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Trauma systems: the potential impact of a trauma divert policy on a regional ambulance service
  1. Ross Moy,
  2. Kyee Han,
  3. G Dean Smith,
  4. Jeremy Henning
  1. Department of Academic Emergency Medicine, Academic Centre, James Cook University Hospital, Middlesbrough, UK
  1. Correspondence to Major Ross Moy, Research Fellow, Academic Department of Emergency Medicine, Academic Centre, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK; rjmoy{at}doctors.org.uk

Abstract

Introduction Recent initiatives in the Care of the Trauma patient in the UK have led to the establishment of Major Trauma Centres (MTCs), supporting a Trauma Network. It is envisaged that any person suffering from major trauma will be taken directly to one of these centres, with an expectant increase in survivability and decrease in morbidity. This will have an impact on the Ambulance Service in terms of journey times, and the MTCs in terms of bed days. Whilst these are not ‘new’ patients to the NHS, they may require a redistribution of funds. Most of the modelling into the effects of this has been carried out in London, which may not be applicable to more rural areas. We therefore determined to gain data on how a similar policy would affect trauma services in our rural region.

Method A retrospective study of all trauma patients conveyed by a regional ambulance service. The London Trauma Divert Criteria were applied to the patient report forms, and the number of patients who may have transported directly (or by secondary transfer) to MTCs identified.

Results We found that between 28 and 58 additional patients a month would be transferred.

Conclusion As this is more than 1 patient a day, there may be considerable strain on the MTCs and Ambulance Services. We believe service commissioners in rural areas need to consider the funding and organisational arrangements for major trauma in light of this.

  • Emergency ambulance systems
  • prehospital care
  • clinical management
  • research
  • operational
  • trauma
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Introduction

In recent years, several high level reports have criticised the care of trauma patients in the UK, and it has been suggested that this is leading to avoidable deaths.1 2 Many UK centres currently see fewer than one seriously injured patient per week, indicating there is currently insufficient workload to maintain experience and expertise in managing these patients.1 A recent national study reports that fewer than half of all major trauma patients receive good care, possibly as a result of this fragmentation of services.3 There is also evidence that improvement of trauma services in the UK has stagnated. Significant improvements in survival had been gained in the years leading up to 1995, but this appears to have reached a plateau.4 It has been recognised since work performed in the 1970s that numbers of preventable deaths are much lower when trauma patients are taken to a centre that specialises in the management of major injuries.5 6

There is currently a major initiative to improve UK trauma services, with recognition of the significant burden of serious injury. In 2003, Albert and Phillips proposed an integrated trauma network across the UK, and this idea is currently being more fully implemented.7 Trauma services are being organised into trauma networks. Within each network, there will be a designated major trauma centre (MTC) as a hub, each with satellite trauma units (TUs). The aim of this process is to concentrate expertise in the management of seriously injured patients, and to ensure continuity of care from the point of injury through to rehabilitation. This is a major departure from previous practice, when each stage of the process was considered individually.8

In order to ensure that the seriously injured are conveyed to the correct institution, ambulance services will need to triage their major trauma patients. Patients meeting the criteria will be taken directly to the MTC, even if this increases journey times. However, it is recognised that a small proportion of critically injured patients will need initial stabilisation at the local TU before onward transfer. By definition, these will be critically ill patients and therefore require specialised medical, nursing and ambulance assets, to ensure safe patient transfer.

Although these changes are focused on better care for the major trauma victim, with anticipated cost saving to society, there are implications for all healthcare services. Increased ambulance journey times may affect the provision of emergency services to other patients, and an increased workload for the MTCs may affect their ability to look after other patients.

The London Trauma System, based on the above concepts, went live in April 2010, and has reported on how the system has worked so far.9 The experience and findings, however, may not be directly transferable to systems outside metropolitan areas. We therefore decided to investigate and anticipate the effect that such a policy may have in a rural region. Our aim was to gain data that could inform service design for both the MTCs and the ambulance service. Potential considerations for the MTCs include emergency department (ED) capacity and staffing, radiology, theatre capacity, intensive therapy unit (ITU) and ward bed availability, and provision of specialist rehabilitation services. For the ambulance service, the considerations are additional training of prehospital clinicians in triage and trauma assessment, prolonged transfer times, removal of assets from designated areas, and the increase in resources needed for more frequent secondary transfers. In our region, the North East Ambulance Service (NEAS) covers a population of 2.66 million and an area of 3200 square miles, with a uniquely shaped geographical footprint. The routine use of divert may involve crews travelling considerable additional distances, with a consequential impact on resources in already thinly covered rural areas.

Methods

A retrospective analysis of ambulance patient report forms (PRFs) from NEAS for the months of October and December 2009, along with April 2010, was carried out. All patients who were coded under the ‘trauma’ categories were included, with those under ‘medical’ codes excluded. The selection of months was a compromise between the desire to be comprehensive, and the need to keep the number of PRFs examined realistic. We attempted to spread the months, to get a better overall picture of trauma activity.

