2015 Peer Review of Royal Sussex County Hospitals Major Trauma Centre

Compliance against national measures:

Reception and resuscitation – 52%

Definitive care – 67%

Rehabilitation – 39%

 

Review Date: 26th February 2015

RECEPTION AND RESUSCITATION

Brighton and Sussex University Hospitals is based across two sites, in Brighton at the Royal Sussex County Hospital (RSCH) and in Haywards Heath at the Princess Royal hospital (PRH) which is approximately 15.5 miles away in distance. The Major Trauma Centre (MTC) was set up in 2012 and is based on the RSCH site, covering a population of approximately 1.6 million.

Currently the RSCH is going through a period of transition as it transfers neurological services from PRH to RSCH; this is due to be completed by May 2015. The reviewers were assured on the day that the project is currently on target however, failure to achieve the transfer would potentially result in an immediate risk as major trauma patients with head injuries requiring neurosurgical input are currently managed on the PRH site some distance from the Major Trauma Centre.

Paediatric services are provided by either Kings College Hospital, St Georges Hospital or Southampton General Hospital depending on the place of residence.

The review team met with a well-represented trauma team, who benefited from good executive and clinical team engagement.

Although it was apparent, through the evidence that response times meet the five minute criteria for team members, there is a need for team leaders to ensure they undertake appropriate trauma team leader training.

At the time of review there is no ATNC course in place, though this is mitigated by the cohort of seven senior nurses who provide twenty four hour, seven day a week cover in the resuscitation area. It is positive that the network is working on developing a network wide solution, which will ensure team members are compliant with this measure. Other nurse training was recorded thoroughly which is good practice. Of further note was the role of the technical assistants who ensured resuscitation bays are re-stocked in a timely manner.

A trauma activation policy is well established and is embedded in practice.

There is a twenty four hour, seven day a week rota for Emergency Department consultant cover, and the review team believe this model is unsustainable in the long term due to the current number of consultants in post. It was noted that the existing consultants are covering periods between Friday and Sunday by doing locums.

There is twenty four hour, seven day a week access to appropriate staff in the event of a thoracotomy being undertaken, with cross-cover provided by the cardio-thoracic senior team.

Despite reassurance to the contrary, it is noted that TARN data for the period April 2014 to September 2014, indicates that MTC consultant presence on arrival and consultant present within 30 minutes following trauma team activation is 77.5% and 81.3% respectively, and these are below expected levels. The Trust is encouraged to audit these areas as matter of urgency.

The evidence was well presented and aided the review preparation.

The computerised tomography (CT) scanner is located within the emergency department area, and benefits from a twenty four hour, seven day a week on site radiographer presence. It is noted that where requested, a verbal report is available within five minutes.

The review team believe it would be beneficial to consider implementing a radiology primary assessment proforma, which is available from the Royal College of Radiologists, whilst awaiting a formal full report.

At weekends radiology reports are outsourced, and the MTC highlighted that local audits had indicated no major discrepancy.

TARN data indicated that 47.9% of patients are receiving a CT scan within 30 minutes of arrival at the MTC, and a 100% of patients who met NICE criteria for head injuries received a CT within 60 minutes.

An audit of CT reporting in September 2014 demonstrated an average time of 1 hour 33 min. It is anticipated this will improve during 2015 when the registrar on-call rota is changed from non-resident to resident. This audit also showed no discrepancy between the reporting of the registrar and the verification by the consultant which is commendable.

MRI scanning is available twenty four hours a day, seven days a week at RSCH, however the service does not currently allow for scanning of patients under sedation/anaesthesia out of hours, and this needs to be resolved.

An interventional radiology service commenced in January 2014, with a theatre suite opened during July 2014. The review team understand that a further interventional radiologist appointment will be made during 2015.

The network has agreed that individual organisations will use their own CT protocol as a clinical guideline.

All radiologists have access from home to all hospitals images in the trauma network, which are linked via PACS. This is available to the MTC.

The review team understand that there is twenty four hour, seven days a week access to emergency theatre and surgery. However currently there is only limited access to interventional radiology, although the review team understand that as stated previously a further appointment is anticipated during 2015.

