1999-2000 Report of the Working Party on the Management of Patients with Head Injuries 1999
2007
2008
2009
2009
? 2010
MAJOR TRAUMA IMPROVEMENT SUMMIT improving treatment and rehabilitation for major trauma patients May 2010
Pre-Hospital Care <ul><li>Paramedic in Control Room </li></ul><ul><li>Clinical advice and support </li></ul><ul><li>Enhanc...
The New Rules <ul><li>All major trauma patients go to a major trauma centre: </li></ul><ul><ul><li>If journey < 45 minutes...
 
Stoke-on-Trent Birmingham Coventry 60 miles
60 miles 45 minutes by land ambulance 45 minutes by helicopter Stoke-on-Trent Birmingham Coventry
ACS 2006 Physiology Anatomy Mechanism Special features
Accuracy of ACS Triage Criteria
Acute Care and Surgery Trauma Team and activation Trauma Team Leader Emergency Radiology Emergency Surgery Clinical Adviso...
Care should be led by consultants experienced in major trauma Major trauma is most likely to occur at night-time or at wee...
Resident Consultant Trauma Team Leaders in Major Trauma Centres <ul><li>24-hour consultant presence in emergency departmen...
Trauma Team Leader <ul><li>Often but not necessarily emergency medicine </li></ul><ul><li>Resident status or immediately a...
 
 
 
Ongoing Care and Reconstruction Patient-centred care Dedicated trauma wards and theatres Intensive care Repatriation Clini...
Head Injury ‘Scandal’ 1 Time to decompression
Mendelow AD,  et al . Extradural haematoma: effect of delayed treatment. British Medical Journal  1979; 1 :1240-1241 Acute...
Leach P,  et al.  Transfer times for patients with extradural and subdural haematomas to neurosurgery in Greater Mancheste...
Sergides IG,  et al.  Is the recommended target of 4 hours from head injury to emergency craniotomy achievable? British Jo...
Head Injury ‘Scandal’ 2 Refusing non-operable cases
 
Old and New Rules <ul><li>Closed door to non-operable head injuries </li></ul><ul><li>Gatekeeper protectionism </li></ul><...
Head Injury ‘Scandal’ 3 Inappropriate repatriation
Appointments <ul><li>Director/Clinical Lead in Major Trauma Care </li></ul><ul><li>Trauma Nurse Coordinator(s) </li></ul><...
Rehabilitation Early start Director of Rehabilitation Coordination Country-wide review Clinical Advisory Group Recommendat...
Appointments <ul><li>Clinical Lead in Acute Trauma Rehabilitation </li></ul><ul><li>Trauma Rehabilitation Coordinator(s) <...
Journal of Rehabilitation Medicine  2010; 42 :(in press)
 
Uncoupling Acute Care from Rehabilitation <ul><li>As soon as appropriate after injury </li></ul><ul><li>Converts a ‘push’ ...
The costs of major trauma are not fully understood, and there is no national tariff to underpin the commissioning of servi...
HRG Grid for Major Trauma Professor Keith Willett (in development)
Network Organisation Definitions and designation Boundaries based on needs Responsibility for transfer TARN mandatory Perf...
By September 2011: TARN Compliance Primary care trusts should use their commissioning powers to require all acute and foun...
 
 
 
Incidence of Major Trauma <ul><li>200 per million per year  NCEPOD </li></ul><ul><li>300 per million per year admitted to ...
Avery B. Nathens; Gregory J. Jurkovich; Ronald V. Maier; et al. Relationship Between Trauma Center Volume and Outcomes JAM...
Penetrating Abdominal Injury Multisystem Blunt Trauma
 
 
 
 
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Peter Oakley Report to West Midlands SHA on 30th June 2010

