PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM)

PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Regional Trauma Network Trauma Centre Trauma Service SVTN North Bristol NHS Trust North Bristol NHS Trust Reception and Resuscitation Measures (T14-2B-1) - 2014/15 Peer Review Visit Date 13th March 2015 Compliance RECEPTION AND RESUSCITATION MEASURES Zonal Statement Completed By Job Title Self Assessment Lucy Evans 100.0% (23/23) Quality Manager Peer Review 91.3% (21/23) Date Completed 21st of May 2015 Agreed By (Clinical Lead/Quality Director) Sally Edwards Date Agreed Key Themes RECEPTION Within North Bristol NHS Trust (NBT) the Major Trauma Centre (MTC) is based at Southmead Hospital (SH) and is the network host of the Severn Major Trauma Network (STN). The reviewers were informed that previously the MTC was based at Frenchay Hospital (FH) which is part of NBT. In May 2014 all services for adult major trauma care were transferred to the new 800 bedded hospital at Southmead Hospital. At the same time all the children's services re-located to Bristol Children's Hospital. The reviewers congratulated the team on the infrastructural changes that have led to improvements in the management of trauma patients and have raised this as a significant achievement. Within the Seven Trauma Network there are six Trauma Units (TU). These are based at Gloucester Royal Hospital which is part of Gloucestershire Hospitals NHS Foundation Trust, Great Western Hospitals NHS Foundation Trust, Musgrove Park Hospital which is part of Taunton and Somerset NHS Foundation Trust, Royal United Hospitals NHS Trust, University PEER REVIEW VISIT REPORT for North Bristol NHS Trust - Reception and Resuscitation Measures (published: 29th June 2015) Page: 1/6

Hospitals Bristol NHS Trust and Yeovil District Hospital NHS Foundation Trust. Ambulance services within STN are provided by South Western Ambulance Services NHS Foundation Trust (SWAST). There are two air ambulances covering the network, Dorset and Somerset Air Ambulance (DSAA) serves the counties of Dorset and Somerset while Wiltshire is covered by Wiltshire Air Ambulance, the latter is one of the UKs few air ambulances that has night flying capabilities. Additional pre-hospital care is provided by the Great Western Ambulance Critical Care Team (GWACCT). This is a team of doctors and critical care paramedics who work closely in conjunction with both the ambulance service and the air ambulance charities. Pre-hospital care providers within the STN use a Major Trauma Triage Tool which will determine whether the patient should receive care at the local TU or whether they are required to bypass the TU and go straight to the MTC and trigger a pre-alert call to the MTC. Following pre alert from the ambulance service the Trauma Team Leader (TTL) and the Band 7 Emergency Department (ED) nurses on duty will use pre-defined criteria to decide whether a trauma team is activated. The MTC has consultant Trauma Team Leaders (TTL) available within five minutes of the trauma call 24 hours a day, seven days a week. There are up to four ED Consultants during weekdays in the ED. One of the consultants will be onsite until 23:00, seven days a week. During the weekend a consortium consultant resident rota is used. This is made up of selected clinicians, from different specialties, from the MTC and Tu's. The on-call rota goes from 07:30 Saturday to 07:30 Monday. The reviewers raised as an area of good practice the consortium consultant rota, providing TTL support 24 hours a day seven days a week. The MTC Trauma Audit and Research Network (TARN) clinical reports show that consultant presence on arrival for patients with Injury Severity Score (ISS) greater than 15 is 74.5%, the national mean is 73.4%. For triage positive patients this figure rose to 100%, national mean is 93.4%. The use of TU consultant within the MTC has help to develop working relationships across the network, this is supported by the TARN data which shows that 97.1% of patients had rapid access to specialist MTC care within two days of TU referral request, again above the national mean which is 94.8%. The roles and responsibilities for the Trauma Team Leader (TTL) are taught through the Network-wide training programme. However, the reviewers noted that not all the TTL's have completed the required training. In relation to nurse training, at the review meeting the team confirmed that not all nurses are trained in the Advanced Trauma Nursing Course (ATNC) or equivalent. But a large proportion of nurses have attended the Trauma Immediate Life Support (TILS) training. The reviewers raised a concern that not all ED nurses are trained in ATNC or equivalent. RADIOLOGY The MTC informed the reviewers that trauma patients are supported by two dedicated Computerised Tomography (CT) scanners one is located within the resuscitation department and one within the radiology suite, providing scans 24 hours a day, seven days a week. The team explained that there is an on-site radiographer 24 hours a day, seven days a week and an on call radiographer located within 30 minutes of the hospital to facilitate rapid access to CT scans. PEER REVIEW VISIT REPORT for North Bristol NHS Trust - Reception and Resuscitation Measures (published: 29th June 2015) Page: 2/6

