A Major Problem for the Health Service

1. A Major Problem for the Health Service Worldwide injury is a major public health problem The commonest cause of death between the ages of 1 and 40 years is injury For every fatality there are 2 survivors with serious and permanent disability There appears to be a strong relationship between social deprivation and injury Facilities for treatment of the injured and their effectiveness varies across the UK By way of introduction Injury is a major public health problem worldwide It is still the most common cause of death between the ages of 1 and 40. More so than cancer and heart disease combined. Importantly for every fatality there are 2 survivors with serious and permanent disability. Involving both emotional and monetary costs. Interestingly there appears to be a strong relationship between social deprivation and injury. There is a 5 times larger chance of you being injured if you live in a social class V area compared with a social class I area. Also you will have far more Pre-existing diseases and therefore you will have a worse outcome after injury. From work supported by the RCS in 1988 and by the Trauma Network facilities for treatment of the injured and their effectiveness varies across the UK By way of introduction Injury is a major public health problem worldwide It is still the most common cause of death between the ages of 1 and 40. More so than cancer and heart disease combined. Importantly for every fatality there are 2 survivors with serious and permanent disability. Involving both emotional and monetary costs. Interestingly there appears to be a strong relationship between social deprivation and injury. There is a 5 times larger chance of you being injured if you live in a social class V area compared with a social class I area. Also you will have far more Pre-existing diseases and therefore you will have a worse outcome after injury. From work supported by the RCS in 1988 and by the Trauma Network facilities for treatment of the injured and their effectiveness varies across the UK

2. Our Healthier Nation Quotes from this document indicate the importance of �injury� and its consequences: � It is clearly important that we continue to reduce the number of deaths from accidents.� �� many people suffer prolonged distress and poor quality of life as the result of a serious accident � The document entitled �Our Healthier Nation� was presented to parliament in February 1998 and focuses on a small number of national targets and health inequalities. It has been estimated that more than one person every hour died of accidental injury in England in 1996 and that treating injuries costs the NHS in the region of 1.2 billion pounds each year. Therefore in this document it was proposed that the rate of accidents be reduced by 20% by 2010 from a 1996 baseline. The reduction in accidents and reducing death and disability after injury can be challenged in various ways. PRIMARY - reduction in the incidence of injury SECONDARY - improvements in car design and seat belt laws TERTIARYThe document entitled �Our Healthier Nation� was presented to parliament in February 1998 and focuses on a small number of national targets and health inequalities. It has been estimated that more than one person every hour died of accidental injury in England in 1996 and that treating injuries costs the NHS in the region of 1.2 billion pounds each year. Therefore in this document it was proposed that the rate of accidents be reduced by 20% by 2010 from a 1996 baseline. The reduction in accidents and reducing death and disability after injury can be challenged in various ways. PRIMARY - reduction in the incidence of injury SECONDARY - improvements in car design and seat belt laws TERTIARY

3. Is there potential for improvement in the care of injured patients? Working Party on the Management of Patients with Major Injury, Royal College of Surgeons 1988 ��.this report reveals significant deficiencies in the management of seriously injured patients.� �Standards of hospital care of the injured should be monitored through a national audit scheme�..� Evidence that trauma care is NOT optimal was provided in 1988 by the RCS The RCS report on the management of major injury included evidence that trauma care was NOT optimal in all areas of the country with wide variation. The report also recommended the following: NEXT SLIDE Evidence that trauma care is NOT optimal was provided in 1988 by the RCS The RCS report on the management of major injury included evidence that trauma care was NOT optimal in all areas of the country with wide variation. The report also recommended the following: NEXT SLIDE

4. Improvements in systems of trauma care may be achieved by :- Enhancing pre-hospital care, ensuring appropriate medical intervention rapid transfer to best local facility Assessing the use of helicopters Adopting ATLS principles Integrating trauma care services within and between hospitals Investing in rehabilitation services and Auditing and Researching injury and systems of care The enhancement of pre-hospital care, ensuring appropriate medical intervention rapid transfer to the best local facility Assessing the use of helicopters in different areas of the country Adopting ATLS principles Integrating trauma care services within and between hospitals Investing in rehabilitation services AND Auditing and Researching injury and systems of careThe enhancement of pre-hospital care, ensuring appropriate medical intervention rapid transfer to the best local facility Assessing the use of helicopters in different areas of the country Adopting ATLS principles Integrating trauma care services within and between hospitals Investing in rehabilitation services AND Auditing and Researching injury and systems of care

