A Major Problem for the Health Service
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Transcript of A Major Problem for the Health Service
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A Major Problem for A Major Problem for the Health Servicethe Health Service
Worldwide injury is a major public health problem The commonest cause of death between the ages
of 1 and 40 years is injury For every fatality there are 2 survivors with serious and
permanent disability There appears to be a strong relationship between social
deprivation and injury Facilities for treatment of the injured and their
effectiveness varies across the UK
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Our Healthier NationOur Healthier Nation
Quotes from this document indicate the importance of ‘injury’ and its consequences:
“ It is clearly important that we continue to reduce the number of deaths from accidents.”
“… many people suffer prolonged distress and poor quality of life as the result of a serious accident ”
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Is there potential for improvement Is there potential for improvement in the care of injured patients?in the care of injured patients?
Working Party on the
Management of Patients with Major Injury,
Royal College of Surgeons 1988
“….this report reveals significant deficiencies
in the management of seriously injured patients.”
“Standards of hospital care of the injured should be monitored through a national audit scheme…..”
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Improvements in systems of trauma Improvements in systems of trauma care may be achieved by :-care may be achieved by :-
Enhancing pre-hospital care, ensuring– appropriate medical intervention
– rapid transfer to best local facility
Assessing the use of helicopters Adopting ATLS principles Integrating trauma care services within
and between hospitals Investing in rehabilitation services
and Auditing and Researching injury and systems of care
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Trauma NetworkTrauma NetworkBackground 1988 the Major Trauma Outcome Study was
established 1992 1st REPORT published in BMJ:
- UK mortality rate higher than US- large interhospital variation- slow response time- lack of senior input
1994 Statistical analysis was improved and modified 1996 New funding system1998 104 hospitals in Europe audited their trauma services
through the Network
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Widespread ParticipationWidespread Participation
Annual new Attendances
at A &E Departments
< 30,000
30,001 - 40,000
40,001 - 50,000
50,000 - 60,000
60,001 - 70,000
70,001 - 80,000
>80,000
Total
Active members
October 1998
13
18
31
15
8
7
10
104
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Trauma NetworkTrauma NetworkObjectives
collect and analyse
clinical and epidemiological data
provide a statistical base
to support clinical audit
aid the development of trauma services
and inform the research agenda
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Quality CycleQuality Cycle
Health Care Systems
Measurement
Analysis
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MeasurementMeasurementData collection should be:
Accurate
Complete
Comprehensive
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Measurement / Data CollectionMeasurement / Data Collection
Simple vs Complex
Accurate, complete, comprehensive
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Patient Inclusion CriteriaPatient Inclusion Criteria Admission > 72 hours Admission to an intensive care area Transfers for continuing care > 72 hours All deaths
Excluding:
Fractures of the femoral neck or single pubic rami
(age > 65yrs)
OR SIMPLE isolated injuries
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The Trauma NetworkAnalysis
INPUT PROCESS OUTPUT
Common standards for severity measurement
Common measures for performance assessment
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Assessment of Trauma Severity
Anatomical Injury Physiological Measurements
AgeBlunt/Penetrating
Probability of survival of individual patientsProbability of survival of individual patients
Hospital ComparisonsHospital Comparisons
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Physiological - Physiological - Revised Trauma ScoreRevised Trauma Score
Is a physiological measurement and by convention, recorded on arrival at
hospital
The RTS includes: Respiratory rate Systolic blood pressure Glasgow Coma Scale
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Abbreviated Injury Scale (AIS 90)
1 injury = 1 code with a range of 0 - 6
Injury Severity Score (ISS)Uses a formula to represent multiple injuries in 1 number with a range of 0 - 75
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INJURY SEVERITY SCORE INJURY SEVERITY SCORE Example
Abbreviated Injury Scale
Small subdural haematoma 4
Parietal lobe swelling 3
Major liver laceration 4
Upper tibial fracture (displaced) 3
ISS = 42 + 42 + 32 = 41
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Ps cannot be applied to individualsPs cannot be applied to individuals
If the Probability of Survival (Ps) of an injured patient = 0.4
Then, on average, 6 out of 10 patients will die
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The Trauma Network ReportsThe Trauma Network ReportsMonthly:
Clinical activities
Quarterly:
Outcome statistics (anonymous)
Process filters
Ad Hoc Reports
Formatted data
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Process Measures Time intervals
– injury and arrival at A&E
– arrival in A&E and 1st doctor seeing the patient
– transfer to another hospital Seniority of staff
Haemo/pneumothorax– evidence of chest drains
# skull, brain & spinal injury (AIS3+ )– evidence of CT scan
– immobilisation of spine
– recorded GCS
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Hospital comparisons 1994 - 1998 Summary Ws scores and 95%CI. Blunt injuries, excl. referrals
-9
-7
-5
-3
-1
1
3
5
7
9
Ws
& 9
5% C
I
The UK TRAUMA Audit & Research NETWORKCompiled November 1998
More survivors
More deaths
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Morbidity
Wider variation than with mortality Inadequate scoring systems What to estimate?
– temporary– permanent
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Trauma Audit - Closing the loop
D Yates, J Bancewicz, M Woodford, P Driscoll, RAC Jones, R Kishen, D Marsh, S Hollis.
Injury (1994) 25:511
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Conclusions and lessons learnt
Close inter-disciplinary cooperation and clinical improvement at a senior level.
Application of protocols to provide continuity of care from the scene of the accident through to the hospital ward.
Frequent statistical analysis of performance at audit meetings to ‘close the loop’ is an essential part of the strategy to improve trauma care.
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Setting quality standards
National Institute for Clinical Excellence
Clinical Governance
Commission for Health Improvement
National Service Frameworks