TRAUMA UNIT OPERATIONAL POLICY

TRAUMA UNIT OPERATIONAL POLICY Document Author Written By: TARN Co-ordinator Authorised Authorised By: Chief Executive Date: 28/08/2016 Date: 13 th December 2016 Lead Director: Medical Director Effective Date: 13 th December 2016 Review Date: 12 th December 2019 Approval at: Corporate Governance & Risk Sub-Committee Date Approved: 13 th December 2016 Version 1.0 Page 1 of 25

DOCUMENT HISTORY (Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing a procedural document for the first time the initial draft will be version 0.1) Date of Issue Version No. Date Approved Director Responsible for Change Nature of Change Ratification / Approval 28/08/16 0.1 Medical Director Policy 25/11/16 0.1 Medical Director Policy for ratification 13/12/16 1.0 13/12/2016 Medical Director Policy for ratification/approval NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust Clinical Standards Group Corporate Governance & Risk Sub-Committee Version 1.0 Page 2 of 25

Contents 1 Executive Summary... 4 2 Introduction... 4 3 Definitions... 4 4 Scope... 4 5 Purpose... 4 6 Roles and Responsibilities... 5 7 Policy detail/course of Action... 6 8 Consultation... 12 9 Training... 12 10 Monitoring Compliance and Effectiveness... 13 11 Links to other Organisational Documents... 13 12 References... 13 13 Appendices... 13 Version 1.0 Page 3 of 25

1 Executive Summary This policy defines the standards required by the Isle of Wight Trust to operate as a Trauma unit and how to work to achieve these standards within the existing structure. The policy clearly defines what provision we have available and how we would respond to deliver the highest standards of trauma care to the multiply injured patient. 2 Introduction Major Trauma is defined as isolated or multiple serious injuries that may result in death or disability. Common causes include road incidents, sporting injurues and acts of violence. It remains as the most common cause of death in the under 40 age group. St Marys is a trauma unit within the Southern Trauma network system and is a satellite service associated with Southampton NHS Trust. The Trust Trauma unit is over 45 mins from the Trauma centre in Southampton General Hospital, this would usually result in the Trust unit being bypassed and the seriously ill trauma patients being taken straight to the Trauma centre at Southampton, however the Trust is separated from the mainland by the Solent and this makes the Trust geographically different to other units. The Trust Trauma unit is staffed, trained and equipped to receive Major trauma patients from The Isle of Wight Ambulance and also the Hampshire and Isle of Wight Air ambulance, St Marys also provides care and preparation for secondary transfers by HIOWAA and the Coastguard Helicopter. 3 Definitions Major Trauma is defined as isolated or multiple serious injuries that may result in death or disability. Common causes include road incidents, sporting injuries and acts of violence. It remains as the most common cause of death in the under 40 age group. 4 Scope This policy pertains to all members of staff within the Trust involved with Major Trauma not only the Emergency Department staff but all who form part of the Trauma team. This policy defines the standards required by the Isle of Wight Trust to operate as a Trauma Unit and how we work to achieve those standards within in the structure of our Trust. The policy clearly defines what provision we have available and how we would respond to deliver the highest standards of trauma care to the multiply injured patient. 5 Purpose This policy sets out the standards required by the Isle of Wight Trust in order to operate a Trauma unit and how to achieve these standards within the existing structure. The policy clearly defines what provision we have available and how we would respond to deliver the highest standards of trauma care to the multiple injured patient. Version 1.0 Page 4 of 25

6 Roles and Responsibilities 6.1 Chief Executive In line with the requirements of Governance, the Chief Executive carries ultimate responsibility for assuring the quality of the services provided by the Trust that is included within this policy document. 6.2 Executive Director of Nursing and Quality The Chief Executive Officer has delegated responsibility for ensuring the quality of services to the Executive Director of Nursing and Quality 6.3 Chief Operating Office The Chief Operating Officer will work with the named Lead Clinician for Trauma Care and the Clinical Leads to deliver to the clinical standards defined in the NHS IOW Trauma Unit standards document. 6.4 Lead Clinician for Trauma Care The Lead Clinician for Trauma Care will: Establish the overall principles within this policy Represent the Trust at local and National Trauma Network meetings Work with Clinical Business Unit management to ensure the necessary standards are met within their clinical discipline Oversee the necessary trauma training provision for all staff Lead on ensuring that the trauma unit Incident reporting process and Critical Incident investigations review through the Datix system is robust. Feed back to the Executives on all issues relating to trauma care within our TU and the Trauma Network Liaise with Trust CQUIN lead for any indicator related to Emergency Trauma care 6.5 Clinical Specialty Leads The Clinical Specialty Leads will work with Clinical Business Unit to ensure that the necessary standards are met within their clinical discipline. 6.6 Consultants All consultants in the key disciplines in the Trauma Pathway are expected to support the Trust in delivering trauma care to the standards required. 6.7 Trauma Leads for St Marys Hospital Executive Director Chief Operating Officer Medical Director Director of Nursing, and Quality Version 1.0 Page 5 of 25

