2015 Peer Review report for Conquest Hospital Trauma Unit

Conquest Hospital Trauma Unit Compliance against national measures:

Reception and resuscitation – 71%

Definitive care – 80%

Rehabilitation – 20%

 

Review date: 25th February 2015

RECEPTION AND RESUSCITATION

The East Sussex Hospitals NHS Trust (ESHT) is a two hospital site trust based at Eastbourne (459 beds) and the Conquest Hospital in Hastings (450 beds). The designated trauma unit (TU) is based at the Conquest Hospital. The sites are approximately 18 miles apart and cover a combined population of 525,000.

There are currently four resuscitation bays, including a dedicated paediatric bay, and there is a plan to expand to six bays. There are seven Emergency Department (ED) consultants in the department, and this is backed up by a full surgical shift rota at night, with orthopaedic on site presence until late at night and weekends. All consultants on the on-call rota are available within 30 minutes- if not, they stay locally when on call.

Evidence was well presented on the day, and enabled the review team to utilise their time well. However there is a need to ensure that evidence relating to practice is contained in one over-arching operational policy, which was acknowledged by the team within their work programme.

Through discussion it was apparent that the team are committed to developing their work programme with the Network over the coming year.

The review team met with a committed team that has benefitted, following a period of transition, from moving surgical and orthopaedic services from Eastbourne to Hastings. It was particularly good to see the investment in consultant presence seven days a week across specialties for trauma patients. The service is supported by a good governance structure, including engagement at executive level.

The review team were not provided with evidence of an audit of attendance at trauma calls, though were subsequently made aware that this is in place.

Of 51,353 patients seen in 2014, 214 were TARN eligible. 223 trauma calls saw 26 patients with an ISS of greater than 15.

Through discussion it was noted that a good training programme is in place for nurses and doctors, ensuring that the team is led by an ATLS qualified team leader. Paediatric trauma training takes place and all middle grades have undertaken EPLS and more than 50% APLS training. This ensures good access to paediatric trained trauma staff where necessary.

ATLS is undertaken at Eastbourne (two courses per annum) and Hastings (annually), and the Trust has 30 ATLS instructors. Nurses also undertake ATLS observer training and TILS, it is noted that plans exist to develop ATNC at Brighton and band 6 and 7 nurses from ESHT will attend. It is noted that the Trauma lead nurse is an ATNC instructor.

There is a monthly training session in the trauma simulation suite or in the resuscitation room in the emergency department. All middle grades undergo this process.

No audit was available to the team for response times for trauma calls.

The trauma assisted discharge service (TADS) has undertaken a fractured neck of femur patient survey, which could be implemented more widely across team members as the service develops.

The team viewed a trauma activation policy which was very extensive.

The team has agreed the network transfer policy, though it would be beneficial to undertake an audit of the patients transferred to the MTC. The review team understand that patients with isolated head injuries are taken to Hurstwood Park neurological centre. Where a patient has other injuries in addition to a head injury they are likely to go to Kings Healthcare.

When a trauma call is raised, the full team are present on arrival, including an ED consultant and registrar, a radiographer and a Paediatric consultant for a child of fifteen years old or younger. A surgical registrar and an Orthopaedic Senior House Officer are also present. The computed tomography department is notified and the patient is taken to the CT scanner as soon as is appropriate.

Eastbourne hospital, has an emergency department on site, with surgical middle grade cover 24 hours a day, seven days a week. There is no orthopaedic presence out of hours and if necessary patients are sent to the Conquest hospital or MTC.

SECAMB has audited and shared results with the Trust. Improvements are being made following the serious concern raised last year and two Patient Pathway Co-ordinators have been appointed at Eastbourne, to monitor patient flow and ensure pathways are adhered to. It was noted that this also facilitates the identification of TARN eligible patients.

The review team was satisfied with the CT scanning practices and reporting. All appropriate protocols are in place.

The team indicated that there may be the opportunity to improve time to CT further, through greater use of protocols to streamline the process.

The CT scanner is less than a minute away (53 seconds) from the ED, and two scanners are always available. Radiographers are contractually obliged to be present within 20 minutes.

The median time to CT is 45.5 minutes from arrival. Twenty patients had their CT within 30 minutes of arrival, rather than from the time of request.

The reporting times for CT range from 19 minutes to 248 minutes, averaging 70 minutes. The median being 57.5 minutes to being typed and on the system.

The Interventional Radiology suite opened in 2013, and there are six interventional radiologists available seven days a week, 24 hours a day.

A monthly trauma review meeting is in place, and CT times, appropriateness of calls, risks, and attendance by specialty are all discussed. Any issues are then highlighted to the Conquest Trauma Committee and Trauma Delivery Group and, if appropriate, to the network.

There is a seven day trauma theatre, as well as a CEPOD theatre, and there are options for additional theatre capacity should the occasion arise. Good levels of staffing are in place for each of the three theatres, which include an extended working day, seven days a week.

There is good access to all specialties within 30 minutes of request; this was clearly evidenced both in the documentation provided and in conversation with the team.