Approval for the study was gained from the NEAS Information Governance Department. Only the authors have examined the original forms. All PRFs that met the criteria were retained securely at NEAS headquarters until the end of the study. As the study was anonymous retrospective service evaluation, and there was no change to patient care, there was no need to seek ethics approval. After completion of data collection, the patient-identifiable data were securely destroyed.

The PRFs were then examined by the authors (RM, DS) by hand, and assessed against the London Ambulance Service Major Trauma Decision Tree trauma triage tool.10 Those patients who fit the criteria for bypass were identified, on the basis of vital signs, anatomy of injury or mechanism. Also identified were those who would need immediate airway protection, and should be conveyed to the nearest ED, for stabilisation and prompt secondary transfer. The decision tree includes certain patients who, by virtue of age, pregnancy, obesity or bleeding diathesis may require MTC admission. Clinical judgement was used for these patients, and if it was felt that they had suffered major trauma, they were included.

Results

Overall, we found that between 28 and 59 additional patients would be diverted to MTCs in the months we examined (figure 1 and table 1). As there are two MTCs in our region, assuming that the workload is evenly spread, we predict between 14 and 29 additional patients per centre per month. It is unfortunately not possible to say for certain where patients would be taken, as the location of the incident is not recorded on the PRF. One cannot therefore be sure which MTC is closest. A 50:50 split may not be accurate, but is a reasonable planning assumption, as our region has two major population centres, with sparse population in between. Other regions may find that splits are less equal.

Figure 1

Numbers of patients transferred. LAS, London Ambulance Service; MTC, major trauma centre.

Table 1

Numbers of patients transferred

With regard to the number of secondary transfers, for our purposes, we have assumed 100% survival. In practice, these patients are very seriously injured, and a few were already in cardiac arrest. As only around 2% of patients with traumatic cardiac arrest survive to discharge, many of these patients are likely to die.11 The true number of secondary transfers required therefore may be less than our estimate (figures 2 and 3).

Figure 2

Current distribution of trauma, by primary destination.

Figure 3

Predicted distribution of trauma, by primary destination.

We note that, at present, nearly three-quarters of the patient workload of major trauma in our region is being taken to non-trauma centres. The transfer of these patients is therefore likely to have a significant effect on the work patterns of both the MTCs and the TUs.

Discussion

Our results show that, at present in our region, the majority of the major trauma cases transported by land ambulances from NEAS are primarily received in hospitals that are not MTCs. Introduction of an inclusive trauma system with two networks will require a considerable change in resource allocation and work patterns for all healthcare communities that provide trauma care. Although the absolute numbers of patients involved are not great, they are very resource intensive.

One interesting observation is the disparity between October 2009 and the other months examined. We have no obvious explanation for this disparity, but major trauma is unpredictable, and it is possible that none of these months may be representative. It is possible that daylight savings time is the reason for more injuries because of darker nights. The only way to be sure would be to conduct a follow-up study, extended over a full year, to capture seasonal variation in patients. One other possible explanation is the fact that October is the month when the Great North Air Ambulance Service restrict their flying hours, because of less daylight, leaving more patients to be transferred by road ambulance.

A National Audit Office Report published in February 2010 admitted that there are no clear data on the numbers of major trauma cases dealt with by ambulance services.12 The best figure they can offer is an estimate of 20 000 cases per year, although they do not state how they arrive at this figure. We therefore have few published data for comparison. That said, our findings appear similar to the preliminary data released by the London Ambulance Service.9

Consideration was given to comparing our data with those of the Trauma Audit Research Network, in order to validate our figures. We were concerned, however, that not all hospitals in the North East of England submit data, and of those that do, some have poor data entry.13 We therefore felt that we could not confidently compare the datasets, and that the NEAS data would be more comprehensive.

The London data suggest that 30% of the patients considered required ITU admission. With an expected increase of 28–50 patients per month, we may expect a commensurate increase in ITU admissions of 9–16 per month, assuming 30% admission rates. This will have effects on bed planning, and may adversely affect the ability of hospitals to conduct elective procedures. It is difficult to make direct correlations with our data, as injury patterns in rural areas are different, having more agricultural trauma and less interpersonal violence. We therefore attempted to compare these data with the Trauma Audit Research Network figures; however, their estimates of patients requiring critical care are dependent on injury, and they do not offer an estimated total. Further work is needed to gather data on ITU admission rates in rural trauma, which would further inform service construction.

With regard to secondary critical care transfers, we are likely to see a significant change. Figures from the Intensive Care National Audit and Research Centre showed 55 critical care transfers in a year for major trauma patients in the North East.14 The data do not specify whether the transfers were for upgrade of care or as a result of ITU bed capacity issues. As a result of the new system, many of these will be transported directly to the MTCs, preventing some of these secondary transfers. We did note that some patients will be taken to the nearest trauma unit for airway management and stabilisation. These patients, assuming they all survive, will require secondary transfer to an MTC. As we expect none of these patients to remain in the hospital they are taken to once stable, planned transfer protocols will be necessary for safe and smooth ongoing transfer. Given the long distances involved, a dedicated secondary transfer service may be required. This will avoid ambulances being removed from frontline service for prolonged periods. This is likely to be a serious problem in the most rural and sparsely covered areas. Consideration should be given to use all other resources including the air assets available to us. Most English air ambulance services are used for primary retrieval, whereas the Scottish Air Ambulance is more commonly used for secondary transfers from rural hospitals. The principle problem with this will be that our air assets are restricted to daylight operation only, and so, especially in the winter, will be available for only part of the day.