Clinical Lead for Business Unit Operational Manager for Emergency Care Lead Clinician for Trauma Care Head of Nursing and Quality for the business unit Matron Specialty Leads Emergency Medicine Trauma and Orthopaedics General Surgery Anaesthesia and Intensive Care Radiology Transfusion Lead Clinician Paediatrics Trauma Coordinator Rehabilitation Co-ordinator TARN co-ordinator 7 Policy detail/course of Action Operational Policy standard for the Trauma Unit 7.1 RECEPTION and RESUSITATION T14-2B-302 Trauma Team Activation Protocol. In the event of a pre-alert by paramedics to the Emergency Department (ED), the senior member of nursing and medical staff should be informed and the trauma team activation protocol should be consulted (Appendix 1). If the criteria are met then a trauma call should be activated by dialing 2222 via switchboard. If the patient is less than 16 years of age a paediatric trauma call should be requested. If the patient is known to be pregnant of duration greater than 20 weeks then an obstetric emergency call should be activated in addition. Patients who self-present should be assessed at triage, any patient presenting with a mechanism that may result in a spinal cord injury should be triple immobilized and consideration of the trauma call activation protocol should be considered as above. The Consultant on call in the Emergency Department should also be informed if not already present. A minimum of one ED Consultant is present in the department from 0800 to 1700 five days a week. 24 hour Middle grade cover is available. 24 hour Orthopaedic cover is provided by a junior grade. The Middle grade Orthopaedic on call doctor is not resident on site out of hours and therefore must be notified by long range bleep and by the Orthopaedic on call doctor. All Trauma team members should report to the resuscitation room in anticipation of the arrival of the patient. 7.1.1 Trauma Team Leader T14-2B-301 - The Emergency Department staff grade will be the trauma team leader initially. All Trauma team leaders will be Advanced Trauma Life support and Advanced Paediatric life support providers or equivalently trained as evidenced by CPD logs. The Emergency Medicine Middle grade is required to inform the Consultant on call if not present who should be in attendance within 30 minutes of contact. The on call radiographer will notify the resident CT radiographer on receipt of a trauma call. 7.1.2 Trauma Team Composition Staff Expected to respond to the trauma call activation: Version 1.0 Page 6 of 25

Emergency Department middle grade Emergency Department Consultant if present (to be contacted when on call) Anaesthetic Middle Grade Surgical Registrar/Middle Grade Trauma Coordinator (when on site) Additional Supportive staff also notified: Emergency Department Porter Transfusion Services Senior Nurse on call for Theatres Radiographer on call. Additional Staff required to respond in event of a Paediatric Trauma Call: (Paediatric Consultant to be informed) Paediatric Middle Grade Additional Staff required to respond in event of an Obstetric Trauma Call: Neonatal Senior Doctor on call Neonatal Nurse 7.2 T14-2B-303 Agreement to Network Transfer Protocol form Trauma Units to Major Trauma Centres In the event of a patient either self-presenting or arriving at St Marys Trauma unit by ambulance identified after primary survey as having pathology that cannot be treated at the trauma unit or may require damage limitation surgery that cannot be provided within thirty minutes, should be transferred to the Major Trauma Centre Emergency Department after initial stabilization under the secondary transfer protocol (available on the CBU website). 7. 3 RADIOLOGY T14-2B-304, T14-2B-305 The trust has 24/7 access to a CT scanner and on site radiographer. The radiographer is on the trauma call. There is a 24/7 consultant led radiology rota for reporting via Medica Whole body CT (WBCT) requests indications pathway from A&E referrals for CT. A single positive parameter from any of the three categories leads to the possibility of serious internal injury and WBCT should be considered. Version 1.0 Page 7 of 25

