MAJOR TRAUMA AUDIT - Amazon S3s3-eu-west-1.amazonaws.com/noca-uploads/general/Major... · 2020. 2....

MAJOR TRAUMA AUDITNATIONAL REPORT 2018

PREVENTION OF MAJOR TRAUMA IS NO ACCIDENT – THINK SAFETY FIRST

Dr Conor DeasyMajor Trauma Audit Clinical Lead

Louise BrentIrish Hip Fracture Database and Major Trauma Audit ManagerNational Office of Clinical Audit

Olga BrychData analyst National Office of Clinical Audit

Dr Jacinta McElligottConsultant, Rehabilitation Medicine

Rosie QuinnClinical Specialist PhysiotherapistOur Lady of Lourdes Hospital, Drogheda

Dr Fionnola KellyHead of Data Analytics and ResearchNational Office of Clinical Audit

Dr Rachael DoyleConsultant Geriatrician

REPORT PREPARED WITH ASSISTANCE FROM MEMBERS OF THE MTA GOVERNANCE COMMITTEE

NATIONAL OFFICE OF CLINICAL AUDIT (NOCA)

NOCA was established in 2012 to create sustainable clinical audit programmes at national level. NOCA is funded by the Health Service Executive Quality Improvement Team and operationally supported by the Royal College of Surgeons in Ireland.

The National Clinical Effectiveness Committee (NCEC, 2015, p.2) defines national clinical audit as “a cyclical process that aims to improve patient care and outcomes by systematic, structured review and evaluation of clinical care against explicit clinical standards on a national basis”. NOCA supports hospitals to learn from their audit cycles.

Electronic copies of this report can be found at: https://www.noca.ie/publicationsBrief extracts from this publication may be reproduced provided the source is fully acknowledged.

Citation for this report:National Office of Clinical Audit, (2020)Major Trauma Audit National Report 2018. Dublin: National Office of Clinical Audit.

ISSN 2009-9673 (Print)ISSN 2009-9681 (Electronic)

This report was published on 12 February 2020

National Office of Clinical Audit, 2nd Floor, Ardilaun House, 111 St Stephen’s Green, Dublin 2, D02 VN51

Tel: + (353) 1 402 8577Email: [email protected]

DESIGNED BY For more information about this report, contact:

ACKNOWLEDGMENTS

This work uses data provided by patients and collected by their healthcare providers as part of their care. NOCA would like to thank the valuable contribution of all participating hospitals, in particular the Major Trauma Audit coordinators and clinical leads. Without their continued support and input, this audit could not continue to produce meaningful analysis of trauma care in Ireland.

NATIONAL CLINICAL EFFECTIVENESS COMMITTEE (NCEC)

The National Clinical Effectiveness Committee (NCEC) is a Ministerial committee of key stakeholders in patient safety and clinical effectiveness. Its mission is to provide a framework for endorsement of guidelines and audit to optimise patient and service user care. The NCEC’s remit is to establish and implement processes for the prioritisation and quality assurance of clinical guidelines and clinical audit and subsequently recommend them to the Minister for Health for endorsement and mandating for national implementation. Major Trauma Audit

NCEC National Clinical Audit No. 1

NOCA would like to thank Mr Kieran Minihane; Mrs Aoife Minihane and The National Ambulance Service for supplying imagery used throughout this report.

ACKNOWLEDGING SIGNIFICANT CONTRIBUTIONS FROM THE FOLLOWING:

NOCA has engaged the internationally recognised Trauma Audit and Research Network (TARN) to provide its methodological approach for MTA in Ireland. TARN has been in operation in the UK since the 1990s and has been at the forefront of quality and research initiatives in trauma care. It is the largest trauma registry in Europe and is clinically led, academic and independent.

TARN use a standardised dataset for trauma patients, allowing review of care at both organisational and national level, thereby assuring the quality of and ultimately improving trauma care.

The Quality Improvement Team (QIT) was established to support the development of a culture that ensures improvement of quality of care is at the heart of all services that the HSE delivers. HSE QIT works in partnership with patients, families and all who work in the health system to innovate and improve the quality and safety of its care.

Major Trauma AuditNational Report

2018

NOCA NATIONAL OFFICE OF CLINICAL AUDIT04

CONTENTS

01

02

03

04

05

FOREWORD 09GLOSSARY OF TERMS AND DEFINITIONS 10EXECUTIVE SUMMARY 12KEY FINDINGS 14KEY RECOMMENDATIONS 15IMPACT OF THE MTA TO DATE 16CAPTURING PATIENT PERSPECTIVES 17WHAT IS MAJOR TRAUMA? 18KEY FINDINGS INFOGRAPH 20 CHAPTER 1: INTRODUCTION 23Who is this report aimed at? 26

Aim and objectives 27

Hospitals and people we work with 28

CHAPTER 2: METHODOLOGY 31Inclusion criteria 32

Exclusion criteria 33

Data entry 35

Data analysis 35

CHAPTER 3: DATA QUALITY 37Data for this MTA report 38

Data quality statement 38

Data coverage by hospital 44

Data accreditation by hospital 45

CHAPTER 4: WHO WAS INJURED AND HOW WERE THEY INJURED? 47Gender and age band 48

Pre-existing medical conditions 50

Mechanism of injury 52

Injuries sustained 54

Injury severity score (ISS) 55

Place of injury 57

Injuries sustained at home 59

Type of road trauma 62

Head injuries 64

Key findings from Chapter 4 68

CHAPTER 5: FALLS 69Gender and age band 72

Presentation by time of day and age band 74

Injuries sustained by body region 75

Injury severity score 76

Severe injury falls and pre-alert 77

Severe injury falls and reception by a trauma team 78


MAJOR TRAUMA AUDIT NATIONAL REPORT 2018 05

CHAPTER 6: THE PATIENT JOURNEY 81The patient journey 82

Mode of arrival 82

Most senior healthcare professional 83

TBI and admissions to a neurosurgical unit 84

Transfers of patients (subgroup analysis) 86

Transfers by hospital 87

Gender and transfers 91

Age and transfers 92

ISS and transfers 93

Mechanism of injury and transfers 94

Body region injured and transfers 95

Location of injury and transfers 96


CHAPTER 7: CARE OF MAJOR TRAUMA PATIENTS IN THE ACUTE HOSPITAL SERVICE 99Presentation by time of day 100

Pre-alert 101

Reception by a trauma team 103

Grade of most senior doctor treating patient on arrival 105

Time to see patients on arrival at hospitals 106

Surgery 107

Hospital systems performance 110


CHAPTER 8: OUTCOMES 119Mortality at 30 days post-discharge 120

Mortality and age 120

Mortality by gender and age 121

Mortality by mechanism of injury 122

Mortality by ISS 124

Mortality by body region injured 125

Discharge destination 126

Risk-adjusted benchmarking 127


CHAPTER 9: AUDIT UPDATE 131 CHAPTER 10: RECOMMENDATIONS AND CONCLUSION 133Key recommendations 134

Conclusion 135

REFERENCES 137 APPENDICES 141APPENDIX 1: INCLUSION CRITERIA 142APPENDIX 2: MTA GOVERNANCE COMMITTEE 146APPENDIX 3: FREQUENCY TABLES 147

07

06

08

0910


FIGURES

FIGURE 3.1: Data coverage percentages by hospital 44

FIGURE 3.2: Data accreditation percentages by hospital 45

FIGURE 3.3: Data accreditation by key data fields 46

FIGURE 4.1: Percentage of MTA patients by gender (N=5429) 48

FIGURE 4.1A: Percentage of MTA patients by gender and age group (N=5429) 49

FIGURE 4.2: CCI score of MTA patients (N=5429) 50

FIGURE 4.2A: CCI score of MTA patients by age group (N=5429) 51

FIGURE 4.3: Mechanism of injury (N=5429) 52

FIGURE 4.3A: Mechanism of injury by age group (N=5429) 53

FIGURE 4.4: Injuries sustained by body region (N=8008) 54

FIGURE 4.5: Percentage of patients by ISS (N=5429) 55

FIGURE 4.5A: Injury severity by age group (N=5429) 56

FIGURE 4.6: Place of injury (N=5429) 57

FIGURE 4.6A: Place of injury by age group (N=5429) 58

FIGURE 4.6B: Place of injury by ISS (N=5211) 58

FIGURE 4.7: Injuries sustained at home by gender (n=2696) 59

FIGURE 4.8: Injuries sustained at home by mechanism of injury (n=2696) 60

FIGURE 4.9: CCI score of patients injured at home by age (n=2678) 60

FIGURE 4.10: Injuries sustained at home by ISS and age group (n=2696) 61

FIGURE 4.11: Injuries sustained at home by mortality (n=2696) 61

FIGURE 4.12: Type of road trauma (n=875) 62

FIGURE 4.12A: Type of road trauma by ISS (n=860) 63

FIGURE 4.13: Severe head injury patients by AIS classification (AIS ≥3) (n=1175), further classified into TBI severity by GCS 64

FIGURE 4.13A: TBI severity by GCS score, by age group for patients with severe head injuries (AIS ≥3) (n=1175) 65

FIGURE 4.13B: Cause of injury in patients with severe TBI (AIS ≥3 and GCS <9) (n=179) 66

FIGURE 4.13C: Mortality of major trauma patients with severe head injury by AIS classification and by age group (n=1222) 67

FIGURE 5.1: Falls by gender (n=3726) 72

FIGURE 5.2: Falls by age (n=3726) 73

FIGURE 5.3: Falls by presentation by time of the day and age (n=3713) 74

FIGURE 5.4: Falls and most severely injured body area (n=3607) 75

FIGURE 5.5: Falls and injury severity score (n=3726) 76

FIGURE 5.6: Falls with ISS >15 by pre-alert status (n=1041) 77

FIGURE 5.7: Falls with ISS >15 and reception by trauma team (n=1041) 78

FIGURE 6.1: Mode of arrival at hospital (n=4911) 82

FIGURE 6.2: Most senior pre-hospital healthcare professional (n=3754) 83

FIGURE 6.3: Care pathway of patients with severe head injury by AIS (n=1221) 84

FIGURE 6.3A: Patients with severe TBI and admissions to a neurosurgical unit (AIS ≥3 and GCS <9) (n=179) 85

FIGURE 6.4: Percentage of patients transferred to another hospital (N=5429) 86

FIGURE 6.5: Percentage of transfers out by hospital (n=6135) 89

FIGURE 6.6: Percentage of transfers in by hospital (n=6135) 90

FIGURE 6.7: Percentage of transfers by gender (n=1077) 91

FIGURE 6.8: Proportion of each age group that was transferred (N=5429) 92

FIGURE 6.9: Percentage of patients transferred versus not transferred by ISS (N=5429) 93

FIGURE 6.10: Percentage of patients transferred versus not transferred by mechanism of injury (N=5429) 94


FIGURE 6.11: Percentage of patients transferred versus not transferred by body region injured (N=5429) 95

FIGURE 6.12: Percentage of patients transferred versus not transferred by location of injury (N=5429) 96

FIGURE 7.1: Presentation by time of day (N=5143) 100

FIGURE 7.2: Pre-alerted by age group (n=5085) 101

FIGURE 7.2A: Pre-alerted with ISS >15 by age group (n=1596) 102

FIGURE 7.3: Reception by a trauma team by age group (n=5085) 103

FIGURE 7.3A: Reception by a trauma team with ISS >15 by age group (n=1596) 104

FIGURE 7.4: Grade of most senior doctor treating patient on arrival by age group (n=5085) 105

FIGURE 7.5: Surgical intervention by body region (n=2348) 107

FIGURE 7.6: Surgical intervention by body region and ISS (n=2348) 108

FIGURE 7.7: Surgical intervention by body region and gender (n=2348) 109

FIGURE 7.8: Airway management of patients with a GCS <9 (n=239) 110

FIGURE 7.9: Survival of shocked patients (n=649) 111

FIGURE 7.10: Percentage of patients to receive a CT scan within 1 hour (n=273) 112

FIGURE 7.10A: Proportion of eligible patients receiving CT scan within 1 hour with a GCS <13 by hospital (n=273) 113

FIGURE 7.11: Median ICU LOS by hospital (n=875) 115

FIGURE 7.11A: Total number of ICU bed days occupied per hospital (n=5829) 115

FIGURE 7.12: Hospital LOS by age group (N=5429) 116

FIGURE 7.12A: Median LOS by hospital (n=6135) 117

FIGURE 7.12B: Total number of bed days occupied per hospital (n=87768) 117

FIGURE 8.1: Mortality by age group (n=286) 120

FIGURE 8.2: Mortality by gender (n=286) 121

FIGURE 8.3: Mortality by mechanism of injury (n=286) 122

FIGURE 8.3A: Mortality by mechanism of injury and age group (n=286) 123

FIGURE 8.4: Mortality by ISS category (n=286) 124

FIGURE 8.5: Mortality by body region most severly injured (n=286) 125

FIGURE 8.6: Discharge destination (N=5429) 126

FIGURE 8.7: Irish hospital WS scores, 2018 128

TABLESTABLE 1: Glossary of terms and definitions 10

TABLE 2: Impact of the MTA to date 16

TABLE 2.1: Exclusion criteria 33

TABLE 2.2: Data collection calendar 2018 35

TABLE 3.1: Data analysis for MTA Report 2018 38

TABLE 3.2: Overview of data quality for MTA 2018 39

TABLE 4.1: Number of body regions injured per patient (N=5429) 54

TABLE 4.2: ISS Classification 55

TABLE 6.1: Number of patients who were transferred by hospital 88

TABLE 7.1: Reception by a trauma team 104

TABLE 7.2: Most senior doctor seeing the patient in the ED and those with an ISS >15 106

TABLE 7.3: ICU Length of stay (LOS) 114

TABLE 7.4: Hospital length of stay (LOS) for major trauma patients 116

TABLE 8.1: Case-mix-standardised rate of survival for Ireland, 2018 127

Dr Conor DeasyClinical LeadMajor Trauma AuditNational Office of Clinical Audit2nd Floor, Ardilaun House111 St. Stephen’s GreenDublin 2

17th January 2020

Dear Dr Deasy,

I wish to acknowledge receipt of the Major Trauma Audit National Report 2018. Following your presentation to the NOCA Governance Board on the 16th January 2020 and feedback from our membership, we are delighted to endorse this report.

