Improving UK trauma care: the NCEPOD trauma report

Authors


The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report on Trauma, entitled ‘Trauma: Who cares?’ was published in November [1] with widespread publicity in the medical and lay press. The report examined clinical and organisational aspects of prehospital and in–hospital care given to 795 trauma patients (with injury severity scores > 16) admitted to participating emergency departments over a 3-month period in 2006. The results were gloomy, although perhaps not entirely unexpected. The report ‘headline’ was that, according to the expert panel of assessors, almost 60% of patients in the study received sub-optimal care. This may have been an underestimate because only 78% of case notes of initially identified trauma patients were received, patients who died in the prehospital phase or on arrival at hospital were not included, and some data were provided by clinicians involved in managing the cases. The cohort was typical of other UK trauma studies: 75% male, mostly young and just over half involved in road traffic collisions. Over 60% had head injuries and more than half presented ‘out of hours’. The report emphasised the infrequency of major trauma patient admission in many hospitals: 129 (91.5%) hospitals in the study dealt with fewer than one severely injured patient per week and 25 hospitals that were expected to participate failed to identify a single serious trauma patient during the 12-week study period. Despite the difficulties that the investigators obviously had collecting a full dataset at every stage of the study, a great deal of useful information is presented.

The report recognises the vital role that good prehospital care can contribute to trauma patients. In the UK the majority of the first hour after injury is spent in the prehospital phase [2] and this country differs significantly from the majority of Europe in that prehospital care for the seriously injured is delivered by paramedics and technicians rather than physicians [3–6]. There is some consensus in the practice of prehospital trauma care. Most clinicians favour a prehospital system that attends the scene rapidly, deals with immediate patient needs and transfers rapidly to an appropriate hospital. Unfortunately NCEPOD failed to get ambulance services to agree to complete questionnaires on patient care and one-third of case notes contained no ambulance report form. The remainder demonstrated no relationship between mortality and ambulance response times (13% had response times of more than 20 min). The report emphasised that, in non-trapped patients, the scene time frequently exceeded the previously recommended 10-min maximum [7]. There is undoubtedly room for improvement in scene times but the difficulties of a crew of only two moving a patient from a block of flats, or down a staircase, after completing even minimal interventions and immobilisation, are not to be underestimated. Curiously many patients had a secondary survey recorded in the prehospital phase, which is clearly not appropriate and a waste of valuable time. 25.5% of patients taken to hospital by ambulance had to have secondary transfers. These are associated with a high rate of adverse physiological events that may influence outcome negatively [8, 9]. The secondary transfer rate of those patients taken to hospital by helicopter was much less at 11.9%. The helicopters would have had a mixture of paramedic only and doctor-paramedic crews. The expert advisors judged that all of the helicopter transfers were to an appropriate hospital. However, a secondary transfer rate of 11% in a doctor-paramedic system is unacceptably high and this rate should be significantly less in the increasing number of doctor-paramedic staffed air ambulances. The report did not attempt to establish whether patients attended by doctors in the prehospital phase had improved care or outcome.

A major recurring theme of this report which is of particular interest to anaesthetists is the suboptimal level of airway care. Eighty-five (17%) cases had partial or complete airway obstruction on scene and 12.6% of patients arrived at hospital in the same state. Thirty-five percent of patients (85) whose tracheas were intubated in hospital had the procedure within 10 min of arrival, which implies urgent need. Of the patients with head injury, 22% were not given oxygen in the prehospital phase. Patients with severe head injury had a high rate of failed prehospital intubation; most were transported unintubated and a significant number arrived with total or partial airway obstruction and documented hypoxaemia and hypercapnia. This makes uncomfortable reading and suggests that the current system is failing some trauma patients in a basic area. The report recommends that prehospital anaesthesia should be available to ensure that trauma patients are not subject to secondary insults before arrival in hospital. It is stated that ‘if prehospital intubation is to be part of prehospital trauma management then it needs to be in the context of a physician based prehospital care system’. Achieving this level of care may appear challenging but significant progress has been made recently. The inclusion of doctors on UK air ambulances is proceeding rapidly. A few years ago only London’s air ambulance carried doctors. This service has now been joined by another six regional services and more are planned. Clinical governance in voluntary schemes is being implemented [10] and The Faculty of Pre-hospital Care of the Royal College of Surgeons of Edinburgh is preparing, with the other relevant organisations, a submission to the postgraduate medical education and training board for sub-speciality recognition in prehospital care [11, 12]. Ensuring the quality of prehospital physician anaesthesia is vital and the Association of Anaesthetists of Great Britain and Ireland have convened a working party representing all relevant organisations that will publish a document on the subject later this year.

