Major Trauma Review Implications

Meeting: NoSPG Date: 19 th February 2014 Item: 09/14 (a) NORTH OF SCOTLAND PLANNING GROUP Major Trauma Review Implications Introduction The National Planning Forum Major Trauma Sub Group developed a quality framework and recommendations for development of major trauma services across Scotland reporting to the NPF in September 2013. In November 2013, the Board Chief Executives unanimously agreed to support the NPFs recommendations and to implement the major trauma network and quality framework across NHS Scotland, subject to local and regional planning requirements and identification of any associated costs. A major trauma oversight group has been established to oversee local and regional implementation and this paper sets out the requirements falling from the first meeting of that oversight group and the implications for the NoSPG. Major Trauma Role and Remit This group is a NPF advisory group and, as such, does not have direct lead responsibility for taking forward any of the recommendations. Nevertheless, the oversight group has a clear responsibility to monitor progress locally and regionally against each of the recommendations and, where appropriate, to identify pieces of work that may require to be taken forward nationally or once for Scotland. The oversight group has clinical and planning representation from those NHS Boards which will host one of the four identified major trauma centres at Southern General, Edinburgh Royal Infirmary, Aberdeen Royal Infirmary and Ninewells hospitals, the Chairs of each of the 3 Regional Planning Groups, SAS, including ScotSTAR, STAG, and Scottish Government. The group will meet quarterly to monitor progress and will co-opt any additional members as necessary dependent upon issues to be discussed. At the first meeting of the oversight group the role, remit and membership were agreed along with timescales and lead for each of the 15 recommendations. Implementation Overview There is a clear expectation that NoSPG, along with the other two regional planning groups, develop and progress clear implementation plans to take forward the recommendations. There is also a clear expectation that this work is implemented within existing financial capacity where possible and that any anticipated financial impact be clearly identified as part of the development of regional plans. The table overleaf sets out the detail of that with timescales, which were agreed at that first meeting: North of Scotland Planning Group is a collaboration between NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles 1

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. Regions to lead with advice and support from National All 15 NPF recommendations including implementation of the Major Trauma Quality Framework (set out in the NPF report) should be implemented. Regional Plans should be developed, communicated and implemented. Regions to provide NPF with regular progress updates. develop Regional level plans MTOG work plan needs to be developed and agreed to progress national recommendations and communicated to stakeholders. MTOG and regions need to agree/ clarify support and advice mechanisms. MTOG needs to agree how it will monitor regions progress, its own progress with national work and provide regular updates to NPF. 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. Recommendation 3: NHS Boards should implement the agreed major trauma pathway set out in the RCSE Trauma Care in Scotland report. Regions to lead with advice and support from National Regions and SAS with advice and support from National Regions to develop and implement local major trauma networked that consists of regional major trauma centres that link with hospitals in their region to provide timely access to definitive care. Regions to ensure that the majority of major trauma cases are 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. Regions to ensure that the existing capability within acute hospitals will remain the same, and also benefit from the enhanced advice and support provided by the MTC in their area. The enhancements in care/ improvements in outcomes, dedicated leadership and effective organisation required in major trauma centres on 4 sites should be brought about through implementation of the agreed major trauma pathway and supporting advice in the Major Trauma Quality Framework set out in the NPF report. Regions and SAS should work to implement the Quality Framework. The National should ensure that regions/ SAS are properly supported and monitor their progress. review and identify network capacity as part of development of regional plan develop Regional level plans setting out anticipated timescales for full implementati on 2

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. STAG NPF agreed the recommendation that Scotland should aim to virtually abolish transfers through the reconfiguration of major trauma services. Evaluation of outcome for all transfers must therefore be compulsory. 3 months 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 9.2.2. SAS, working with regions to agree trauma network capacity and any bypass requirements There are around 40 hospitals (including community 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. NHS Boards/ Regions/ SAS will need to assess readiness of all 40 hospitals and agree detour protocols that ensure that all major trauma patients who are able to be taken to a MTC within 45 minutes are taken there and ensure those who are not, are taken to the most appropriate setting to be stabilized before transfer. complete review and agree by pass requirements MTOG to provide advice when needed, share good practice and monitor Boards/ Regions progress. Recommendation 6: Process and outcome data must also be reviewed for each major trauma case as part of an ongoing quality improvement process. NHS Boards/ STAG NHS Boards/ Regions/ SAS must review the impact of the agreed detour protocols and amend as necessary to ensure continuous improvement in patient outcomes. MTOG to provide advice when needed, share good practice and monitor Boards / Regions progress. 9 months to bring all sites on board and capture full data set 3