On behalf of the NOCA Governance Board, I wish to congratulate you and your committee on an excellent report which gives assurance to the major trauma patients that their care is being carefully monitored in Irish hospitals.

Please accept this as formal endorsement from the NOCA Governance Board.

Yours sincerely,

Dr Brian CreedonClinical DirectorNational Office of Clinical Audit

National Office of Clinical Audit2nd Floor

Ardilaun House, Block B111 St Stephen’s Green

Dublin 2, D02 VN51Tel: + (353) 1 402 8577

Email: [email protected]


The Major Trauma Audit National Report 2018 highlights the excellent work of the National Office of Clinical Audit and the Major Trauma Audit Governance Committee. I would like to acknowledge and commend those who worked on collecting, collating and inputting the data used to produce this 2018 Report. This is the third year that the MTA has received data from all 26 hospitals currently providing trauma care. The contributions of all participating hospitals have led to continued improvements in the quality and extent of the data available from this report.

The HSE is committed to implementing the recommendations from ‘A Trauma System for Ireland, Report of the Trauma Steering Group’. The report recommends the establishment of an inclusive trauma system consisting of a South and a Central Trauma Network, where facilities and services co-ordinate care of injured patients along standardised pathways. Inclusive trauma systems have been shown to significantly reduce the number of deaths and disabilities caused by major trauma.

MTA data has identified a significant increase in access to CT within 1 hour for head injury patients from only 33% in 2016 and 41% in 2017 to 48% (n=132) in 2018, with a median time of 1.1 hours. Another notable improvement is that the number of patients requiring secondary transfer to another hospital for care has decreased; 28% in 2016, 21% in 2017 to 20% in 2018 indicating that more patients are getting to the right place at the right time than previously.

As the work on implementing the Trauma Steering Group Report’s recommendations progresses, the information available from the MTA will continue to be used to inform the detailed planning of trauma services in Ireland and directing service development. Accurate and appropriate data collection is vital to facilitating evidence informed decision making across the health system. The data from the MTA will aid decision making in the areas of trauma prevention, rehabilitation and bypass protocols to ensure that all patients receive the right care in the right place at the right time. MTA data will also enable the National Office for Trauma Services to monitor the impact of the two Trauma Networks to ensure that the advantages of an inclusive trauma system are demonstrably realised.

The Major Trauma Audit National Report 2018 is an exemplary example of how clinical audit can inform and influence improved outcomes for patients who suffer major trauma and without it planning for the establishment of an inclusive trauma system would be extremely difficult. The National Office for Trauma Services HSE will work closely with the National Office of Clinical Audit as the implementation of the ‘Trauma System for Ireland’ strategy report continues.

Mr Keith SynnottNational Clinical Lead for Trauma Services

FOREWORD

MR KEITH SYNNOTT

GLOSSARY OF TERMS AND DEFINITIONS


ACRONYM FULL TERM

AFFINITY National Falls and Bone Health Project (2018–2023)

AIS Abbreviated Injury Scale

BOAST British Orthopaedic Association Standards for Trauma and Orthopaedics

CCI Charlson Comorbidity Index

CI confidence interval

CT Computed tomography is a scanning technique that uses X-rays to take highly detailed images of the body.

DFB Dublin Fire Brigade

ECMO extracorporeal membrane oxygenation

ED emergency department

ePCR electronic patient care report

GCS Glasgow Coma Scale

GOSE Glasgow Outcome Scale Extended

HEMS Helicopter Emergency Medical Service

HIPE Hospital In-Patient Enquiry

HIQA Health Information and Quality Authority

HPO Healthcare Pricing Office

HSCP health and social care professional

HSE Health Service Executive

IAEM Irish Association for Emergency Medicine

IARM Irish Association of Rehabilitation Medicine

ICD 10 International Classification of Diseases, Tenth Revision

ICU intensive care unit

IGS Irish Gerontological Society

IQR interquartile range

IROC Irish Rehabilitation Outcomes Collaborative

ISCP Irish Society of Chartered Physiotherapists

ISS The Injury Severity Score is a score ranging from 1 (indicating minor injuries) to 75 (indicating very severe injuries that are very likely to result in death). An ISS between 9 and 15 is considered moderate. An ISS of >15 is considered severe and signifies major trauma.

IT information technology

LOS length of stay

major trauma centre (MTC)

A major trauma centre is a multispecialty hospital, on a single site, which is optimised for the provision of trauma care, and integrated with the rest of the trauma network.


ACRONYM FULL TERM

major trauma Major trauma describes serious and often multiple injuries where there is a strong possibility of death or disability.

MTA Major Trauma Audit

NAS National Ambulance Service

NCEC National Clinical Effectiveness Committee

NHS National Health Service

NOCA National Office of Clinical Audit

PPI Public and Patient Interest

PS A probability of survival (PS) is calculated for each injured patient and retained on the Trauma Audit & Research Network database. This allows comparative outcome analyses for hospitals and for other groups of patients to be performed.

RCPI Royal College of Physicians of Ireland

RCSI Royal College of Surgeons in Ireland

SCA State Claims Agency

SD standard deviation

SHO Senior House Officer

SPSS Statistical Package for the Social Sciences

TARN Trauma Audit & Research Network

TBI traumatic brain injury

TILDA The Irish Longitudinal Study on Ageing

trauma Trauma is a term which refers to physical injuries of sudden onset and severity which require immediate medical attention.

trauma network A trauma network is a coordinated, integrated system within a defined geographical region to deliver care to injured patients from injury to recovery, through prevention, pre-hospital care and transportation, emergency and acute hospital care, and rehabilitation.

trauma unit A trauma unit is a major hospital within a trauma network that provides care for most injured patients.

TRIG Trauma Review Implementation Group

UK United Kingdom

WHO World Health Organisation

Ws This calculation of probability of survival (PS) allows all the individual survival probabilities for TARN-eligible patients presenting to each hospital over a given time period to be summed. This then gives the expected rate of survival for all patients treated, which is then subtracted from the observed or actual rate of survival. The figure derived is called the standardised W score (Ws), which is equivalent to the observed minus the expected survival rate for TARN-eligible patients for the time period specified (Bouamra et al., 2006).

The Major Trauma Audit (MTA) is a clinically led audit established by the National Office of Clinical Audit (NOCA) in 2013. This audit focuses on the care of the more severely injured trauma patients in our healthcare system. The methodological approach for the MTA is provided by the Trauma Audit & Research Network (TARN) based in the University of Manchester, United Kingdom. In 2016, the MTA became the first national clinical audit endorsed by the National Clinical Effectiveness Committee (NCEC) and mandated by the Minister for Health.

The data are collected in local hospitals by audit coordinators who enter the data retrospectively from patient medical records and hospital information technology (IT) systems. The data are entered onto the TARN website. TARN sends clinical reports three times per year and dashboard reports twice per year to hospitals, audit coordinators and clinical leads in each hospital. Hospitals can also generate local reports. In addition, NOCA issues quarterly reports to the Hospital Groups. Since 2016, all 26 eligible hospitals have been participating in the audit and data have been collected on more than 21,000 trauma patients. The improved data quality and maturity of the audit has enabled hospital-level reporting since 2017.

The publication of A Trauma System for Ireland: Report of the Trauma Steering Group by the Department of Health in 2018 highlighted the importance of clinical audit data for the development and monitoring of the new inclusive trauma system. This includes robust data collection that can measure access to care, standards of care, process measures and outcomes. This information can be used by healthcare commissioners, stakeholders and wider society to monitor the effects of the reconfiguration of trauma care delivery.

In 2018, the focus for the MTA has been on aligning itself with the various ‘Think Safety First’ campaigns including workplace safety in agriculture and other industries, as well as child and home safety campaigns.

Each hospital, through its MTA governance committee, is encouraged to use MTA reports for continuous quality improvement. Without the constant leadership provided by the hospital clinical leads and the dedication and hard work of the audit coordinators, this audit would not be possible. The NOCA Executive Team and the MTA Governance Committee wish to thank the clinical leads, audit coordinators, and staff in the participating hospitals for their continued commitment to, and engagement with, this audit.

EXECUTIVE SUMMARY



PROGRESS SINCE THE LAST REPORT

Informing trauma policy

• The data from the MTA continue to support the development of a coordinated trauma system following the publication of A Trauma System for Ireland: Report of the Trauma Steering Group.

• The MTA has built a growing alliance with the National Clinical Lead for Trauma Services and the Trauma Review Implementation Group (TRIG).

Strategic developments

• NOCA is working towards providing the wider healthcare system with more details about the most common cause of major trauma injury, which is falls. This report dedicates a full chapter to that mechanism of injury. NOCA is also working closely with the Health Service Executive (HSE) AFFINITY National Falls and Bone Health Project (2018–2023) and the HSE National Quality Improvement Team on a number of falls collaboratives.

Data quality

• There has been a further improvement in data coverage, meaning that this audit provides a very reliable picture of the current state of the national trauma system.

Clinical

• There is evidence of improvement in areas such as access to computed tomography (CT) and a reduction in the percentage of patients being transferred to another hospital for further care.


KEY

FIN

DIN

GS

KEY FINDINGS

The total number of major trauma patients captured in 2018 was 5,429, representing 88% coverage.

Males (n=3083) were more likely than females to sustain a major trauma injury.

Fifty-one per cent of major trauma patients (n=2740) were aged 15–64 years and were therefore in the working-age population. Older adults, aged 65 years and over, represented 46% (n=2509) of major trauma patients.

Falls of less than 2 m, termed ‘low falls’, continue to be the most frequent cause of injury (58%, n=3169).

Half of all major trauma injuries occurred at home (n=2696), while 37% (n=1997) of injuries occurred in a public place or road.

Head injuries accounted for 18% (n=1418) of all major trauma injuries.

The predominant mechanisms of injury in patients with severe traumatic brain injury (TBI) (n=179) were road trauma (31%, n=56) and low falls (38%, n=68).

In 2018, 20% (n=1077) of patients required onward transfer to another hospital(s) for further care.

There is a variance in the percentage of ‘transfers in’ across hospitals, ranging from 0% to 56%, similarly there is a variance in the percentage of ‘transfers out’ across hospitals, ranging from 0% to 47%.

Younger patients continue to be more likely to be pre-alerted than older patients.

The overall percentage of major trauma patients received by a trauma team at the first receiving hospital remains low, at 8% (n=425).

Nine per cent (n=450) of major trauma patients were documented as having been reviewed by a consultant within 30 minutes of arrival to the emergency department.

In 2018, 2,348 surgeries were performed, the most common type being limb surgery (60%, n=1403).

A total of 649 shocked patients were recorded in 2018, representing 12% of all major trauma patients. Of those, 90% (n=587) survived and 10% (n=62) died.

In 2018, of the 273 patients who required a CT brain scan, 48% (n=132) received it within one hour. This is an increase of seven percentage points since 2017.

A total of 87,768 hospital bed days were occupied by major trauma patients in 2018, compared to 82,930 in 2017.

Forty-one per cent (n=2200) of major trauma patients were not discharged directly home from hospital.

The highest proportion of deaths occurred in patients who were aged 75 years and over (n=147).

The highest proportion of deaths continues to occur in males (63%, n=179).

The highest proportion of deaths continues to be attributable to falls less than 2 m (59%, n=170).


KEY RECOMMENDATIONS

STRATEGIC

• The MTA continues to highlight the need for a coordinated trauma system that can deliver direct and timely access to established and properly resourced trauma teams, key investigations and interventions including early CT and well coordinated multidisciplinary rehabilitation as well as to promote injury prevention.

