Evaluation of Manchester's Trauma Network

Introduction

Major trauma is serious or multiple injuries that could result in death or significant disability and is the leading cause of death in all groups under 45 years of age in the UK with more than 20,000 incidents resulting in 10,000 deaths annually (1,2,3). A report by the National Confidential Enquiry into Patient Outcome and Death in 2007 revealed substandard care in over 60% of injured patients in the UK (4). The NAO report in 2010(5), highlighted the deficiencies in trauma care in England. This report resulted in recommendations  to establish a regional Major Trauma Network. A Major Trauma Network delivers major trauma care through an ‘inclusive’ delivery model. Following this recommendation there are now 27 Major Trauma Centres created by the NHS forming a series of Regional Trauma Networks throughout England (8). Any patient with an Injury Severity Score of >15 is classed as having major trauma  and patients with an ISS of 9-15 are classed as having moderate trauma.(9). Each network has designated hospitals providing a level of trauma care within their capabilities(10); Major Trauma Centres (MTCs), Trauma Units (TUs) and local Emergency Hospitals as shown in Figure 1 (2,11).

FIGURE 1 NHS England. NHS STANDARD CONTRACT FOR MAJOR TRAUMA SERVICE (ALL AGES) [Internet]. NHS England; 2013 [cited 3 October 2019]. Available from: https://www.england.nhs.uk/wp-content/uploads/2014/04/d15-major-trauma-0414.pdf

Greater Manchester Trauma Network

The Greater Manchester Trauma Network (GMTN) was developed in 2012. The Pre-hospital Care is provided by North West Ambulance Service (NWAS)(12). A HEMS service is also available through the North West Air Ambulance Charity which is manned by Paramedics and has one aircraft that responds with a Paramedic and Doctor crew(13). There is also the provision of inter-facility/hospital transfers that can be classed as Pre-hospital care if the patient is initially transported to a TU for stabilisation prior to transferring to a MTC for definitive care or visa versa if the patient has been over-triaged to an MTC and is calculated to have an ISS of 9-15 and a suitable candidate for treatment at a TU(5,8,11,20).

The Network comprises of a collaboration between two level 1 trauma centres; Salford Royal Hospital(SRH) and Manchester Royal Infirmary(MRI), three trauma units and a number of local hospitals creating an inclusive trauma system. There is also the Royal Manchester Children’s Hospital which is a designated MTC for children(8). Inclusive Trauma Systems include pre-hospital care, acute care, reconstruction and rehabilitation provided through MTCs, local TUs, local ambulance and rehabilitation services (6) whereas an exclusive trauma system involves one hospital being a stand-alone MTC  that has surgical specialties and will treat the most severely injured patients in a specific population but often has no links with surrounding hospitals or pre-hospital services(7).  The collaboration of MRI and SRH and the children’s MTC in the Network have all the necessary facilities and specialities to treat adult and children with any injuries in any combination as specified by the  NHS Standard contract for major trauma services(2).

Early access to rehabilitation, from the initial trauma through to when the patient no longer requires or benefits from rehabilitation is an essential component of regional trauma networks and improves the chances of a ‘good outcome’ for a trauma patient(6,8,11). Historically the cost of providing rehabilitation was a concern for hospitals, however this burden was eased when funding of £37 million was secured for hospitals providing trauma care and under a best practice tariff at least £1500 is paid to the MTC for every patient given a rehabilitation prescription(21,22). In Greater Manchester, Salford Royal Foundation Trust  has 20 hyper-acute Neurorehabilitation, 10 acute Neurorehabilitation and 12 Major Trauma rehabilitation beds(23,24).

STRENGTHS AND WEAKNESSES OF THE GREATER MANCHESTER TRAUMA NETWORK

Pre-hospital Care

Nice guidelines recommend that Ambulance crews are provided with a major trauma triage tool so they can ensure that patients are appropriately triaged and transported to either a major trauma centre or a trauma unit dependant on their injuries for definitive treatment (14,15).  In England there are several trauma tools used regionally which are based on the American College of Surgeons (ACS) 2006 ‘Guidelines for Field Triage of Injured Patients’. This system works well in NWAS showing sensitivity to be 0.63-0.84 and specificity at 0.75-0.97 (15). However, a weakness of this system is its unreliability for identifying major trauma in older patients. This is largely due to the triage tool focusing on the mechanism of injury, primarily involving high energy transfer mechanisms which is causing under triage of these elderly patients (17,18) despite evidence showing that elderly people suffer serious injuries from falls of less than 2 meters/standing and are the highest cause of major trauma in England (19).