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  • GOS at 3 months. Mendelow death (GOS 1) = 16.9% = worse; GOS 5 = 59% = same. Seelig death 57% = worse; GOS 4&amp;5 = 34% = worse
  • GOS at 3 months. No correlation between time from injury to craniotomy and GOS
  • April 2011
  • &lt; 0.2% of work of ED; public consultation; expertise at start with later care nearer home.
  • Peter Oakley Report to West Midlands SHA on 30th June 2010

    1. 1. 1999-2000 Report of the Working Party on the Management of Patients with Head Injuries 1999
    2. 2. 2007
    3. 3. 2008
    4. 4. 2009
    5. 5. 2009
    6. 6. ? 2010
    7. 7. MAJOR TRAUMA IMPROVEMENT SUMMIT improving treatment and rehabilitation for major trauma patients May 2010
    8. 8. Pre-Hospital Care <ul><li>Paramedic in Control Room </li></ul><ul><li>Clinical advice and support </li></ul><ul><li>Enhanced care teams </li></ul><ul><li>Major trauma to major centre </li></ul><ul><li>45-minute isochrones </li></ul><ul><li>Clinical Advisory Group Recommendations to the </li></ul><ul><li>Department of Health </li></ul>
    9. 9. The New Rules <ul><li>All major trauma patients go to a major trauma centre: </li></ul><ul><ul><li>If journey < 45 minutes, directly </li></ul></ul><ul><ul><li>If journey > 45 minutes, they still go to the major trauma centre – indirectly or directly </li></ul></ul><ul><ul><li>If deteriorating, they still go to the major trauma centre – indirectly or directly </li></ul></ul><ul><li>Exceptions </li></ul><ul><ul><li>If treated immediately at trauma unit and no longer at risk </li></ul></ul><ul><ul><li>If immediate trauma unit assessment excludes major trauma </li></ul></ul>Advisory Group on Pre-Hospital Care 2010
    10. 11. Stoke-on-Trent Birmingham Coventry 60 miles
    11. 12. 60 miles 45 minutes by land ambulance 45 minutes by helicopter Stoke-on-Trent Birmingham Coventry
    12. 13. ACS 2006 Physiology Anatomy Mechanism Special features
    13. 14. Accuracy of ACS Triage Criteria
    14. 15. Acute Care and Surgery Trauma Team and activation Trauma Team Leader Emergency Radiology Emergency Surgery Clinical Advisory Group Recommendations to the Department of Health
    15. 16. Care should be led by consultants experienced in major trauma Major trauma is most likely to occur at night-time or at weekends National Audit Office 2010
    16. 17. Resident Consultant Trauma Team Leaders in Major Trauma Centres <ul><li>24-hour consultant presence in emergency departments treating major trauma patients </li></ul><ul><li>Resident consultant team leader in major trauma centre and ≥ ST4 in trauma unit </li></ul><ul><li>Other consultants available within 30 minutes </li></ul>
    17. 18. Trauma Team Leader <ul><li>Often but not necessarily emergency medicine </li></ul><ul><li>Resident status or immediately available </li></ul><ul><li>No conflicting duties – dedicated role </li></ul><ul><li>1-4 PA per hour versus 1 PA per week </li></ul>
    18. 22. Ongoing Care and Reconstruction Patient-centred care Dedicated trauma wards and theatres Intensive care Repatriation Clinical Advisory Group Recommendations to the Department of Health
    19. 23. Head Injury ‘Scandal’ 1 Time to decompression
    20. 24. Mendelow AD, et al . Extradural haematoma: effect of delayed treatment. British Medical Journal 1979; 1 :1240-1241 Acute extradural haematomas have a better outcome if evacuated promptly A delay of more than 2 hours from clinical deterioration to haematoma evacuation led to significantly worse outcome