• The MTA advocates for the implementation of the ‘Trauma System for Ireland’ strategy report as a matter of urgency and will provide data monitoring capacity to ensure the National Clinical Lead for Trauma Services and Trauma Review Implementation Group (TRIG) and Trauma Networks can monitor the system’s performance and react and prioritize resources appropriately.

• The MTA continues to highlight the need for a multi-agency, multidisciplinary and coordinated strategy to address prevention and management of the most common mechanism of injury in Ireland: low falls.

GOVERNANCE

• Each hospital should have an active MTA hospital governance committee engaged in using the reports from this audit to actively engage in quality improvement and reduce the variation in performance across all hospital sites.

• NOCA will conduct a survey of MTA hospital governance committees and will provide guidance and tools to support this.

DATA QUALITY

• NOCA will continue to work with hospitals to improve data quality e.g. matching patient cases that have been transferred from one hospital to another.

OUTCOMES

• The MTA will progress the development of key data fields in order to capture meaningful data for rehabilitation in Ireland through the rehabilitation subcommittee and the MTA Governance Committee.

• The MTA will continue to progress the development of longer-term outcome measures for the audit.

NATIONAL• Increase in coverage • Increase in access to CT • Reduction in transfers

LOCAL• Audit coordinator and clinical lead

workshops to support data collection and reporting at hospital level

SYSTEM• Support for the trauma system

reconfiguration• Support for the designation of the

Major Trauma Centre in the Central Trauma Network

• Endorsement of TraumaDoc

PUBLIC• Summary report • Social media presence• NOCA website updated with MTA

resources

IMPACT OF THE IHFD

TABLE 2: IMPACT OF THE MTA TO DATE



In 2019, I became a member of the MTA Governance Committee as the Public and Patient Interest (PPI) Representative. In my role at Spinal Injuries Ireland, I act as an advocate to support people in addressing issues encountered across a variety of health and social care settings. As a new member of the MTA Governance Committee, I will use my experience to contribute to this audit by highlighting aspects of the patient’s experience which are important for the patients and which sometimes get lost when the focus is primarily on clinical outcomes.

Patients with major trauma injuries should be supported both in hospital and beyond on their journey to recovery. For many patients, this may not be a complete recovery, and life may have changed irreversibly. Learning to adapt and cope with this change takes a lot longer than recovering from physical injuries alone, and supports need to be available to help people. At Spinal Injuries Ireland, we engage with service users who have suffered spinal cord injury (and their family members) in order to address barriers to full participation in society and to empower service users to work towards achieving their personal, social and vocational goals. We do this by providing ongoing personalised support services for people with a spinal cord injury to help them live an independent and fulfilling life at home – for as long as they need us. As part of Spinal Injuries Ireland’s strategic plan, we are keen to engage with service users and their families from the moment their injury has occurred. Due to long waiting lists for specialist rehabilitation at the National Rehabilitation Hospital (NRH), those with a spinal cord injury are being left in a vacuum not knowing what the next steps will be or when they will receive services. Spinal Injuries Ireland knows that this is the most traumatic time for patients, and is dedicated to providing them with vital one-to-one support from the time their spinal cord injury has occurred for as long as we are needed. As the MTA 2018 Report shows that 17% of patients recorded in the audit suffered a spinal injury, I will apply my experience from Spinal Injuries Ireland to patients who have suffered a major trauma.

This year, the focus of the report is “Think Safety First”, as often accidents and injuries could have potentially been avoided by better falls prevention measures, as well as improved safety in the workplace and on the roads. We each have a role to play in preventing life-changing major trauma events. The information in this report is not only of relevance to hospital professionals, but also to patients and the wider public.

This next section explains major trauma and how it is defined, as well as some common causes. Key advice is shared as to how to prevent the most common mechanism of injury: low falls.

Naomi FitzgibbonSpinal Injuries Ireland

CAPTURING PATIENT PERSPECTIVES

NAOMI FITZGIBBON


WHAT IS MAJOR TRAUMA?

Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma. These injuries can be caused by blunt or penetrating mechanisms such as falls, motor vehicle collisions, stab wounds, and gunshot wounds (World Health Organization, 2018).

WHAT ARE THE MOST COMMON CAUSES OF MAJOR TRAUMA?

Falls from less than 2 m, termed ‘low falls’, are the most common cause of major trauma in Ireland, followed by road trauma and falls more than 2 m. Falls are commonly defined as “inadvertently coming to rest on the ground, floor or other lower level, excluding intentional change in position to rest in furniture, wall or other objects” (WHO, 2018).The majority of falls occur in people’s own homes. Attention to the following details can help prevent a fall.


KITCHEN: Mop up spills straight away. Do not climb on chairs to reach high cupboards.

GARDEN AREAS: Make sure that paths are even and free of moss. Keep paths free of garden tools.

PETS: Be aware of where your pets are.

FLOORS: Secure rugs (or remove them). Have non-slip floors.

LIGHTING: Ensure adequate lighting in all rooms, steps and stairs. Use night lights inside and sensor lights outside.

BEDROOM: If you feel off balance or have difficulty dressing yourself, sit on the bed and get dressed there.

CORDS AND CABLES: Remove cords and cables from walkways.

BATHROOM: Install grab rails. Use a non-slip mat. Be careful on wet floors.

CHECK YOUR SURROUNDINGS AND TAKE STEPS TO MAKE THEM SAFER

STAIRS AND STEPS: Mark edges of steps clearly. Use slip-resistant strips. Install handrails the full length of the stairs/steps.

REMOVE CLUTTER


REPORT HIGHLIGHTS 2018

50%50% of patients

sustained an injury in their own home

48%48% of patients with GCS <13 received a

CT within 1 hour

58%58% of patients had

a ‘low fall’ of less than 2 metres

88%88% data coverage

62Median age

was 62 years


59%59% of patients were discharged

directly home

9Median length

of acute hospital stay was 9 days

87,76887, 768 acute

bed days for major trauma patients

20%20% of patients were transferred

to another hospital for further care

25%25% of patients sustained limb

injuries

CHAPTER 1INTRODUCTION


Approximately 5.8 million people globally die each year as a result of injuries. This accounts for 10% of the world’s deaths, 32% more than the number of fatalities that result from malaria, tuberculosis, and HIV/AIDS combined (World Health Organization, 2015). Nearly one-third of the 5.8 million deaths from injuries are a result of violence – suicide, homicide and war – and nearly one-quarter are a result of road traffic crashes. Other main causes of death from injuries are falls, drowning, burns and poisoning (World Health Organization, 2018).

This is the fourth Major Trauma Audit (MTA) National Report published by the National Office of Clinical Audit (NOCA). The MTA was developed using the Trauma Audit & Research Network (TARN) methodology. TARN has been in operation in the United Kingdom (UK) since the 1980s, and has been at the forefront of quality and research initiatives in trauma care. It is the largest trauma registry in Europe and is clinically led, academic and independent. TARN has been integral to the reconfiguration of trauma care delivery in the UK and monitors the effects of the changes implemented. TARN receives and analyses anonymised MTA submissions from participating Irish hospitals and reports back to these hospitals. This feedback from TARN and NOCA supports hospitals’ and clinicians’ learning and the continuous improvement of care delivered to patients with major trauma. The MTA has gathered data on more than 21,000 major trauma patients in Ireland since 2013.

The data from the MTA have informed key system changes, such as the reconfiguration of the trauma system and the designation of major trauma centres and trauma units (Department of Health, 2018). The MTA enables hospitals to measure their care against defined clinical standards in a transparent way and supports active engagement in quality improvement. International evidence has shown us that the synergy between care standards, audit and feedback drive measurable improvements in hip fracture outcomes for patients, including a reduction in mortality (NHFD, 2015); this also applies to major trauma.

Major trauma patients often spend a prolonged period in hospital; in 2018, this equated to 87,768 acute hospital bed days. The variance in access to services – including emergency services, specialty services, critical care capacity and rehabilitation – continues to challenge the Irish healthcare system. Often, these patients require input and care from multiple specialties; the MTA Governance Committee welcomes the progress towards the designation of the major trauma centres and trauma units currently under way and continues to recommend a coordinated, integrated, inclusive trauma system with predetermined, seamless patient pathways in place. In the UK, the development of such a system has led to an odds of survival increase of 19% since 2012 (Moran et al., 2018).

INTRODUCTION

CHAPTER 1


CHAPTER 1

Approximately 5.8 million people globally die each year as a result of injuries. This accounts for 10% of the world’s deaths, 32% more than the number of fatalities that result from malaria, tuberculosis, and HIV/AIDS combined (World Health Organization, 2018).


CHAPTER 1

The work reported here is intended for the use of a wide range of individuals and organisations, including:

• patients and carers• patient organisations• healthcare professionals• hospital managers• Hospital Groups• policy-makers.

The report has been designed in two parts:

1 The Major Trauma Audit National Report 2018 presents our key findings from the audit, including case mix, patient pathway and outcomes.

2 The Major Trauma Audit Summary Report 2018: will be of particular interest to patients, patient organisations and the public.

WHO IS THIS REPORT AIMED AT?


AIM AND OBJECTIVES

OBJECTIVE 3

To provide high-quality data in order to enable research.

OBJECTIVE 2

To promote the use of the data for reflective clinical practice, peer review and quality improvement in order to improve quality of care and reduce death and disability from trauma.

OBJECTIVE 4

To work towards collecting quality-of-life and functional outcome measures which provide greater sensitivity to patient-centred outcomes.

OBJECTIVE 1

To support the collection of high-quality data in line with Health Information and Quality Authority (HIQA) standards on all major trauma patients in Ireland for local, national and international reporting and comparison.

OUR AIMThe MTA will drive

system-wide quality improvement to achieve the best

outcomes for trauma patients in Ireland.

CHAPTER 1


NOTE: Dublin Hospitals have been displayed collectively by hospital group

SAOLTA UNIVERSITY HEALTH CARE GROUPLetterkenny University HospitalMayo University HospitalSligo University HospitalUniversity Hospital Galway and Merlin Park University Hospital

RCSI HOSPITALSBeaumont HospitalCavan General HospitalConnolly HospitalOur Lady of Lourdes Hospital, Drogheda

DUBLIN MIDLANDS HOSPITAL GROUPMidland Regional Hospital, TullamoreMidland Regional Hospital, PortlaoiseNaas General HospitalSt James’s HospitalTallaght University Hospital

IRELAND EAST HOSPITAL GROUPMater Misericordiae University HospitalRegional Hospital MullingarSt Luke’s General Hospital, KilkennySt Vincent’s University HospitalWexford General Hospital

CHILDREN’S HEALTH IRELANDChildren’s Health Ireland at CrumlinChildren’s Health Ireland at Temple Street

UL HOSPITAL GROUPUniversity Hospital Limerick

SOUTH/SOUTH WEST HOSPITAL GROUPCork University HospitalMercy University HospitalSouth Tipperary General HospitalUniversity Hospital KerryUniversity Hospital Waterford

