The national major trauma system within the United Kingdom: inclusive regionalized networks of care : Emergency and Critical Care Medicine

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The national major trauma system within the United Kingdom: inclusive regionalized networks of care

Cole, Elaine

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Emergency and Critical Care Medicine 2(2):p 76-79, June 2022. | DOI: 10.1097/EC9.0000000000000040
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Abstract

Introduction

The United Kingdom has a population of 67 million people and is divided into 4 nations: England, Wales, Scotland, and the North of Ireland. Healthcare is provided free to all within each nation via the National Health Service (NHS), which is funded by taxes and national insurance payments. Each year, there are approximately 22,000 cases of “major trauma” in the UK across the 4 nations[1–3] and it remains the leading cause of death amongst children and adults up to their mid-40s. As the ageing population increases, severe injury is also becoming a significant burden for older people.[4] In the UK, the majority of major trauma is caused by blunt force (predominantly road traffic incidents, falls, assaults); however, there are increasing numbers of penetrating injuries (mainly knives) occurring in urban settings.

Prior to 2010, trauma patients in the UK were managed at any acute hospital with an Emergency Department, irrespective of resource availability or clinical experience and expertise. National reports had identified significant variation or serious failings in the organization of UK trauma care.[1,5] These reports, together with political drivers for centralized services, led to the formation of the national trauma system made up of regional trauma networks. In April 2010 the first regional “Major Trauma” networks were launched in London. Implementation of networks across the rest of England continued in 2012 and Scotland, Wales, and Northern Ireland followed between 2017 and 2020. Five years after the re-organization of UK major trauma care there was a 19% increase in the odds of survival for patients who reach the hospital alive.[6]

The main challenge to the implementation of major trauma networks was the acceptance of change by hospitals that would no longer receive severely injured patients. There were fears of a loss of staff or key services, and clinical “de-skilling.” Nevertheless the compelling evidence provided in the national reports clearly outlined the need for change to improve patient outcomes. This evidence, together with public consultation and the political desire to change health delivery, led to the acceptance and development of trauma networks. To maximize engagement, senior clinicians and other healthcare staff were involved in the trauma network planning, hospital designation and validation processes.

Pre-hospital

Prehospital trauma care is provided by 13 regional NHS land ambulance services, each with dedicated despatch centres. There are also emergency air ambulance helicopters in all areas of the UK which are predominantly operated by charities.

Positive aspects

  • National universal emergency telephone number for the whole of the UK (999).
  • Regional trauma triage tools, with very low rates of under and over triage.
  • NHS paramedics are educated to degree level and can work within protocols to deliver emergency treatment, IV medications, etc.
  • Pre-hospital services are linked to trauma networks and collaborate in governance meetings, audit, education, and training.

Aspects to avoid or improve

  • Challenges with pre-hospital triage of older patients who may not “present” as significant major trauma (due to comorbidities, altered physiology, innocuous mechanisms of injury). This requires consideration in training and guidelines.
  • There is no formal, national data linkage between pre-hospital and in-hospital registries which makes evaluation of the whole patient pathway challenging.

Facility-based care

Major Trauma Centres (MTC) are specialist hospitals with the clinical, organizational and equipment resources available to manage severely injured patients 24 hours a day. Each MTC has a designated clinical lead who oversees the major trauma service within the hospital. Medical, nursing and allied health staff are educated and trained in the management of injured patients, on short clinical courses such as Advanced Trauma Life Support (ATLS) or Trauma Nursing Core Course (TNCC) through to Masters and PhD programmes. Trauma Units (TU) are acute hospitals, designated to manage less severely injured patients or to ensure safe onwards transfer for those who require MTC level care within the region.

Positive aspects

  • The most severely injured patients are managed by the most experienced clinicians in consistently resourced MTCs.
  • Severely injured patients can be managed within their own geographical region.
  • Patients are cohorted on specialist Major Trauma wards within the MTC.
  • There are dedicated pediatric MTCs for injured children and young people.
  • Clear transfer policies between TU and MTC mandate automatic acceptance of patients within the regional network.