The reviewers were informed that consultants working in the pre-hospital setting can request a CT scan prior to arrival. The layout of the new facilities allows for an immediate CT to be undertaken prior to the pre-hospital handover in ED. Within the ED department the MTC team have access to a large radiology suite, consisting of four plain film digital imaging rooms, an ultrasound room, reporting rooms for radiologist as well as the two CT scanners. Magnetic Resonance Imaging (MRI) scanning and Interventional Radiology (IR) are located on level 2 of the hospital and are accessible 24 hours a day, seven days a week. The reviewers were also informed that they have radiology nurses on call 24 hours a day to provide emergency interventional radiology service. The Trust submits data to the Trauma Audit and Research Network (TARN). The team confirmed that the dashboard figures for 2014 Quarter 2 have shown that since moving to the new MTC the time to CT within the 30 minute requirement has increased to 51%, previously only 35% and the median time to CT has reduced to 0.32 hours in patients with head injury. The report also shows that the proportion of patients meeting the NICE head injury guidelines that receive a CT scan within 60 minutes of arrival is 90.9%, this is above the national mean of 88.1%. The team have recently undertaken an audit of times to CT broken down by the identity of the Trauma Team Leaders. The results have shown considerable differences between TTL performances and will be continued to be monitored and reviewed. The team commented that they have continued to audit their CT reporting times to ensure that a formal report, both internal and external, is completed within the required 60 minutes. A â hot' report from an ST3 or above is available immediately after scanning has completed. SURGERY All ED consultants have been trained in resuscitative thoracotomy.the team stated that they have an agreement with University Hospitals Bristol NHS Foundation Trust (UHB) and the trauma network committee for patients with cardiac or thoracic injuries which might require cardiothoracic intervention. Thoracic surgeons from UHB can either treat the patient at NBT or transfer the patient to UHB. Craniofacial and maxillofacial consultants are based in UHB. Both specialities are able to operate at the MTC when required and will occupy emergency theatre operating lists which are available seven days a week. Occasionally some patients will be transferred to UHB for surgery. There are daily emergency operating lists for general surgery, plastic surgery and neurosurgery with access to a fully staffed and equipped emergency theatre, with resident anesthetists and surgeons 24/7. There is also a dedicated orthopaedic trauma theatre which runs seven days a week, Monday to Thursday 8:00 to 19:30 and Friday to Sunday 8:00 to 17:00. The team also commented that four other theatres can be utilised for othopaedic/trauma on a daily basis if needed. The team has three pelvic and acetabular trauma surgeons at NBT who are available to provide fixation of pelvic ring injuries within 24 hours and provide out of hours advice. At the review meeting the team highlighted that there are regular damage control surgery PEER REVIEW VISIT REPORT for North Bristol NHS Trust - Reception and Resuscitation Measures (published: 29th June 2015) Page: 3/6

courses run by the network. There are plans to develop the Damage Control Training to include educational sessions and simulation training involving multiple specialities. The team confirmed that all surgeons within the Network have completed the training, with the exception of one surgeon who is booked on the training course in September 2015. The MTC has agreed the network trauma management guidelines and have gone through their local governance committees for agreement and adoption. INTENSIVE CARE The Intensive Care Unit (ITU) at Southmead Hospital is a 48 bedded unit, split into four pods. The team informed the reviewers that ITU at NBT maintains three beds overnight for emergency patients therefore beds are always available for major trauma patients. The ITU is also part of the Critical Care Network and participates in the national audit (ICNARC) which is regularly discussed and reviewed. The reviewers were informed that the new hospital has considerably increased the critical care capacity and the majority of major trauma patients are admitted as level one, two or three patients. The TARN report for April to September 2014 shows an increase in length of stay within critical care from a median of four days, with a range from two to nine days, when at Frenchay Hospital in 2013/14 to a median of six days, ranging from three to 15 days. There is provision for two hours of ICU consultant time five days a week to provide outreach type care (in conjunction with the trauma nurse coordinators) for the more seriously injured patients who are not within the critical care unit. Sessions are specifically funded by the trauma service for this role. Any problems which require more input from the trauma service on a day to day basis or significant operational issues are dealt with by direct contact with the MTC clinical lead (or network director in his absence). PAIN MANAGEMENT As part of the Acute Care Team, there are two acute pain consultants available for major trauma patients available 24/7 and three pain nurses. Monday to Friday there is at least one nurse available and out of hour's patient's pain concerns are managed by the on call anaesthetists or recovery staff. The team commented that the majority of patients with a severe chest injury are managed on ITU. The reviewers noted that there is a clear pain management pathway for patients with severe chest injuries and rib fractures. It was noted that the pain audit was completed in 2012 and would benefit from being repeated. TRANSFUSION The MTC Massive Transfusion Protocol has been agreed by the STN and there is a named clinical lead for transfusion with transfusion advice available 24/7 from a Registrar who can contact a consultant. There is a protocol and process pathway in place for the administration of PEER REVIEW VISIT REPORT for North Bristol NHS Trust - Reception and Resuscitation Measures (published: 29th June 2015) Page: 4/6

Tranexamic Acid (TXA) within 3 hours of injury. The team's latest TARN data, Quarter2 2014/15, indicates that 100% of patients in the reported period received TXA within three hours of injury, this is above the national mean of 88.5% Good Practice Good Practice/Significant Achievements Significant achievement: infrastructural changes in merging the two hospitals and move of the MTC. Consortium consultant rota, providing TTL support 24 hours a day, seven days a week. Pre-hospital initiated CT scan undertaken prior to handover in ED. Increased critical care capacity. Concerns and Recommendations Immediate Risks Identified? Not Identified Immediate Risks Immediate Risks Resolved? Not Applicable Immediate Risks Resolution Serious Concerns Identified? Identified Serious Concerns Not all nurses within the trauma team have been trained in the Advanced Trauma Nurse Course (ATNC) or equivalent therefore there is not an appropriately trained trauma nurse on every shift PEER REVIEW VISIT REPORT for North Bristol NHS Trust - Reception and Resuscitation Measures (published: 29th June 2015) Page: 5/6

which could influence the quality of care received by these patients. The Trust has responded to the this serious concern stating that the network has set up a European Trauma Course, launching in July, which will ensure both MTC and network can comply with this. Serious Concerns Resolved? Not Resolved Serious Concerns Resolution Concerns Unclear why there has been an increase in the length of stay in critical care unit. PEER REVIEW VISIT REPORT for North Bristol NHS Trust - Reception and Resuscitation Measures (published: 29th June 2015) Page: 6/6