01.06.12
The right place at the right time
Source: National Health Executive May/June 2012
A major trauma network is being set up across the UK to improve patient outcomes. Dr Andy Eynon, director of major trauma at University Hospital Southampton NHS Foundation Trust, makes the case for centralisation.
A new system of trauma care, as seen in the US and Australia, has now been implemented in the UK to improve outcomes by getting patients to the right place at the right time.
From April 2, Southampton became part of a network of major trauma centres that bypass local hospitals for emergency transfers. Director of the centre, Dr Andy Eynon, talked to NHE about focusing resources on key hospitals.
Following Lord Darzi’s report in 2007 promoting greater centralisation in the NHS, the plan to reorganise trauma care is finally being implemented.
Dr Eynon said: “It’s changing nationwide. Essentially, the fact remains that major trauma is the most common killer of people under 40, and that’s the same for the whole of the Western world.”
22 hospitals have been identified as centres with all the necessary trauma services to treat major injury. Historically, the ambulance service would take patients straight to the nearest hospital where they would be transferred to one of the larger hospitals only after review, resuscitation, scans, reports, decisions and arrangements for transport.
Direct transfer
Following the opening of the network, paramedics will now transport patients directly to a major centre within a 45-minute radius. These centres are obliged to take patients and have been charged with reaching a certain standard for treating major trauma.
The centres were trialled first in London, where in the first year of operation, the four centres saved an additional 52 lives. The model has now been rolled out to Plymouth, Bristol, Oxford, Southampton, Brighton, Birmingham, Coventry, Stoke-on-Trent, Manchester, Liverpool, Leeds, Middlesbrough, Newcastle, Cambridge, Nottingham, Hull and East Yorkshire, Sheffield and Preston.
It is estimated that the network will save 20% more lives within five to eight years. Measures to test success are already in place at the London centres, with data contributed to the TARN database (Trauma Audit Research Network). Here outcomes are analysed for categories of patients and compared against different hospitals and networks.
The creation of a network provides a focus for trauma services, and means nearby hospitals – which will have to process patients who are more than 45 minutes from a major centre – can be identified for further improvements.
Dr Eynon explained: “We’re looking at what hospitals need to beef up their trauma services, be able to receive patients, stabilise quickly and move them on automatically and which hospitals don’t need to, and can stay as they are at the moment.”
Work to improve these departments includes increasing the presence of senior consultants, rapid access to CT scanning, and better training to higher standards in trauma management.
“In 2010 there was only one hospital in the UK that had a consultant in the emergency department 24/7, seven days a week. One hospital,” he said.
Making room
For major centres, refusing patients is no longer an option and people suffering from major trauma will be accepted automatically.
Dr Eynon said: “You need to be swift and up to the mark. Previously there was always a bit of to-ing and fro-ing: ‘Have we got a bed, do they really need to come?’
“Now it doesn’t matter whether you have a bed, these people are being transferred to you automatically and it’s your responsibility. The fact that you may have limited resources doesn’t mean that a patient injured in your area should have a lesser standard of care.”
Although this is surely commendable, there may be questions over the feasibility of such high standards, especially in times of financial pressure. Dr Eynon acknowledged that this presented a considerable challenge, saying: “It’s bloody difficult! The bottom line is they are in the system, these are all patients in the NHS. They exist already,” he continued, citing the fact that the network is simply reorganising demand. “We need to be ruthlessly efficient – get these people to the right place at the right time, to be managed by the right people. If we do that quickly then their complications will be reduced, their outcomes improved, their time in rehabilitation lessened. Their entire journey through the whole NHS will be quicker.”
He added that although the cost to the NHS of managing major trauma is between a third and half a billion pounds a year, the cost to society is more like £3.5bn due to the impact of taking time of work to recover.
A leaner system
The move to consolidate the best services in fewer locations, rather than poorer quality treatment available in every hospital, is something that has had much support from within the NHS. Many health professionals acknowledge that pooling resources can improve outcomes whilst cutting costs and Dr Eynon supports further extension of this concept.
