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 6th March 2014 Compliance NETWORK ORGANISATION MEASURES Zonal Statement Completed By Julia Hill Self Assessment % (0/0) Peer Review 50.0% (4/8) Job Title Deputy National Programme Director Date Completed 06/03/14 Agreed By (Clinical Lead/Quality Director) Ruth Bridgeman National Programme Director Date Agreed 02.05.14 Key Themes Network Governance Measures The Sussex Trauma Network (STN) serves a population of approximately 1.6 million. The major trauma centre (MTC) is the Royal Sussex County Hospital (Brighton and Sussex University Hospitals NHS Trust and there are 4 trauma units (TU) at Conquest Hospital part of East Sussex Healthcare NHS Trust), Worthing Hospital (Western Sussex Hospitals NHS Foundation Trust), St Richards Hospital Chichester (Western Sussex Hospitals NHS Foundation Trust) and East Surrey Hospital Redhill (Surrey and Sussex Healthcare NHS Trust). Ambulance services are provided by South East Coast Ambulance Services (SECam) and Kent Surrey and Sussex Air Ambulance Trust.(KSSAAT) The STN has very recently reformed following changes to the organisational arrangements, having had no formal network in place over the past year. This is reflected in the lack of implementation and and establishment of formal processes and protocols. The panel are aware the network is in development and as yet the network manager has not commenced in post. PEER REVIEW VISIT REPORT for - Network Organisation Measures (published: 6th May 2014) Page: 1/4

There is also a forthcoming change to the chair which is anticipated to be from one of the trauma units, which is seen as an opportunity to re-establish the structures that were in place prior to last year. There are a number of plans in place and the network is in the process of developing its protocols and governance structures. The review team was reassured to see that the clinical leadership saw the network as a key area for redevelopment particularly from the perspective of rehabilitation, governance and data collection. There was little representation from the trauma units at the review and it is important to ensure that the wider engagement across all constituent organisations is achieved in order to achieve the best pathway for patients. The panel have raised a particular concern regarding the lack of clarity regarding the status of Eastbourne General Hospital with regard to its position as a trauma unit, as it is apparent that major trauma patients are still being transferred there, and the extent to which any changes in its status are understood by SECAmb and other stakeholders. There were also concerns with respect to informal or ungoverned flow of major trauma patients from the Western boundary of the network (Chichester) out of the network to Southampton Major Trauma Centre, based upon pre-network referral patterns. These concerns reflected the to the lack of clarity across the whole network regarding the criteria for transfer of patients with potentially life threatening injuries to trauma units and needs to be addressed as a matter of priority. Good Practice Good Practice/Significant Achievements There are good plans in place for the leadership and development of the network Concerns and Recommendations Immediate Risks Identified? Not Identified Immediate Risks Immediate Risks Resolved? Immediate Risks Resolution PEER REVIEW VISIT REPORT for - Network Organisation Measures (published: 6th May 2014) Page: 2/4

Serious Concerns Identified? Identified Serious Concerns There is a lack of clarity across the whole network regarding the criteria for transfer of patients with potentially life threatening injuries to trauma units, with some areas where changes in service provision leave the patient at risk. In response to this being raised at the review as host for the network Brighton and Sussex University Hospitals has advised: Following the recent service reconfiguration within East Sussex Healthcare NHS Trust, Eastbourne Hospital no longer has the range of services immediately available on site that allow it to retain Trauma Unit status, specifically the immediate availability of surgical input. South East Coast Ambulance issued a written notice to all their staff when the service at Eastbourne Hospital changed, making clear that patients who fulfil trauma criteria as defined by the SECAmb trauma decision tree are not taken to Eastbourne Hospital. The lead for trauma at East Sussex Healthcare NHS Trust, has confirmed any patient who self-presents to Eastbourne Hospital with trauma injuries is transferred as appropriate to the Trauma Unit at Hastings or the MTC in Brighton. The Princess Royal Hospital, Haywards Heath (part of BSUH) provides a similar range of services to Eastbourne Hospital, and I can confirm the same arrangements are in place there. These units may undertake life-saving interventions such as intubation, but only as a precursor to immediate secondary transfer. To ensure protocols are being followed, the ODN will audit all patients who should have gone directly to a TU or the MTC, whatever their mode of presentation. This information will form part of the governance log for the network and will be reviewed on a regular basis. Serious Concerns Resolved? Not Resolved Serious Concerns Resolution Concerns Need to ensure engagement from all trauma units Need to ensure plans for governance framework are implemented Ensure the development of network wide documentation PEER REVIEW VISIT REPORT for - Network Organisation Measures (published: 6th May 2014) Page: 3/4

