‘Stealth trauma’ in the young and the old: the next challenge for major trauma networks?

Open fractures incur significant morbidity and mortality, and as such have standardised guidelines for their management. Photography of open fractures is an essential component of documentation in the treatment of open fractures as per the British Orthopaedic Association Standards of Trauma and National Institute for Health and Care Excellence guidelines. Smartphones have made photography easily accessible to the clinician, but serious concerns exist regarding data security and the consent process around the use of sensitive clinical images. This project sought to overcome this issue by developing a Caldicott-compliant hospital imaging protocol that allows clinicians to use their smartphone to upload open fracture images into the patient's permanent record. Implementation of the protocol was audited and resulted in the increase of safe and secure open fracture photographic storage to inpatient medical records. This protocol would be transferrable to other hospital trusts and could be adopted across major trauma networks.

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General principles of trauma

10.1093/med/9780199659579.003.0054 ◽

2017 ◽

Author(s):

Graham Sleat ◽

David Noyes

Keyword(s):

Major Trauma ◽

Public Health Problem ◽

Major Public Health Problem ◽

Term Survival ◽

Organization And Management ◽

Mortality Burden ◽

Trauma Networks ◽

Key Steps ◽

Substantial Morbidity

Trauma is a major public health problem worldwide, responsible for a substantial morbidity and mortality burden. All surgeons need to be familiar with the key steps in managing traumatized patients not only for injuries that are relevant to their specialty, but also in the wider management of trauma as part of the multidisciplinary team. These include recent advances in care such as the use of tranexamic acid, major transfusion protocols, and changes to the organization and management of trauma care after the implementation of regional trauma networks for major trauma in England. Appropriate and timely care during the initial stages after significant trauma improves long-term survival, but if patients are to return to a socially and economically productive life then tailored input from rehabilitation and re-enablement services is required. In many respects, after surviving their traumatic insult, this is the most important phase of their treatment.

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Missed orthopaedic injuries in adult trauma patients at a major trauma centre

10.31219/osf.io/qgx5n ◽

2020 ◽

Author(s):

Christopher David Roche

Keyword(s):

Major Trauma ◽

Whole Body ◽

Trauma Patients ◽

Injury Incidence ◽

Injury Rates ◽

Missed Injuries ◽

Missed Injury ◽

Radiology Reports ◽

Trauma Networks ◽

The Impact

IntroductionDespite advances in trauma care, missed injury remains a significant cause of morbidity and mortality in trauma worldwide. In England, few have published their missed injury rates and there are no recent data for London. In 2010 London trauma networks were restructured and the impact on missed injury rates is not known. This study aimed to determine the incidence of missed orthopaedic injury for adult trauma patients at St George’s Hospital, London, and to analyse missed injuries and comment on risk factors.MethodTrauma patients were recorded prospectively at the daily trauma meeting from July to September 2012. The researcher attended clinical activities and reviewed the patient notes and radiology reports daily whilst each patient was an inpatient until discharge. Missed injuries were defined as fractures or dislocations discovered more than 12 h after arrival in the emergency department. The notes for missed injury patients were reviewed again at six months. Missed injury details were recorded/analysed.ResultsThree hundred and forty three adult trauma patients were referred to trauma and orthopaedics in the three-month study period; 5 (1.5%) had a missed injury and 148 (43.1%) had an ISS>15. All missed injuries occurred in these major trauma patients, giving an incidence of 5/148 (3.4%). Four were extremity injuries and one was cervical. All missed injury patients had a GCS of 15/15, were admitted outside normal working hours, were direct admissions and had whole-body CT.ConclusionsAt 3.4% our missed injury incidence is comparable to those published from similar major trauma centres. This provides recent London data following the restructuring of trauma networks.