The pre-alert system used within NWAS works very well. All ambulance staff are able to provide a pre-alert to their control centre to be passed onto the receiving MTC and provide an accurate handover using the ATMIST mnemonic. However, there is no evidence that the use of a standardised handover tool reduces the possibility of critical details being missed (15,16). An accurate standardised pre-alert ensures that the receiving MTC have any specialist staff needed and a space in resus available on the patient’s arrival (2,11). NWAS clinicians have access to Trauma Cell which is staffed by Advanced Paramedics (AP’s) who give senior clinical support and proactive co-ordination to crews on scene. Once it is established by a crew that their patient is a major trauma, Trauma Cell pre-alert the receiving MTC on behalf of the crew. The  APs can also pass on a ‘Code Red Massive Haemorrhage’ pre-alert for patients identified to have massive haemorrhage so receiving MTC’s can activate their major haemorrhage protocol (25,26).

In NWAS the transportation of patients works well. As well as access to land ambulances, NWAS has access to HEMS with 3 helicopters from the North West Air Ambulance charity. Helicopters were used in a civilian role in the wake of evidence that they reduce the mortality and morbidity rates in trauma patients (27). One of the helicopters is physician led meaning the patients have access to enhanced critical care procedures such as anaesthesia and blood transfusions on scene. With the obvious advantage of speed this also meant patients could be transported to a MTC for definitive care faster than a road ambulance (28). Although transportation to an MTC is faster by air, the on-scene times were longer for helicopter crews and patients arrived at a MTC 6 minutes later on average than with a land ambulance (29). A further weakness is at the current time NWAA does not have the capability to fly at night limiting the service to day light hours only which has an impact on patients as most major trauma incidents occur at night (13,30).

ACUTE EMERGENCY CARE, SURGERY AND ONGOING CARE

In the GMTN the figures from TARN indicate that Salford Royal and Manchester Royal Infirmary perform very well as a collaboration for major trauma emergency care and surgery and both hospitals mostly bettered the national average markers in all areas(31,32).

A weakness of this collaboration is the fragmentation of services. Isolated head injuries are treated at Salford Royal hospital and penetrating trauma is treated at Manchester Royal Infirmary(33,34). Dependant on where the initial insult occurs could result in a delay of definitive care due to travel distances and time.

Since Salford Royal became the principle receiving site for major trauma it is in the top quartile based on national performance and survival rates. Both hospitals submit data to the UK Trauma Audit and Research Network (UKTARN) which ensures quality improvement of trauma services and encourages best practice through monitoring key performance indicators, conducting quarterly morbidity and mortality reviews(32,35). A weakness of this process is that Trauma units are not currently eligible for best practice tariff meaning they have no incentive to submit data to TARN meaning  incomplete data collection weakening the statistics(36).

Rehabilitation

In the GMTN, Salford Royal Foundation Trust(SRFT) has 20 hyper-acute Neurorehabilitation, 10 acute Neurorehabilitation and 12 Major Trauma rehabilitation beds(23,24). However, Manchester Royal Infirmary has no major trauma rehabilitation which means any patients requiring hyper acute/acute neurorehabilitation need to be transferred to SRFT which is detrimental to the patient as this causes a delay in the patient receiving treatment in a clinically appropriate facility(37).  There are a number of external rehabilitation centres for onward care in the community as seen in Figure 3.

FIGURE 3 Rehabilitation Destinations – By Network [Internet]. TARN; 2017 [cited 14 October 2019]. Available from: https://www.tarn.ac.uk/content/downloads/53/Rehab%20Units%20by%20Destination%20-%20December%202017.pdf

Although it would appear that there are sufficient rehabilitation service providers in the GMTN, evidence shows that there is a distinct lack of community neurorehabilitation services resulting in longer stays in in-patient and community services which adversely  results in the bed blocking of inpatient services due to no community neuro-rehabilitation services. The community services that do exist are suffering a lack of staffing and some referrals to therapy are taking almost two years. This is having an adverse effect on patient outcomes leading to restricted life plan and a failure to achieve a patient’s true potential which consequently leads to a poor patient experience (39).

References

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