5. Trauma NetworkBackground 1988 the Major Trauma Outcome Study was established 1992 1st REPORT published in BMJ: - UK mortality rate higher than US - large interhospital variation - slow response time - lack of senior input 1994 Statistical analysis was improved and modified 1996 New funding system1998 104 hospitals in Europe audited their trauma services through the Network The Major Trauma Outcome Study was first established in 1988 after the RCS report In 1992 the 1st REPORT was published in the BMJ and showed that - UK mortality rate higher than US - large interhospital variation - slow response time - lack of senior input Initially the statistical analysis used was that initiated by Howard Champion in North America. In 1994 the methodology was improved drastically and now uses UK data to set up the regression model AND includes age (by decade) as one of the predictors of outcome. In 1996, 106 hospitals in Europe audited their trauma services through the Network In 1997 the Central Health Outcome Unit (part of the DoH, headed by Asim Lakhani) became involved and followed our work more closely 1998/99, 104 hospitals in England, Wales and NI are members and use the Trauma Network as part of their Clinical Governance strategy The Major Trauma Outcome Study was first established in 1988 after the RCS report In 1992 the 1st REPORT was published in the BMJ and showed that - UK mortality rate higher than US - large interhospital variation - slow response time - lack of senior input Initially the statistical analysis used was that initiated by Howard Champion in North America. In 1994 the methodology was improved drastically and now uses UK data to set up the regression model AND includes age (by decade) as one of the predictors of outcome. In 1996, 106 hospitals in Europe audited their trauma services through the Network In 1997 the Central Health Outcome Unit (part of the DoH, headed by Asim Lakhani) became involved and followed our work more closely 1998/99, 104 hospitals in England, Wales and NI are members and use the Trauma Network as part of their Clinical Governance strategy

6. Widespread Participation Annual new Attendances at A &E Departments < 30,000 30,001 - 40,000 40,001 - 50,000 50,000 - 60,000 60,001 - 70,000 70,001 - 80,000 >80,000 Total Active members October 1998 13 18 31 15 8 7 10 104

7. Trauma NetworkObjectives collect and analyse clinical and epidemiological data provide a statistical base to support clinical audit aid the development of trauma services and inform the research agenda Our Objectives are to Collect and analyse clinical data from the time of injury thru to discharge including epidemiological data - postcodes from the place of injury and the patients� home. Provide a statistical base rather than anecdotal evidence to support clinical audit Aid the development of trauma services AND Inform the research agenda - in 3 ways provide a database to highlight ideas and issues to be tested in a more formal research project e.g.RCTs use the Trauma Network and its communication links to test if new findings are being implemented use a core group of hospitals to look more closely at certain issues Our Objectives are to Collect and analyse clinical data from the time of injury thru to discharge including epidemiological data - postcodes from the place of injury and the patients� home. Provide a statistical base rather than anecdotal evidence to support clinical audit Aid the development of trauma services AND Inform the research agenda - in 3 ways provide a database to highlight ideas and issues to be tested in a more formal research project e.g.RCTs use the Trauma Network and its communication links to test if new findings are being implemented use a core group of hospitals to look more closely at certain issues

8. Quality Cycle The system revolves around a circle or loop and whatever you do you should always re-audit and action or implement change. Measurement of performance is only valuable if it identifies areas of concern and thereby stimulates appropriate change.The system revolves around a circle or loop and whatever you do you should always re-audit and action or implement change. Measurement of performance is only valuable if it identifies areas of concern and thereby stimulates appropriate change.

