including 4 beds level 2 ITU. Children s severe spinal injuries requiring regional centre care are very rare on average 2 children per year are cared for. Children if cared for at the unit are cared for in single/double room to allow parents to stay if necessary. If a child is being considered for rehabilitation in the specialist unit this is discussed with family and family preferences are taken into consideration. 6.19 The key issue for severe spinal injuries is that they are referred early to the spinal unit the target is within 4 hours of the event for advice on on-going care. A Consultant from the Spinal Unit will attend and review child in MTC and provide outreach within 4 days. Management Muscoskeletal Trauma (Ref T16-2C-209) 6.20 The ChMTCs provides a comprehensive musculoskeletal trauma service. Consultant Orthopaedic Surgeons provide acute trauma care. On-going trauma and reconstructive care is provided by Orthopaedic Consultants with specialist skills in trauma management, and whose job plans are predominantly trauma-related. 6.21 There are facilities to allow joint emergency management of severe open fractures by plastic surgeons and orthopaedic surgeons on the ChMTC sites. Management of Hand Trauma (Ref T16-2C-210) 6.22 Within the network there is expertise available in the management of tissue loss. At the ChMTC s there are consultants with specialist expertise in hand surgery in management of hand trauma and reconstruction, including tissue loss. This includes specialised hand therapy. All the consultants on the on-call rota are trained in micro vascular surgery and reconstruction following tissue loss. There are very close working relationships with the orthopaedic department in the management of complex hand trauma. 6.23 The names of the hand surgery specialists are Professor Paul McArthur, Alder Hey Children s Hospital Mr Matt Nixon, Royal Manchester Children s Hospital 6.24 The names of the dedicated hand therapists are Joanne Moore, Alder Hey Children s Hospital Rachel Downey, Royal Manchester Children s Hospital Management of Complex Peripheral Nerve Injuries (Ref T16-2C-211) 6.25 Complex peripheral nerve expertise is available within the network and is treated in specialist units at the ChMTCs. Peripheral nerve injuries are managed by the on call plastic surgeon consultants and complex reconstruction cases are referred to a lead consultant in the hand unit. 6.26 At AHCH a consultant who is skilled in the management Brachial plexus injuries who can provide surgical care where appropriate (service is supported by Royal Liverpool Hospital) The Plastic Surgical Team at UHSM supports the Plastic Surgery Team at RMCH. This team has Plastic Surgeons specialising in brachial plexus injuries and there is an agreement between UHSM and RMCH to provide this care at RMCH for paediatric patients should that be necessary Management of Maxillofacial Trauma (Ref T16-2C-212) 6.27 Maxillo facial, ENT and Neurosurgery are co-located in CMTCs with 24 hour on call consultant and junior doctor cover with availability within 30minutes. All maxillo facial surgery is managed in the ChMTC s. Page 17 of 21

Designated Specialist Burns Care (Ref T16-2C-213) 6.28 The Burns Services for the Network ( at AHCH and RMCH) provide custom-built specialised units that manage all complex burned children from acute, critical care management to a fully comprehensive after-care service as well as reconstructive and rehabilitation management. They each have a hospital based multi-disciplinary team who work with community teams (RMCH has shared care with the community teams) to ensure best practice is facilitated outside the hospital. Both burns services cater for all levels of burn injured children. 6.29 Both offer a dedicated after-care clinic for on-going wound management on an out-patient basis as well as multi-professional led post-burn scar management service. The out-patient clinics are consultant-led and provide a multi-professional input for long-term care of the patient. There is provision of school-re-integration for burn injured children. 6.30 Transition pathways exist for transfer of burned children to the adult sector. Young patients from AHCH are referred to Whiston Hospital and RMCH transfer their patients to the University Hospital South Manchester site where continuity of care is maintained by same consultants working across both sites. Patient Transfer (Ref T16-2C-214) 6.31 There is an agreed protocol for transfer of patients (please see Network Clinical Guidelines) Specialist Dietetic Support (Ref T16-2C-215) 6.32 Policies are in place for effective nutritional management in the ChMTCs Recognised methods of assessment of nutritional status, risk and requirements are used by the dietetic team and are identified in the dietetic department s critical care nutrition support guidelines. 24/7 Access to Psychiatric Advice (Ref T16-2C-216) 6.33 There is 24/7 access to urgent psychiatric advice for major trauma patients in the ChMTCs available Patient Information (Ref T16-2C-217) 6.34 There is a selection of written information for parents from a variety of speciality services at both ChMTCs Discharge Summary (Ref T16-2C-219) 6.35 A summary is completed at discharge from the ChMTC which includes A list of all injuries; Details of operations (with dates); Instructions for next stage rehabilitation for each injury (including braces and casts); Follow-up clinic appointments 7 Rehabilitation Clinical Lead for Acute Trauma Rehabilitation Services (Ref T16-2D-201) 7.1 The named clinical lead for Acute Trauma Rehabilitation is: Alder Hey Children s Hospital: Dr Ram Kumar, Consultant Neurologist Royal Manchester Children s Hospital: Dr Rob Boon, Consultant Paediatrician 7.2 There agreed responsibilities for the role including providing leadership on rehabilitation in the ChMTC Page 18 of 21