HOSPITALS AND PEOPLE WE WORK WITH

LETTERKENNY UNIVERSITY HOSPITAL

CLINICAL LEAD: Dr Sinead O’Gorman

AUDIT COORDINATOR: Patrick McGonagle

MAYO UNIVERSITY HOSPITAL

CLINICAL LEAD: Dr Ciara Canavan

CLINICAL LEAD: Dr Ann Shortt

AUDIT COORDINATOR: Paul Crisham

SLIGO UNIVERSITY HOSPITAL

CLINICAL LEAD: Dr Kieran Cunningham

AUDIT COORDINATOR: Erin Lyons

UNIVERSITY HOSPITAL LIMERICK

CLINICAL LEAD: Dr Cormac Meighan

AUDIT COORDINATOR: Michael Fitzpatrick

MIDLANDS REGIONAL HOSPITAL, PORTLAOISE

CLINICAL LEAD: Dr Suvarna Maharaj

AUDIT COORDINATOR: Louise Cooke

UNIVERSITY HOSPITAL KERRY

CLINICAL LEAD: Dr Niamh Feely

AUDIT COORDINATOR: Esther O’Mahony

CORK UNIVERSITY HOSPITAL

CLINICAL LEAD: Mr James Clover

AUDIT COORDINATOR: Ann Deasy

AUDIT COORDINATOR: Karina Caine

UNIVERSITY HOSPITAL WATERFORD

CLINICAL LEAD: Mr Morgan McMonagle

AUDIT COORDINATOR: Margaret Mulcahy

SOUTH TIPPERARY GENERAL HOSPITAL

CLINICAL LEAD: Dr Cyrus Mobed

AUDIT COORDINATOR: Susan Ryan

MERCY UNIVERSITY HOSPITAL

CLINICAL LEAD: Dr Adrian Murphy

AUDIT COORDINATOR: Ann Deasy

CHAPTER 1

CLINICAL LEAD: Mr Alan Hussey

AUDIT COORDINATOR: Paul Crisham

UNIVERSITY HOSPITAL GALWAY AND MERLIN PARK UNIVERSITY HOSPITAL


BEAUMONT HOSPITAL

CLINICAL LEAD: Dr Patricia Houlihan

AUDIT COORDINATOR: Anna Duffy

AUDIT COORDINATOR: Andrea Ormond

AUDIT COORDINATOR: Anthony O’Loughlin

CAVAN GENERAL HOSPITAL

CLINICAL LEAD: Dr Ashraf Butt

AUDIT COORDINATOR: Eilish Sweeney

CONNOLLY HOSPITAL

CLINICAL LEAD: Dr Emily O’Connor

AUDIT COORDINATOR: Therese Yore

CLINICAL LEAD: Dr Niall O’Connor

AUDIT COORDINATOR: Deborah McDaniel

OUR LADY OF LOURDES HOSPITAL, DROGHEDA

ST VINCENT’S UNIVERSITY HOSPITAL

CLINICAL LEAD: Dr John Cronin

AUDIT COORDINATOR: Brenda Cormican

AUDIT COORDINATOR: Keith O’Brien

WEXFORD GENERAL HOSPITAL

CLINICAL LEAD: Dr Paul Kelly

CLINICAL LEAD: Dr Michael Molloy

AUDIT COORDINATOR: Roisin O’Neill

CLINICAL LEAD: Dr Tomás Breslin

CLINICAL LEAD: Mr Seamus Morris

AUDIT COORDINATOR: Marion Lynders

MATER MISERICORDIAE UNIVERSITY HOSPITAL

CLINICAL LEAD: Dr Carol Blackburn

CLINICAL LEAD: Mr Brian Sweeney

AUDIT COORDINATOR: Suzanne Byrne

AUDIT COORDINATOR: Louise Purcell

AUDIT COORDINATOR: Trisha Hynds

CHILDREN’S HEALTH IRELAND AT CRUMLIN

CLINICAL LEAD: Prof Alf Nicholson

AUDIT COORDINATOR: Jennifer Doyle

CHILDREN’S HEALTH IRELAND AT TEMPLE STREET

REGIONAL HOSPITAL MULLINGAR

CLINICAL LEAD: Dr Sam Kuan

AUDIT COORDINATOR: Helen Evans

ST LUKE’S GENERAL HOSPITAL

CLINICAL LEAD: Dr David Maritz

AUDIT COORDINATOR: Frances Walsh

CLINICAL LEAD: Dr Anna Moore

AUDIT COORDINATOR: Anita Sawyer

MIDLANDS REGIONAL HOSPITAL, TULLAMORE

TALLAGHT UNIVERSITY HOSPITAL

CLINICAL LEAD: Dr Jean O’Sullivan

CLINICAL LEAD: Dr Ciara Martin

AUDIT COORDINATOR: Noel Redmond

CHAPTER 1

ST JAMES’S HOSPITAL

CLINICAL LEAD: Mr Niall Hogan

CLINICAL LEAD: Dr Geraldine McMahon

AUDIT COORDINATOR: Ricardo Paco

NAAS GENERAL HOSPITAL

CLINICAL LEAD: Mr George Little

AUDIT COORDINATOR: Martina Wyse

CHAPTER 2METHODOLOGY


DATA COLLECTION PROCESS (INCLUSION CRITERIA)i

All trauma patients, irrespective of age

who fulfil one of the following length-of-stay (LOS) criteria

and whose isolated injuries meet one of the criteria identified in Appendix 1

GOVERNANCE STRUCTURE

NOCA Governance Board

MTA Governance Committee

MTA Operational Team

Deaths including deaths in the ED, even

if cause of death is medical

Transferred out for specialist care

or repatriation (total LOS > 3days)

Transferred in for specialist care

or repatriation (total LOS >3 days)

Admitted to a critical care

area (regardless of LOS)

In hospital for >3 days

MTA METHODOLOGY

CHAPTER 2

i This report details all major trauma patients who fulfill the inclusion criteria, including those with all classifications of Injury Severity Score (ISS).


CHAPTER 2

EXCLUSION CRITERIA

HIPEIN ISOLATION:

Scalp injuries Muscle injury

Spontaneous haemorrhage (stroke, aneurysm)

Tendon injury

Loss of consciousness Sprain

All skin injuries Hand or foot fracture/s

Closed/stable fractures of the face (even if multiple)

Crush: Digits alone

All other injuries to the eye Amputation: Digits alone

All injuries to ear ≤10% superficial or partial thickness burns

Nerve injury (neck) Bruises

Spinal strain (whiplash) Abrasions

Ligament injuries Minor skin lacerations

Hip fractures in patients aged ≥65 years old

Minor penetrating injuries to skin

Single pubic rami fracture Hypothermia

Closed fractures and/or dislocations of one limb (even if multiple)

TABLE 2.1: EXCLUSION CRITERIA


CHAPTER 2

DATA COLLECTION PROCESS

Data are collected from various sources such as the pre-hospital patient care report (PCR); hospital clinical records, including laboratory and radiology; the Hospital In-Patient Enquiry (HIPE) scheme;

the Integrated Patient Management System (IPMS); coroners’ reports; and other data systems. Audit coordinators submit these anonymised data to TARN.

SCORES ASSIGNED TO EACH PATIENT

Abbreviated Injury Scale (AIS) and Injury Severity

Score (ISS)

PROBABILITY OF SURVIVAL

ASSIGNED

TARN


CHAPTER 2

DATA ENTRY

DATA ANALYSIS

Data collection period Data entry target Data reporting date

01/01/2018–31/03/2018 30/09/2018 18/10/2018

01/04/2018–30/06/2018 31/12/2018 30/01/2019

01/07/2018–30/09/2018 31/03/2019 18/04/2019

01/10/2018–31/12/2018 30/06/2019 30/07/2019

TABLE 2.2: DATA COLLECTION CALENDAR 2018

NOCA received the data extract from TARN on 30 July 2019, and analysis was completed by the NOCA Data Analyst following data checks with TARN. The analysis was conducted using Statistical Package for the Social Sciences (SPSS) V25.

CHAPTER 3DATA

QUALITYRelevance

Accessibility and clarity

Timeliness and punctuality

Coherence and comparability

Accuracy and reliability

CHAPTER 3

DATA FOR THIS MTA REPORT

This report includes patients who:1. Arrived for trauma care between 1 January 2018 and 31 December 2018.2. Fulfilled the TARN eligibility criteria for inclusion (see Appendix 1).

DATA QUALITY STATEMENT

The purpose of the data quality statement (Table 3.2) is to highlight the assessment of the quality of the MTA 2018 data using internationally agreed dimensions of data quality as laid out in Guidance on a data quality framework for health and social care (Health Information and Quality Authority, 2018). An overview of the aim and objectives of the MTA data collection is included in Chapter 1, and the MTA data source description is detailed in Chapter 2. The data quality statement identifies strengths (e.g. decrease in the percentage of ‘not knowns’ in airway management in patients with a Glasgow Coma Scale (GCS) <9) and areas for improvement (e.g. matching of TARN submissions). An overview of the assessment of MTA against the dimensions of data quality is presented in Table 3.2.

DATA QUALITY

TABLE 3.1: DATA ANALYSIS FOR MTA REPORT 2018

2018

Number of participating hospitals 26

All TARN submissions 6135

Individual patients 5429

Not transferred (into or out of first hospital) 4352

Direct admissions 5085


CHAPTER 3


TABLE 3.2: OVERVIEW OF DATA QUALITY FOR MTA 2018

Dimensions of data quality

Definition (HIQA, 2018)

Assessment of dimension (MTA)

Relevance Relevant data meet the current and potential future needs of users.

The MTA dataset is reviewed continuously as part of the TARN and MTA governance structures in order to ensure that all data fields are relevant. All core data fields are reported on in the national report and in local hospital reports. Monthly teleconferences with the audit coordinators enable any new data fields or definitions to be discussed and feedback given to TARN.

In 2018, the MTA Governance Committee identified a need to improve the data collection in Ireland for rehabilitation of trauma patients included in the MTA. A rehabilitation subgroup was established, including experts in rehabilitation and geriatrics, health and social care professionals (HSCPs), and the MTA Manager. Several meetings took place in 2018 and early 2019, and a pilot data collection tool was developed based on TARN’s Major Trauma Rehabilitation Prescription guidance. In February 2019, the paper-based data collection tool for rehabilitation was introduced at the MTA workshop in the Royal College of Surgeons in Ireland (RCSI), and 10 hospitals were asked to pilot it. The results of this pilot will be reviewed by the rehabilitation subgroup. Final results will be provided to the MTA Governance Committee and new data field recommendations made to TARN.

Feedback on the relevance of the data is sought through interactions with other organisations such as the Healthcare Pricing Office (HPO), the Trauma Review Implementation Group (TRIG), the Health Service Executive (HSE) and researchers. Regular meetings took place in 2018 in fulfillment of this. The NOCA quarterly reports for 2019 are being improved based on feedback and reviews of the 2018 reports in order to further enhance the quality of these reports.

CHAPTER 3


TABLE 3.2: OVERVIEW OF DATA QUALITY FOR MTA 2018 (CONTINUED)




Accuracy and reliability

Data correctly and consistently describes what it was designed to measure.

The MTA collects data on trauma patients through a secure portal on the TARN website. The reference population for the national report focuses only on patients who have the relevant trauma-related codes and length of stay criteria detailed in Appendix 1.

The coverage for the reference population has been reported at hospital level in the annual national report, and quarterly to the Hospital Groups, since 2017. The expected standard is a minimum of 80% coverage. In 2018, 20 hospitals achieved above the 80% coverage target, with the final national coverage being 88%.

NOCA collaborates with hospitals and TARN to improve data entry, identify duplicates and clarify missing or incorrect data. TARN provides an accreditation report which calculates the completion of key data fields (detailed in Figure 3.3).

In 2018, two workshops were held for audit coordinators and clinical leads. These workshops were provided by TARN and consisted of a morning session focused on data entry and an afternoon session focused on interpretation of TARN reports. Both workshops were well attended. TARN provides biannual dashboard validation reports to hospitals; these are used by the hospitals in order to review data quality. Other validation reports are also available by logging on to the TARN website (www.tarn.ac.uk).

Although most MTA submissions (i.e. patient journeys) are matched when patients move from one hospital to another, there are a small number of cases that are not, and therefore this will be a key area of focus for improvement within the audit.

CHAPTER 3






Timeliness and punctuality

Data is collected within a reasonable agreed time period and is delivered on the dates promised.

NOCA issues data collection targets for each hospital to collect a minimum of 80% of data per reporting quarter. The timeliness of submissions per quarter for 2018 was as follows:

Quarter 1: 30 September 2018 Quarter 2: 31 December 2018 Quarter 3: 31 March 2019 Quarter 4: 30 June 2019

These data are processed and reported (released) by NOCA to Hospital Groups within three weeks of the end of the reporting quarter, one quarter in arrears. The MTA NOCA reporting calendar is provided in Chapter 2 (Table 2.2).

These reports highlight the national coverage versus the individual hospital coverage in relation to the data collection target and compliance with a number of clinical standards.

These reports are in addition to the TARN clinical working reports, dashboard reports and local reports generated by the hospitals.

Data entry targets are reviewed quarterly at each MTA Governance Committee meeting. The closing date for data entry for 2018 was 30 June 2019. The NOCA monitoring and escalation policy details the process of escalation. In 2018, 20 hospitals met the annual target of 80% data coverage and 6 did not. Any hospitals which were not meeting the quarterly targets were contacted and supported by the MTA Manager in achieving their targets. Some hospitals did not have an audit coordinator during the data collection period for 2018 for various reasons, and therefore had a considerable backlog of data. NOCA supported these hospitals to enter the backlog by providing extra training.

CHAPTER 3






Coherence and comparability

Data is consistent over time and across providers and can be easily combined with other sources.

The MTA uses validated and comparable metrics to allow benchmarking, including the International Classification of Diseases, Tenth Revision (ICD 10) codes used in the Hospital In-Patient Enquiry (HIPE) system, the Charlson Comorbidity Index (CCI), the Glasgow Outcome Scale Extended (GOSE), the British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST), the Injury Severity Score (ISS) and the Abbreviated Injury Scale (AIS).

TARN has a procedure manual for the Republic of Ireland (updated April 2019) available from the TARN website, and NOCA provides a handbook for data collection, which is available on the NOCA website www.noca.ie.

In 2018, a more detailed data dictionary for MTA was commenced, in line with HIQA’s Guidance on a data quality framework for health and social care (HIQA, 2018).

MTA data can be compared directly with data in the UK through the TARN audit. Some definitions vary slightly, but overall, the audit acts as an appropriate international comparator.

Any changes to the dataset, definitions and methodology are documented on the TARN website (www.tarn.ac.uk), and any relevant changes would be noted in the MTA National Report. Changes in data collection are highlighted in the national report and on the TARN website. There have been no changes documented to date.

CHAPTER 3






Accessibility and clarity

Data is easily obtainable and clearly presented in a way that can be understood.