It was noted that at the time of review not all surgeons had undertaken training in damage control surgery. It is essential that this is addressed as a matter of urgency and this is raised as a ‘serious concern’.

It was noted on the rotas provided that general vascular and orthopaedic surgeons are ST3 and above and there is a need to ensure the grade of staff is ST4 in line with the measures from the Manual of Trauma Services. Anaesthesia and Intensive care however do have ST4 grade staff available.

Through discussion, the MTC demonstrated that with the exception of neurosurgery and interventional radiology, there is satisfactory access to relevant consultant team members.

Trauma management guidelines are in the process of being completed at a network level and further work was detailed within the work programme.

TARN data indicated that patients requiring acute intervention for haemorrhage control were seen appropriately.

At the time of review the Intensive Care Unit (ICU) has 28 beds. All poly-trauma patients requiring level 2 or level 3 care are admitted direct to ICU. The review team understand that additional ITU capacity is being created at the RSCH site to cater for the neurosurgery service which is due to commence at RSCH during May 2015.

Collection of ICNARC data commenced in October and at the time of review the MTC had not received its’ first set of results.

There is twenty four hour, seven day a week access to anaesthetic support and all patients are referred to the pain service, but no audit was provided of patients of IS3+ and above.

There is a named lead for transfusion, and rota’s provided indicated expert advice is available twenty four hours a day, seven days a week.

A massive transfusion protocol is in place, though this is a trust level document. It is important that the network works towards developing a more consistent document across Sussex. It was noted that the MTC use of products is thromboelastometry (ROTEM) guided.

Evidence provided indicated that the Trust met the three hour criteria only 50% of the time, however this was felt to be due to recording discrepancies. The review team commends the fact that SECAMB are moving towards tablet recording systems.

Good practice / significant achievements

  • Executive team engagement and commitment.
  • Commitment to the peer review process by the Trauma team including HPNC colleagues and commissioners.
  • All radiologists have access from home to all hospitals images in the trauma network.
  • CT reporting audit demonstrated no discrepancy between the reporting of the registrar and the verification by the consultant.
  • Twenty four hour, seven day a week on site CT radiographer presence.
  • The evidence was well presented and aided the review preparation.
  • Nursing training was well recorded.
  • Role of the technical assistants who ensure resuscitation bays are re-stocked in a timely manner.

Serious Concerns

At the time of review not all surgeons performing lifesaving emergency surgery had undertaken training in damage control surgery. It is essential that this is addressed as a matter of urgency and this is raised as a serious concern.

The trust has responded to the above ‘serious concern’ and advised:

This is identified within the MTC work programme for 2015/16 as a priority to address. All surgeons on the surgical on call rota are GI surgeons, and we have a separate vascular surgery rota. Since the visit, two of the eight surgeons on the general on call rota have enrolled to participate in a Damage Control Surgery course run at St George’s Hospital in London this week, and will be updating the department at a Clinical Governance meeting the following week.

We are committed to ensuring there is always a Damage Control Surgery trained surgeon on call and the vascular surgeons who are trained in damage control surgery will support their general surgical colleagues in achieving this. Finally we have funding in place to recruit a cadre of general surgical consultants with a specialist interest in emergency surgery which will provide far greater long term assurance around provision in this area. We hope in the future to be able to hold our own damage control surgery courses as part of our commitment to providing education and expertise to the Sussex Trauma Network.

Concerns

  • Administering of tranexamic acid showing as 50%.
  • Limited access to interventional radiology.
  • ED model of twenty four hour, seven day a week consultant model, unsustainable in the longer term due to numbers of consultants.
  • General vascular and orthopaedic surgeons’ rotas indicated staff of ST3 and above, and there is a need to ensure the grade of staff is ST4.
  • Delays in time to surgery.
  • Trauma team leader training to be rolled out to all relevant team members.
  • No ATNC course in place.
  • Audit of MTC consultant presence should be undertaken to review discrepancies.

DEFINITIVE CARE

The review team was impressed with the commitment and enthusiasm of the MTC lead clinician who has been instrumental in developing trauma services at the RSCH and more widely across the network. This enthusiasm and good leadership was also evident in the poly-trauma consultants, who manage the inpatient multiple trauma patients.

