PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Regional Trauma Network Trauma Centre Trauma Service RMTN Network Organisation Measures (T13-1C-1) - 2013/14 Peer Review Visit Date 29th April 2014 Compliance NETWORK ORGANISATION MEASURES Zonal Statement Completed By Job Title Self Assessment % (0/0) Marie Cummins Programme Manager Peer Review 100.0% (8/8) Date Completed 17th May 2014 Agreed By (Clinical Lead/Quality Director) Julia Hill Date Agreed 8.7.14 Key Themes Network Governance Measures The East Midlands Major Trauma Network has a population of 4.6 million and includes one Major Trauma Centre (MTC), the MTC is the Queen's Medical Centre, Nottingham; it has six Trauma Units (TU's), University Hospitals of Leicester NHS Trust, Derby Hospitals NHS FT, United Lincolnshire Hospitals NHS Trust (this combines two Trauma Units, Lincoln County Hospital and Pilgrim Hospital), Chesterfield Royal Hospitals NHS FT and Sherwood Forest Hospitals NHS FT. One ambulance service; East Midlands Ambulance Service (EMAS) with robust Clinical Governance links with West Midlands Ambulance Service (WMAS) and Yorkshire & The Humber Ambulance Service (YAS). Paediatric Major Trauma is received at the Queen's Medical Centre. The Network operates as an Operational Delivery Network. The funding remains an issue for the East Midlands Major Trauma Network. The Network was established on the 1st March 2012 and it has implemented a planned staged 'roll-out' of the Major Trauma system in the region. It has undertaken an assurance visit with each Trauma Unit. The Network is hosted by East PEER REVIEW VISIT REPORT for - Network Organisation Measures (published: 8th July 2014) Page: 1/3
Midlands Ambulance Service (EMAS). Overall the MTC and Network need to be commended on an outstanding service and there is no doubt that the East Midlands Trauma Network will continue to develop the Major Trauma service. Good Practice Good Practice/Significant Achievements 1. Development and maintenance of Operational Delivery Network. 2. The 'Assurance process' carried out with the Trauma Units is to be commended. Concerns and Recommendations Immediate Risks Identified? Immediate Risks Immediate Risks Resolved? Immediate Risks Resolution Serious Concerns Identified? Serious Concerns Serious Concerns Resolved? PEER REVIEW VISIT REPORT for - Network Organisation Measures (published: 8th July 2014) Page: 2/3
Serious Concerns Resolution Concerns 1. The review panel acknowledged the 36% reduction in historical Network funding levels with no current allocation to fund the Major Trauma or Rehabilitation Networks. A sustainable future funding model needs to be explored to maintain the Critical Care, Major Trauma and Rehabilitation Networks in the region. 2. The review panel had concerns about TARN completeness and submissions from the Trauma Units. 3. The review panel felt that developing a system such as datix would help collate adverse incidents and assist with identifying themes. This would support the increased engagement of the Trauma Units to review the themes at a Network level on a regular basis as opposed to an ad-hoc system. PEER REVIEW VISIT REPORT for - Network Organisation Measures (published: 8th July 2014) Page: 3/3
PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Regional Trauma Network Trauma Centre Trauma Service RMTN Pre-Hospital Measures (T13-2A-1) - 2013/14 Peer Review Visit Date 29th April 2014 Compliance PRE-HOSPITAL MEASURES Zonal Statement Completed By Job Title Self Assessment % (0/0) Marie Cummins Programme Manager Peer Review 80.0% (8/10) Date Completed 17th May 2014 Agreed By (Clinical Lead/Quality Director) Julia Hill Date Agreed 8.7.14 Key Themes Pre-Hospital Measures The East Midlands Major Trauma Network includes one Major Trauma Centre (MTC), the MTC is the Queen's Medical Centre, Nottingham; it has six Trauma Units (TU's) and one ambulance service; East Midlands Ambulance Service (EMAS) with robust Clinical Governance links with West Midlands Ambulance Service (WMAS) and Yorkshire & The Humber Ambulance