A list of publications for the years 2014-2017 is available on the NOCA website under Reports and Research www.noca.ie.

Hospitals and Hospital Groups (if requested) can access their TARN data via a secure portal on the TARN website. This includes three clinical working reports, two dashboard reports, and a number of local reports. Access to TARN data for Ireland is managed and governed by NOCA. Policies relating to this are being reviewed in 2019 in order to align with evolving data protection legislation (Data Protection Act 2018 (Section 36(2)) (Health Research Regulations 2018).

The data access request policy is available by contacting NOCA [email protected]

Ad-hoc requests for data or audit reports must receive approval from the MTA Governance Committee.

CHAPTER 3


DATA COVERAGE BY HOSPITALThe data coverage refers to the measure of major trauma cases entered against the overall expected number of cases (this is also referred to as case ascertainment). The expected number of cases is initially estimated based on the HIPE codes for the previous year, and then amended throughout the reporting year when the national HIPE file closes for the actual reporting year (i.e. 2018). The TARN eligibility criteria for inclusion (Appendix 1) are applied to the national HIPE codes in order to estimate how many patients in each hospital potentially meet the inclusion criteria for the audit. The limitations to this process were identified in the Major Trauma Audit National Report 2016, and during 2017 and 2018, NOCA worked with the HPO and TARN in order to enable the audit coordinators from the hospitals to identify cases that did not meet the inclusion criteria for the audit and exclude these from the hospital denominators.

The national coverage for the Major Trauma Audit National Report 2018 is 88%, a two-percentage-point improvement from the 2017 report (Figure 3.1). This is a direct result of the hard work and commitment of our audit coordinators and clinical leads. Twenty hospitals achieved the TARN coverage (case ascertainment) target of 80%, and six hospitals did not. Several of the hospitals that did not meet this target did not have an audit coordinator in place for a prolonged period of time during 2018–2019.

In 2018, St James’s Hospital did not enter data on burns patients, as these data were being entered into another clinical audit focused specifically on burns. The MTA Governance Committee agreed that from 2019 onwards, these data should be entered into the MTA in order to provide a full national picture of major trauma.

FIGURE 3.1: DATA COVERAGE PERCENTAGES BY HOSPITAL

DDAATTAA CCOOVVEERRAAGGEE 33..11

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Tem

ple

Stre

et

St. J

ames

's

Con

nolly

Bea

umon

t

Kilk

enny

Wex

ford

Tipp

erar

y

Mer

cy

Mul

linga

r

Port

laoi

se

Cor

k

Lim

eric

k

Cav

an

Dro

ghed

a

May

o

Tulla

mor

e

Mat

er

St. V

ince

nt's

Ker

ry

Talla

ght

Slig

o

Wat

erfo

rd

Gal

way

Lett

erke

nny

Naa

s

Cru

mlin

Nat

iona

l

PERC

ENTA

GE

HOSPITALS

National CompletenessCompleteness Target completeness

CHAPTER 3


DATA ACCREDITATION BY HOSPITALThe completion of key data fields is used as the second measure of data quality (Figure 3.3). TARN applies a standard of 95% for this measure. The national data accreditation level for the 2018 MTA is 94%, which is lower than the expected standard and three percentage points lower than the 2017 report (Figure 3.2). This is a concerning development, but it is due in part to the lack of audit coordinator replacement in a number of hospitals throughout the year, as well as the lack of protected time for the audit coordinators to validate data in a timely fashion. Many of the data discrepancies will be rectified in time for the subsequent TARN reports issued to the hospitals, but, due to staffing and other issues, could not be corrected in a timely manner for the publication of this report.

FIGURE 3.2: DATA ACCREDITATION PERCENTAGES BY HOSPITAL

DDAATTAA CCOOVVEERRAAGGEE 33..22

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Dro

ghed

a

Mat

er

May

o

Mer

cy

Tem

ple

Stre

et

Cor

k

Gal

way

Cav

an

Con

nolly

Lett

erke

nny

Kilk

enny

Wat

erfo

rd

Bea

umon

t

Slig

o

Talla

ght

Ker

ry

Sout

h Ti

pper

ary

Mul

linga

r

Wex

ford

Lim

eric

k

St. V

ince

nt's

St J

ames

's

Cru

mlin

Port

laoi

se

Tulla

mor

e

Naa

s

Nat

iona

l

PERC

ENTA

GE

HOSPITALS

Completeness Target completeness National Completeness

CHAPTER 3


FIGURE 3.3: DATA ACCREDITATION BY KEY DATA FIELDS

FFIIGGUURREE 33..33:: DDAATTAA AACCCCRREEDDIITTAATTIIOONN BBYY KKEEYY DDAATTAA FFIIEELLDDSS

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre-existingconditions

Arrival time Operationdetails

Computedtomography

details

Doctors in theemergencydepartment

GCS Injury details Transfer details Pupil reactivity Incident/999call details

PERC

ENTA

GE

KEY DATA FIELDS

94%

National Mean Accreditation

CHAPTER 4WHO WAS INJURED

AND HOW WERE THEY INJURED

CHAPTER 4

WHO WAS INJURED AND HOW WERE THEY INJURED?


GENDER AND AGE BAND

The mean age of patients in this report is 59 years, and the median age is 62 years; this is an increase of one year, respectively, on the Major Trauma Audit National Report 2017. Major trauma could be described as affecting younger men and older women. While overall, 57% (n=3083) of patients in 2018 were male (Figure 4.1), among those aged 85 years or over, females were the predominant gender (Figure 4.1A).

FIGURE 4.1: PERCENTAGE OF MTA PATIENTS BY GENDER (N=5429)

57% 43%

57% 43%

MaleFemale

CHAPTER 4


FIGURE 4.1A: PERCENTAGE OF MTA PATIENTS BY GENDER AND AGE GROUP (N=5429)

FFIIGGUURREE 44..11AA:: PPEERRCCEENNTTAAGGEE OOFF MMTTAA PPAATTIIEENNTTSS BBYY GGEENNDDEERR AANNDD AAGGEE GGRROOUUPP ((NN==55442299))

Male 93 331 345 354 424 457 404 452 223

Female 87 89 97 117 169 357 395 562 473

AGE GROUP

48%

21% 22% 25% 28%

44%49%

55%

68%

52%

79% 78% 75% 72%

56%51%

45%

32%

0%

20%

40%

60%

80%

100%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

PERC

ENTA

GE

AGE GROUP

93MALE (n) 424345 404331 457354 452 223

0-14 45-5425-34 65-7415-24 55-6435-44 75-84 85+

87FEMALE (n) 16997 39589 357117 562 473

Fifty-one per cent of patients (n=2740) were aged 15–64 and were therefore in the working-age population. Older adults, aged 65 years and over, represented 46% (n=2509) of patients.

CHAPTER 4

PRE-EXISTING MEDICAL CONDITIONS

The CCI has been adapted and validated for predicting the outcome and risk of death for many comorbid diseases (Charlson et al., 1987). The CCI is used in statistical adjustment for comorbidities in TARN. Older patients will generally have a greater burden of significant comorbidities.

Figure 4.2 shows that, in 2018, 46% of patients (n=2501) had no significant pre-existing conditions, 37% (n=2009) had mild comorbidities, 12% (n=660) had moderate comorbidities and 4% (n=220) had severe comorbidities. The distribution of comorbidities, when presented by age band, shows that the number of comorbidities increases with age (Figure 4.2A).


FIGURE 4.2: CCI SCORE OF MTA PATIENTS (N=5429)

FFIIGGUURREE 44..22:: CCCCII SSCCOORREE OOFF MMTTAA PPAATTIIEENNTTSS ((NN==55442299))

11%%

44%%

1122%%

3377%%

4466%%

0% 10% 20% 30% 40% 50%

Not recorded

Severe comorbidities (>10)

Moderate comorbidities (6 - 10)

Mild comorbidities (1 - 5)

No significant pre-existing comorbidities

PERCENTAGE

CCI s

core

CHAPTER 4


FFIIGGUURREE 44..22AA:: CCCCII SSCCOORREE OOFF MMTTAA PPAATTIIEENNTTSS BBYY AAGGEE GGRROOUUPP ((NN==55442299))

93%83%

74%

61%53%

45%38%

23% 22%

3%16%

23%

32%35%

39%42%

46% 50%

1%4% 8%

8% 14%24% 23%

1% 4% 4% 6% 5% 5% 5%3% 1% 1% 0% 1% 1% 0% 0% 1%

0%

20%

40%

60%

80%

100%

0–14 15–24 25–34 35–44 45–54 55–64 65–74 75–84 85+

PERC

ENTA

GE

AGE BAND

No significant pre-existing comorbidities Mild comorbidities (1-5)

Moderate comorbidities (6-10) Severe comorbidities (>10)

Not recorded

FIGURE 4.2A: CCI SCORE OF MTA PATIENTS BY AGE GROUP (N=5429)

CHAPTER 4


MECHANISM OF INJURY

Falls of less than 2 m, termed ‘low falls’, continue to be the most frequent cause of injury (58%, n=3169). Falls will be further explored in Chapter 5. The second most frequent cause of major trauma is road trauma (16%, n=875), followed by falls of greater than 2 m (10%, n=557) (Figure 4.3). Low falls are the most common mechanism of injury in those aged 35 years and over and in children. In children, a height of 2 m could be considered high relative to their height. In those aged 15–34 years, the most common mechanisms of injury are road trauma and blows (Figure 4.3A).

FIGURE 4.3: MECHANISM OF INJURY (N=5429)

FFIIGGUURREE 44..33:: MMEECCHHAANNIISSMM OOFF IINNJJUURRYY ((NN==55442299))

1%

1%

1%

3%

10%

10%

16%

58%

0% 10% 20% 30% 40% 50% 60%

Crush

Stabbing

Burn

Other

Blow(s)

Fall more than 2 m

Road trauma

Fall less than 2 m

PPEERRCCEENNTTAAGGEE

MMEECC

HHAA

NNIISS

MM OO

FF IINN

JJUURR

YY

CHAPTER 4


FFIIGGUURREE 44..33AA:: MMEECCHHAANNIISSMM OOFF IINNJJUURRYY BBYY AAGGEE GGRROOUUPP ((NN==55442299))

11%

34%28%

15%10%

5% 4% 2% 1%

44%

12%18%

28%46%

64% 69%82%

93%

9%

10% 13%15%

15%

14%10%

7%

2%

13%

9%10% 15%

8%

3% 3%

2%

1%22% 34% 30% 27% 22% 14% 13% 7% 3%

0%

20%

40%

60%

80%

100%

0–14 15–24 25–34 35–44 45–54 55–64 65–74 75–84 85+

PERC

ENTA

GE

AGE BAND

Blow(s) Fall less than 2 m Fall more than 2 m Other Road trauma

FIGURE 4.3A: MECHANISM OF INJURY BY AGE GROUP (N=5429)1

* Please note: Percentages may not sum to 100% due to rounding.

CHAPTER 4


FIGURE 4.4: INJURIES SUSTAINED BY BODY REGION (N=8008)*

INJURIES SUSTAINED

HEAD LIMBFACE

All head injuries: 1418 (18%*)Severe head injuries: 1222 (86%)Isolated severe head injuries 656 (54%)Severe head injuries and other associated injuries 566 (46%)

All limb injuries 1960 (25%)Severe limb injuries 1239 (63%)Isolated severe limb injuries 998 (81%)Severe limb injuries and other associated injuries 241 (20%)

All face injuries 766 (10%)Severe face injuries 10 (1%)Isolated severe face injuries <5 (20%)Severe face injuries and other associated injuries 8 (80%)

18%10% 25%

SPINAL

All spinal injuries 1392 (17%)Severe spinal injuries 708 (51%)Isolated severe spinal injuries 444 (63%)Severe spinal injuries and other associated injuries 264 (37%)

17%

PELVIC

All pelvic injuries 653 (8%)Severe pelvic injuries 150 (23%)Isolated severe pelvic injuries 56 (37%)Severe pelvic injuries and other associated injuries 94 (63%)

8%

CHEST AND ABDOMINAL

All chest and abdominal injuries 1541 (19%)Severe chest and abdominal injuries 1104 (72%)Isolated severe chest and abdominal injuries 393 (36%)Severe chest and abdominal injuries and other associated injuries 711 (64%)

19%

OTHER

All other injuries 278 (4%)Severe other injuries 96 (35%)Isolated other injuries 75 (78%)Severe other injuries and other associated injuries 21 (22%)

4%

All injures1 recorded (N=8008)

TABLE 4.1: NUMBER OF BODY REGIONS INJURED PER PATIENT (N=5429)

NUMBER OF BODY REGIONS INJURED NUMBER OF PATIENTS %

1 3688 70%2 1176 22%3 366 7%4 141 3%5 44 1%6 12 <1%7 2 0.0%Total 5429 100%

Almost one-third (32%, n=1741) of major trauma patients have injured two or more body regions (Table 4.1).