There is variability with TARN data collection across the network which needs to reviewed PEER REVIEW VISIT REPORT for - Network Organisation Measures (published: 6th May 2014) Page: 4/4

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 6th March 2014 Compliance PRE-HOSPITAL MEASURES Zonal Statement Completed By Julia Hill Self Assessment % (0/0) Peer Review 80.0% (8/10) Job Title Deputy National Programme Director Date Completed 06/03/14 Agreed By (Clinical Lead/Quality Director) Ruth Bridgeman National Programme Director Date Agreed 02.05.14 Key Themes Pre-Hospital Measures South East Coast Ambulance Services(SECam) is the single ambulance provider for the network. There is a governance structure in place. At present this does not link in with the network however there are plans to do so as the network arrangements are developed. There is also a need for a more robust method of incident review and recording. SECam is currently undertaking a review of the triage tools used as it also covers Wessex and South West London trauma networks and has found discrepencies in acceptance it is therefor hoping to develop a unified tool which the panel fully support. There is an agreement in place for the immediate transfer of major trauma to the MTC however across the network there is lack of clarity with regard the criteria for transfer of patients. The panel recommend that SECam ensure that crews are updated regarding the transfer policies to ensure they are applied.crews will also need to ensure they are fully aware of the changes PEER REVIEW VISIT REPORT for - Pre-Hospital Measures (published: 6th May 2014) Page: 1/3

following the move of neurosurgery to the Royal Sussex Hospital. The ASHICE tool is currently used for pre-alert and handover. SECam has critical care paramedics which are based in units across the network. Medical advice is available from the medical director however the panel would recommend that a more formal robust arrangement is required. The panel also recommends that SECam consider the development of a MERIT service to enhance the current provision. SECam works with Kent Surrey and Sussex Air Ambulance Trust (KSST) which provides 24/7 enhanced care either with helicopters or with a car based service when helicopters are not available. The panel commended this service which is able to provide advanced life saving interventions and also carries packed red blood cells. The panel were interested to note that there are plans for the development of a new helipad at the MTC which will greatly improve the access via air ambulance which requires road transfer from the current site. There are protocols in place for the administration of pain relief and Tranexamic Acid under patient guided directives. Good Practice Good Practice/Significant Achievements Provision of enhanced care through the air ambulance and car based services Carrying of packed red blood cells Information data sharing Concerns and Recommendations Immediate Risks Identified? Not Identified Immediate Risks Immediate Risks Resolved? PEER REVIEW VISIT REPORT for - Pre-Hospital Measures (published: 6th May 2014) Page: 2/3

Immediate Risks Resolution Serious Concerns Identified? Not Identified Serious Concerns Serious Concerns Resolved? Serious Concerns Resolution Concerns The panel recommend that consideration be given to the development of a MERIT service to enhance current service provision There is a need to develop a unified triage tool More robust review and reporting arrangements for incidents are required SECam will need to work with the network to ensure implementation of transfer policies and criteria PEER REVIEW VISIT REPORT for - Pre-Hospital Measures (published: 6th May 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 6th March 2014 Compliance RECEPTION AND RESUSCITATION MEASURES Zonal Statement Completed By Self Assessment Julia Hill % (0/0) Peer Review 58.3% (14/24) Job Title Deputy National Programme Director Date Completed 06/03/14 Agreed By (Clinical Lead/Quality Director) Ruth Bridgeman National Programme Director Date Agreed 02.05.14 Key Themes RECEPTION The panel were pleased to see the high level of engagement and commitment from the trust executive to the development of the Royal Sussex Hospital as a major trauma centre. The MTC at present does not receive any major trauma with head injuries due to the off site location of neurosurgery. All such patients are transferred to other MTC. There is however a significant redevelopment plan underway which will accomodate neurosurgery onsite later this year. It is anticipated this will see a change in the number of major trauma patients including an increase in elderly trauma. The ED is currently ensuring its preparedness for this change. There is good leadership and confidence in the plans. The panel are aware there are future plans for an onsite helipad and would recommend that this development should be considered as a matter of priority to support the anticipated increase in the number of major trauma patients and minimise the transfer times for patients, which at present require a further road transfer from the current helipad. PEER REVIEW VISIT REPORT for - Reception and Resuscitation Measures (published: 6th May 2014) Page: 1/4