Mechanism Apparent Injury Vital Signs Any high speed RTA, e.g. Evidence of blunt thoraco-abdominal >30mph trauma Evidence of open thoraco-abdominal trauma 2 or more long bone # Significant CNS trauma suspected Intubated at scene Car v pedestrian/cyclist (high energy) Fall > 3m (use judgment) Significant assault to trunk Blast or burn + trauma Other high energy mechanism GCS < 9 Sys BP < 90mmHg (guide) Persistent tachycardia >100 Resp Rate <10 or > 29 SaO2 < 93% 7.3.1 T14-2B-306 and T14-2B 307 The Trust aims to provide the CT scan within 30 minutes of the request being received and approved, subject to the patient being promptly transferred to the CT scan suite in a suitable condition. A report will be provided in accordance with the IOW Standard Operating Procedure for Patient CT Referrals from Accident and Emergency. The report should aim to be available within 60 minutes of the completion of the scan wherever practicable, as agreed in principle by the Clinical Director of Radiology. Images can be transferred via the Image Exchange Portal to the PACS. Requests for imaging of the head or cervical spine are made in accordance with the NICE guidance via the duty Radiologist. CT for trauma in paediatrics is requested in accordance with the Royal College of Radiologists Paediatric Trauma Protocols (Royal College of Radiologists, 2014). 7.4 SURGERY T14-2B-308 and T14-2B-309 The following staff are available on site on a 24/7 cover rota: A general surgeon of ST3 level or above An anaesthetist of ST3 level or above The following staff are available within 30 minutes on a 24/7 cover rota A trauma and orthopaedic surgeon of ST3 or above The IOW NHS Trust has no dedicated trauma operating theatre but can accommodate urgent surgery; staff are available 24 hours a day, 7 days a week. Scheduled lists for theatres run from 0930 until 1800 but are available for emergency work outside of these hours. 7.5 T14-2B-310 Trauma Management Guidelines Where appropriate the Regional Trauma Network guidelines will be followed for initial management and secondary transfer protocol followed for major trauma presentations. Version 1.0 Page 8 of 25

7.6 Penetrating Cardiac Injuries Severe or penetrating injuries should be discussed with the Emergency Department Consultant or the Major Trauma Centre as to whether transfer under the secondary transfer protocol is appropriate or whether discussion with the cardiothoracic surgical team is required. In severe and unstable injury cardiothoracic surgeons should be contacted with regard to the team travelling to the Trauma Unit for consideration of haemorrhage control surgery locally. In the event of a cardiac arrest from penetrating trauma the Network protocol for traumatic cardiac arrest should be followed (Resuscitative thoracotomy). This should be undertaken by the most experienced doctors, with appropriate training, available within the timeframe. Training for this procedure has been highlighted as a requirement locally and throughout the region for Trauma Units and at present is acknowledged as a risk in this pathway 7.7 Unstable Pelvic Fractures. Pelvic injuries will be managed in accordance with ATLS principles and in accordance with IOW guidelines for the management of Haemodynamically unstable pelvic fractures. 7.8 Chest Drain Insertion The Trust has an existing policy on the insertion of Chest drains. Chest drains will be inserted independently by those Middle Grade staff or junior staff who have demonstrated appropriate competence through previous supervision. If a doctor with this competency is not immediately available the on call Consultant of the concerned Directorate should be informed as necessary and assistance sought from an appropriate middle grade Doctor on call. It is the Consultant s responsibility to identify adequately trained doctors to perform the procedure. All doctors expected to be able to insert a chest drain should be trained using a combination of didactic lecture, simulated practice and supervised practice until considered competent. Chest drain insertion is a core competency expected of doctors doing A&E, Medical, Surgical, Anaesthetics and Intensive Care training. Each Business Unit should review the provision of training and assessment of competence relevant to the specialty. 7.9 Severe Traumatic Brain Injury Head injured patients are investigated according to NICE head and cervical spine injury guidance. Patients with positive CT should be discussed with the Emergency Medicine Consultant or Middle Grade and considered for either transfer under the secondary transfer protocol or management under The IOW Critical Care Network guidance for management of the Trauma Patients with GCS equal or less than 13. 7.10 Drowning and Hypothermia Patients who have drowned and are hypothermic should be discussed with the cardiothoracic surgeons on call at the major trauma centre for consideration of cardiopulmonary bypass at Southampton University Hospital 7.11 TRANSFUSION T14-2B-311and T14-2b-312 There is a named Consultant Haematologist designated as clinical lead for transfusion. The Trust has on-site Haematology service support 24/7 in addition to available Consultant Haematologists throughout the day and on-call out of hours 24/7 to provide transfusion advice. 7.11.1 T14-2B-313 The Trust has a massive transfusion protocol which is being updated to parallel the massive transfusion protocol used at Southampton University Hospital. This is currently Version 1.0 Page 9 of 25

