PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM)

PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Regional Trauma Network Trauma Centre Trauma Service RMTN Network Organisation Measures (T13-1C-1) - 2013/14 Peer Review Visit Date 13th March 2014 Compliance NETWORK ORGANISATION MEASURES Zonal Statement Completed By Job Title Self Assessment % (0/0) Marie Cummins Programme Manager Peer Review 100.0% (8/8) Date Completed 28/03/14 Agreed By (Clinical Lead/Quality Director) Julia Hill Date Agreed 4.6.14 Key Themes Network Governance Measures North West London Trauma Network includes six trauma units: Chelsea and Westminster Hospital, Ealing Hospital, Hillingdon Hospital, Northwick Park Hospital, North Middlesex Hospital and Watford General. Charing Cross Hospital is now de-designated as a Trauma Unit. The Major Trauma Centre (MTC) is based at St Mary's Hospital. The two ambulance services covered by the network are London Ambulance Service (LAS) and East of England Ambulance Service (EEAS). The MTC and Network continue to deliver a high quality major trauma service to patients. This is recognised with such initiatives as: the provision of a 24/7 Consultant-led Trauma team, Consultant of the Week, dedicated ring-fenced Trauma theatre and a dedicated Major Trauma Ward. There is excellent clinical engagement throughout the Network. The MTC has very good Patient Experience feedback which is collected by the dedicated Major Trauma Ward. There is a delay with the Network moving towards an Operational Delivery Network (ODN). Overall the North West London Trauma Network is an outstanding model which needs to be PEER REVIEW VISIT REPORT for - Network Organisation Measures (published: 5th June 2014) Page: 1/3

much-admired. There are fantastic examples of innovations and drivers to move this highly performing MTC and Network even further forward. Major Trauma is recognised as an important aspect to the MTC and Trauma Units and the culture of 'business as normal' is fully embedded. There is a sense of attention to detail and of sensible pragmatic solutions to logistical problems. These features, together with strong clinical leadership and very supportive management, demonstrate a system that is evolving well and showing very good outcomes. Good Practice Good Practice/Significant Achievements 1. Excellent leadership and management of the Network. 2. A sound and forward thinking development of Network and clinical governance. 3. Strong commitment to openness and data transparency. 4. Education with the development of programmes and courses specific to major trauma. 5. The valuable innovation of injury prevention work being carried out. Concerns and Recommendations Immediate Risks Identified? Immediate Risks Immediate Risks Resolved? Immediate Risks Resolution Serious Concerns Identified? Serious Concerns Serious Concerns Resolved? PEER REVIEW VISIT REPORT for - Network Organisation Measures (published: 5th June 2014) Page: 2/3

Serious Concerns Resolution Concerns 1. Ensuring that all appropriate ISS>15 patients are transferred from Trauma Units. 2. The Trauma Units have relatively low data accreditation scores (indicating 'case capture') in the TARN reports, though this is typical of Trauma Units throughout England. Submission of TARN data from the Trauma Units is varied across the network and the Major Trauma Centre is working to improve the data completeness. 3. The population is not well defined but it is estimated to be about 3 million and significantly higher including commuters. The incidence of major trauma seen at the Major Trauma Centre is less than about 120/million/year, while 200/million/year severly injured patients are seen in some other centres. This could be explained by a relatively low incidence of major trauma in North West London, loss of some of the patients to other Major Trauma Centres because of the lack of a helipad, relatively high numbers of patients with severe injuries being kept in Trauma Units, or incomplete case capture. If the number of patients does increase, the Major Trauma Centre Emergency Department and the Intensive Care Unit may be put under pressure. 4. The Major Trauma Network needs to evolve to an Operational Delivery Network which will enable further development of robust governance arrangements within this new network 'model'. PEER REVIEW VISIT REPORT for - Network Organisation Measures (published: 5th June 2014) Page: 3/3

PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Regional Trauma Network Trauma Centre Trauma Service RMTN Pre-Hospital Measures (T13-2A-1) - 2013/14 Peer Review Visit Date 13th March 2014 Compliance PRE-HOSPITAL MEASURES Zonal Statement Completed By Job Title Self Assessment % (0/0) Marie Cummins Programme Manager Peer Review 100.0% (10/10) Date Completed 28/03/14 Agreed By (Clinical Lead/Quality Director) Julia Hill Date Agreed 4.6.14 Key Themes Pre-Hospital Measures The North West London (NWL) Trauma Network provides a high level of pre-hospital care. There is an inclusive system of clinical governance that is facilitated by the network involving two stakeholder ambulance services, London Ambulance Service (LAS) and covering a smaller area within the region the East of England Ambulance Service. The LAS in partnership with London Air Ambulance have a HEMS paramedic in their control room 24/7, this paramedic forms part of the clinical hub and co-ordination desk. They are responsible for providing a first point of contact for trauma enquiries. They form part of the team of clinicians within the Emergency Operations Centre (EOC) and are supported by an on-call clinician who can provide senior advice by the Gold Doctor rota. This provides Consultant level input 24/7. SECAmb have a local dispatch desk which is managed 24/7 by a paramedic. A Trauma Triage Tool has been in place since 2010 and revised in 2012 following a full evaluation of the activity data and the over and under triage rates. The network has a secondary transfer protocol and has agreed Trauma documentation which is used by all Trauma Units. PEER REVIEW VISIT REPORT for - Pre-Hospital Measures (published: 5th June 2014) Page: 1/3

Enhanced Care teams provide a high quality standard of care. London uses the MERIT and BASICS system; additional air ambulance services (Herts, Cambridge, Kent, Surrey and Sussex) serve the counties outside the M25. Good Practice Good Practice/Significant Achievements 1. The provision of an Enhanced Care Team. 2. Application of protocols for Tranexamic Acid, Pelvic Binders and Analgesia. Concerns and Recommendations Immediate Risks Identified? Immediate Risks Immediate Risks Resolved? Immediate Risks Resolution Serious Concerns Identified? Serious Concerns Serious Concerns Resolved? Serious Concerns Resolution PEER REVIEW VISIT REPORT for - Pre-Hospital Measures (published: 5th June 2014) Page: 2/3

Concerns None identified. PEER REVIEW VISIT REPORT for - Pre-Hospital Measures (published: 5th June 2014) Page: 3/3

PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Regional Trauma Network Trauma Centre Trauma Service RMTN Reception and Resuscitation Measures (T13-2B-1) - 2013/14 Peer Review Visit Date 13th March 2014 Compliance RECEPTION AND RESUSCITATION MEASURES Zonal Statement Completed By Job Title Self Assessment % (0/0) Marie Cummins Programme Manager Peer Review 95.8% (23/24) Date Completed 28/03/14 Agreed By (Clinical Lead/Quality Director) Julia Hill Date Agreed 4.6.14 Key Themes RECEPTION The St Mary's Trauma team is led by a Consultant Trauma Team Leader (TTL) 24/7. The team is supported by a dedicated ODP and Radiographer. A Trauma Consultant of the week (CoW) is named and a dedicated Trauma Anaesthetist is part of the Trauma team. There is a separate Paediatric Trauma team. A Trauma Team Activation protocol is in place and audited regularly. It can be activated as a normal trauma call or as a 'Code Red' trauma call. RADIOLOGY The CT scanner is not co- located and is located on the ground floor with a dedicated trauma lift between the Emergency Department and Radiology. There is a protocol in place for rapid written reports. PEER REVIEW VISIT REPORT for - Reception and Resuscitation Measures (published: 5th June 2014) Page: 1/4

SURGERY Most of the key surgical specialities are on-site. The TTL's at St Mary's have received training to enable them to perform an emergency resuscitative thoracotomy for penetrating trauma. A fully equipped and staffed ring-fenced theatre is available at the Major Trauma Centre (MTC) 24/7. The principles of Damage Control Surgery are key to the ethos of the MTC and a new Damage Control Surgery course has been introduced for all general surgical trainees and this model is recommended to continue. There is a clear commitment to trauma care and Consultants are no longer than 30mins away from the Trust. INTENSIVE CARE The Adult Intensive Care at the MTC comprises of 16 level 3 beds and a Paediatric Intensive Care with 10 beds; 8 level 3 beds and 2 level 2 beds. A selection of High Dependency beds are situated across the Trust. A business case is being developed to increase the capacity of the Intensive Care Unit with another 16 level 2/3 beds. The Critical Care Unit is an active member of the North West London Critical Care Network. The units submit to ICNARC (Intensive Care National Audit & Research Centre) and PICANet (Paediatric Intensive Care Audit Network). PAIN MANAGEMENT A comprehensive acute pain service, with a Consultant lead is in place. TRANSFUSION A Massive Haemorrhage protocol for Adult and Paediatric major trauma is in place. There is a separate Tranexamic Acid protocol used. Good Practice Good Practice/Significant Achievements 1. A fully equipped and staffed ring-fenced trauma theatre. 2. A dedicated trauma Anaesthetist is part of the Trauma team. 3. Analgesic pathways in place for both Adult and Paediatric Major Trauma patients. 4. The input and collaboration from Radiology is commended. 5. The innovation of Consultant of the week (CoW) is applauded. 6. The system of 'rapid resuscitation transit' for penetrating trauma is excellent. The 'code red' variant on a major trauma call works very well and is associated with a very high Consultant turn out from the outset. 7. There are very good, pragmatic arrangements for providing a Trauma Team Leader (TTL) on PEER REVIEW VISIT REPORT for - Reception and Resuscitation Measures (published: 5th June 2014) Page: 2/4