Aspects to avoid or improve

  • Staff working in TUs require knowledge and skill updated to ensure the management of “self-presenting” major trauma, or for those who have been under-triaged to a TU.
  • Limited availability of in-patient beds for burn-injured patients.
  • Delays in local hospitals repatriating patients from the MTC once the acute trauma phase of management is completed.

Trauma network

The UK trauma system is made up of 22 regional trauma networks. These are organized in a “hub and spoke” model where each region has 1 or 2 designated Major Trauma Centres (level 1 equivalent) and a number of Trauma Units (level 2–3 equivalent)—depending on geographical location. Each trauma network has a board with representation from MTCs, TUs, differing clinical specialties and a dedicated network manager. Trauma networks oversee governance (annual review, revalidation processes) of their MTCs and TUs, using nationally determined criteria and evidence.

Positive aspects

  • Trauma networks are inclusive with oversight of MTC and TU levels of care.
  • MTCs are the central component of the network with “inclusive” responsibility to support TU clinicians in patient management, clinical advice, etc.
  • Clinical guidelines and protocols are developed and agreed at a network level.
  • Medical staff conduct their specialist training in MTCs and TUs within the network gaining experience in both levels of care.

Aspects to avoid or improve

  • Funding for TUs.
  • Local network autonomy to respond to regional requirements.

Trauma registry

The Trauma Audit and Research Network is the national trauma registry for England, Wales, and Northern Ireland. Data in Scotland is collected via the Scottish Trauma Audit Group. The registries include patients of any age who sustain injury resulting in: hospital admission >72 hours, critical care admission, transfer to an MTC from a TU or death within 30 days of injury. Simple isolated injuries and fragility fractures in patients aged ≥65 years are excluded. Data are completed by identified collectors and submitted within 25 days of discharge.

Positive aspects

  • Comprehensive data collection from hospital admission through to discharge, and quality of life follow up at 6 months post injury.
  • Data can be used to support research activity and generate evidence.
  • Directly linked to governance (eg, trauma team activity, “time to” process measures, outcomes).
  • Allows for performance comparisons between networks and MTCs.

Aspects to avoid or improve

  • Variable data completion and submission by some smaller TUs.
  • Does not collect data on patients with a hospital stay of <72 hours; therefore rates of pediatric cases and penetrating trauma are under-reported.
  • Limited data on pre-hospital care.

Rehabilitation

Each network has a named Director of Rehabilitation and the MTCs require a rehabilitation clinical lead who heads up a multidisciplinary team including:

  • Consultant (attending) in rehabilitation medicine
  • Physiotherapist
  • Occupational therapist
  • Speech and language therapist
  • Dietitian
  • Clinical psychologist/neuropsychologist
  • Rehabilitation coordinator

Complex, high level rehabilitation is provided at specialist tertiary hospitals/community settings, led by a consultant (attending) in rehabilitation medicine. Less complex rehabilitation is delivered locally by therapists in MTCs and TUs. The provision of complex, high level rehabilitation is variable across the UK, dependent on resources and bed availability including pediatric provision.

Positive aspects

  • Each network has a named individual with responsibility for rehabilitation oversight.
  • Early access to the multidisciplinary rehabilitation team in MTCs.
  • National Institute for Clinical Evidence guidance on “Rehabilitation after traumatic injury” available for any practitioner working in trauma rehabilitation.[7]
  • Rehabilitation needs and prescription are captured within the national trauma registry.

Aspects to avoid or improve

  • Variable availability of specialist complex trauma rehabilitation in-patient beds (more funding required).
  • Limited vocational “return to work” rehabilitation funding in some networks.