Service (YAS) with the Trauma Units that boarder other MTC's. Paediatric Major Trauma is received at the Queen's Medical Centre. The Trauma Triage Tool is the same for Adults and Paediatrics and has been recently audited, this audit highlighted an over triage. The tool has been redeveloped and will be piloted for three months, starting from the 1st June 2014. During this time data will be collected to ascertain the level of over-triage. Following the three month trial period the Network Clinical Steering Group will make a decision in respect of whether the tool needs further revision. EMAS currently do not have a 24/7 paramedic present in the Ambulance Control room, it is the PEER REVIEW VISIT REPORT for - Pre-Hospital Measures (published: 8th July 2014) Page: 1/3
Medical Director's stance that the Clinician on scene will make the assessment of the patient and carry out 'Clinician to Clinician' pre alerts. However, EMAS are reviewing the function of their Emergency Operations Centre and the requirement for a dedicated 'Trauma Desk'. EMAS are having meetings with YAS and WMAS to investigate further the models used within these two Ambulance Trusts. The Network is hosted by EMAS; it has designed and implemented a Major Trauma Secondary Patient Transfer Care Pathway. EMAS do not provide a 24/7 Enhanced Care team, but have introduced major trauma packs and host the Hazardous Area Response Team (HART) who have specialised equipment and skills. This is supported by three Air Ambulances and a Helicopter Emergency Medical Service (HEMS). EMAS introduced ATMIST Trauma Pre Alert. Good Practice Good Practice/Significant Achievements 1. The review panel commended the recent audit of the Trauma Triage Tool and the redevelopment of the tool following the findings. 2. It is to be applauded that EMAS are working with YAS and WMAS to investigate other models. Concerns and Recommendations Immediate Risks Identified? Immediate Risks Immediate Risks Resolved? Immediate Risks Resolution Serious Concerns Identified? Serious Concerns PEER REVIEW VISIT REPORT for - Pre-Hospital Measures (published: 8th July 2014) Page: 2/3
Serious Concerns Resolved? Serious Concerns Resolution Concerns 1. A concern raised by the review panel is the 'tasking' of the medical cover within Pre Hospital care. 2. It was recognised by the review panel that the Trauma Triage Tool needed to be better adapted for Paediatric Major Trauma. 3. The review panel recommend increasing the availability of appropriately trained doctors on board the Air Ambulance. PEER REVIEW VISIT REPORT for - Pre-Hospital Measures (published: 8th July 2014) Page: 3/3
PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Regional Trauma Network Trauma Centre Trauma Service RMTN Reception and Resuscitation Measures (T13-2B-1) - 2013/14 Peer Review Visit Date 29th April 2014 Compliance RECEPTION AND RESUSCITATION MEASURES Zonal Statement Completed By Job Title Self Assessment 100.0% (3/3) Marie Cummins Programme Manager Peer Review 95.8% (23/24) Date Completed 17th May 2014 Agreed By (Clinical Lead/Quality Director) Julia Hill Date Agreed 8.7.14 Key Themes RECEPTION The Trauma Team Leader (TTL) is an Emergency Medicine Consultant and provides a 24/7 cover, however some of this cover is delivered by a 'locum' Consultant overnight. There is an established Trauma Team available 24/7 and the Trauma Team Leader (TTL) programme is being rolled out. The Major Trauma Centre (MTC) has a Trauma Team Activation protocol. There is surgical and resuscitative thoracotomy capability within the Trauma Team. RADIOLOGY The CT scanner is co-located within the Emergency Department and is available 24/7. MRI scanning is available 24/7 and there is provision for Interventional Radiology within 60 minutes 24/7. The Consultant CT report is checked as part of the Tertiary Survey. PEER REVIEW VISIT REPORT for - Reception and Resuscitation Measures (published: 8th July 2014) Page: 1/3