site 24/7. Emergency Department Consultants act as the TTL from 08.00 to 20.00, with multi-disciplinary Consultants out of these hours. 8. There is very good induction and training of TTLs and all TTLs are capable of performing an immediate thorocotomy and relieving cardiac tamponade. Concerns and Recommendations Immediate Risks Identified? Immediate Risks Immediate Risks Resolved? Immediate Risks Resolution Serious Concerns Identified? Serious Concerns Serious Concerns Resolved? Serious Concerns Resolution Concerns 1. It was recommended by the Peer Review panel that the Major Trauma Centre would benefit from a helipad. 2. The reliability of response from the Cardiothoracic Surgery service, based off-site at the PEER REVIEW VISIT REPORT for - Reception and Resuscitation Measures (published: 5th June 2014) Page: 3/4

Hammersmith Hospital, remains a concern, especially given that there is a relatively high frequency of penetrating trunk trauma in London. The Cardiothoracic Surgeons are generally able to respond within 30 minutes, but there are concerns about potential delays in initiating emergency surgery. The hospital is addressing this issue by aiming to provide a damage control response from 'cavity surgeons', capable of initiating damage control surgery in the chest. A convincing case was made for the development of this service and several highly competent individual surgeons are available to contribute to this service. However, it will be important to ensure that there is sufficient ongoing experience and education updates to maintain expertise. 3. The CT scanner is not co-located with the Resuscitation Room. Moving the patient there requires the use of a lift. Nethertheless, the Major Trauma Centre achieves above-average times to CT scan, reflecting a well-organised team. 4. There is no blood fridge in the Emergency Department. Fresh frozen plasma is supplied thawed rather than pre-thawed. There are no reported problems accessing platelets. PEER REVIEW VISIT REPORT for - Reception and Resuscitation Measures (published: 5th June 2014) Page: 4/4

PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Regional Trauma Network Trauma Centre Trauma Service RMTN Definitive Care Measures (T13-2C-1) - 2013/14 Peer Review Visit Date 13th March 2014 Compliance DEFINITIVE CARE MEASURES Zonal Statement Completed By Job Title Self Assessment % (0/0) Marie Cummins Programme Manager Peer Review 100.0% (17/17) Date Completed 28/03/14 Agreed By (Clinical Lead/Quality Director) Julia Hill Date Agreed 4.6.14 Key Themes Definitive Care Measures All specialities required to provide definitive care following major trauma are available at the Major Trauma Centre at St Mary's Hospital. All patients are initially admitted under the care of the Trauma Consultant of the week (CoW) with a secondary dominant injury Consultant highlighted. There is a daily ward round led by the Trauma CoW starting on the Intensive Care Unit with the Consultant Intensivist and Consultant Neurosurgeon followed by an MDT Trauma ward round attended by Therapists, Pharmacy, Dieticians and Microbiologists. There is a purpose built Major Trauma ward adjacent to the Intensive Care Unit. Single organ injury patients may, following a full assessment be admitted to a subspecialty ward directly. The Cardiothoracic Service is based at the Hammersmith Hospital site and the Cardiothoracic team no longer routinely attend all the trauma calls. To ensure the Cardiothoracic team can meet the designation criteria of availability within 30 minutes, the team consists of one Consultant and two Registrars on their on-call rota 24/7. PEER REVIEW VISIT REPORT for - Definitive Care Measures (published: 5th June 2014) Page: 1/3

