There are at least 20,000 cases of major trauma each year in England, the most common cause being a road traffic accident, which results in 5,400 deaths.
There are currently 193 hospitals in England that provide major trauma services within their emergency departments. Major trauma is, however, a minor element of emergency department work equating to less than 0.2% of total activity.
A recent National Audit Office (NAO) report, called Major trauma care in England, estimates that major trauma costs the NHS up to £0.4 billion a year in immediate treatment, and significantly more in subsequent treatment.
Since 1988, a number of studies have identified deficiencies in the care provided to severely injured patients in England. In 2007, a report by the National Confidential Enquiry into Patient Outcome and Death concluded that 60% of major trauma patients received a standard of care that was ‘less than good practice’.
There has, however, been little progress in addressing these deficiencies and recent research has identified a 20% higher in-hospital mortality rate for trauma patients in England compared to the US.
In 2008, Lord Darzi’s NHS Next Stage Review reported that there were ‘compelling arguments for saving lives by creating specialised centres for major trauma’ and strategic health authorities were asked to develop regional plans on this basis. The Department of Health is supporting the work through its Regional Trauma Networks Programme, although no timescales were set for the completion of this process.
The NAO report evaluates major trauma services in England and identifies what improvements need to be made. The following is a summary:
1. Despite repeated reports identifying poor practice, the DoH and NHS trusts have taken very little action to improve major trauma care.
2. Survival rates for major trauma vary significantly between hospitals, reflecting variations in the quality of care. Data from TARN, to which 114 hospitals (59% of hospitals delivering trauma care) voluntarily submit trauma data for analyses and comparison, show a range of outcomes following trauma from five unexpected survivors to eight unexpected deaths per 100 trauma patients. The performance of the 41% per cent of trauma receiving hospitals that do not submit data to TARN cannot be gauged.
3. As major trauma is a relatively small part of the work of an emergency department, optimal care cannot be delivered cost-effectively by all hospitals. People who have suffered major trauma often have multiple injuries which need to be treated by different surgical specialties. Whilst specialties such as orthopaedic surgery are commonly available in hospitals, this is not the case for neurosurgery or cardiac surgery. A generally acknowledged solution to this issue is the development of trauma networks.
4. Evidence shows that care should be led by consultants experienced in major trauma, but major trauma is most likely to occur at night-time or at weekends when consultants are not present in emergency departments.
5. The delivery of major trauma care lacks coordination and can lead to unnecessary delays in diagnosis, treatment and surgery. There are currently no formal protocols for determining where people should be taken for treatment, nor a formal system for transferring patients between hospitals. TARN data show that only 36% of patients requiring a transfer from one hospital to another more specialist facility actually get transferred and, for those who are transferred, the efficiency of the process often relies on adhoc arrangements.
6. Information on major trauma is not complete and quality of care is not measured by all hospitals. Data on major trauma is either lacking entirely, incomplete or is not brought together in a usable way. Not all hospitals contribute to TARN, and measures of quality almost exclusively focus on death during the initial period of hospitalisation. This lack of data means that it is not possible to fully understand the effectiveness of the current or future organisation of major trauma care.
7. Ambulance trusts have no systematic way of monitoring the standard of care they provide for people who have suffered major trauma and opportunities for improving care may be missed.
8. The availability of rehabilitation varies widely across the country, and services have not developed on the basis of geographical need.
9. The costs of major trauma are not fully understood, and there is no national tariff to underpin the commissioning of services. If the regional trauma networks now planned are to be successful, trusts need to have appropriate funding arrangements that facilitate the easy transfer of patients to more specialist care and rehabilitation.
Interim actions (by September 2011)
1. PCTs and ambulance trusts should develop and implement triage protocols to determine which emergency departments seriously injured patients should be taken for treatment.
2. All acute and foundations trusts with emergency departments that receive trauma patients must submit data to TARN.
3. SHAs should develop protocols for the transfer of patients requiring specialist care or surgical procedures not available at the receiving hospital.
Longer term actions
1. SHAs should develop measures of outcomes to enable the quality of major trauma services to be better assessed. These measures should cover the entire patient pathway from pre-hospital care through to acute care and rehabilitation.
2. Using TARN data, hospital trusts should benchmark performance with other trusts to help identify best practice and ways to improve patient care.
3. Ambulance trusts should collect data on the resources dispatched and treatment provided. It should be linked with data collected by NHS acute trusts in order to monitor the quality and safety of care provided in the pre-hospital environment.
4. TARN data and ambulance trust data should be routinely analysed by SHAs and PCTs and used to performance manage trauma networks.
5. DoH and NICE should develop standards for major trauma care.
6. SHAs should work with PCTs, ambulance trusts, hospital trusts and social care providers to develop protocols for the effective delivery of major trauma care against the standards set by NICE.
7. Hospital and ambulance trusts should develop procedures through which they can obtain assurance that defined clinical standards are being followed by their staff.
8. Protocols should be developed for improving the overall management of critical care capacity.
9. SHAs should review the current organisation of rehabilitation services when considering their plans for developing trauma networks.
10. The low incidence and high complexity of major trauma means it is important to have well established systems in place, following recognised standards including: 24-hour attendance of consultants with experience in major trauma; major trauma teams in place to coordinate care; by-pass and transfer protocols; and the collection of accurate and complete information on treatment and outcomes.
The published literature suggests that where trauma systems have been introduced, in-hospital mortality reduces by 15% to 20%. On the basis of our estimate of 3,000 deaths in hospital from major trauma each year, this suggests an additional 450 to 600 lives could be saved each year across England.
The current absence of such systems and standards means that patients do not consistently receive timely and coordinated care, which leads to poorer patient outcomes and, in some cases, death.
The NAO report concludes that major trauma care in England does not represent value for money because the service is not being delivered efficiently or effectively.
Amyas Morse, head of the National Audit Office, said: “Current services for people who suffer major trauma are not good enough. There is unacceptable variation, which means that if you are unlucky enough to have an accident at night or at the weekend, in many areas you are likely to receive worse quality of care and are more likely to die. The Department of Health and the NHS must get a grip on coordinating services through trauma networks, on costs and on information on major trauma care, if they are to prevent unnecessary deaths.”
Read the full report.
Read the Royal College of Surgeons’ report.