an ongoing process. A network protocol has not been agreed due to the difference in availability of blood products at different trauma units. The IOW currently holds 2 units of platelets for use with Major trauma patients. (Trust guidelines) 7.11.2 T14-2B-314 In patients with significant haemorrhage, Tranexamic acid should be given within 3 hours of injury and receive a second dose in accordance with the CRASH-2 protocol. Tranexamic acid is available for trauma patients as part of the major haemorrhage protocol. 7.12 DEFINITIVE CARE MEASURES T14-2C-301 Major Trauma Lead Clinician There is a named Emergency Medicine Consultant designated for major trauma. The Lead Clinician has managerial responsibility for the service and allocated programmed activity specified in their Job Plan. 7.13 T14-2C-302 Designated Specialty Patients who attend with traumatic head injuries not requiring secondary transfer to the Major trauma Centre are currently admitted under the care of the General Surgical Consultant on call 7.14 T14-2C-303 Trauma Coordinator Service There is currently no trauma coordinator service; it should be available Monday to Friday for the coordination of trauma patients The purpose of the role is: To enhance the patient s experience and to ensure a multi-disciplinary approach to the care and management of patients undergoing trauma surgery and outpatient fracture management focusing upon improved quality and enhanced access. To integrate into part of the clinical team to ensure care is performed in a timely manner, that patients are transferred to the MTC as per protocol. Liasing with MTC for timely repatriations and rehabilitation service for trauma plans To ensure that trauma patients are managed in a most timely and appropriate fashion according to their needs. 7.15 T14-2C-303 Management of Spinal Injuries Inpatient care of spinal injuries is overseen by the Orthopaedic team. Spinal injuries should be managed in consultation on a consultant to consultant basis with the Spinal Cord Injury Centre Service at Southampton University Hospital. Liaison with this service is the responsibility of the Orthopaedic team. Any spinal injured patient with definite neurology on presentation to the Emergency Department meeting the criteria outlined by the National Spinal Cord Injury Strategy Board recommendations will be transferred to the Major Trauma Centre under the secondary transfer protocol. All patients with a spinal fracture should have imaging of the whole spine as 10% will have a noncontiguous fracture (ATLS, 9th Edition). 7.16 T14-2C-305 Management of Multiple Rib Fractures. Chest trauma requiring admission but not requiring cardiothoracic intervention should be admitted under the surgical team to either the admissions ward or high dependency unit. Penetrating trauma should be discussed with the Emergency Department Consultant and review if transfer under the secondary transfer protocol is indicated or further discussion with Cardiothoracic Surgical team is required. Version 1.0 Page 10 of 25

Chest trauma should be managed in accordance with our MTC rib injury management guidance. Consider admission to high dependency area for patients with multiple rib fractures for pain control and monitoring. Patients with 4 or more displaced or flail rib fractures that are intubated or likely to require intubation with no other life threatening conditions should be discussed with rib fracture fixation service at SouthamptonUniversity Hospital. 7.17 T14-2C-306 Management of Musculoskeletal Trauma All long bone fractures associated with major trauma are to be seen and assessed by the orthopaedic junior grade and discussed with a senior grade. 7.17.1 Neck of Femur Management All patients with suspected Neck of Femur injuries are to be rapidly assessed and managed in accordance with the Neck of Femur Fast track Pathway. Transfer should not be delayed by Orthopaedic team review in the Emergency Department unless a specific need is identified. 7.17.2 Open Fractures of Lower Limbs Open lower limb fractures this includes all grades of open fracture (I to IV). Gustello Fracture classification should be documented in accordance with BOAST4 requirements. Management should be as recommended in BOAST 4 guidance. (available on the CBU website) 7.17.3 T14-2C-307 Fixation of Fractures There are on site facilities for the management of patients with isolated long bone fractures - a 24/7 Trauma operating theatre, fully staffed, with an Orthopaedic Consultant on call and available on site during working hours. There is also an Orthopaedic Consultant or above on call 24/7 who can be on site within 30 minutes. 7.17.4 T14-2C-308 Specialist Burns care All non-complex burns are managed and followed up as per the Regional Burn Care Network management protocol. Complex burns are referred to the local burns units Salisbury District Hospital (Appendix 4) 7.17.5 T14-2C-309 Discharge Summary A discharge summary detailing a list of all injuries, any operations (including date), instructions for follow up and instructions for community rehabilitation should be available for all trauma patients. REHABILITATION MEASURES 7.18 T14-2D-301 Rehabilitation Coordinator The named Rehabilitation Coordinators are a physiotherapist and a registered nurse. The rehabilitation coordinator is responsible for coordination and communication regarding the patient s current and future rehabilitation. 7. 18.1 T14-2d-302 Trauma Unit Agreement to Network Repatriation Policy Agreed protocol for acceptance of patients from the major trauma centre as outlined in the MTC TU policy. 7.18.2 T14-2D-303 Physiotherapy Services Version 1.0 Page 11 of 25

