Healthcare The London for London Trauma System Launch

1. The TRAUMA Audit & Research NETWORK HealthcareThe London for LondonTrauma System Launch The Trauma Audit & Research Network Maralyn Woodford

2. The Trauma Audit & Research Network • Background • Measuring trauma severity • Performance comparisons of trauma care • Data Coordination across Networks The London Trauma System Launch 10th September 2009

3. TARN The TRAUMA Audit & Research NETWORK Universities of Manchester & Leicester • Established in 1990 • Non Profit making organisation - self funded through hospital membership fees in England, Wales, Ireland, Denmark & Switzerland • Core work - supporting improvements in trauma care through audit & research

4. The Role of The Trauma Audit & Research Network • ensure Quality Data coordination • provide regular and informative Feedback with adherence to • Benchmarks & Standards • maintain a statistical base to support clinical governance • offer responsive local reports & specific local improvement • publish National reports to inform the planning of trauma services • Improvements in Trauma Care

5. The Benefits of TARN Improvement in trauma care locally by: • Reviewing outlier patients • unexpected survivors – what did we do right? • unexpected deaths – what did we do wrong? • Compare outcomes through case-mix standardisation • Compare processes of care through clinically-defined standards of trauma care

6. Measuring and monitoring trauma care

7. Assessment of Trauma SeverityLogistic regression modelling‘ – ‘weights’ those parameters that predict survival. Anatomical Injury ISS Physiological Measure GCS Age / Gender Probability of survival of individual patients Case mix standardised comparisons of actual and predicted outcome

8. An improved approach to outcome predictions Where:GCS = Glasgow Coma Scale scoreISS = Injury Severity Scoreb0……..b26 are coefficients derived from regression analysis applied to data from TARN 2001 - 2006.b0 = constant 4.729b1 = 0 and applies when the GCS = 13 - 15b2 = -1.076 and applies when the GCS = 9 - 12b3 = -1.543 and applies when the GCS = 6 – 8b4 = -2.446 and applies when the GCS = 4 - 5b5 = -3.413 and applies when the GCS = 3b6 = -2.046 and applies when Intubatedb7 = -3.867b8 = -3.313b9 = 0 and applies when gender = maleb10 = -0.089 and applies when gender = femaleb11 = -0.083 and applies when Age = 0 – 5b12= 0.676 and applies when Age = 6 - 10b13 = 0.329 and applies when Age = 11 – 15b14 = 0 and applies when Age = 16 - 44b15 = -0.533 and applies when Age = 45 – 54b16 = -1.101 and applies when Age = 55 - 64b17 = -1.755 and applies when Age = 65 – 74b18 = -3.221 and applies when Age = > 74b19 = -0.237 and applies when Age = 0 – 5 and gender = femaleb20 = -0.216 and applies when Age = 6 – 10 and gender = femaleb21 = 0.042 and applies when Age = 11 – 15 and gender = femaleb22 = 0 and applies when Age = 16 - 44 and gender = female (or male)b23= 0.274 and applies when Age = 45 - 54 and gender = femaleb24 = 0.184 and applies when Age = 55 - 64 and gender = femaleb25 = 0.095 and applies when Age = 65 - 74 and gender = femaleb26 = 0.366 and applies when Age >74 and gender = femaleThe constant e = 2.718282 (the base of Napierian logarithms).

9. Comparing Outcomes 2005 - 2008 10 8 Average top 10 TARN Hospitals (+2.5) 6 4 More 2 survivors 0 Ws & 95% CI More deaths -2 -4 95% Confidence Intervals -6 Incomplete data collection -8 Average bottom10 TARN Hospitals(-3) -10

10. The Trauma Centre: A Speciality Hospital, not a Hospital of SpecialitiesR. A. Davenport et alBJS 2009accepted for publication

11. Current TARN Reports & Feedback • Every 3 months • in depth analysis • themed: head, thoracic, orthopaedic, abdomen & spine - monitors the RCS / BOA & NICE Guidelines - senior input in trauma team - timeliness and transfers - regional organisation - role of the local hospital • Electronic Reports & self production using the eDCR • Network Reports

12. TARN Developments • Improved data collection & reporting - eDCR • Successful publication of performance comparisons of standards of trauma care www.tarn.ac.uk The Trauma Audit & Research Network

14. Accessing a hospital from region

15. Completeness of Data Data Accreditation

17. Standards of Trauma Care Injuries to the Brain & Skull Time to CT Transfer to Neurosurgical centres Injuries to the Spine Transfer rates of unstable spinal injuries Injuries to the Chest Most senior Cardiothoracic clinician attending patient Injuries to the Limbs & Pelvis Time to theatre for open limb injuries Most senior Surgeon attending to patient

18. Data CoordinationThe Electronic Data Collection & Reporting system

19. the eDCR System • online system requiring no specialist software • data is instantly validated • Confidential, Secure, Encrypted data, Backup service • PIAG approval

20. Data coordination across a network Requirements: • Resources - membership fees - data collection • Comprehensive data collection dependant on: - skills - management - time - geography

21. Data Quality……….. • is Important • √√√√ - indicators of data completeness and accreditation • Outcome and Process measures reviewed with confidence

23. Inequality in Trauma Care? • “….this report reveals significant deficiencies in the management of seriously injured patients…..” • “…..up to one third of trauma deaths potentially avoidable.” • Royal College of Surgeons 1988 • Working Party on the Management of Patients with Major Injury Royal College of Surgeons 1988

24. Royal College of Surgeons 1988 Proposals for change: • Improve pre-hospital care • Introduce ATLS principles to improve resuscitation, especially shock control • Invest in rehabilitation services • Integrate trauma services • Clinical audit & research to review efficacy of care

25. HealthcareThe London for LondonTrauma System Launch Questions? • Acknowledgements • TARN staff • Executive Committee and Board • Clinicians and data co-ordinators at TARN participating hospitals 10th September 2009