Burns patients are treated at Chelsea and Westminster Hospital or triaged at the Major Trauma Centre and then transferred on once initial stabilisation and fluid resuscitation has taken place. Good Practice Good Practice/Significant Achievements 1. Clinical engagement across the surgical specialties is excellent, with strong cohesive clinical leadership. The managerial support for major trauma is excellent, with a very good clinical understanding and attention to detail. 2. High level of Consultant-delivered care. 3. The daily ward-round arrangements for the Major Trauma Service are excellent. 4. There is a good comprehensive documentation of policies and procedures. 5. It is commended that the attendance at the Major Trauma governance/case review meetings is very high, reflecting the enthusiasm and commitment shown in the Trust. 6. It is to be applauded that some surgeons have undertaken the Definitive Surgical Trauma Skills course at the Royal College of Surgeons and it is noted that the Trust has committed funding for increased places. It is recommended that this is further taken up as a matter of priority. Concerns and Recommendations Immediate Risks Identified? Immediate Risks Immediate Risks Resolved? Immediate Risks Resolution Serious Concerns Identified? Serious Concerns PEER REVIEW VISIT REPORT for - Definitive Care Measures (published: 5th June 2014) Page: 2/3

Serious Concerns Resolved? Serious Concerns Resolution Concerns 1. Two important services remain off site: Cardiothoracic Surgery, based at the Hammersmith Hospital and Maxillofacial Surgery based at Northwick Park Hospital. 2. A concern by the review panel regarding the provision of both level 2 and level 3 Critical Care beds. It was felt further provision was required and it was acknowledged that this was being explored within the Trust. PEER REVIEW VISIT REPORT for - Definitive Care Measures (published: 5th June 2014) Page: 3/3

PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Regional Trauma Network Trauma Centre Trauma Service RMTN Rehabilitation Measures (T13-2D-1) - 2013/14 Peer Review Visit Date 13th March 2014 Compliance REHABILITATION MEASURES Zonal Statement Completed By Job Title Self Assessment % (0/0) Marie Cummins Programme Manager Peer Review 92.9% (13/14) Date Completed 28/03/14 Agreed By (Clinical Lead/Quality Director) Julia Hill Date Agreed 4.6.14 Key Themes Rehabilitation Measures The Director of Rehabilitation at the Major Trauma Centre is one of the Neurosurgeons. Two external Consultants in Rehabilitation Medicine provide sessions at St Mary's Hospital, each providing an afternoon every two weeks. With the current national emphasis on Rehabilitation in Major Trauma Networks, this represents insufficient Consultant input. The current acute clinical management system is very well integrated between the Emergency Physicians, the various on-site Speciality Surgeons, the Anaesthetists and Intensivists. It would be highly effective to add locally-based Consultants in Rehabilitation Medicine, with more regular consultant sessions through the week, to this integrated team. Across the Major Trauma Network there is a comprehensive multi-disciplinary team. The development of a Brain Injury Co-ordinator post has been started, this is an 18 month project funded by the ICH Charity and Irwin Mitchell which started in September 2013. The Rehabilitation prescription is rolled out and a key worker is identified for each patient. PEER REVIEW VISIT REPORT for - Rehabilitation Measures (published: 5th June 2014) Page: 1/3

The regional Rehabilitation Unit is based at Northwick Park Hospital. Case Co-ordinators are in post across North West London. Spinal Injury patient details are recorded on a Spinal Injury web-based tool and an early referral is made and assessed by an outreach nurse from the accepting unit. Good Practice Good Practice/Significant Achievements 1. Brain Injury Co-ordinator post is to be commended. 2. Neurotrauma Research being carried out is admirable innovation. Concerns and Recommendations Immediate Risks Identified? Immediate Risks Immediate Risks Resolved? Immediate Risks Resolution Serious Concerns Identified? Serious Concerns Serious Concerns Resolved? Serious Concerns Resolution PEER REVIEW VISIT REPORT for - Rehabilitation Measures (published: 5th June 2014) Page: 2/3

Concerns 1. The Rehabilitation pathways for Major Trauma, especially in relation to Paediatrics need to be more robust. 2. The review panel felt there was insufficient Consultant input and required more dedicated Consultant time in order to ensure the Major Trauma patient had a seamless pathway of care. PEER REVIEW VISIT REPORT for - Rehabilitation Measures (published: 5th June 2014) Page: 3/3