    21. 25. Leach P, et al. Transfer times for patients with extradural and subdural haematomas to neurosurgery in Greater Manchester British Journal of Neurosurgery 2007; 21 :11-15 * Mendelow 1979 ** Seelig 1981 59.0% (59*) GOS 5 (good recovery)‏ 7.2% 7.7% GOS 2 & 3 (PVS or severe disability)‏ 54.8% (34**) 23.1% GOS 4 (moderate disability)‏ 38.1% (57**) 10.3% (17*) GOS 1 (death)‏ 6.0 h 5.25 h Overall transfer time 0.75 h 0.75 h Arrival to surgery 2.38 h 2.5 h CT to arrival 2.25 h 2.0 h Deterioration or injury to CT 42 39 Number of patients Acute Subdural Haematoma Acute Extradural Haematoma
    22. 26. Sergides IG, et al. Is the recommended target of 4 hours from head injury to emergency craniotomy achievable? British Journal of Neurosurgery 2006; 20 :301-305 Number of patients 23 Isolated extradural 9 Mixed extradural and subdural 1 Isolated subdural 7 Intracerebral 4 Mixed subdural and intracerebral 2 Number operated < 4 hours of injury 0 GOS 1 (death) 21.7% GOS 2 & 3 (PVS or severe disability) 13.0% GOS 4 (moderate disability) 21.7% GOS 5 (good recovery) 43.5%
    23. 27. Head Injury ‘Scandal’ 2 Refusing non-operable cases
    24. 29. Old and New Rules <ul><li>Closed door to non-operable head injuries </li></ul><ul><li>Gatekeeper protectionism </li></ul><ul><li>Open door to life-threatening intracranial haematomas </li></ul><ul><li>Immediate transfer of responsibility to neurosurgeons </li></ul>NHS East Midlands NHS North West
    25. 30. Head Injury ‘Scandal’ 3 Inappropriate repatriation
    26. 31. Appointments <ul><li>Director/Clinical Lead in Major Trauma Care </li></ul><ul><li>Trauma Nurse Coordinator(s) </li></ul><ul><li>To oversee and review early trauma care </li></ul><ul><li>To deliver ‘real-time’ clinical governance </li></ul><ul><li>To serve as a bridge between the immediate care and rehabilitation teams </li></ul>
    27. 32. Rehabilitation Early start Director of Rehabilitation Coordination Country-wide review Clinical Advisory Group Recommendations to the Department of Health
    28. 33. Appointments <ul><li>Clinical Lead in Acute Trauma Rehabilitation </li></ul><ul><li>Trauma Rehabilitation Coordinator(s) </li></ul><ul><li>To coordinate and deliver early trauma rehabilitation </li></ul><ul><li>To serve as a single point of contact for patients, family and other support </li></ul>
    29. 34. Journal of Rehabilitation Medicine 2010; 42 :(in press)
    30. 36. Uncoupling Acute Care from Rehabilitation <ul><li>As soon as appropriate after injury </li></ul><ul><li>Converts a ‘push’ system to a ‘pull’ one </li></ul>Professor Keith Willett (in development)
    31. 37. The costs of major trauma are not fully understood, and there is no national tariff to underpin the commissioning of services Funding arrangements do not reflect the true costs National Audit Office 2010
    32. 38. HRG Grid for Major Trauma Professor Keith Willett (in development)
    33. 39. Network Organisation Definitions and designation Boundaries based on needs Responsibility for transfer TARN mandatory Performance framework Clinical Advisory Group Recommendations to the Department of Health
    34. 40. By September 2011: TARN Compliance Primary care trusts should use their commissioning powers to require all acute and foundations trusts with emergency departments that receive trauma patients to submit data to TARN National Audit Office 2010
    35. 44. Incidence of Major Trauma <ul><li>200 per million per year NCEPOD </li></ul><ul><li>300 per million per year admitted to hospital Intercollegiate Group </li></ul>
    36. 45. Avery B. Nathens; Gregory J. Jurkovich; Ronald V. Maier; et al. Relationship Between Trauma Center Volume and Outcomes JAMA. 2001;285(9):1164-1171
    37. 46. Penetrating Abdominal Injury Multisystem Blunt Trauma

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