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The impact of trauma centre designation on open tibial fracture management

Annals of The Royal College of Surgeons of England ◽

10.1308/003588413x13511609957416 ◽

2013 ◽

Vol 95 (3) ◽

pp. 184-187 ◽

Cited By ~ 10

Author(s):

J Stammers ◽

D Williams ◽

J Hunter ◽

M Vesely ◽

D Nielsen

Keyword(s):

Major Trauma ◽

Average Length ◽

Trauma Centre ◽

Tibial Fractures ◽

Open Tibial Fractures ◽

Major Trauma Centre ◽

Fracture Management ◽

Before And After ◽

Trauma Networks ◽

The Impact

Introduction The British Orthopaedic Association/British Association of Plastic, Reconstructive and Aesthetic Surgeons guidelines for the management of open tibial fractures recommend early senior combined orthopaedic and plastic surgical input with appropriate facilities to manage a high caseload. The aim of this study was to assess whether becoming a major trauma centre has affected the management of patients with open tibial fractures. Methods Data were obtained prospectively on consecutive open tibial fractures during two eight-month periods: before and after becoming a trauma centre. Results Overall, 29 open tibial fractures were admitted after designation as a major trauma centre compared with 15 previously. Of the 29 patients, 21 came directly or as transfers from another accident and emergency deparment (previously 8 of 15). The time to transfer patients admitted initially to local orthopaedic departments has fallen from 205.7 hours to 37.4 hours (p=0.084). Tertiary transferred patients had a longer hospital stay (16.3 vs 14.9 days) and had more operations (3.7 vs 2.6, p=0.08) than direct admissions. As a trauma centre, there were improvements in time to definitive skeletal stabilisation (4.7 vs 2.2 days, p=0.06), skin coverage (8.3 vs 3.7 days, p=0.06), average number of operations (4.2 vs 2.3, p=0.002) and average length of hospital admission (26.6 vs 15.3 days, p=0.05). Conclusions The volume and management of open tibial fractures, independent of fracture grade, has been directly affected by the introduction of a trauma centre enabling early combined senior orthopaedic and plastic surgical input. Our data strongly support the benefits of trauma centres and the continuing development of trauma networks in the management of open tibial fractures.

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A study of mapping usual care and unmet need for vocational rehabilitation and psychological support following major trauma in five health districts in the UK

Clinical Rehabilitation ◽

10.1177/0269215520971777 ◽

2020 ◽

pp. 026921552097177

Author(s):

Jade Kettlewell ◽

Stephen Timmons ◽

Kay Bridger ◽

Denise Kendrick ◽

Blerina Kellezi ◽

...

Keyword(s):

Focus Groups ◽

Vocational Rehabilitation ◽

Usual Care ◽

Major Trauma ◽

Service Providers ◽

Psychological Support ◽

Trauma Survivors ◽

Systems Methodology ◽

Trauma Networks ◽

The Uk

Objective: To identify where and how trauma survivors’ rehabilitation needs are met after trauma, to map rehabilitation across five UK major trauma networks, and to compare with recommended pathways. Design: Qualitative study (interviews, focus groups, workshops) using soft-systems methodology to map usual care across trauma networks and explore service gaps. Publicly available documents were consulted. CATWOE (Customers, Actors, Transformation, Worldview, Owners, Environment) was used as an analytic framework to explore the relationship between stakeholders in the pathway. Setting: Five major trauma networks across the UK. Subjects: 106 key rehabilitation stakeholders (service providers, trauma survivors) were recruited to interviews ( n = 46), focus groups ( n = 4 groups, 17 participants) and workshops ( n = 5 workshops, 43 participants). Interventions: None. Results: Mapping of rehabilitation pathways identified several issues: (1) lack of vocational/psychological support particularly for musculoskeletal injuries; (2) inconsistent service provision in areas located further from major trauma centres; (3) lack of communication between acute and community care; (4) long waiting lists (up to 12 months) for community rehabilitation; (5) most well-established pathways were neurologically focused. Conclusions: The trauma rehabilitation pathway is complex and varies across the UK with few, if any patients following the recommended pathway. Services have developed piecemeal to address specific issues, but rarely meet the needs of individuals with multiple impairments post-trauma, with a lack of vocational rehabilitation and psychological support for this population.