9. MeasurementData collection should be: Accurate Complete Comprehensive

10. Measurement / Data Collection Simple data or more complex? Can we get meaningfull results from a simple data collection process? Do I need more details to tease out the reasons for a specific outcome ? What outcome am I going to record and evaluate? We have now a well validated data collection system with a specific inclusion criteria and a standardised data collection form which is scanned AFTER injury coding and validation and results are turned around within one month of receipt and this will be reduced further this year with the introduction of a new database. We can provide a watertight experienced service with a prompt response HOWEVER ACCURACY is important. You need to decide that data is complete and comprehensive. The old adage still works. - Rubbish IN Rubbish OUTSimple data or more complex? Can we get meaningfull results from a simple data collection process? Do I need more details to tease out the reasons for a specific outcome ? What outcome am I going to record and evaluate? We have now a well validated data collection system with a specific inclusion criteria and a standardised data collection form which is scanned AFTER injury coding and validation and results are turned around within one month of receipt and this will be reduced further this year with the introduction of a new database. We can provide a watertight experienced service with a prompt response HOWEVER ACCURACY is important. You need to decide that data is complete and comprehensive. The old adage still works. - Rubbish IN Rubbish OUT

11. Patient Inclusion Criteria Admission > 72 hours Admission to an intensive care area Transfers for continuing care > 72 hours All deaths Excluding: Fractures of the femoral neck or single pubic rami (age > 65yrs) OR SIMPLE isolated injuries

12. The Trauma NetworkAnalysis INPUT PROCESS OUTPUT Common standards for severity measurement Common measures for performance assessment After data collection and validation - Analysis The Trauma Network monitors input, process and outcome. The input or severity of anatomical injury and the physiological derangement is standardised as part of the Trauma Network data collection and processing. The output is death or survival. Outcome IS an obvious important measure but if process can be shown to be related to outcome then process measures can be used to monitor care. Why is that useful? Death is quite rare and therefore evaluating process provides more opportunities to monitor care. 2. Outcome (less deaths and improved levels of disability ) after injury to the brain resulting in EDH is improved if times to definitive treatment is less than 4hours. Therefore we analyse the times to theatre. After data collection and validation - Analysis The Trauma Network monitors input, process and outcome. The input or severity of anatomical injury and the physiological derangement is standardised as part of the Trauma Network data collection and processing. The output is death or survival. Outcome IS an obvious important measure but if process can be shown to be related to outcome then process measures can be used to monitor care. Why is that useful? Death is quite rare and therefore evaluating process provides more opportunities to monitor care. 2. Outcome (less deaths and improved levels of disability ) after injury to the brain resulting in EDH is improved if times to definitive treatment is less than 4hours. Therefore we analyse the times to theatre.

13. Assessment of Trauma Severity The injury scoring system that is used is described very simply on this slide. The Anatomical injury is combined with the physiological derangement and the patient�s age and type of wounding. An individual patient can be assessed. All patients are then combined so that an individual hospital can be assessed. The standardisation importantly accounts for different injury severity mixes. We have refined this methodology from the database that has been built up over time in the UK. This provides a system which can be used to assess the effectiveness or process of trauma care. The following slide illustrates this concept graphically: The injury scoring system that is used is described very simply on this slide. The Anatomical injury is combined with the physiological derangement and the patient�s age and type of wounding. An individual patient can be assessed. All patients are then combined so that an individual hospital can be assessed. The standardisation importantly accounts for different injury severity mixes. We have refined this methodology from the database that has been built up over time in the UK. This provides a system which can be used to assess the effectiveness or process of trauma care. The following slide illustrates this concept graphically:

14. Physiological - Revised Trauma Score Is a physiological measurement and by convention, recorded on arrival at hospital The RTS includes: Respiratory rate Systolic blood pressure Glasgow Coma Scale

15. Abbreviated Injury Scale (AIS 90) 1 injury = 1 code with a range of 0 - 6 Injury Severity Score (ISS) Uses a formula to represent multiple injuries in 1 number with a range of 0 - 75

16. INJURY SEVERITY SCORE Example Abbreviated Injury Scale Small subdural haematoma 4 Parietal lobe swelling 3 Major liver laceration 4 Upper tibial fracture (displaced) 3 ISS = 42 + 42 + 32 = 41

17. Ps cannot be applied to individuals If the Probability of Survival (Ps) of an injured patient = 0.4 Then, on average, 6 out of 10 patients will die

18. The Trauma Network Reports Monthly: Clinical activities Quarterly: Outcome statistics (anonymous) Process filters Ad Hoc Reports Formatted data