Specialist Rehabilitation Team (Ref T16-2D-202) 7.3 There are Specialist Rehabilitation Services which are Consultant led and have a skilled and resourced MDT, for the following groups of patients: Acquired Brain Injury Burns Neurosurgery Orthopaedic Spinal 7.4 For children whose injuries are not part of a specialist team the Rehabilitation Consultant and Rehabilitation Co-ordinator will liaise with the appropriate disciplines to develop an individualised rehabilitation plan. 7.5 All patients are discussed weekly at the Major Trauma Ward Round to ensure that they are having the necessary input to facilitate their rehabilitation, to update their management plans and rehabilitation prescriptions. The weekly MDT attendance will vary dependent upon the current patient s needs. 7.6 The members of the teams include: Rehabilitation Consultant Lead Consultant Paediatrician Consultant Nurse Clinical/Neuro Psychology Safeguarding Team Family support Specialist Nurses Dietitians Speech and Language Therapists Physiotherapist Occupational Therapist Teachers Play Specialist Youth Worker Music therapists Charity funded Support Worker 7.7 The MDT will link into other services when required including: Pain team Pharmacist Orthotic/prosthetic services Wheelchair services Surgical appliance service Tissue Viability Team Infection Control Rehabilitation Coordinator Post (Ref T16-2D-203) 7.8 There are designated Band 7 Rehabilitation Coordinator s for each MTC. Cover for the Rehabilitation Co-ordinator during holidays and sickness is by the acute Trauma Coordinator and at weekends by therapy services. The Rehabilitation Co-ordinators are responsible for the coordination and communication regarding the patient s current and future rehabilitation needs. 7.9 The rehabilitation coordinators are Helen Blakesley, Royal Manchester Children s Hospital Sharon Charlton, Alder Hey Children s Hospital Page 19 of 21

Specialist Rehabilitation Pathways 7.10 Referrals pathways are in place for specialist rehabilitation services within the hospital however it is evident that referral to community services varies dependent on the child s condition and lead team. 7.11 Examples of good practice include the acquired brain injury services, complex musculoskeletal service and complex spinal injuries. These services liaise with community teams and ensure reintegration back into education and maximising potential outcomes. 7.12 Work is being undertaken by the Children s Rehabilitation Board-North under the guidance of NHS England to design services that provide for the individual rehabilitation needs of a child or young person and their family. This will ensure a seamless and efficient journey for all children and young people affected by trauma and other acquired conditions. Key Worker (Ref T16-2D-205) 7.13 The Rehabilitation Co-ordinators act as the key worker for the rehabilitation of children immediately after major trauma injury. If a child has access to a specialist rehabilitation service due to the speciality of their injuries the key worker role will handover to a member of this team to continue to co-ordinate the child s rehabilitation pathway. The name of the child s and family s key worker is documented in the Rehabilitation Prescription. Rehabilitation for Traumatic Amputation (Ref T16-2D-207) 7.14 The named linked prosthetic centres and outreach service for Traumatic Amputations are Disablement Services Centre(DSC) University Hospital South Manchester The Donald Todd Rehabilitation Centre (DSC) Liverpool 7.15 The DSC provides a comprehensive one stop for amputee/limb loss rehabilitation, specialised seating and all limb loss (congenital/acquired) special seating needs. It also helps to improve mobility posture and seating through wheelchairs and assisted equipment. At both DSC s there are Consultants in Rehabilitation Medicine, rotational specialist registrar s and staff grade doctors. There are also Counsellor s, Physiotherapist, Occupational Therapist, Rehabilitation Engineers, Specialist Nurse s and Prosthetics. 7.16 Each patient who has experienced traumatic amputation is assessed on an individual basis by the Pain Team, Plastic Team, Orthopaedic Team and Traumatic Amputation Service to ensure that effective pain relief is achieved for each patient. The patient is reviewed daily using local pain guidelines. 7.17 Clinical Psychology support following traumatic amputation is provided. The names of the Clinical Psychologists are: Dr Sian Trenchard, Royal Manchester Children s Hospital Dr Jennifer Dainty, Alder Hey Children s Hospital Referral Guidelines to Rehabilitation Services (Ref T16-2D-208) 7.18 Within the MTC referrals are made for Speech and Language services, written referrals for Psychology and Traumatic Brain Injury Services or verbal referrals for all other specialities. Referrals to community services are made via referral letter, forms or telephone. Spinal Injuries are referred via the National Spinal Cord Injury Database System with direct liaison with Southport SIC. 7.19 For children who require specialist commissioning the Continuing Care documentation is completed and the case is taken to the local area specialist commissioning panel for health, social and education. Cases for additional therapy support, care package or specialist rehabilitation placement will all go to the Specialist Commissioning Panel. 7.20 Referrals made to rehabilitation services out with the Trusts are initiated by a telephone call to the community service and their referral procedure will be followed. Prior to discharge, where appropriate, community rehabilitation services will be invited to attend the Multidisciplinary Page 20 of 21

Team meetings that take place. A formal written discharge summary is provided at the point of discharge and is copied to the child s General Practitioner to ensure continuity of care. Clinical Psychologist for Trauma Rehabilitation (Ref T16-2D-209) 7.21 A number of pathways are in place to support the mental health needs of major trauma patients at both ChMTCs. The psychosocial services have an open referral pathway and referrals are accepted from all members of the trauma team, subject to consent of the family and the named lead consultant. 7.22 The rehabilitation prescription is completed for all major trauma patients and highlights the need for psychological screening. The psychology department are deciding upon the most valid and reliable screening tool which will provide evidence for the requirement for psychological assessment and assist in the identification of children and their families with mental health difficulties. 7.23 Established psychology services are in place at the ChMTCs within the Burns and Acquired Brain Injury Teams. For these services Clinical Psychologists attend MDT meetings and support the young people and their parents on an individual basis, offering access to a range of evidence based interventions in keeping with best practice guidelines including neuropsychological assessments. Therapeutic input is offered on an in-patient or out-patient basis. Liaison with local services is also facilitated for families when appropriate. 7.24 The psychosocial services also offer training and support to the MDT to ensure they are fully informed regarding mental health needs. Page 21 of 21