It was also noted that the clinical leads for trauma in ITU and the ED are assets to the service and are particularly proactive in resolving issues and instigating change.

There are two MTC trauma co-ordinators who are dedicated and pivotal to the success of the trauma service. However, at the time of review the service is not available seven days a week and is thought to be unsustainable in its current format, particularly given the likely increase in workload following the migration of neuro-services from Hurstwood Park Neurological Centre (HPNC). There is an urgent need to consider how this developing role can be further supported.

There is a robust MDT meeting in place with the appropriate level and variety of MDT members  in the main attending, with the exception of the general surgeons and rehabilitation representation. Plans exist for poly-trauma patients to be co-located within the orthopaedic trauma ward. Neuro-surgery will be in the immediately adjacent ward.

The development of a joint ortho-plastic emergency service following the appointment of an ortho-plastic surgeon is commendable, and will hopefully allow the team to improve compliance with BOAST guidelines. However, the current provision of timely management of complex lower limb trauma was recorded as 40% which is below the national average and this is raised as a ‘serious concern’.

A spinal fixation service is in place at BSUH, partially provided in the MTC, and partially within the neurosciences department. In cases of spinal cord injury there is discussion with Stanmore.

Some patients are referred to St Georges either for specialist support or when there is a gap in the local service. A full service will be provided at the MTC following completion of the reconfiguration of services.

As previously stated neurosurgery is currently provided at HPNC. The Deputy Chief Executive gave an undertaking that services will transfer to the RSCH site by May 2015. If the MTC is to remain viable it is essential this takes place as a matter of urgency and that the necessary support including appropriate rehabilitation service is also developed.

South East burns guidelines have been adopted for the management of burns and the service is provided via Queen Victoria Hospital in East Grinstead.

Although no formal tertiary survey protocol was presented, the poly-trauma consultants provided assurance that an appropriate daily mechanism is in place to support patients following neurosurgery or with isolated head injuries. It is essential the tertiary survey protocol is formalised and agreed between all specialities.

Maxillo-facial services are in place though no formal rota was provided.

Data quality for the Trust is a concern as a number of TARN eligible patients who are admitted to the HPNC with an isolated head injury, are not captured as part of the MTC, though following reconfiguration it is anticipated that this will improve. The review team is concerned regarding the level of TARN support. Although the individual is enthusiastic and committed to the role, the level of cover is unacceptable and needs to be reviewed, to ensure data collection is not compromised during any periods of leave or extended absence.

Good practice / significant achievements

  • Commitment and enthusiasm of the MTC lead clinician who has been instrumental in developing trauma services at the RSCH and more widely across the network.
  • Enthusiasm and leadership provided by poly-trauma consultants.
  • Clinical leads for trauma in ITU and the ED.
  • Commitment of trauma co-ordinators.

Serious concerns

Patients with open limb fractures requiring combined orthoplastic surgery are not always receiving initial coverage within 72 hours. This may result in increased risk of wound infection and may significantly compromise patient outcomes. The current provision of complex lower limb trauma was recorded as 40% which is below the national average.

The trust has responded to this issue:

The review identified that the BOAST 4 standard in relation to fracture fixation and wound closure was not being met in sufficient cases. The data on coverage of open fractures is reported on a rolling 12 month basis through TARN, and up until very recently our rolling total number of cases did not meet the threshold for statistical significance. The orthoplastic and trauma & orthopaedic lead have gone back through the notes for each of the 16 cases submitted to identify where improvements can be made, and have identified one case which had not been recorded accurately. Taking this case into consideration, our performance would have been better than the national average of 40% moving from a 37% to a 43% compliance.

The case review has identified some issues with accuracy of data capture, and the teams are developing a proforma for recording open fracture management within the orthopaedic trauma database. Our plastic surgery service is provided in partnership with the Queen Victoria Hospital, East Grinstead and we are developing plans to extend the current provision to ensure full cover for leave, and subsequently enhanced cover at weekends.

Finally, with the reconfiguration of clinical services in June 2015, that sees Neurosurgery move to the RSCH site and fractured neck of femur surgery move to the Princess Royal, there will be increased availability of theatre time for orthoplastic cases, both with dedicated lists and greater access to general trauma sessions. We will continue to monitor progress in this area monthly via the Trauma Committee as well as via TARN.