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 9.2.2. SAS, with input from clinical leads from each centre See Prehospital Quality Framework set out at 9.2.2 of NPF report. 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 identify patients who might benefit from critical care resources at the scene. SAS 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 paediatric version of the tool will also be required. develop and agree triage and tasking framework and protocols 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. Regions/SAS Triage must be linked to tasking. This is a national system-wide issue. It requires national leadership and oversight. Tasking requires rapid information-sharing 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. 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. Coordination and enhancement of these services, working collaboratively with the SAS, is ongoing. SAS and Regions should seek to build on this work into a functioning network under a single Governance Structure. 12 months to agree national and local standards Recommendation 9: STAG should continue and all hospitals must participate in STAG the audit. This will ensure more complete data collection. Enhancing local level support will be crucial to implementing this recommendation. Regions/ STAG/ ISD MTOG to provide advice and support when needed, and monitor SAS/ Regions progress. Every hospital in Scotland, including paediatric hospitals must participate in STAG. Regions must ensure that every hospital in their area collects patient data in line with the STAG Audit Inclusion and Exclusion Criteria. The regions must ensure all their hospitals contribute and STAG must monitor participation and report to regions to support improvements in data collection. 3 months to have 100% data capture for adults 4

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. STAG/ SAS Data linkage work between STAG and SAS should be progressed. STAG and SAS should develop and implement plans to make this happen. 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. 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. STAG/ ISD STAG / ISD should develop and implement plans to make this happen, with advice and support from national oversight group. 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. STAG/ ISD STAG / ISD should prioritise the development of a paediatric component. Advice and support could be sought from Royal College of Paediatrics and/ or Scottish Colleges Committee on Children s Surgical Services and the national oversight group. 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. 5

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. National Oversight Group/ NPF The national oversight group should consider the GEOS study s findings in due course. Recommendation 14 National system and performance KPIs for the major trauma network should be agreed and measured to help monitor success and drive improvements STAG/ National 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. 6 months 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. Regions/ SAS 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. Major trauma care should be consultant led. Regions should identify local clinical leads to champion the work required to optimise patient outcomes locally. In line with regional plans with expectation that regular, likely quarterly, meeting of clinical leads Pre-hospital 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 pre-hospital care issues. 6

The initial planning phase is expected to be completed within the next 6 months at a regional level. There are some key pieces of work which need to be completed as part of this process which NoSPG will wish to consider: The quality framework should be reviewed to inform the development of the regional implementation plan ensuring the region has the necessary infrastructure in place to deliver; Early identification of the major trauma network across the region beyond the major trauma centre at Aberdeen Royal Infirmary. The pathway is clear that where patients can reach one of the 4 centres within 45 minutes by road or air then they should be taken there directly. For those patients outwith the 45 minutes, there should be discussion with the major trauma centre to ascertain likely timescales and acuity which may result in direct transfer, or, if timescales are excessive, then the patient will be taken to a suitable acute facility to be stabilised for onward transfer to the major trauma centre. Part of the regional plan must identify what facilities will form part of that major trauma network dependent upon capacity and protocols must be agreed with the SAS; For those centres identified as part of the major trauma network for the region, plans should be developed to ensure they are able to support implementation of the quality framework; Clear processes and criteria need to be agreed around rehabilitation of patients in line with the quality framework and discharge and transfer back to a local facility; this was discussed at the oversight group but no definitive recommendations were made, however, this has clear implications in terms of bed capacity and SAS transfer capacity; Stephanie Phillips Head of Strategic Planning & Performance Scottish Ambulance Service 5 th February 2014 7