CHAPTER 4


INJURY SEVERITY SCORE (ISS)

When auditing the management of major trauma, it is important to have a method for grading the severity of trauma sustained by a patient. Each injury is scored between 1 and 6 based on its severity. An Abbreviated Injury Scale (AIS) score of 1 represents a minor injury, whereas an AIS score of 6 represents an injury that is not survivable (Appendix 1). This contributes to the overall ISS for that patient, which is rated on a scale from 0–75 (Baker et al., 1974).

TABLE 4.2: ISS CLASSIFICATION

ISS CLASSIFICATION ISS SCORE EXAMPLES OF INJURIES

Low-severity injury 1-8 Fractured wrist and ankle Simple skull fracture Small bleed in liver

Moderate-severity injury 9-15 Fractured femur Small brain contusion (bruising)

Severe injury > 15 Large subdural haematoma (bleed between skull and brain) Fracture of the pelvis with significant blood loss Severe injuries to multiple body regions

A breakdown of the ISS across all injured patients is presented in Figure 4.5. This shows that, in 2018, 43% (n=2335) of major trauma patients suffered moderate-severity injuries and 32% (n=1727) suffered severe injuries (this figure represents patients whose data were captured at either their admitting hospital or the receiving hospital). The distribution of ISS by age group is shown in Figure 4.5A.

FIGURE 4.5: PERCENTAGE OF PATIENTS BY ISS (N=5429)

FFIIGGUURREE 44.. 55:: PPEERRCCEENNTTAAGGEE OOFF PPAATTIIEENNTTSS BBYY IISSSS ((NN==55442299))

2255%%

4433%%

3322%%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Low-severity injury

Moderate-severity injury

Severe injury

PPEERRCCEENNTTAAGGEE

IISSSS

CHAPTER 4



FIGURE 4.5A: INJURY SEVERITY BY AGE GROUP (N=5429)*

FFIIGGUURREE 44..55AA:: IINNJJUURRYY SSEEVVEERRIITTYY BBYY AAGGEE GGRROOUUPP ((NN==55442299))

17%

39%34%

25%20% 17%

25% 27% 26%

49%

26%31%

42% 49% 56%46% 39% 43%

34% 35% 35% 32% 31% 28% 30%35% 31%

0%

20%

40%

60%

80%

100%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

PERC

ENTA

GE

AGE BAND

Low-severity injury Moderate-severity injury Severe injury

CHAPTER 4


PLACE OF INJURY

Home was recorded as the place where half (50%, n=2696) of major trauma injuries occurred. Thirty-seven per cent (n=1997) of injuries occurred in a public place or road (Figure 4.6). The place of injury is presented by age in Figure 4.6A. Home is the predominant place of injury in the 0–14-year-old age band and among those aged 55 years and over. Major trauma patients aged 15–54 years are more likely to be injured in a public area or on the road (Figure 4.6A). The ISS by place of injury is described in Figure 4.6B.


FIGURE 4.6: PLACE OF INJURY (N=5429)*

Public area or road

Home Farm IndustrialInstitution Other

FFIIGGUURREE 44..66:: PPLLAACCEE OOFF IINNJJUURRYY ((NN==55442299))

50%

37%

4% 4% 2% 4%0%

10%

20%

30%

40%

50%

Home Public area or road Institution Farm Industrial Other

PERC

ENTA

GE

PLACE OF INJURY

FFIIGGUURREE 44..66:: PPLLAACCEE OOFF IINNJJUURRYY ((NN==55442299))

50%

37%

4% 4% 2% 4%0%

10%

20%

30%

40%

50%


PERC

ENTA

GE

PLACE OF INJURY

CHAPTER 4


6 218 cases had ‘Other’ recorded, these cases have been excluded from figure 4.6B* Please note: Percentages may not sum to 100% due to rounding.

FIGURE 4.6A: PLACE OF INJURY BY AGE GROUP (N=5429)*

FFIIGGUURREE 44..66AA:: PPLLAACCEE OOFF IINNJJUURRYY BBYY AAGGEE GGRROOUUPP ((NN==55442299))

49%

14%20%

29%

39%

49%

59%

69%74%

4%

1%

1%

2%

2%

3%

7%

11%

4%

4%

3%

4%

4%

5%

5%

3%

1%

1%

1%

3%

5%

4%

3%

2%

4%

5%

4%

7%

7%

4%

3%

3%

1%

38%

76%69%

53%45%

36%28%

18%11%

0%

20%

40%

60%

80%

100%

0–14 15–24 25–34 35–44 45–54 55–64 65–74 75–84 85+

PERC

ENTA

GE

AGE BANDHome Institution Farm

Industrial Other Public area or road

FIGURE 4.6B: PLACE OF INJURY BY ISS (N=5211)6*

FFIIGGUURREE 44..66BB:: PPLLAACCEE OOFF IINNJJUURRYY BBYY IISSSS ((NN==55221111))

24% 28%21% 20% 22%

47% 38%41% 42% 43%

29%34% 37% 38% 35%

0%

20%

40%

60%

80%

100%

Home Public area or road Institution Farm Industrial

PERC

ENTA

GE

PLACE OF INJURY


FIGURE 4.7: INJURIES SUSTAINED AT HOME BY GENDER (n=2696)

45% 55%

MaleFemale

45% 55%

CHAPTER 4


INJURIES SUSTAINED AT HOME

Home was the most common place of injury, with 50% (n=2696) of injuries sustained there (Figure 4.6). In order to determine what factors may influence such a high incidence of injuries in this location, the following were examined: gender and age, place of injury by gender, and mechanism of injury.

• Fifty-five per cent (n=1470) of major trauma patients injured at home were female (Figure 4.7).

• Low falls were the most common mechanism of injury, seen in 78% (n=2100) of cases of injuries occurring at home (Figure 4.8).

CHAPTER 4


3 18 cases did not have a CCI score recorded.* Please note: Percentages may not sum to 100% due to rounding.

Older patients who sustained injuries at home were more likely to have moderate to severe comorbidities than their younger counterparts (Figure 4.9). FFIIGGUURREE 44..99:: CCCCII SSCCOORREE OOFF PPAATTIIEENNTTSS IINNJJUURREEDD AATT HHOOMMEE BBYY AAGGEE ((nn==22667788))

5%

41%36%

47%39%

45% 46% 47% 50%

1%

1%

4%10%

9%15%

25% 23%

2%

3% 5%

8%6%

5% 4%

94%

59% 61%

46% 45%38% 34%

23% 23%

0%

20%

40%

60%

80%

100%

0-14 15–24 25–34 35–44 45–54 55–64 65–74 75–84 85+

PERC

ENTA

GE

AGE BAND

Mild comorbidities (1–5) Moderate comorbidities (6–10)

Severe comorbidities (>10) No significant pre-existing condition

FIGURE 4.9: CCI SCORE OF PATIENTS INJURED AT HOME BY AGE (n=2678)3*

FIGURE 4.8: INJURIES SUSTAINED AT HOME BY MECHANISM OF INJURY (n=2696)*

FFIIGGUURREE 44..88:: IINNJJUURRIIEESS SSUUSSTTAAIINNEEDD AATT HHOOMMEE BBYY MMEECCHHAANNIISSMM OOFF IINNJJUURRYY ((nn==22669966))

78%

12%3% 2% 1%

3%

0%

20%

40%

60%

80%

Fall less than 2 m Fall more than 2 m Blow(s) Burn Stabbing Other

PERC

ENTA

GE

MECHANISM OF INJURY

CHAPTER 4


FIGURE 4.10: INJURIES SUSTAINED AT HOME BY ISS AND AGE GROUP (n=2696)

FFIIGGUURREE 44..1100:: IINNJJUURRIIEESS SSUUSSTTAAIINNEEDD AATT HHOOMMEE BBYY IISSSS AANNDD AAGGEE GGRROOUUPP ((nn==22669966))

17%

31%25% 21% 18% 18%

25% 28% 26%

48%

37%

37% 45% 52%61% 48% 39% 45%

35% 32%38%

34% 30%21%

27%33%

29%

0%

20%

40%

60%

80%

100%

0–14 15–24 25–34 35–44 45–54 55–64 65–74 75–84 85+

PERC

ENTA

GE

AGE BAND

Low–severity injury Moderate–severity injury Severe injury

Figure 4.10 shows the distribution of injury severity score for those who fell at home by age group (n=2696).

Of those injured at home (n=2696), 6% (n=170) died in hospital (Figure 4.11). The median age of those who died was 72.6. The majority of those who died as a result of injuries sustained at home had a severe injury (68%, n=115). Falls less than 2 m (70%, n-119) was the most prominent mechanism of injury for this cohort, and head injury (53%, n=90) accounted for half of deaths.

FIGURE 4.11: INJURIES SUSTAINED AT HOME BY MORTALITY (n=2696)4

DeadAlive

6%

94%

4 Mortality is reported at 30 days post-discharge.

CHAPTER 4


TYPE OF ROAD TRAUMA

Road trauma accounts for 16% (n=875) of all trauma included in this report. Car occupants accounted for 44% (n=386) of road trauma patients, of whom 67% (n=259) were in the driver’s seat; 19% (n=168) of road trauma patients were cyclists, 18% (n=160) were pedestrians and 17% (n=146) were motorcyclists (Figure 4.12).

Pedestrians continue to have the highest percentage of severe injuries (ISS >15) caused by road trauma (50%, n=80) (Figure 4.12A).

FIGURE 4.12: TYPE OF ROAD TRAUMA (n=875)

FFIIGGUURREE 44..1122:: TTYYPPEE OOFF RROOAADD TTRRAAUUMMAA ((nn==887755))

44%

19% 18%17%

2%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Car Cyclist Pedestrian Motorcycle Not known

PPEERR

CCEENN

TTAAGG

EE

TTYYPPEE OOFF RROOAADD TTRRAAUUMMAA

CHAPTER 4


5 The ‘Not known’ category was excluded from this figure.

FIGURE 4.12A: TYPE OF ROAD TRAUMA BY ISS (n=860)5

FFIIGGUURREE 44..1122AA:: TTYYPPEE OOFF RROOAADD TTRRAAUUMMAA BBYY IISSSS ((nn==886600))

24% 21%15% 18%

37%37%

35%

40%

39% 42%50%

42%

0%

20%

40%

60%

80%

100%

Car Cyclist Pedestrian Motorcycle

PERC

ENTA

GE

TYPE OF ROAD TRAUMA


CHAPTER 4


HEAD INJURIES

Head injuries accounted for 18% (n=1418) of all major trauma injuries (N=8008); this includes all severities of head injury (AIS 1–6) (Figure 4.13). Severity of head injury can be classified using a combination of AIS classification on the basis of brain computed tomography (CT) scan findings (Appendix 1) and the Glasgow Coma Scale (GCS), which can be classified as mild (GCS 13–15), moderate (GCS 9–12) and severe (GCS <9).

Figure 4.13A shows the severity of traumatic brain injury (TBI) by age group. The predominant mechanisms of injury in patients with severe TBI (n=179) were low falls (38%, n=68) and road trauma (31%, n=56). Falls of greater than 2 m accounted for 17% (n=31) of patients with severe TBI (Figure 4.13B). As age increases, major trauma patients with a severe head injury are more likely to die (Figure 4.13C).

6 47 cases had no GCS recorded and have been excluded from 4.13 figure

FIGURE 4.13: SEVERE HEAD INJURY PATIENTS BY AIS CLASSIFICATION (AIS ≥3) (n=1175), FURTHER CLASSIFIED INTO TBI SEVERITY BY GCS6

9%15% 76%Low-severity injury

Moderate-severity injury

Severe injury

CHAPTER 4


FIGURE 4.13A: TBI SEVERITY BY GCS SCORE, BY AGE GROUP FOR PATIENTS WITH SEVERE HEAD INJURIES (AIS ≥3) (N=1175)7*

FFIIGGUURREE 44..1133AA:: TTBBII SSEEVVEERRIITTYY BBYY GGCCSS SSCCOORREE,, BBYY AAGGEE GGRROOUUPP FFOORR PPAATTIIEENNTTSS WWIITTHH SSEEVVEERREE HHEEAADD IINNJJUURRIIEESS ((AAIISS ≥≥33)) ((nn==11117755))

86%

57% 60%67% 67% 68%

87% 83% 84%

4%

11%

16%

12% 10% 11%

5% 9% 7%

10%

33%24% 20% 22% 20%

8% 8% 10%

0%

20%

40%

60%

80%

100%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

PERC

ENTA

GE

AGE GROUP

Mild TBI Moderate TBI Severe TBI

7 47 cases had no GCS recorded and have been excluded from 4.13A figure* Please note: Percentages may not sum to 100% due to rounding.