Concerns

  • Delay in transferring neurosurgery despite previous assurance, failure to move services by end of May would potentially impact on viability of this service.
  • Trauma co-ordination only available five days a week and considered to be unsustainable, given the likely increase in work following the migration neuro-services from HPNC.
  • Lack of surgical and rehabilitation input to trauma MDT meeting.
  • Lack of acute spinal injury service in Brighton and the review team is unclear how referrals are managed.
  • Data quality, not all TARN eligible patients being recorded due to split site arrangements.
  • Level of support for TARN coordinator

REHABILITATION

At the time of review there is no consultant in rehabilitation medicine currently leading the MTC Acute Trauma Rehabilitation Service. Recurrent funding is however, in place for the MTC, though currently no substantive appointment has been made and this is raised as a ‘serious concern’. At the time of review rehabilitation consultants are employed by the community trust.

Rehabilitation co-ordination has been taken on by the trauma co-ordinators, which although commendable, may not be sustainable in the longer term given the likely influx of patients from Hurstwood Park Neurological Centre (HPNC), and there is a need to increase the establishment of this role to ensure that patients or staff are not disadvantaged. It is noted that currently this is not a seven day service.

There is a dedicated rehabilitation team that only works with trauma patients, providing a service to outlying all complex trauma patients irrespective on which wards they admitted.

Good working relationships were described at the review meeting with neuro-surgical teams at HPNC. There are two head injury nurses at HPNC who provide support for their cohort of patients.

There is access in place for psychological services on a twenty four hour, seven day a week basis, which also facilitates access to outpatient appointments post discharge.

The trust links with Roehampton for trauma amputation using their guidelines accordingly.

Patient information would benefit from a review in collaboration with the patient/family representative and network. There is evidence of some good work on Patient Reported Outcome Measures (PROMS), but consideration needs to be given as to how this is circulated more widely within the trust and wider network.

A repatriation policy is in place, however the memorandum of understanding between the MTC and the TUs needs to be fully embedded in practice. The MTC has initiated the rehabilitation prescription but these are yet to be fully rolled out to the TUs.

There continues to be a lack of a comprehensive roll out of rehabilitation prescriptions into the community. There is a high level of commitment and support from the network management team to implement this, and a number of projects had commenced across the network.

There is a high level rehabilitation directory of services in place, but there is a need to include contact details, with other details also requiring review and updating.

Good Practice

  • Network rehabilitation steering group.
  • Some work undertaken on PROM information.
  • Good working relationship with HPNC.
  • Good access to psychological provision

Serious Concerns

There is no consultant in rehabilitation medicine currently leading the MTC Acute Trauma Rehabilitation Service. In the absence of this dedicated lead clinician discussion at Board level/Commissioner level is less likely and therefore resources more difficult to obtain to improve this part of the pathway.

The trust has responded to the above issue:

The review identified the lack of consultant in rehabilitation medicine. Within the work programme for the MTC this is identified as a priority for the 2015/16 year. Full funding is in place for this post. The delay in recruitment has largely been because we needed to agree a service model for the delivery of medical care in rehabilitation that coordinated the services required on the RSCH site for the MTC, and also for the Sussex Rehabilitation Centre, our specialist rehabilitation service on the Princess Royal campus. The consultant cover for this service has hitherto been provided by Sussex Community Trust, but all parties agreed that to achieve clinical congruence between the services and reliable cross cover for major trauma, the consultants needed to come under a single employer. Negotiations to achieve this have been severely hampered by an ongoing HR dispute between Sussex Community Trust and one of their rehabilitation consultants. BSUH has taken professional advice and concluded the only approach that will deliver a stable service in the long term is to terminate the SLA with Sussex Community Trust and employ all the medical staff required for both the MTC and rehabilitation centre directly. This process is now underway, and a revised job description for the vacant post is being prepared for college approval. Progress will be monitored both via the Trauma Committee, and also at executive level via the relevant service line.

Concerns

  • No dedicated rehabilitation co-ordinators, work currently undertaken by Trauma Co-ordinators.
  • Limited access to level 1 and level 2 rehabilitation facilities.