2015 Peer Review report for St Richards Hospital Trauma Unit

St Richards Hospital Trauma Unit Compliance against national measures:

Reception and resuscitation – 64%

Definitive care – 60%

Rehabilitation – 20%

 

Review date: 24th February 2015

 

RECEPTION AND RESUSCITATION

Western Sussex Hospitals NHS (WSHT) consists of two trauma units (TU) based at St Richard’s Hospital in Chichester and Worthing Hospital. The sites are approximately 20 miles apart and cover a combined population of 485,000.

St. Richard’s Hospital sits between two Major Trauma Centres (MTC) at Brighton (33 miles in distance) and at Southampton (36 miles in distance). Currently, this results in patient pathways being across multiple networks, with a majority of patients from St Richard’s being transferred to Southampton, within the Wessex Trauma Network, pending the full configuration of trauma services at Brighton.

St Richard’s Hospital is a 400 bedded hospital, and the Emergency Department has nine major treatment cubicles, four resuscitation cubicles and is supported by an eleven bedded Accident and Emergency (A&E) ward.

Although there are two separate TUs, both teams work from the same local protocols and are part of the Sussex Trauma Network.

The review team noted that there were 25 trauma activation calls for patients with an Injury Severity Score (ISS) greater than 15.

There is a ‘Trauma Activation’ policy in place and this is used across both sites.

Local audit figures for St Richard’s for the period 2014-15, indicated that the Accident and Emergency consultant or middle grade attended ‘trauma activation calls’ in 100% of cases.

Emergency department consultants alone, attended 60% of calls. It was noted that this was an improvement on the previous TARN data from 2013/14 which indicated that middle grades and consultants attended 59% of activated calls, though 31% cases did not have the ST grade recorded.

Advanced Trauma Life Support (ATLS) training is built into the appraisal system. When the TU was designated three years ago 50% of surgeons had received damage control surgery. The review team understand that a decision has been made not to refresh this training based on an informal risk assessment. Given the potential level of risk it would be beneficial to review the risk assessment more formally and include the result in the trust wide risk register.

A lot of anecdotal evidence was given regarding a training programme which included recognised trauma training material and local simulation training. However, no information was presented regarding the level of monitoring of training received by staff members.

There is a paediatric consultant in place at St Richards with a significant interest in paediatric trauma.

No evidence was provided for St Richard’s relating to patient experience feedback, although team members expressed a desire to work towards a network solution.

There is immediate physical access to computed tomography (CT) and the team described the process that is in place and how images are reported. The review team was impressed with the training provided to non-CT radiographers in order to enhance service provision.

TARN data from 2013/14 indicated that the median time to CT was 45 minutes from arrival.

More recent local figures indicated that the median time to CT is 47 minutes with the reporting time 20 minutes which is commendable.

At the time of review it was understood that the network CT protocol was not recognised, although the MTC protocol had been discussed within the multi-disciplinary team meeting with a view to implementing it.

At the time of review the network trauma management guidelines are in development, though local guidelines exist for some of the criteria outlined within the measure from the Manual of Trauma Services although these were not presented during the visit. No evidence was provided relating to the management and fixation of rib fractures and musculo-skeletal trauma.

The review team was impressed with the theatre access on both sites as described by the Clinical Director for Theatres and Critical Care. In the event of a multiple theatre requirement a contingency is in place, however this needs to be detailed within the operational policy.

Documentation provided, indicated a named trust lead for transfusion that covers both sites, with advice available via the haematological team on-call rota on a seven day a week basis.

The reviewers noted the ‘Massive Transfusion’ protocol is in place but this needs to be updated.

At the time of review TARN data indicated that there had been no cases of tranexamic acid being administered.

Good practice / significant achievements

  • Cross-site working.
  • Immediate access to CT.
  • Local audit figures for St Richards indicated that the Accident and Emergency consultant or middle grade attended in 100% of cases.
  • CT reporting times.
  • Advanced Trauma Life Support (ATLS) training is built into the appraisal system.
  • Paediatric support.
  • Working to a single set of operational policies.
  • Training up of non-CT radiographers

Concerns

  • Lack of updated damage control training in surgical team.
  • Lack of formalised training programme and recording.
  • Operational policy needs to be updated to reflect practice

 

DEFINITIVE CARE

The designated lead at St Richards Hospital is also the trust lead for trauma. The review team understand that the lead clinician has 2.5 sessions of programmed activity (PAs), which include any duties as required for trauma lead.

Governance processes were described to the review team, however the discussion did not reflect the detail provided within the evidence, and there is a need to describe more fully all the processes in place, in order to provide necessary transparency and demonstrate how they link with the overall network objectives.

It was unfortunate that the lead nurse was unavailable for the review visit, though it was noted that the transfusion nurse attended who covered both sites.

There is a need for greater clarity regarding specialty ownership of trauma patients upon admission, and the review team was unclear regarding the process for who manages patients at St Richards. The apparent lack of co-ordination or oversight of trauma patients could be attributed to the lack of overall trauma co-ordinator, which as a consequence could result in a lack of clear decision making for designated specialty and this needs to be reviewed. It was noted that there is one Orthopaedic Trauma Co-ordinator at St Richards Hospital with two deputies. As indicated it is important that this role is extended to cover all trauma.