Trauma specific physiotherapists provide a service seven days a week with extended working day shift patterns and an on call rota to cover 24/7. 7.18.3 T14-2D-304 Access to Rehabilitation Specialists The Discharge Liaison Team that aims to facilitate effective, efficient and timely discharge of patients from hospital. Particular emphasis is placed upon complex multidisciplinary assessments and case conferences including patients with complex needs, palliative care and rehabilitation needs. The role involves working across professional boundaries with multi agencies including local health and social care staff. There are Speech and Language Therapy and Occupational Heath Therapists available. These services are available from 8.30 to 16.30 Monday to Friday. The Trust has an Emergency Care Therapy Team, composed of Physiotherapists and Occupational Therapists to assist in the discharge planning of low severity trauma with access to physiotherapy and rehabilitation beds in the community. At present there is no pathway for referral to neuro-rehabilitation services for traumatic head injury patients not requiring surgery but with positive CT changes, the service is operated on an individual need basis 7.19 Patient transfer to Major Trauma Centre Level 2 and Level 3 patient transfers will be facilitated by the IOW NHS Trust.A transfer callout alert is in operation for suitably trained staff to escort patients to receiving hospitals when required.(link available on Trust intranet)) 8 Consultation The Trauma unit operational policy defines the standards required by the IOW Trust to operate as a Trauma unit and how to work to achieve these standards within the existing structure of our Trust. All members of the existing Trauma team respondees should be made aware of this document and have the opportunity to respond. 9 Training 9.1 In House Teaching Programs Trauma management is a regular part of the annual mandatory training Emergency Department nursing teaching programme. All band 6 nurses have attended the ATNC and all ED staff attended the locally delivered TILS as part of their mandatory training. All medical staff attend the ATLS course and have the opportunity to attend the TILS as part of the multi- disciplinary team. 9.2 Trauma Simulation Drills As part of Emergency Department formal teaching programs medical staff should have simulation suite based trauma teaching. There should be a weekly program of in situ simulation training for nursing and medical staff. This simulation program includes core skill drill training four times per year including adult, paediatric major trauma and obstetric trauma/cardiac arrest. These drills will test the trauma call out procedure and attendance will be monitored. Version 1.0 Page 12 of 25

10 Monitoring Compliance and Effectiveness Audit and Governance TARN submission The Trust supports the Trauma Audit Research Network (TARN) database with all suitable cases submitted by our TARN Coordinator. A summary of IOW NHS Trust data is outlined in the Annual report document. Regional Trauma Network Collaborative Group Trauma Lead clinician or Trauma nurse co-ordinator attends the bi monthly Regional Trauma CAG meeting. Trauma Network Morbidly and Mortality Meeting Trauma Lead clinician or nominated deputy attends the M&M meeting held at IOW NHS Trust and other Consultant representation are encouraged to attend and present cases when appropriate. Trust MDT Trauma Group Trust MDT Trauma Group meets a minimum of four times per year. Emergency Surgery Morning Meeting An Emergency Surgery meeting takes place every day at 8am where all new admissions in the last 12 hours to the on call surgical team are discussed, and plans for treatment agreed for those patients potentially requiring surgery. For major laparotomy procedures the consultant responsible for the patient should take part in the surgery whenever possible. Peer review Annual peer review either by TQuins or/and self-assessment. 11 Links to other Organisational Documents Trauma Team call out criteria (available on AUCCBU website) Wessex Major Trauma Secondary transfer protocol (available on AUCCBU website) Wessex Orthoplastic Trauma referral tool. (Available on AUCCBU website) Burns triage tool (available on AUCCBU website) Major incident Policy (available on Trust Intranet) Advanced Trauma Life Support (available on Trust intranet) Advanced Paediatric Life Support (available on Trust intranet) 12 References Royal College of Radiologists 2014 Advanced Trauma Life Support 9 th edition. 13 Appendices Appendix 1 Self assessment matrix Appendix 2 Financial and Resourcing Impact Assessment on Policy Implementation Appendix 3 Equality Impact Assessment (EIA) Screening Tool Version 1.0 Page 13 of 25