Governance, financing, and quality assurance

Nationally, governance is overseen by the centralised Major Trauma and Burns Clinical Reference Group (CRG). This is a group of clinicians, government commissioners, public health experts, patient representatives, and professional associations. CRGs lead on the development of clinical commissioning policies, service specifications, and quality standards. The CRG provides networks with MTC and TU quality indicators for use during designation revalidation and local governance.

In addition to national Department of Health funding for all healthcare, major trauma has an extra payment: the “Best Practice Tariff” (BPT). This payment is provided to encourage best practice management of significantly injured patients within a regional trauma network. The BPT is made up of 2 levels of payment, differentiated by the patients injury severity score (ISS ≥ 9 and ≥16) and is conditional on achieving criteria such as admission to an MTC, time to CT scan in brain injured patients, registry data completion, etc. BPT is only payed to MTCs currently and there is no additional funding for TUs.

Positive aspects

  • A standardised, national approach to governance and quality assurance.
  • Clinical representation for trauma networks at a national level.
  • The most severely injured patients who require the most resources receive extra BPT funding.

Aspects to avoid or improve

  • No BPT funding for TUs despite some severely injured patients presenting to this level of care.
  • Some regional variations (due to varying geographical location or patient demographics) may not be accounted for at a central national level.

Future: what are plans for the future?

The UK trauma system is comprised of inclusive networks of designated hospitals and pre-hospital partners within geographical regions. Network-led trauma pathways, clinical guidance and governance have been embedded into practice as the system has matured.

Key factors to success are: a shared vision of the network and its annual plans, identified roles and responsibilities within the network, and collegial, inclusive relationships within and between hospitals and pre-hospital teams.

Current and future planning includes:

  • A continued focus on delivering equity of specialist rehabilitation provision across all networks.
  • Ongoing network “inclusive” support, education and training for TUs.
  • Trauma specific funding for severely injured patients who remain at a TU.
  • Continue to develop and refine the network and national responses to Mass Casualty Events.
  • Increased network autonomy (de-centralisation) to allow funding/governance to be used to meet specific regional and/or network requirements.

Conflict of interest statement

The author declares no conflict of interest.

Author contributions

Cole E wrote the paper.

Funding

None.

Ethical approval of studies and informed consent

Not applicable.

Acknowledgements

None.

References

[1]. Major trauma care in England. National Audit Office. Available at: https://www.nao.org.uk/report/major-trauma-care-in-england/. Accessed March 15, 2022.
[2]. Audit of trauma management in Scotland. Public Health Scotland. Available at: https://publichealthscotland.scot/publications/audit-of-trauma-management-in-scotland/audit-of-trauma-management-in-scotland-reporting-on-2020/. Accessed March 15, 2022.
[3]. Northern Ireland Major Trauma Network Annual report. Health and Social Care Board. Available at: http://www.hscboard.hscni.net/majortrauma/. Accessed March 15, 2022.
[4]. Major trauma in older people. Trauma Audit Research Network. Available at: https://www.tarn.ac.uk/Content.aspx?c=3793. Accessed March 15, 2022.
[5]. Findlay GM, Smith N, Martin IC, Weyman D, Carter S, Mason M. Trauma who cares? A report of the National Confidential Enquiry into Patient Outcome and Death. London: National Confidential Enquiry into Patient Outcome and Death; 2007. Available at: https://www.ncepod.org.uk/2007report2/Downloads/SIP_report.pdf. Accessed March 15, 2022
[6]. Moran CG, Lecky F, Bouamra O, et al. Changing the system—major trauma patients and their outcomes in the NHS (England) 2008–17. EClinicalMedicine. 2018;2–3:13–21. doi:10.1016/j.eclinm.2018.07.001
[7]. Rehabilitation after traumatic injury. National Institute of Clinical Excellence. Available at: https://www.nice.org.uk/guidance/ng211. Accessed March 15, 2022.
Keywords:

Inclusive; Major trauma center; Trauma network; Trauma system; Trauma unit

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