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Pre-hospital emergency medicine and the trauma intensive care unit

Journal of the Intensive Care Society ◽

10.1177/1751143718783601 ◽

2018 ◽

Vol 20 (3) ◽

pp. 242-247

Author(s):

Emily Frostick ◽

Christopher Johnson

Keyword(s):

Intensive Care Unit ◽

Emergency Medicine ◽

Intensive Care ◽

Trauma Care ◽

Major Trauma ◽

Trauma Patients ◽

Care Providers ◽

Hospital Emergency ◽

Trauma Networks ◽

National Training

The system of trauma care has been revolutionised over the last decade with the introduction of major trauma networks across the United Kingdom and the development of subspecialist national training in pre-hospital emergency medicine. Pre-hospital care providers feed trauma patients into trauma units or major trauma centres depending upon the severity of their injuries and their stability for a potentially longer primary transfer to access specialist major trauma services. Trauma services are continually adapting and improving with the introduction of more advanced techniques into the pre-hospital arena are on the horizon, enabling trauma patients to receive more specialised treatment from medical professionals earlier after injury; this article will discuss some of the recent developments within pre-hospital emergency medicine, in-hospital trauma care and on into the intensive care unit, and how this has led to improved outcomes.

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Prehospital tranexamic acid shortens the interval to administration by half in Major Trauma Networks: a service evaluation

Emergency Medicine Journal ◽

10.1136/emermed-2018-208118 ◽

2019 ◽

pp. emermed-2018-208118 ◽

Cited By ~ 1

Author(s):

Max E R Marsden ◽

Andrea Rossetto ◽

Charles A B Duffield ◽

Thomas G D Woolley ◽

William P Buxton ◽

...

Keyword(s):

Tranexamic Acid ◽

Major Trauma ◽

Service Evaluation ◽

Research Network ◽

Trauma Patients ◽

Nice Guidelines ◽

Trauma Registries ◽

Trauma Networks ◽

Local Trauma ◽

Patients At Risk

IntroductionTranexamic acid (TXA) reduces bleeding and mortality. Recent trials have demonstrated improved survival with shorter intervals to TXA administration. The aims of this service evaluation were to assess the interval from injury to TXA administration and describe the characteristics of patients who received TXA pre-hospital and in-hospital.MethodsWe reviewed Trauma and Audit Research Network records and local trauma registries to identify patients of any age that received TXA at all London Major Trauma Centres and Queen’s Medical Centre, Nottingham, during 2017. We used the 2016 NICE Guidelines (NG39) which state that TXA should be given within 3 hours of injury.ResultsWe identified 1018 patients who received TXA, of whom 661 (65%) had sufficient data to assess the time from injury to TXA administration. The median interval was 74 min (IQR: 47–116). 92% of patients received TXA within 3 hours from injury, and 59% within 1 hour. Half of the patients (54%) received prehospital TXA. The median time to TXA administration when given prehospital was 51 min (IQR: 39–72), and 112 min (IQR: 84–160) if given in-hospital (p<0.001). In-hospital TXA patients had less haemodynamic derangement and lower base deficit on admission compared with patients given prehospital TXA.ConclusionPrehospital administration of TXA is associated with a shorter interval from injury to drug delivery. Identifying a proportion of patients at risk of haemorrhage remains a challenge. However, further reinforcement is needed to empower pre-hospital clinicians to administer TXA to trauma patients without overt signs of shock.

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Age and the distribution of major injury across a national trauma system

Age and Ageing ◽

10.1093/ageing/afz151 ◽

2019 ◽

Vol 49 (2) ◽

pp. 218-226

Author(s):

Jan Robert Dixon ◽

Fiona Lecky ◽

Omar Bouamra ◽

Paul Dixon ◽

Faye Wilson ◽

...