The increase in use of ITU resources may also change the distribution of ITU patients in the region. As more of the trauma patients will be directly admitted to MTC trauma beds, there will need to be an increase in ITU capacity. The trade off for this will be an increase in ITU availability at the TUs. This may mean that more patients are transferred out to TUs when more stable. This will free up MTC ITU beds, but it will make it harder for the MTC to provide holistic care of the patient, right through to rehabilitation. Without provision of additional resources, it will be difficult to square this. It may need to be accepted that patients be ‘stepped down’ to their local TU when stable. Although this means that the original model of the MTC needs to be altered, in rural areas this can be beneficial. The transport distances involved are considerable, making visits difficult for families. Having patients move closer to home provides benefits to morale, but may challenge rehabilitation services and dilute expertise in trauma rehabilitation.

Care will be needed to avoid over-triage of patients, as the significant distances involved mean that removing ambulance assets from areas for significant times will have to be clinically justified. While the London Ambulance Service tool is currently the best we have for triage, we would advocate a robust audit programme be instituted along with it. They have noted, in preliminary figures, that around 16% of their patients are discharged from the ED.15 In our region, distances to hospital may be up to 55 miles, and transfer times up to an hour and a half, often on poor roads. In other parts of the UK, distances may be even greater. To transfer a patient that distance, only to be discharged from the ED is not the best use of resources. We may find that we have to alter the criteria with experience, in order to provide the correct trade off between increased transfer times and taking the patients to the most appropriate centre. On the other hand, under-triage could lead to patients being denied the potential benefits of MTC care and, given the previously quoted worse outcomes, should be avoided more assiduously.

Cost is certainly an implication in the design and successful implementation of an inclusive regional trauma system. The National Clinical Director for Trauma has enabled a major change to the payment tariff to hospital trusts for major trauma patients, reflecting the increased costs they bring to hospitals.16 This is both in terms of the management cost of patients themselves, and also the costs of the critical care and orthopaedic capacity they may require, preventing elective procedures. The tariff is procedure based, bringing additional money to assist in the care of the most seriously injured. St Georges Trust estimate that to become a MTC would cost them overall around £1 m per year, if only the costs of the trauma patients are considered, despite the new tariff.17 We also note that their figures do not include any additional spending on equipment and staff, only the increase in costs associated with the patients themselves. This is despite an additional direct payment from Healthcare for London. They believe, on balance, that the costs of activity lost would be greater should they choose not to do this. In other words, they accept that becoming an MTC would cost them significant money, but it would be to their long-term detriment not to do so, and that they would accept that cost.

The problem that the new tariff presents us with is that, although under the new system the money will follow the patient, it does not take account of the capital investment that will be required to upgrade the MTCs. Nor does a procedure- and diagnosis-based tariff take account of the significantly greater transport complexities and costs in rural regions. In other words, the hospital trusts will be properly supported for the extra activity, but there has been little consideration given to the increased costs to provide pre-hospital care and transport in rural areas.

We accept that our study has certain limitations. It suffers from the usual constraints of being a retrospective study, although in our case we feel that it adds a certain strength. By being a snapshot of past practice, it avoids bias of crews knowing they are being observed, possibly introducing differences into practice. This gives us a fuller picture of current practice, before the concept of trauma triage is introduced in the region. One other concern is that our figures were compiled by two doctors with a special interest in prehospital trauma and who could apply common standards to all the patients. When rolled out, the triage will be performed under field conditions, by a large number of paramedics and technicians, with varying levels of knowledge and experience. Our figures may not therefore directly reflect the effects of the policy in practice.

We have excluded data from the Great North Air Ambulance Service, which does bring a significant proportion of trauma cases to hospital. The air ambulance, however, by virtue of having a doctor and paramedic on board, is able to triage patients at scene better; with Rapid Sequence Intubation capability and short journey times it has been standard practice for some time to bring more seriously injured patients to the two MTCs, delivering the right patient to the right place first time.

Conclusion

We believe that primary triage of severe trauma patients direct to the MTC has the potential to offer significantly better care and outcomes, by concentrating the most seriously injured patients where the expertise exists to care for them. There are, however, significant resource implications, which need to be considered in adapting the urban plan to more rural areas. At present, the majority of these patients are managed in TUs, and both the ambulance service and the MTCs need adequate resources and training to manage the change.

Acknowledgments

We thank Ms Jay Duckett and the Audit Department of NEAS for their help in this work.

References

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Footnotes

  • The opinions expressed in this paper are those of the authors, and do not reflect official Ministry of Defence policy.

  • Competing interests None.

  • Ethics approval Formal ethics approval was not sought, as the study was a retrospective examination of records, did not impact on patient care, and was entirely anonymous. Approval was gained from the Caldicott Guardian of North East Ambulance Service for access to patient records; copies of this are available on request from the corresponding author.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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