15 T-QUINS SELF ASSESSMENT MATRIX Appendix 1 PLEASE NOTE: Previous measures were numbered T13-xx-xxx (2013). The revised measures included herewith are numbered T14-xx-xxx (2014). Where the number for the measure for T13 and T14 remains the same no indication of change is given and the only change is that T14 replaces T13. However, where any measure now numbered T14 was previously included under a different number as T13 this is indicated for ease of reference to assist with the identification of previous evidence supplied against the previous T13 measure number. Network Governance Measures Adults MTC T14-1C-101 Children s Major Trauma Trauma Units Measure MTN MTC Trauma Unit Network configuration Pre- Hospital T14-1C-102 Network Governance structure T14-1C-104 T14-1C-105 T14-1C-106 T13-1C-105) T14-1C-107 T13-2B-110) T14-1C-108 T14-1C-109 T14-1C-111 T14-1C-112 T14-1C-113 T14-1C-114 T13-1C-108) T14-1C-115 (Also rehab measure T14-2D-101) T13-2D-101) T14-1C-116 T13-2D-110) T14-1C-117 (also rehab measure T14-2D-109) T13-2D-111) T14-2D-201 T14-2D-210 T14-2D-211 (included in reception and Resuscitation Measure T14-2B- 307) (included in Reception and Resuscitation Measures T14-2B- 306) Individual Pre-Hospital Provider Feedback Network transfer Protocol from Trauma units to MTC Network Transfusion Protocols For Trauma units Teleradiology Facilities Network CT Protocol for Adults Network imaging Protocol for Children Trauma Management Guidelines Management of severe Head injury Management of Spinal injuries Emergency planning The Trauma Network Director of Rehabilitation Directory of Rehabilitation Services Referral Guidelines to Rehabilitation Services Version 1.0 Page 14 of 25

T14-1C-118 (also rehab measure T14-2D-110) T14-1C-119 (also rehab measure T14-2D-111) T14-2D-212 Pre-Hospital Care Measures Patient Transfer Network Patient Repatriation Policy Adults MTC Children s Major Trauma Trauma Units Measure MTN MTC Trauma Unit Pre- Hospital T14-2A-101 Pre-Hospital Care Clinical Governance T14-2A-102 Trauma Triage Tool and immediate transfer policy T14-2A-103 24/7 Consultant Medical advice for the Ambulance control room T14-2A-104 24/7 Paramedic advice in the control room T14-2A-105 T13-2A-106) T14-2A-106 T13-2A-107) T14-2A-107 Enhanced care teams available 24/7 Pain management protocol for Adults Pain management Protocol for Children T14-2A-108 Pre-Hospital Administration of Tranexamic Acid for Adults T14-2A-109 Application of Pelvic Binders T14-2A-110 Hospital pre-alert and handover Version 1.0 Page 15 of 25

Reception and Resuscitation Measures Adults MTC Children s Major Trauma Trauma Units Measure MTN MTC Trauma Unit Pre- Hospital T14-2B-101 T14-2B-201 T14-2B-301 Trauma Team leader T14-2B-103 T14-2B-203 T14-2B-302 T14-2B-303 Trauma Team Activation Protocol Agreement to Network Transfer Protocol from TUs to MTCs T14-2B-104 T14-2B-204 24/7 Surgical and Resuscitative Thoracotomy Capability T14-2B-105 T14-2B-205 T14-2B-304 24/7 CT Scanner Facilities and on-site Radiographer T14-2B-106 Included in Network Measures T14-1C-108) Included in Network Measures T14-1C-107) T14-2B-107 T14-2B-108 T14-2B-109 T14-2B-110 T13-2B-111) T14-2B-111 T13-2B-112) T14-2B-112 T13-2B-113) T14-2B-206 Included in Network Measures T14-1C- 109) T14-2B-207 T14-2B-208 T14-2B-209 T14-2B-210 T14-2B-211 T14-2B-305 T14-2B-306 T14-2B-307 T14-2B-308 CT Reporting Network CT Protocols Teleradiology Facilities 24/7 MRI Scanning Facilities 24/7 Interventional Radiology Interventional Radiology Facilities 24/7 Access to Emergency, Theatre and Surgery Damage control Training for Emergency Trauma Consultant Surgeons 24/7 Access to on-site Surgical Staff 24/7 Access to Surgical Staff T14-2B-114 T13-2B-115) T14-2B-115 T13-2B-116) T14-2B-116 T13-2B-117) T14-2B-117 T13-2B-118) T14-2B-213 T14-2B-214 T14-2B-215 T14-2B-309 T14-2B-310 Dedicated Orthopaedic Trauma Operating Theatre Provision of Surgeons and Facilities for Fixation of pelvic Ring Injuries Trauma Management Guidelines as specified in T14-1C-111, MTC and TU should include relevant local details On-Site Intensive Care Unit Version 1.0 Page 16 of 25