CHAPTER 4



FIGURE 4.13B: CAUSE OF INJURY IN PATIENTS WITH SEVERE TBI (AIS ≥3 & GCS<9) (N=179)*

FFIIGGUURREE 44..1133BB:: CCAAUUSSEE OOFF IINNJJUURRYY IINN PPAATTIIEENNTTSS WWIITTHH SSEEVVEERREE TTBBII ((AAIISS ≥≥33 && GGCCSS<<99)) ((nn==117799))

38%

31%

17%

13%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Fall less than 2 m Road trauma Fall more than 2 m Other

PERC

ENTA

GE

MECHANISM OF INJURY

FFIIGGUURREE 44..1133BB:: CCAAUUSSEE OOFF IINNJJUURRYY IINN PPAATTIIEENNTTSS WWIITTHH SSEEVVEERREE TTBBII ((AAIISS ≥≥33 && GGCCSS<<99)) ((nn==117799))

38%

31%

17%

13%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Fall less than 2 m Road trauma Fall more than 2 m Other

PERC

ENTA

GE

MECHANISM OF INJURY

CHAPTER 4


FIGURE 4.13C: MORTALITY OF MTA PATIENTS WITH SEVERE HEAD INJURY BY AIS CLASSIFICATION AND BY AGE GROUP (N=1222)

FFIIGGUURREE 44..1133CC:: MMOORRTTAALLIITTYY OOFF MMTTAA PPAATTIIEENNTTSS WWIITTHH SSEEVVEERREE HHEEAADD IINNJJUURRYY BBYY AAIISS CCLLAASSSSIIFFIICCAATTIIOONN AANNDD BBYY AAGGEE GGRROOUUPP ((nn==11222222))

4%13% 9%

4%10% 12% 9%

18% 22%13%

96%87% 91%

96%90% 88% 91%

82% 78%87%

0%

20%

40%

60%

80%

100%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total

PERC

ENTA

GE

AGE GROUP

Dead Alive

CHAPTER 4


KEY FINDINGS FROM CHAPTER 4• Fifty-one per cent of patients (n=2740) were aged 15–64 and were therefore in the

working-age population. Older adults, aged 65 years and over, represented 46% (n=2509) of patients.

• Falls of less than 2 m, termed ‘low falls’, continue to be the most frequent cause of major trauma (58%, n=3169). They are the most common mechanism of major trauma in those aged 35 years and over and in children. In those aged 15–34 years, the most common mechanism of injury is road trauma.

• Almost one-third (32%, n=1741) of major trauma patients have injured two or more body regions; 68% had an isolated injury.

• Of the 5,429 patients captured by the MTA, 43% (n=2335) suffered moderate-severity injuries and 32% (n=1727) suffered severe injuries.

• Half (n=2696) of all major trauma injuries occurred at home, while 37% (n=1997) of injuries occurred in a public place or road.

• Major trauma patients aged 15–54 years are more likely to be injured in a public area or on the road.

• Head injuries accounted for 18% (n=1418) of all major trauma injuries (N=8008).

• The predominant mechanisms of injury in patients with severe TBI (n=179) were road trauma (31%, n=56) and low falls (38%, n=68). Falls of greater than 2 m accounted for 17% (n=31) of patients with severe TBI.

CHAPTER 5FALLS

CHAPTER 5


Fall-related injuries are more common among older persons and are a major cause of disability, loss of independence and premature death. This is reflected in the many policy documents and strategies published to address this phenomenon (World Health Organization, 2018; The Irish Longitudinal Study on Ageing, 2014; Health Service Executive, National Council on Ageing and Older People, Department of Health and Children, 2008).

Between 28% and 35% of people aged 65 years and over fall each year, increasing to between 32% and 42% for those over 70 years of age. The financial costs are substantial and are increasing worldwide, with the World Health Organization (WHO) forecasting the population over 60 years of age as the fastest-growing age group (World Health Organization, 2015). It projects this age group to grow from 12% of the total population in 2015 to 22% in 2050. In addition, the proportion of people over 80 years of age is set to triple: currently, there are 125 million people over 80 years of age globally, which is expected to grow to 434 million by 2050 (World Health Organization, 2015). The WHO estimates the annual cost of falls to be in excess of €400 billion.

Each year, the MTA has highlighted the increasing incidence and impact of falls in leading to major trauma; in an effort to better describe the causative factors and opportunities for prevention, this chapter looks at falls in more detail. Since the 2017 report, the MTA Manager and Clinical Lead have met and built a relationship with the National Falls and Bone Health Project (2018–2023) (AFFINITY) Lead in order to support the Health Service Executive’s (HSE’s) efforts to address falls on a national scale.

AFFINITY is the national falls and bone health project, which was set up to reduce harm from falls in Ireland’s population as it ages. The work is being led by the HSE in collaboration with the State Claims Agency (SCA), Age Friendly Ireland and, most importantly, older people.

Originally, AFFINITY commenced in 2013 to deliver the vision described in the Strategy to Prevent Falls and Fractures in Ireland’s Ageing Population (Department of Health & Health Service Executive, 2008). In 2016, the project was refocused in light of changes in HSE structures and the need to significantly scale up the implementation of falls and fracture prevention.

AFFINITY (2018–2023) has been set up to bring renewed focus, coordination and clear direction to the spectrum of falls and fracture prevention service improvement initiatives currently under way in the community and within acute services across the country. The MTA will be a supportive partner for this work and will use the data to increase awareness of the preventable nature of falls, as well as to enable older people, communities, and health and social care providers to reduce the risk and rate of falling where possible, reduce the severity of injuries, and promote the best possible outcomes for people who have suffered a fall-related injury. A multidisciplinary, multi-agency approach will be required in order to reduce the number of falls and injuries from falls.

FALLS

CHAPTER 5


This chapter describes all falls recorded in the MTA in 2018. Falls termed ‘low falls’ (i.e. less than 2 m) account for 58% (n=3169) of all injuries, whereas falls of greater than 2 m account for a smaller proportion, but not an insignificant amount, of injuries overall (10%, n=557). Therefore, falls of both less than and greater than 2 m accounted for 69% (n=3726) of all injuries, and both types of falls are included in this chapter.

Effectively targeting resources for the prevention of falls and related injuries requires enhanced knowledge of the scale and nature of the problem, as well as evidence on effective interventions. This requires raising awareness of the magnitude of falls among older adults, intensifying research efforts and encouraging action towards prevention worldwide (World Health Organization, 2015). From reviewing the free text descriptions of many of the falls contained within this report, there were many opportunities for prevention identified. The most common descriptions of the falls were slips and trips: many involved steps or stairs; falling from chairs, sofas or beds; or falling over pets in the home. Slipping on wet surfaces, balance issues or tripping over ill-fitting footwear were also commonly described. To a lesser extent, alcohol and recent illnesses played a factor in some falls. Although previous falls were mentioned in some cases, the majority of descriptions did not mention any previous falls history.

The MTA welcomes researchers using this rich source of data for the purposes of falls prevention.

CHAPTER 5


GENDER AND AGE BAND

The majority of patients who sustained injuries due to falls were female (52%, n=1939); however, when looking at distribution of falls of more than 2 m, men were more likely to sustain an injury due to such a fall (70%, n=390). Women were more likely to sustain an injury due to a fall of less than 2 m (56%, n=1772) (Figure 5.1).

The mean age of patients who had a fall was 66 years. The mean age for falls less than 2 m was 69 years, and for falls more than 2 m this was 53 years. The likelihood of sustaining an injury due to a fall grows as age increases (Figure 5.2). Distribution of falls shows that adults aged 65 years and over were more likely to sustain an injury due to a fall of less than 2 m than due to a fall of more than 2 m.

FIGURE 5.1: FALLS BY GENDER (n=3726)

FFIIGGUURREE 55..11:: FFAALLLLSS BBYY GGEENNDDEERR ((nn==33772266))

44%

70%

56%

30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Fall less than 2 m Fall more than 2 m

PERC

ENTA

GE

MECHANISM OF INJURY

Male Female

FFIIGGUURREE 55..11:: FFAALLLLSS BBYY GGEENNDDEERR ((nn==33772266))

44%

70%

56%

30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


PERC

ENTA

GE

MECHANISM OF INJURY

Male Female

CHAPTER 5


FFIIGGUURREE 55..22:: FFAALLLLSS BBYY AAGGEE ((nn==33772266))

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Fall less than 2 m (n) 80 52 81 130 271 517 555 836 647

Fall more than 2 m (n) 16 44 58 73 87 111 83 68 17

83%

54% 58%64%

76%82% 87%

92%97%

85%

17%

46% 42%36%

24%18% 13%

8%3%

15%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total

PERC

ENTA

GE

AGE GROUPFall less than 2 m Fall more than 2 m

FIGURE 5.2: FALLS BY AGE (N=3726)

80Falls less than 2m (n) 27181 55552 517130 836 647

0-14 45-5425-34 65-7415-24 55-6435-44 75-84 85+

16Falls more than 2m (n) 8758 8344 11173 68 17

CHAPTER 5


PRESENTATION BY TIME OF DAY AND AGE BAND

Over a half of the 0-14-year-olds (53%, n=50) who were admitted to hospital after falling were admitted between 16.00pm and midnight.

Out of all the age groups, children were the least likely to be admitted to hospital after falling between midnight and 8.00am (5%, n=5). (Figure 5.3). FFIIGGUURREE 55..33 FFAALLLLSS BBYY PPRREESSEENNTTAATTIIOONN BBYY TTIIMMEE OOFF TTHHEE DDAAYY AANNDD AAGGEE BBAANNDD ((nn==33771133))

5%

33%27%

21%13%

18% 15% 15% 15%

42%

27%29% 39%

46%42% 43% 46% 47%

53%

40% 44% 40% 41% 40% 42% 39% 38%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

PERC

ENTA

GE

AGE GROUP

00.00-07.59 08.00-15.59 16.00-23.59

FIGURE 5.3: FALLS BY PRESENTATION BY TIME OF THE DAY AND AGE BAND (n=3713)8*

8 Patients with missing information on time point of admission (n=13) are excluded.* Please note: Percentages may not sum to 100% due to rounding.

CHAPTER 5


INJURIES SUSTAINED BY BODY REGION

Limb injury was the most common injury sustained due to a fall of less than 2 m (37%, n=1140), followed by a head injury (24%, n=747) (Figure 5.4). It is likely that the majority of the limb injuries sustained were fragility fractures resulting from diminished bone health in older persons. Major trauma patients who suffer a low fall and sustain fractures should have a bone health and specialist falls assessment and review by an orthogeriatrician in accordance with best practice as published by the Dreinhöfer et al, 2018). Head and spine injuries were the most common injuries sustained from a fall of more than 2 m (24%, n=132, and 24%, n=130, respectively).

FIGURE 5.4: FALLS AND MOST SEVERELY INJURED BODY AREA (n=3607)9*

FFIIGGUURREE 55..44:: FFAALLLLSS AANNDD MMOOSSTT SSEEVVEERREELLYY IINNJJUURREEDD BBOODDYY AARREEAA ((nn==33660077))

13%18%

24%24%

37%20%

5%

14%

20% 24%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


PERC

ENTA

GE

MECHANISM OF INJURY

Chest Head Limbs Multiple Spine

9 Other severe injuries’ has been excluded from figure 5.4* Please note: Percentages may not sum to 100% due to rounding.

CHAPTER 5


INJURY SEVERITY SCORE

The severity of injury based on whether the fall was from greater or less than 2 m is shown in Figure 5.5. Higher falls are associated with a greater proportion of severe injuries (ISS >15) (44%, n=243), as one would expect, but low falls are also associated with a high proportion of severely injured patients (ISS >15) (28%, n=877) (Figure 5.5).

FIGURE 5.5: FALLS AND INJURY SEVERITY SCORE (n=3726)

FFIIGGUURREE 55..55:: FFAALLLLSS AANNDD IINNJJUURRYY SSEEVVEERRIITTYY SSCCOORREE ((nn==33772266))

23%

19%

49%

37%

28%

44%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Fall less than 2 m

Fall more than 2 m

PERCENTAGE

MEC

HA

NIS

M O

F IN

JURY


CHAPTER 5


SEVERE INJURY FALLS AND PRE-ALERT

This section focuses on patients who sustained severe injuries (ISS >15) from a fall. Out of all patients who had severe injuries sustained from a fall, a small percentage were pre-alerted (12%, n=130). Patients who had a fall of less than 2 m were less likely to be pre-alerted (8%, n=68) than those who fell more than 2 m (26%, n=62) (Figure 5.6).

There continues to be a very low percentage of patients documented as having been pre-alerted. This is in part due to issues with the pre-hospital documentation not being either legible or accessible by the audit coordinators. The National Ambulance Service (NAS) has developed an electronic patient care report (ePCR) which is currently being rolled out across the health service. It is hoped that this will improve data collection for pre-alert; other solutions will also be worked on for the Dublin Fire Brigade (DFB), which does not operate an ePCR.