SURGERY There is 24/7 access to a fully staffed emergency theatre and the Consultant Surgeons involved in caring for major trauma patients are capable in the principles of damage control surgery. There are good examples of joint working across the key specialities. INTENSIVE CARE There are 21 Critical Care beds and 20 surgical High Dependency beds. There is a medical High Dependency Unit located at the Queen's Medical Centre. The Critical Care service is an active member of the Mid Trent Critical Care Network (MTCCN) and is an Operational Delivery Network. Additionally the Paediatric Intensive Care Unit has 10 beds. The unit submits to ICNARC (Intensive Care National Audit & Research Centre). PAIN MANAGEMENT There is a 24/7 acute pain service, with a Consultant lead is in place at the MTC. Rib plating is being performed where appropriate by one of the Orthopaedic Consultants. TRANSFUSION A Massive Transfusion Protocol is in place and once activated the cases are reviewed to ensure compliance to the protocol in a timely manner Good Practice Good Practice/Significant Achievements 1. Good engagement with Radiology with the presence of a radiologist at the Trauma calls.. 2. It was applauded that there was a dedicated anaesthetist as part of the Trauma Team. 3. The access to emergency theatres was commended. 4. The review panel acknowledged the good and effective model used for the Trauma Team for Paediatric Major Trauma Concerns and Recommendations Immediate Risks Identified? PEER REVIEW VISIT REPORT for - Reception and Resuscitation Measures (published: 8th July 2014) Page: 2/3
Immediate Risks Immediate Risks Resolved? Immediate Risks Resolution Serious Concerns Identified? Serious Concerns Serious Concerns Resolved? Serious Concerns Resolution Concerns 1. It was recommended by the review panel that the TTL programme to be rolled out across the Network. 2. A concern was raised by the review panel regarding the use of 'locum' Consultant overnight cover for the Consultant TTL; however it was acknowledged that the locum was mainly an internal member of staff, however this was not in all cases. PEER REVIEW VISIT REPORT for - Reception and Resuscitation Measures (published: 8th July 2014) Page: 3/3
PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Regional Trauma Network Trauma Centre Trauma Service RMTN Definitive Care Measures (T13-2C-1) - 2013/14 Peer Review Visit Date 29th April 2014 Compliance DEFINITIVE CARE MEASURES Zonal Statement Completed By Job Title Self Assessment % (0/0) Marie Cummins Programme Manager Peer Review 100.0% (17/17) Date Completed 17th May 2014 Agreed By (Clinical Lead/Quality Director) Julia Hill Date Agreed 8.7.14 Key Themes Definitive Care Measures The Major Trauma Consultants attend trauma calls during on-site hours until 21.00 hours and are from the following specialties: HPB, Orthopaedics, Vascular, Intensivists and General Surgery. It is the aim to have a Consultant from each of the Trauma Units as part of the Trauma service and there has been a successful integration of Consultants with appropriate skills into the Major Trauma Centre. The Major Trauma Consultant will attend trauma calls along with the Emergency Department Consultant to ensure the correct ongoing care decisions are made in resus. The Major Trauma Consultant will be responsible for the Major Trauma patients care for the whole stay in the Major Trauma Centre. The Major Trauma Consultant has sole admitting rights to the Major Trauma Unit. The Major Trauma Unit has up to 12 level 1 beds and 6 level 0 beds. The role of the Major Trauma Case Manager is a good innovation within the Major Trauma service. There are three Major Trauma Case Managers and all major trauma admissions are presented and discussed at a daily MDT meeting each morning where all cases are discussed. All of the key surgical specialties are on-site at the MTC and there is clear evidence of a 24/7 PEER REVIEW VISIT REPORT for - Definitive Care Measures (published: 8th July 2014) Page: 1/3