T14-2B-119 T13-2A-120) T14-2B-217 24/7 Specialist Acute pain Service T14-2B-120 T13-2A-121) T14-2B-218 T14-2B-311 Transfusion Lead Clinician T14-2B-121 T13-2A-122) T14-2B-219 T14-2B-312 24/7 Specialist Transfusion Advice T14-2B-122 T13-2A-123) T14-2B-220 Massive Transfusion Protocol For the Major Trauma Centre T14-2B-313 Network Transfusion Protocol T14-2B-123 T13-2A-124) T14-2B-221 T14-2B-314 Administration of Tranexamic Acid Version 1.0 Page 17 of 25

Definitive Care Measures Adults MTC Children s Major Trauma Trauma Units Measure MTN MTC Trauma Unit Pre- Hospital T14-2C-101 T14-2C-201 Major Trauma Centre Lead Clinician T14-2C-301 T14-2C-302 Major Trauma Lead Clinician Designated Speciality T14-2C-102 T14-2C-103 T14-2C-202 T14-2C-203 Major Trauma Service Major Trauma Coordinator Service T14-2C-303 Trauma Coordinator Service T14-2C-104 T14-2C-204 Major Trauma MDT Meeting T14-2C-105 T14-2C-205 MDT Conference Facilities T14-2C-106 T14-2C-206 Dedicated Major Trauma Ward or Clinical Area T14-2C-107 T14-2C-207 Protocol for Formal Tertiary T14-2C-108 T14-2C-208 Management of Neurosurgical Trauma T14-2C-109 T14-2C-209 Management of Craniofacial Trauma T14-2C-110 T14-2C-210 T14-2C-304 Management of Spinal injuries T14-2C-305 Management of Multiple Rib Fractures T14-2C-111 T14-2C-211 T14-2C-306 Management of Multiple Musculoskeletal Trauma Facilities for Fixation of Fractures T14-2C-112 T14-2C-212 Management of Hand Trauma T14-2C-113 T14-2C-213 Management of Complex Peripheral Nerve Injuries T14-2C-114 T14-2C-115 T13-2C-114) T14-2C-214 Management of Maxillofacial Trauma Vascular and Endovascular Surgery T14-2C-116 T13-2C-115) T14-2C-215 T14-2C-308 Designated Specialist Burns Care Version 1.0 Page 18 of 25

T14-2C-117 T13-2C-116) T14-2C-216 Nutritional Management Policy T14-2C-118 T13-2C-117) T14-2C-217 T14-2C-309 Discharge Summary Version 1.0 Page 19 of 25

Rehabilitation Measures Adults MTC Children s Major Trauma Trauma Units Measure MTN MTC Trauma Unit Pre- Hospital T14-2D-101 (also Network Measure T14-1C-115) previously T13-2D-101 The Trauma Network Director of Rehabilitation T14-2D-201 Clinical Lead for Acute Trauma Rehabilitation T14-2D-102 T1432D-103) T14-2D-202 T14-2D-301 Rehabilitation Coordinator Post T14-2C-103 T14-2D-203 Specialist Rehabilitation service T14-2D-104 T13-2D-105) T14-2D-204 Key Worker T14-2D-105 T13-2D-106) T14-2D-205 T14-2D-305 Rehabilitation Prescriptions T14-2D-106 T13-2D-107) T14-2D-206 Rehabilitation for Traumatic Amputation T14-2D-107 T13-2D-108) T14-2D-207 Facilities for Families / Carers T14-2D-108 T13-2D-109) T14-2D-208 Patient Information T14-2D-109 (also Network Measure T14-1C-117) previously T13-2D-111 T14-2D-209 Referral Guidelines to Rehabilitation Services T14-2D-110 (also Network Measure T14-1C-118) previously T13-2D-112 T14-2D-111 (also Network Measure T14-1C-119) T14-2D-210 T14-2D-211 Patient Transfer Network Patient Repatriation Policy T14-2D-112 (also Network Measure T13-1D-113) T14-2D-113 (also Network Measure T13-1D-114) T14-2D-212 T14-2D-213 T14-2D-302 Trauma Unit Agreement to the Network Repatriation Policy Clinical Psychologist for Trauma Rehabilitation 24/7 Access to Psychiatric Advice T14-2D-303 Physiotherapy Services T14-2D-304 Access to Rehabilitation Specialists Version 1.0 Page 20 of 25