There is trauma team activation policy in place and the panel were impressed by the 24/7 presence of a consultant in the emergency department(ed). The MTC has recognised there is a need for more trauma team leader training. The panel were interested to learn there was a Band 7 nurse leading a team of band 6 nursing staff which were allocated to resus on a permanent basis providing a continuity and expertise that supported other staff as they were rotated through. They considered this to be good practice. RADIOLOGY There is a CT scanner in the ED and extensive development underway to include a new MRI scanner which is currently a significant distance from the ED and cannot accomodate sedated or anaesthetised patients out of hours. Interventional radiology(ir) facilities are also part of the development which will provide a dedicated IR theatre adjacent to the ED. There are also plans for a 24/7 IR rota covering both trauma and vascular specialties. This needs to be taken forward without delay. Whilst the panel are aware there are informal verbal reports given following CT it recommends this should be a formal written arrangement. SURGERY There is a dedicated emergency theatre available which is fully staffed 24/7. The panel commended that there is a dedicated anaesthetist available for trauma that has no other fixed commitments for the day. There is also good theatre provision for trauma orthopaedics. The MTC recognises the need for more surgical specialty consultants to have training in damage control surgery. To date there has been an apparent lack of engagement from the surgical specialities. Plastic surgery currently only provides 3 days a week cover it is however understood that a recent appointment will increase this to 5 days a week and it is anticipated this will also improve the availability of joint operating sessions. Neurosurgery is currently not available at The Royal Sussex Hospital, this will however change from later in the year when all neurosurgery will move onsite. The MTC has started to develop management guidelines which as yet are an incomplete set. INTENSIVE CARE There is an onsite intensive care unit which is due to expand and following the neurosurgery development there will also be additional neurosurgery intensive care. The panel were pleased to note that whilst not having participated in ICNARC to date the unit is about to join. PEER REVIEW VISIT REPORT for - Reception and Resuscitation Measures (published: 6th May 2014) Page: 2/4

PAIN MANAGEMENT There is a comprehensive acute pain service with dedicated time for trauma patients. This is also enhanced by the support from dedicated anaesthetist and the availability of epidurals when required. TRANSFUSION There is a lead clinician for transfusion and advice is available from the haematologist on call. There is a massive transfusion policy in place and good compliance with administration of tranexamic acid. Good Practice Good Practice/Significant Achievements 24/7 ED consultant presence Dedicated nurse staffing for resuscitation bays Dedicated trauma anaesthetist available each day Acute pain service provision with dedicated time for trauma patients Concerns and Recommendations Immediate Risks Identified? Not Identified Immediate Risks Immediate Risks Resolved? Immediate Risks Resolution PEER REVIEW VISIT REPORT for - Reception and Resuscitation Measures (published: 6th May 2014) Page: 3/4

Serious Concerns Identified? Not Identified Serious Concerns Serious Concerns Resolved? Serious Concerns Resolution Concerns There are apparent delays in time to surgery for surgical specialties There is no formal process for immediate CT reporting. MRI access is limited and cannot accommodate sedated or anaesthetised patients out of hours. The MTC needs to increase trauma team leader training and also damage control surgery training. There is currently limited IR provision. PEER REVIEW VISIT REPORT for - Reception and Resuscitation Measures (published: 6th May 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 6th March 2014 Compliance DEFINITIVE CARE MEASURES Zonal Statement Completed By Julia Hill Self Assessment % (0/0) Peer Review 82.4% (14/17) Job Title Deputy National Programme Director Date Completed 06/03/14 Agreed By (Clinical Lead/Quality Director) Ruth Bridgeman National Programme Director Date Agreed 02.05.14 Key Themes Definitive Care Measures There is a clinical lead for the trauma service and a nominated polytrauma consultant of the week. There are currently two major trauma co-ordinators which provide cover for the service 5 days a week. The panel are concerned that given the likely increase in work, there will also need to be support over the weekend which will require additional resources. At present the co-ordinators also cover rehabilitation needs. With plans for the integration of the neurosurgical service, the panel recommend that a trauma lead for neurosurgery is appointed as soon as possible to ensure any potential issues are identified and resolved prior to the move. The panel are concerned regarding the time to surgery for head injury patients reported in TARN indicated, 8.24 hours. It is imperative that with the investment in the developments of neurosurgery the service is able to demonstrate a significant improvement in this. There is limited spinal cover being provided by two orthopaedic and one neuro surgeons There PEER REVIEW VISIT REPORT for - Definitive Care Measures (published: 6th May 2014) Page: 1/3