Consultant-led service. Good Practice Good Practice/Significant Achievements 1. The Major Trauma Unit is to be applauded. 2. It is to be congratulated on the appointment of the new Neurosurgical post. 3. The Major Trauma Case Manager post is to be commended. 4. The review panel applauded the 'follow up' call; this was seen as good innovation. 5. The review panel acknowledged the good innovation for chest trauma. Concerns and Recommendations Immediate Risks Identified? Immediate Risks Immediate Risks Resolved? Immediate Risks Resolution Serious Concerns Identified? Serious Concerns Serious Concerns Resolved? Serious Concerns Resolution PEER REVIEW VISIT REPORT for - Definitive Care Measures (published: 8th July 2014) Page: 2/3
Concerns 1. The review panel felt that Neurosurgery still required further engagement, but it was felt that the new appointment would assist with the extended engagement. 2. The review panel raised a concern that the BOAST4 compliance remains low with factors such as access to theatres being reported as an issue. 3. The review panel felt that more engagement was required from the Major Trauma Centre to include all of the Trauma Units. PEER REVIEW VISIT REPORT for - Definitive Care Measures (published: 8th July 2014) Page: 3/3
PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Regional Trauma Network Trauma Centre Trauma Service RMTN Rehabilitation Measures (T13-2D-1) - 2013/14 Peer Review Visit Date 29th April 2014 Compliance REHABILITATION MEASURES Zonal Statement Completed By Job Title Self Assessment % (0/0) Marie Cummins Programme Manager Peer Review 92.9% (13/14) Date Completed 17th May 2014 Agreed By (Clinical Lead/Quality Director) Julia Hill Date Agreed 8.7.14 Key Themes Rehabilitation Measures There is a recent recruitment of a Trauma Network Director of Rehabilitation Medicine. There are five Rehabilitation providers for the East Midlands Trauma Network: i. Linden Lodge (Neuro-Rehabilitation), ii. King's Lodge (Neuro-Rehabilitation), iii. Ashby Ward, iv. Chatsworth Rehabilitation Unit, v. Brain Injury Unit and Younger Disabled Unit. Across the five different locations level 2a and level 3 Rehabilitation is provided. However, it was still felt by the Major Trauma Network that the bed capacity for Rehabilitation was inadequate and during these times the Private sector was used. Paediatric Rehabilitation is only provided at the Major Trauma Centre and this gap does impact on transfers of care for Paediatric patients following major trauma. The role of Rehabilitation Co-ordinator role is carried out by the Major Trauma Case Manager, who acts as the patient's key worker. The Rehabilitation Prescription is sent with the patient to the ongoing service and a copy is given to the patient themselves. A directory of Rehabilitation PEER REVIEW VISIT REPORT for - Rehabilitation Measures (published: 8th July 2014) Page: 1/3
services has been developed. Neuropsychology is available and there is access 24/7 to a Psychiatrist. Good Practice Good Practice/Significant Achievements 1. The roll out of the Rehabilitation Prescription is to be applauded. 2. The good engagement and commitment from the therapy teams is to be congratulated. 3. The development of the patient information leaflet is to be commended and the review panel recommend that these are developed throughout the Network for Major Trauma Centre to Trauma Units and from Trauma Units to the Major Trauma Centre. Concerns and Recommendations Immediate Risks Identified? Immediate Risks Immediate Risks Resolved? Immediate Risks Resolution Serious Concerns Identified? Serious Concerns Serious Concerns Resolved? PEER REVIEW VISIT REPORT for - Rehabilitation Measures (published: 8th July 2014) Page: 2/3
Serious Concerns Resolution Concerns 1. The review panel were concerned about the lack of level 1 Rehabilitation capacity. 2. It was felt by the review panel that the reconfiguration had caused issues with accessing Spinal Cord Injury beds. 3. The review panel felt that there was a 'gap' to complex MSK Rehabilitation. 4. Paediatric Rehabilitation for Major Trauma remains a gap nationally. PEER REVIEW VISIT REPORT for - Rehabilitation Measures (published: 8th July 2014) Page: 3/3