Network trauma management guidelines are in development and the team showed that they are keen to work with the network to develop these.

For a head injury, where a theatre is required, the surgical registrar makes appropriate access arrangements. Advice is sought from the head injury centre and from anaesthetics as appropriate. The Surgical consultant is called and the CEPOD theatre is opened, fully staffed, ready to start as soon as the patient is ready. If a patient is already on the table, a divert is put in place to the trauma theatre. Eastbourne has similar processes in place, though these are only activated where a patient cannot be safely transferred to the Conquest site or MTC.

Damage control surgery has been undertaken by surgical team members.

A trust named lead for transfusion was provided to the team, although this needs to be written into the operational policy.

A haematology rota was provided to the review team, which provided good evidence of consultant transfusion advice being available at all times from the on-call consultant Haematologist.

A Network Massive Transfusion protocol has been agreed to, but the team also have their own, which included processes for both adults and paediatrics.

There have been two instances of tranexamic acid being administered to a trauma patient over the past year, both within 30 minutes. The tranexamic acid policy is contained within the massive transfusion policy.

Good practice / significant achievements

  • Trauma team activation protocol.
  • Nurse training highly structured in place with plans to participate to develop a local ATNC course.
  • ATLS training.
  • Seven day presence of consultants.
  • Good governance structure
  • Access to CT.
  • Patient pathway co-ordinators at Eastbourne site.
  • Executive team engagement

Concerns

  • The operational policy needs to be developed by the team to reflect practice and be an all-encompassing document
  • Local audit needs to be undertaken in a number of areas (CT reporting, team member attendance).

DEFINITIVE CARE

The trauma lead clinician has one session of programmed activity in place and there is an executive commitment to continue this to ensure succession planning for the role.

The protocol for designating a lead specialty consultant for patients admitted was clear and was being adhered to.

There is an Orthopaedic trauma co-ordinator who is involved in pre-operative care, but this role does not extend to all trauma cases and this needs to be reviewed to ensure consistency for all trauma patients.

The ‘bed management team’ identifies patients and notifies the relevant members of the trauma team. The ‘hospital intervention team’ also highlights patients.

The co-ordination of patients occurs at the daily orthopaedic trauma morning meeting (8am), where the team liaises with the trauma theatre staff. One team member leads each week, but this covers orthopaedic surgery, rather than other injuries and rehabilitation.

There is a governance process for issues/concerns to be raised through the trauma delivery group, with executive attendance. The network escalation policy is mirrored within the trust.

Rehabilitation is an issue, which is currently being looked at. Patients have orthopaedic trauma rehabilitation, but issues persist around neurological trauma, with patients falling between the Trust and the MTC. Patients are cared for by the specialty most relevant to the presenting injuries. The Trauma Co-ordinator post is lacking, missing the links to the centres, the community and acute provider services.

The team is working collaboratively with the network to develop network guidelines, indicating best practice, and these will complement local ones. The Trust is part of the regional burns network, and, as such, is served for burns by the Queen Victoria Hospital, East Grinstead.

There were examples of discharge summaries provided to the team, although there were no examples of rehabilitation information in the examples given. They are currently quite generic, and could include more structured information, i.e. rehabilitation needs.

The trauma team is fully engaged with the network and the MTC on rehabilitation prescriptions.

TARN data is obtained by the TARN Coordinator. Since 1998 there has been a local trauma database in place. A good process was described for the collection of data, however, there is no cover for the co-ordinator and this needs to be addressed. It was noted that the system enables the trauma team to review data and this high level of detail could be used more productively in relation to audit activity.

Good practice / significant achievements

  • Good process for the collection of data.
  • Clear protocol in place for designating lead consultant

Concerns

  • Documentation needs to reflect the practice of the team.
  • Lack of cover for TARN/Data Co-ordinator.
  • Orthopaedic co-ordinator needs to cover all trauma

 

REHABILITATION

At the time of review there was no rehabilitation co-ordinator in post, but a job description has been developed and has gone through the business planning process. The Chief Operating

Officer attending the meeting, expressed support of this role and it is anticipated that this will ultimately make a positive impact on patient care. The Trust will attempt to recruit to this post at the earliest opportunity.

Occupational Therapy and Speech and Language Therapy are referred to as appropriate but are not dedicated to trauma. The stroke team also take referrals for neurological trauma.

The Physiotherapy service is considered a strength of the team and the Trust is currently looking at seven day a week working. Work is also being undertaken to audit the necessity of service requirement.

Out of hours physiotherapy can be accessed for repatriated patients and is provided via the chest physiotherapist.

There is a network protocol for repatriation of patients in place.

Rehabilitation prescriptions are not in place, but the team is working in collaboration with the network to produce a meaningful document.

Good practice

  • Proactive team with good lines of communication.
  • TADS team looking to increase scope wider than fractured neck of femur to other trauma patients.

Concerns

  • Lack of Rehabilitation Co-ordinator can delay discharge.