Keyword(s):

Older Patients ◽

Major Trauma ◽

National Level ◽

Trauma System ◽

Injured Patient ◽

Healthcare Services ◽

Research Network ◽

Trauma Patients ◽

Significant Burden ◽

Trauma Networks

Abstract Background Trauma places a significant burden on healthcare services, and its management impacts greatly on the injured patient. The demographic of major trauma is changing as the population ages, increasingly unveiling gaps in processes of managing older patients. Key to improving patient care is the ability to characterise current patient distribution. Objectives There is no contemporary evidence available to characterise how age impacts on trauma patient distribution at a national level. Through an analysis of the Trauma Audit Research Network (TARN) database, we describe the nature of Major Trauma in England since the configuration of regional trauma networks, with focus on injury distribution, ultimate treating institution and any transfer in-between. Methods The TARN database was analysed for all patients presenting from April 2012 to the end of October 2017 in NHS England. Results About 307,307 patients were included, of which 63.8% presented directly to a non-specialist hospital (trauma unit (TU)). Fall from standing height in older patients, presenting and largely remaining in TUs, dominates the English trauma caseload. Contrary to perception, major trauma patients currently are being cared for in both specialist (major trauma centres (MTCs)) and non-specialist (TU) hospitals. Paediatric trauma accounts for <5% of trauma cases and is focussed on paediatric MTCs. Conclusions Within adult major trauma patients in England, mechanism of injury is dominated by low level falls, particularly in older people. These patients are predominately cared for in TUs. This work illustrates the reality of current care pathways for major trauma patients in England in the recently configured regional trauma networks.

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Major trauma centres and trauma networks – The potential impact on surgical training

Injury ◽

10.1016/j.injury.2015.01.023 ◽

2015 ◽

Vol 46 (2) ◽

pp. 176-177

Author(s):

Andrew C. Gray ◽

Paul V. Fearon ◽

Rob Gregory

Keyword(s):

Surgical Training ◽

Major Trauma ◽

Trauma Centres ◽

Trauma Networks ◽

Potential Impact

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Patterns of moderate and severe injury in children after the introduction of major trauma networks

Archives of Disease in Childhood ◽

10.1136/archdischild-2018-315636 ◽

2018 ◽

Vol 104 (4) ◽

pp. 366-371 ◽

Cited By ~ 7

Author(s):

Samantha Jones ◽

Sarah Tyson ◽

Michael Young ◽

Matthew Gittins ◽

Naomi Davis

Keyword(s):

Major Trauma ◽

Injury Severity ◽

Research Network ◽

After School ◽

Trauma Network ◽

Body Parts ◽

Severe Injuries ◽

Traumatic Injuries ◽

Trauma Networks ◽

Outcomes For Children

ObjectiveTo describe the demographics, mechanisms, presentation, injury patterns and outcomes for children with traumatic injuries.SettingData collected from the UK’s Trauma and Audit Research Network.Design and patientsThe demographics, mechanisms of injury and outcomes were described for children with moderate and severe injuries admitted to the Major Trauma Network in England between 2012 and 2017.ResultsData regarding 9851 children were collected. Most (69%) were male. The median age was 6.4 (SD 5.2) years, but infants aged 0.1 year (36.5 days) were the most frequently injured of all ages (0–15 years); 447 (36.0%) of injuries in infants aged <1 year were from suspected child abuse. Most injuries occurred in the home, from falls <2 m, after school hours, at weekends and during the summer. The majority of injuries were of moderate severity (median Injury Severity Score 9.0, SD 8.7). The limbs and pelvis, followed by the head, were the most frequently and most severely injured body parts. Ninety-two per cent were discharged home and 72.8% made a ‘good recovery’ according to the Glasgow Outcome Scale. 3.1% of children died, their median age was 7.0 years (SD 5.8), but infants were the most commonly fatally injured group.ConclusionsA common age of injury and mortality was infants aged <1 year. Accident prevention strategies need to focus on the prevention of non-accidental injuries in infants. Trauma services need to be organised to accommodate peak presentation times, which are after school, weekends and the summer.

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