The Trauma team contribute to the TARN database and aided by a TARN Co-ordinator who is contracted for 18 hours. It would be beneficial to consider trust wide cover arrangements for TARN coordination and audit.

There is a need for the Trust to review all of its documentation to include sufficient detail to ensure it reflects actual practice. This should be led by trauma team members.

A number of network protocols are still in development and as a result the trauma team are developing local guidelines based on national guidance and recognised best practice in conjunction with the Sussex network. It is important that both TUs continue to participate in the development of these guidelines within the Sussex Trauma network and then follow these accordingly – this was listed as a priority for the TU going forward. It was acknowledged during the review discussion, that future developments within the network and at the MTC would initiate a review of patient pathways.

It is noted that at the time of review patients from St Richards Hospital are also referred to the MTC at University Hospitals Southampton, and there is a need to also reflect the Wessex network guidelines within the local documentation.

The Trust is part of the Regional Burns network and as such, is served by the Queen Victoria Hospital in East Grinstead, using the London and SE burns network guidelines.

Review team members viewed discharge summaries on both sites and these were satisfactory.

TARN co-ordinators are in place at both sites and it is noted that the level of completeness at St. Richard’s is 48%, with 81% accreditation. There is a need for the team to consider how this can be improved.

Both TUs presented at the network audit event identifying patients with ISS>15 treated definitively within a TU.

 

Good practice / significant achievements

  • TARN Co-ordinator on both sites

Concerns

  • Documentation did not reflect practice and needs review.
  • Greater clarity regarding specialty ownership of trauma patients upon admission.
  • Lack of cohorting of trauma patients onto single location.
  • Trauma co-ordinator currently only covers orthopaedics. It is important that this role is extended to cover all trauma patients.
  • TARN coordination insufficient for two separate TUs.

 

REHABILITATION

The review team was impressed with the proactive team working across therapy and rehabilitation particularly in critical care where they are planning to include patient experience survey results to further improve their pathway.

When a patient comes into the acute setting they go to the ‘Emergency Floor’ at Worthing. There is a need for greater clarity within the documentation regarding the mechanism for identifying patients with high complex rehabilitation needs. Although the review team understood that neurotherapists based at St. Richard’s and Worthing are able to carry out assessments around awareness. Patients requiring complex (out of locality) placements are identified and assessed by the Consultant in Rehabilitation medicine.

Following assessment, patients go to an elderly care rehabilitation ward under the care of an Elderly Care Physician or some patients may be streamed to the stroke ward depending on diagnosis. The criteria for Trauma cases admitted to the acute stroke unit as opposed to an elderly care rehabilitation ward was not available. The review team understand specialist skills-sets exist within neurology (Occupational Therapy, Speech and Language Therapy and Physiotherapy), which are provided as part of an outreach mechanism/ team.

All other non-neurological trauma patients are seen exclusively on the orthopaedic ward where there is a full multi-disciplinary team.

The review team believe the patient pathway could be more streamlined by the presence of a rehabilitation co-ordinator, however in the absence of this post, the patient pathway is supported by a rehabilitation Consultant from Donald Wilson House who is available to review patients in the acute setting as requested. There is good communication across the therapy teams.

On discharge form the acute units, the patient rehabilitation pathway can be to a variety of settings. Donald Wilson House is a level 2a inpatient rehabilitation facility for patients with complex neurological needs. The teams admission criteria is centred around need, complexity and likely clinical outcome and a full multi-professional team is available. Where patients do not meet the admission criteria, a number of intermediate care units are accessed. Patients who are transferred home, are supported by community neuro-rehabilitation teams.

For non-weight bearing patients (NWB) there is an option to refer to intermediate transfer beds at Fairlight Nursing home in Rustington, with rehabilitation and occupational therapy support available from Sussex Community NHS Trust. An in-reach service for NWB patients is also available on Petworth Ward.

For patients with long term tracheostomy requiring rehabilitation, referrals are made to Glenside Manor, Salisbury, or Lane Fox unit for advice. It is important that these pathways are included within documentation.

The teams at WSHT self-identified issues for patients who are:

  • Over 65’s with neurological rehabilitation needs
  • Trauma patient with learning difficulties.

Consultant support for non-orthopaedic trauma patients is good. This is mainly through the Department of Medicine for the Elderly (DOME) and supported in the acute setting by theRehabilitation Medicine Consultant from Donald Wilson House .

With regard to rehabilitation prescriptions the teams at WSHT are not using or receiving the prescription but have indicated that they are keen to engage with the network in the development and implementation of the rehabilitation prescription.

 

Good practice

  • Proactive team working across therapy and rehabilitation particularly in critical care.
  • Good communication across the therapy teams.
  • Good support particularly from consultants on Department of Medicine for the Elderly (DOME)

Concerns

  • Lack of rehabilitation co-ordinator which could delay discharge.