19. Process Measures Time intervals injury and arrival at A&E arrival in A&E and 1st doctor seeing the patient transfer to another hospital Seniority of staff Haemo/pneumothorax evidence of chest drains # skull, brain & spinal injury (AIS3+ ) evidence of CT scan immobilisation of spine recorded GCS Comparative Process measures are part of the Trauma Network monitoring system (included in each quarterly report). The slide shows some of those used over the past year: Times to definitive treatment and grades of staff treating the patients. Evidence of patients having chest drains for certain chest injuries. Patients with Injuries to the skull, brain & spine with a specific severity (AIS3+ ) have also been selected and analysed for evidence of CT scan, immobilisation of spine and if the Glasgow Coma Scale was recorded. Accounting for frequencies and missing data, variations should be investigated at each hospital, data amended (if required) and process monitored as part of a system of good practice. Comparative Process measures are part of the Trauma Network monitoring system (included in each quarterly report). The slide shows some of those used over the past year: Times to definitive treatment and grades of staff treating the patients. Evidence of patients having chest drains for certain chest injuries. Patients with Injuries to the skull, brain & spine with a specific severity (AIS3+ ) have also been selected and analysed for evidence of CT scan, immobilisation of spine and if the Glasgow Coma Scale was recorded. Accounting for frequencies and missing data, variations should be investigated at each hospital, data amended (if required) and process monitored as part of a system of good practice.

20. Hospital comparisons 1994 - 1998 Summary Ws scores and 95%CI. Blunt injuries, excl. referrals The Outcome Measure is the standardised W score which accounts for different severity mixes (the Input). Each hospital is anonymous. The mean Ws with 95% CI is for the top 10 and bottom 10 hospitals has been introduced, Seen on the graph as 2 sets of parallel lines. Both process and Outcome measures are included in the Trauma Network Reports.The Outcome Measure is the standardised W score which accounts for different severity mixes (the Input). Each hospital is anonymous. The mean Ws with 95% CI is for the top 10 and bottom 10 hospitals has been introduced, Seen on the graph as 2 sets of parallel lines. Both process and Outcome measures are included in the Trauma Network Reports.

21. Morbidity Wider variation than with mortality Inadequate scoring systems What to estimate? temporary permanent Death/Survival is the outcome measure at the moment. Obviously morbidity is equally important and over the next 6 months we will be assessing the literature to decide on the best of inadequate scoring systems and what to estimate - temporary or permanent Death/Survival is the outcome measure at the moment. Obviously morbidity is equally important and over the next 6 months we will be assessing the literature to decide on the best of inadequate scoring systems and what to estimate - temporary or permanent

22. Trauma Audit - Closing the loop D Yates, J Bancewicz, M Woodford, P Driscoll, RAC Jones, R Kishen, D Marsh, S Hollis. Injury (1994) 25:511 An example of locally implementation An example of locally implementation

23. Conclusions and lessons learnt Close inter-disciplinary cooperation and clinical improvement at a senior level. Application of protocols to provide continuity of care from the scene of the accident through to the hospital ward. Frequent statistical analysis of performance at audit meetings to �close the loop� is an essential part of the strategy to improve trauma care. Conclusions from the paperConclusions from the paper

24. Setting quality standards National Institute for Clinical Excellence Clinical Governance Commission for Health Improvement National Service Frameworks A word finally about translating the Trauma Network analysis from local level to regional and national level. A 10 year programme was recently introduced by the Government including these links on setting quality standards. ��At present there are unacceptable variations in the quality of care available to different NHS patients in different parts of the country.�� The National Service Frameworks will set out common standards across the country for the treatment of particular conditions. CHIMp is linked with National Service Frameworks and National Patient and User Surveys to monitor standards. Clinical Governance will be linked with Professional self regulation and continuous education The National Institute for Clinical Excellence will act as a nation-wide appraisal body for new and existing treatments, and disseminate consistent advice on what works and what doesn:t. NICE will set clear standards of service A word finally about translating the Trauma Network analysis from local level to regional and national level. A 10 year programme was recently introduced by the Government including these links on setting quality standards. ��At present there are unacceptable variations in the quality of care available to different NHS patients in different parts of the country.�� The National Service Frameworks will set out common standards across the country for the treatment of particular conditions. CHIMp is linked with National Service Frameworks and National Patient and User Surveys to monitor standards. Clinical Governance will be linked with Professional self regulation and continuous education The National Institute for Clinical Excellence will act as a nation-wide appraisal body for new and existing treatments, and disseminate consistent advice on what works and what doesn:t. NICE will set clear standards of service