Realistically, comprehensive physician-led care will not happen overnight and improvements in paramedic airway management must be sought simultaneously. With their current skills, UK paramedics manage trauma airways with difficulty. Most encounter a trauma patient who requires intubation only rarely. They cannot use drugs to assist in intubation and only those patients with low GCS scores and poor airway reflexes can be intubated easily. These patients have a very high mortality rate [13, 14]. It is also possible that intubation of head injured patients without drugs is harmful [15]. Instead of attempting intubation, it is highly likely that meticulous basic airway management [16] and the use of supraglottic airway devices [17] could have prevented hypoxaemia and hypercapnia in a number of the patients described in this report. The importance of having two ambulance providers attending the patient during transport (i.e. in addition to the driver) is recognised in many European systems and good basic airway management is unlikely to happen with only one attendant. This is unfortunately common in UK prehospital practice. Ensuring that basic guidelines are adhered to is fundamental – the failure to administer oxygen to patients with head injuries reported here is inexplicable and runs contrary to basic ambulance technician training. Ensuring that existing skills are applied properly would be a much more sensible use of resource than attempting to train a few paramedics to use drugs to intubate, which has been suggested by some paramedic trainers. Paramedic intubation with drug assistance is carried out by a minority of paramedic systems in the United States and it is a highly controversial area in that country [18, 19]. Part of the reason that physicians are not used in the US may be related to the cost of physician life insurance cover rather than an absence of clinical need.

The report continues to highlight problems after patients arrive in hospital. There are worrying case histories illustrating extreme examples of system breakdown. Only half of patients arrived at hospital with pre-alerts. One in five receiving hospitals did not have a trauma team response. When a specific night was chosen 65% of hospitals stated that a consultant would not be involved in the trauma call. Even worse, 20% stated that an emergency department SpR would not be present and 32% that an anaesthetic SpR would not be present. There seems little point in a structured response which involves only SHOs or their equivalent. Of the seriously injured patients identified in the report, 34% were not seen by any consultant before leaving the emergency department and 18.8% had still not been seen by a consultant 12 h after admission. Inappropriate management was, unsurprisingly, much more frequent in patients managed without consultants. The report recommends that trauma teams should receive all trauma patients and that they should be consultant led. Most consultants would probably not welcome the opportunity to be resident on call but, in centres that receive significant numbers of trauma patients, a high quality response does appear to depend on their presence.

The time to CT scan was often prolonged and the report makes a case for whole body CT scan in patients with multiple injuries. This is a departure from current practice in much of the UK and will undoubtedly be challenged by some radiologists. If implemented, it would prevent the multiple, and sometimes prolonged, trips to the radiology department that seriously unwell patients and their anaesthetists endure regularly. Like interhospital transfer, these increase the chance of secondary insults. It is also stated that there is no evidence for ‘patients being too unstable to scan’ a common reason for delay in diagnosis. The same unstable patients are also often not moved to the operating theatre for urgent surgery. The principle that fluid infusion without surgery to stop non-compressible haemorrhage is illogical, and likely to lead to excess mortality, does not appear to be applied universally.

Several other problems are identified with the in-hospital care of trauma patients. Virtually all could be avoided by early and sustained consultant input and by treatment in centres with appropriate facilities that receive sufficient numbers of seriously injured patients. Although the language and definitions vary slightly this report recommends the formation of ‘Trauma Centres’ and regional trauma services in the same way as the ‘Better care for the severely injured’ report in 2000 [7] and ‘Report of the working party on the management of patients with major injuries’ from the Royal College of Surgeons of England in 1988 [20]. If implemented, there will be understandable misgivings about the loss of this type of work in many hospitals which will not meet the criteria for receiving major trauma and that would be bypassed by an effective prehospital service. However this and other reports have demonstrated that major trauma makes up only a tiny proportion of their workload and that, like other specialised areas of medicine, concentration of resource and expertise to produce better results is inevitable [21–23].

The report also recommends that clinical governance for all components of the trauma patient pathway should be conducted by the regional trauma centre. Individual components (e.g. ambulance services, air ambulances, hospitals) would undoubtedly continue to have their own clinical governance structures but the trauma centre would be in a position to examine the entire patient journey from roadside to rehabilitation. This seems entirely logical but may meet some resistance particularly from ambulance services.

The current state of UK trauma is, however, not all bad news. With falling numbers of traffic fatalities, residents of the UK are considerably less likely to die of trauma than in most other European countries and, although this report highlights problems in the current system, at least we have organisations like NCEPOD to put the problems firmly in the public domain. There has been widespread recognition and standardisation of the basic principles of trauma management and improved technology (imaging) combined with some organisational improvements (e.g. NCEPOD recommended emergency operating lists) has improved trauma care in the UK in the last two decades [2]. Most importantly, the problems identified do not require technological advances or high level research to be solved. The problems are straightforward organisational and resource issues. Looking carefully at this report in combination with earlier reports [7, 20], it could be perceived that UK trauma care is in a giant audit cycle where problems are identified, recommendations made and, at re–audit many years later, the same unresolved problems identified. Responses to the report have been positive [24–26] and hopefully political will along with clinical enthusiasm will address the recommendations of the report to improve the quality and safety of care for UK trauma victims. It would be a great shame to have to read yet another report with similar recommendations in five or ten years’ time.