“I hope that this is just the leader; a lot of the services and the system changes that we have put in for major trauma apply to other cases as well. The same thing applies for heart attack and stroke, and we’re already seeing developments of networks for those services.
“We need to be leaner,” he said, adding that despite significant public support for local hospitals, many do not provide the full range of services necessary for effective treatment.
“If you have major illness or injury, those hospitals are not where you want to be. Your local hospital is there for illness and injury that requires your local hospital but what you want is a system allows you to go straight on to a bigger hospital if your injury exceeds that capability.”
This wasn’t an idea that was particularly new, as he said: “We’ve been doing that for donkey’s years for cardiac surgery; you don’t pop down to your local hospital, you get referred to a big centre that does lots of [cardiac surgery]. The same applies to emergencies. The local hospital cannot deal with all the cases; they don’t have the sophistication to do it. It is reproducing what we’ve been doing for elective services for emergencies.”
Minutes matter
For many, the obvious concern over centralising trauma care is longer journey times, where delays can be deadly. Dr Eynon explained that although the initial transfer may well be longer, the overall time was generally shortened as additional journeys were rendered unnecessary.
This could be a case of an extra 20 minutes in an ambulance, compared with delays at a local hospital that lacks the resources to manage severe trauma, resulting in a wait of hours as the assessment and transfer to a major centre takes place.
He said: “We’re talking about critical illness where minutes matter. It’s not minutes getting into hospital [that matter], it’s minutes getting into a hospital that can look after you. That’s the difference.
“I don’t doubt there will very sadly be some patients who die in an ambulance on their way to a major trauma centre. But the feeling is very much that those patients are very likely to have died whether they were in hospital or not. Overall we should be saving lives and improving outcomes.”
The 22 Major Trauma Centres
• Addenbrooke’s Hospital, Cambridge (Cambridge University Hospitals NHS Foundation Trust)
• Frenchay and Southmead Hospitals, Bristol (North Bristol NHS Trust)
• James Cook University Hospital, Middlesbrough (South Tees Hospitals NHS Foundation Trust)
• John Radcliffe Hospital, Oxford (Oxford Radcliffe University Hospital NHS Trust)
• Leeds General Infirmary, Leeds (The Leeds Teaching Hospitals NHS Trust)
• Queen’s Medical Centre, Nottingham (Nottingham University Hospital NHS Trust)
• Royal Victoria Infirmary, Newcastle (The Newcastle upon Tyne Hospitals NHS Foundation Trust)
• Southampton General Hospital, Southampton (University Hospital Southampton NHS Foundation Trust)
• Derriford Hospital, Plymouth (Plymouth Hospitals NHS Trust)
• Hull Royal Infirmary (Hull and East Yorkshire NHS Trust)
• Northern General Hospital, Sheffield (Sheffield Teaching Hospitals NHS Foundation Trust)
• Queen Elizabeth Hospital, Birmingham (University Hospitals Birmingham NHS Trust)
• Royal Preston Hospital, Preston (Lancashire Teaching Hospitals NHS Foundation Trust)
• Royal Sussex County Hospital, Brighton (Brighton and Sussex University Hospitals NHS Trust)
• University Hospital Coventry (University Hospitals Coventry Warwickshire NHS Trust)
• University Hospital of North Staffordshire NHS Trust Stoke on Trent
• Alder Hey Children’s Hospital NHS Foundation Trust, Liverpool
• Birmingham Children’s Hospital NHS Foundation Trust
• Royal Manchester Children’s Hospital, Manchester (Central Manchester University Hospitals NHS Foundation Trust)
• Sheffield Children’s Hospital, Sheffield (Sheffield Children’s NHS Foundation Trust)
• Manchester collaborative Major Trauma Centre a. Salford Royal NHS Trust b. Manchester Royal Infirmary c. University Hospital South Manchester
• Liverpool Collaborative Major Trauma Centre a. Aintree University Hospital b. Walton Centre c. Royal Liverpool University Hospital
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