Appendix 2 Financial and Resourcing Impact Assessment on Policy Implementation NB this form must be completed where the introduction of this policy will have either a positive or negative impact on resources. Therefore this form should not be completed where the resources are already deployed and the introduction of this policy will have no further resourcing impact. Document title Major Trauma Unit Operational Policy Totals WTE Recurring Manpower Costs 1.0 36,250 Training Staff Equipment & Provision of resources Non Recurring Summary of Impact: Risk Management Issues: Benefits / Savings to the organisation: Equality Impact Assessment Has this been appropriately carried out? YES/NO Are there any reported equality issues? YES/NO If YES please specify: Use additional sheets if necessary. Please include all associated costs where an impact on implementing this policy has been considered. A checklist is included for guidance but is not comprehensive so please ensure you have thought through the impact on staffing, training and equipment carefully and that ALL aspects are covered. Manpower WTE Recurring Non-Recurring Operational running costs 1.0 36,250 Totals: 36,250 Staff Training Impact Recurring Non-Recurring Totals: Version 1.0 Page 21 of 25

Equipment and Provision of Resources Recurring * Non-Recurring * Accommodation / facilities needed Building alterations (extensions/new) IT Hardware / software / licences 500 Medical equipment Stationery / publicity Travel costs 500 Utilities e.g. telephones Process change Rolling replacement of equipment Equipment maintenance Marketing booklets/posters/handouts, etc Totals: 1000 Capital implications 5,000 with life expectancy of more than one year. Funding /costs checked & agreed by finance: Signature & date of financial accountant: Funding / costs have been agreed and are in place: Signature of appropriate Executive or Associate Director: Version 1.0 Page 22 of 25

Appendix 3 Equality Impact Assessment (EIA) Screening Tool Document Title: Purpose of document Major Trauma Unit Operational Policy To outline the pupose and scope of the Trauma Unit Target Audience Trauma Team members.,and Emergency Department personnel Person or Committee undertaken the Equality Impact Assessment Mary Bound 1. To be completed and attached to all procedural/policy documents created within individual services. 2. Does the document have, or have the potential to deliver differential outcomes or affect in an adverse way any of the groups listed below? If no confirm underneath in relevant section the data and/or research which provides evidence e.g. JSNA, Workforce Profile, Quality Improvement Framework, Commissioning Intentions, etc. If yes please detail underneath in relevant section and provide priority rating and determine if full EIA is required. Positive Impact Negative Impact Reasons Gender Race Men Women Asian or Asian British People Black or Black British People Chinese people People of Mixed Race White people (including Irish people) People with Physical Disabilities, Learning Version 1.0 Page 23 of 25

Sexual Orientat ion Age Disabilities or Mental Health Issues Transgender Lesbian, Gay men and bisexual Children Older People (60+) Younger People (17 to 25 yrs) Faith Group Pregnancy & Maternity Equal Opportunities and/or improved relations Notes: Faith groups cover a wide range of groupings, the most common of which are Buddhist, Christian, Hindus, Jews, Muslims and Sikhs. Consider faith categories individually and collectively when considering positive and negative impacts. The categories used in the race section refer to those used in the 2001 Census. Consideration should be given to the specific communities within the broad categories such as Bangladeshi people and the needs of other communities that do not appear as separate categories in the Census, for example, Polish. 3. Level of Impact If you have indicated that there is a negative impact, is that impact: Legal (it is not discriminatory under anti-discriminatory law) YES NO Intended If the negative impact is possibly discriminatory and not intended and/or of high impact then please complete a thorough assessment after completing the rest of this form. 3.1 Could you minimise or remove any negative impact that is of low significance? Explain how below: 3.2 Could you improve the strategy, function or policy positive impact? Explain how below: 3.3 If there is no evidence that this strategy, function or policy promotes equality of opportunity or Version 1.0 Page 24 of 25

improves relations could it be adapted so it does? How? If not why not? Scheduled for Full Impact Assessment Name of persons/group completing the full assessment. Date Initial Screening completed Date: Version 1.0 Page 25 of 25