are plans for an integrated pathway for spinal patients following the relocation of neurosurgery which will provide a 1:6 rota. The plastic surgery service is provided by the Queen Victoria Hospital at East Grinstead. There is currently only cover on site for 3 days a week. With the planned increase to 5 days week this will enable operating on site for flap surgery. There is a vascular service in place, though the numbers are small (3 during last 12 months). The panel would recommend that appropriate on-site intervention is available, especially for thoracic injuries as expertise currently sought from Guys Hospital rather than locally. The panel commend the level of allied health professional support available and in particular the dedicated nutrition support team with a trauma specialist dietician who undertakes a complete nutritional assessment on all trauma patients and a a comprehensive programme for nutritional management. Good Practice Good Practice/Significant Achievements Dedicated nutritional support team with a comprehensive programme for nutritional management Nominated polytrauma consultant for the week Concerns and Recommendations Immediate Risks Identified? Not Identified Immediate Risks Immediate Risks Resolved? Immediate Risks Resolution Serious Concerns Identified? PEER REVIEW VISIT REPORT for - Definitive Care Measures (published: 6th May 2014) Page: 2/3

Not Identified Serious Concerns Serious Concerns Resolved? Serious Concerns Resolution Concerns Capacity of the major trauma co-ordinators to provide cover for the anticipated increase in workload Need to identify a trauma lead for neurosurgery to ensure any issues are identified and resolved prior to the move to the Royal Sussex County Hospital Changes in the neurosurgery service need to be reflected in improvements to the time to surgery for traumatic brain injury patients. PEER REVIEW VISIT REPORT for - Definitive Care Measures (published: 6th May 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 6th March 2014 Compliance REHABILITATION MEASURES Zonal Statement Completed By Julia Hill Self Assessment % (0/0) Peer Review 50.0% (7/14) Job Title Deputy National Programme Director Date Completed 06/03/14 Agreed By (Clinical Lead/Quality Director) Ruth Bridgeman National Programme Director Date Agreed 02.05.14 Key Themes Rehabilitation Measures The network recognises there are significant challenges for trauma rehabilitation. There are enhanced care beds available at the Donald Wilson Unit in West Sussex and the Specialist Rehabilitation Centre, a 39 bedded specialist rehabilitation unit at the Princess Royal Hospital. There is however limited capacity and with very little community provision with specific issues in East Sussex. The rehabilitation for the MTC is provided by the Sussex Rehabilitation Centre at the Princess Royal Hospital. There are plans to appoint an additional rehabilitation consultant which will enable an increase in support to thee times a week. There are currently no dedicated rehabilitation co-ordinators in post this is covered by the two major trauma co-ordinators which is unsustainable in the longterm and reflected in the gaps in service such as patient information and key worker. Although TARN data indicates a good use of rehabilitation prescriptions it was apparent from the discussions these are not being received PEER REVIEW VISIT REPORT for - Rehabilitation Measures (published: 6th May 2014) Page: 1/3

outside the MTC. This will make it difficult to make a true assessment of the rehabilitation requirements for the network and also prevents services achieving tariff. Psychological assessment and treatment for trauma patients has been commissioned through Sussex Partnership NHS Foundation Trust and the MTC has also appointed a mental health psychologist. Good Practice Good Practice/Significant Achievements Access to specialist rehabilitation services Psychological support for trauma patients Appointment of a third rehabilitation consultant Concerns and Recommendations Immediate Risks Identified? Not Identified Immediate Risks Immediate Risks Resolved? Immediate Risks Resolution Serious Concerns Identified? Not Identified Serious Concerns PEER REVIEW VISIT REPORT for - Rehabilitation Measures (published: 6th May 2014) Page: 2/3

Serious Concerns Resolved? Serious Concerns Resolution Concerns Lack of non-specialist rehabilitation across the network No rehabilitation co-ordinators in post and reliance on the major trauma co-ordinators Lack of rehabilitation prescriptions being received PEER REVIEW VISIT REPORT for - Rehabilitation Measures (published: 6th May 2014) Page: 3/3