FFIIGGUURREE 55..66:: FFAALLLLSS WWIITTHH IISSSS >> 1155 AANNDD PPRREE--AALLEERRTTEEDD ((nn==11004411))

83%

50%

67%57%

65% 64%76% 78% 81%

73%

6%

29%

20%33% 19% 18%

8%8%

8%12%

11%21%

12% 10%16% 18% 16% 14% 11% 15%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total

PERC

ENTA

GE

AGE GROUP

Not pre-alerted Pre-alerted Not recorded

FIGURE 5.6: FALLS WITH ISS > 15 AND PRE-ALERT STATUS (n=1041)10*

10 Only direct admissions are included.* Please note: Percentages may not sum to 100% due to rounding.

CHAPTER 5


SEVERE INJURY FALLS AND RECEPTION BY A TRAUMA TEAM

The overall percentage of patients with a severe injury (ISS >15) sustained from a fall and who were received by a trauma team at the first receiving hospital was low, at 9% (n=97). Out of all falls less than 2 m, 62% (n=60) were received by a trauma team, compared with 38% (n=37) of falls more than 2 m (Figure 5.7).

FIGURE 5.7: FALLS WITH ISS > 15 AND RECEPTION BY TRAUMA TEAM (n=1041)11

Not received by trauma team

Received by trauma team

9%

91%

11 Only direct admissions are included.

CHAPTER 5


KEY FINDINGS FROM CHAPTER 5• Falls termed ‘low falls’ (i.e. less than 2 m) account for 58% (n=3169) of all major trauma injures.

• Women were more likely to sustain an injury due to a fall of less than 2 m (56%, n=1772)

• Men were more likely to sustain an injury due to a fall of more than 2 m (70%, n=390).

• The mean age for falls less than 2 m was 69 years, and for falls more than 2 m this was 53 years.

• Limb injury was the most common injury sustained due to a fall of less than 2 m (37%, n=1140), followed by a head injury (24%, n=747).

• Head and spine injuries were the most common injuries sustained from a fall of more than 2 m (24%, n=132, and 24%, n=130, respectively).

• Low falls are also associated with a high proportion of seriously injured patients (ISS >15) (28%, n=877).

• Patients who had a fall of less than 2 m were less likely to be pre-alerted (8%, n=68) than those who fell more than 2 m (26%, n=62).

CHAPTER 6THE PATIENT

JOURNEY


CHAPTER 6

THE PATIENT JOURNEY

Major trauma care is currently being delivered across 26 hospitals in Ireland; however, no one hospital in Ireland has all the necessary trauma services on site, and no hospital in Ireland currently receives the requisite number of severely injured patients to be considered adequate to maintain the trauma management skills of doctors, nurses and health and social care professionals (HSCPs) by international standards. For patients and their families, the current arrangements for the delivery of trauma care are such that access to specialist care is compromised and transfer to another hospital is often required. This interrupts continuity of care and lengthens time to recovery, as care is delivered sequentially rather than concurrently. The provision of a seamless, safe, optimal package of care for patients with multiple injuries is very challenging in the current configuration of trauma care delivery.

The Helicopter Emergency Medical Service (HEMS) is delivered through a service level agreement between the Irish Air Corps, the Department of Defence and the HSE, and is based out of Athlone, offering daytime services. Irish Coast Guard helicopters may, in certain circumstances, be tasked with transporting major trauma patients.

MODE OF ARRIVAL

Road ambulance was the most common mode of transportation to hospital in 2018 (75%, n=3666)

12 Patients who were transferred to another hospital have been excluded. Data on patients whose mode of transport to hospital was ‘Other’ or ‘Unknown’ have not been presented above.


FIGURE 6.1: MODE OF ARRIVAL AT HOSPITAL (n=4911)12*

1%HELICOPTER

75%AMBULANCE

4%WALKING

20%BY CAR

1%HELICOPTER & AMBULANCE

CHAPTER 6


MOST SENIOR HEALTHCARE PROFESSIONAL

Data capture relating to the pre-hospital part of the trauma patient’s journey has been challenging for the MTA; the NAS has recently moved to an ePCR, which is expected to facilitate audit.

Of those major trauma patients attended to by a pre-hospital professional (n=3754), 51% (n=1921) were attended to by a paramedic and 31% (n=1161) were attended to by an advanced paramedic (Figure 6.2). A small number of medical doctors volunteer critical care support to the NAS, and can be tasked to respond by the National Emergency Operations Centre.

FIGURE 6.2: MOST SENIOR PRE-HOSPITAL HEALTHCARE PROFESSIONAL (n=3754)

FFIIGGUURREE 66..22:: MMOOSSTT SSEENNIIOORR PPRREE--HHOOSSPPIITTAALL HHEEAALLTTHHCCAARREE PPRROOFFEESSSSIIOONNAALL ((nn==33775544))

51%

31%

17%

1%0%

10%

20%

30%

40%

50%

60%

Paramedic Advanced paramedic Not known Doctor

PERC

ENTA

GE

HEALTHCARE PROFESSIONAL


TBI AND ADMISSIONS TO A NEUROSURGICAL UNIT

In 2018, there were 1,221 patients with traumatic brain injury (TBI) with an AIS of 3 or higher (Figure 6.3). Of these, 18% (n=220) were admitted directly to a neurosurgical unit. A further 19% (n=234) were subsequently transferred to a neurosurgical unit following reception to hospital.

There were 179 patients with a severe TBI (AIS ≥3, GCS <9); of those, 17% (n=31) were admitted directly to a neurosurgical unit, 32% (n=58) were transferred to a neurosurgical unit from another hospital and 50% (n=90) were not transferred (Figure 6.3A).

CHAPTER 6

FIGURE 6.3: CARE PATHWAY OF PATIENTS WITH SEVERE HEAD INJURY BY AIS (n=1221)

FFIIGGUURREE 66..33:: CCAARREE PPAATTHHWWAAYY OOFF PPAATTIIEENNTTSS WWIITTHH SSEEVVEERREE HHEEAADD IINNJJUURRYY BBYY AAIISS ((nn==11222211))

18%

63%

19%

0%

10%

20%

30%

40%

50%

60%

70%

Direct admission to neurosurgical unit Not transferred to neurosurgical unit Transferred to neurosurgical unit

PERC

ENTA

GE

CARE PATHWAY

CHAPTER 6


FIGURE 6.3A: PATIENTS WITH SEVERE TBI AND ADMISSIONS TO A NEUROSURGICAL UNIT (AIS ≥3 AND GCS <9) (N=179)*

FFIIGGUURREE 66..33AA:: PPAATTIIEENNTTSS WWIITTHH SSEEVVEERREE TTBBII AANNDD AADDMMIISSSSIIOONNSS TTOO AA NNEEUURROOSSUURRGGIICCAALL UUNNIITT ((AAIISS ≥≥33 AANNDD GGCCSS <<99)) ((nn==117799))

17%

32%

50%

0%

10%

20%

30%

40%

50%

60%

Direct admission to neurosurgical unit Transfer to neurosurgical unit Not transferred to neurological unit

PERC

ENTA

GE

CARE PATHWAYS



TRANSFERS OF PATIENTS (SUBGROUP ANALYSIS)

A fundamental principle in healthcare is getting the right person to the right place the first time in order to optimise the outcome for that patient. In 2018, 20% (n=1077) of patients were transferred at least once to another hospital for further care (Figure 6.4). It is anticipated that the development of an integrated trauma system for Ireland, comprising major trauma centres (MTCs) and trauma units organised in networks, will reduce the number of patients who will need subsequent transfer for definitive care, as more patients will be transported directly to the ‘right’ hospital in the first place, and that, where a transfer is required, it will be a more streamlined process (Department of Health, 2018). In 2012, the UK restructured its trauma system in a similar manner to that proposed for Ireland. This resulted in improved access to specialist services for injured patients; the development of high-volume centres with greater consultant-led care and expertise and rapid CT imaging; and rewards (tariffs) for hospitals that met certain quality metrics. Ultimately, the restructuring of the trauma system led to dramatic improvements in both care processes and outcomes, including survival for patients (Moran et al., 2018).

The decision to transfer a patient for management of their injuries and the timeliness of the transfer should be based on medical need and best practice; however, it may also relate to the availability of a bed and other resources at the receiving hospital. The transfer process is cumbersome, requiring multiple phone calls, a transfer team and ambulance, and often denudes smaller hospitals of staff for the duration of the transfer. There are contesting, and sometimes conflicting, priorities at play in the transfer of patients.

This chapter focuses on patients who were transferred for care of their injuries.

CHAPTER 6

FIGURE 6.4: PERCENTAGE OF PATIENTS TRANSFERRED TO ANOTHER HOSPITAL (N=5429)

Not transferredTransferred

20%

80%

CHAPTER 6


Model 3 hospitals provide acute surgery, acute medicine and critical care 24 hours a day, 7 days a week.

Model 4 hospitals provide acute surgery, acute medicine and critical care 24 hours a day, 7 days a week, and also provide tertiary care and, in certain locations, supra-regional care, including orthopaedic, cardiothoracic, plastic surgery, maxillofacial, ear, nose and throat ophthalmology, interventional radiology, and neurosurgery services which may be necessary in the management of major trauma.

Hospitals with supra-regional/national services include:

• Beaumont Hospital – neurosurgery and renal transplant

• Cork University Hospital – plastic and reconstructive surgery, neurosurgery, cardiothoracic surgery, and oral and maxillofacial surgery

• Children’s Health Ireland at Temple Street – neurosurgery

• Mater Misericordiae University Hospital – cardiothoracic surgery, heart and lung transplant, spinal surgery, and extracorporeal membrane oxygenation (ECMO)

• St James’s Hospital – cardiothoracic surgery, burns surgery, plastic and reconstructive surgery, and oral and maxillofacial surgery

• St Vincent’s University Hospital – liver transplant and pancreatic surgery

• Tallaght University Hospital – pelvic and acetabulum reconstruction

TRANSFERS BY HOSPITAL

Table 6.1 shows the number of patients transferred in, out and in and out by hospital. Figure 6.5 shows the percentage of patients transferred out by hospital, including what percentage had a severe injury (ISS >15) and what percentage had a low- or moderate-severity injury (ISS ≤15). This graph shows that there is variance in the percentage of transfers across hospitals. The percentage of patients transferred out was calculated by dividing the number of patients transferred out by the total number of patients admitted to each hospital (please note that a patient may have been admitted to more than one hospital and therefore may be counted twice in this graph). Transfers in were calculated in the same way. Transfers in and out have not been included in either Figures 6.5 or 6.6.

As expected, Model 3 hospitals have a higher percentage of transfers out than Model 4 hospitals. Patients brought to Model 4 hospitals are more likely to receive the definitive care they require.


CHAPTER 6

HOSPITAL

NO TRANSFER

TRANSFER IN

TRANSFER IN AND OUT

TRANSFER OUT TOTAL

N % N % N % N % N

Beaumont Hospital 327 59% 88 16% 117 21% 20 4% 552

Cavan General Hospital 88 53% 0 0% <5 1% 77 46% 166

Children’s Health Ireland at Crumlin 11 44% 14 56% 0 0% 0 0% 25

Children’s Health Ireland at Temple Street 21 49% 13 30% 5 12% <5 9% 43

Connolly Hospital 227 79% 9 3% <5 1% 48 17% 288

Cork University Hospital 586 85% 51 7% 35 5% 21 3% 693

Letterkenny University Hospital 62 79% 0 0% 0 0% 16 21% 78

Mater Misericordiae University Hospital 334 61% 64 12% 118 22% 30 5% 546

Mayo University Hospital 100 90% <5 1% 0 0% 10 9% 111

Mercy University Hospital 19 61% 0 0% 0 0% 12 39% 31

Midland Regional Hospital, Tullamore 150 76% 33 17% <5 1% 14 7% 198

Regional Hospital Mullingar* 77 63% 0 0% <5 2% 43 35% 122

Midland Regional Hospital, Portlaoise 26 87% 0 0% 0 0% <5 13% 30

Naas General Hospital 47 87% <5 2% 0 0% 6 11% 54

Our Lady of Lourdes Hospital, Drogheda 274 68% 58 14% 12 3% 60 15% 404

Sligo University Hospital 96 78% <5 1% 0 0% 26 21% 123

South Tipperary General Hospital 63 61% 0 0% 0 0% 41 39% 104

St James’s Hospital 386 83% 45 10% 8 2% 27 6% 466

St Luke’s General Hospital, Kilkenny 79 66% 0 0% 0 0% 41 34% 120

St Vincent’s University Hospital 315 86% 27 7% <5 0% 25 7% 368

Tallaght University Hospital 238 65% 48 13% 63 17% 19 5% 368

University Hospital Galway and Merlin Park University Hospital

229 80% 33 12% 5 2% 18 6% 285

University Hospital Kerry 148 85% <5 1% 0 0% 26 15% 175

University Hospital Limerick 293 75% 27 7% <5 0% 72 18% 393

University Hospital Waterford 151 53% 80 28% 28 10% 26 9% 285

Wexford General Hospital 56 53% 0 0% 0 0% 49 47% 105

Total 4403 72% 594 10% 401 7% 735 12% 6133

TABLE 6.1: NUMBER OF PATIENTS WHO WERE TRANSFERRED, BY HOSPITAL13

Two patients from Regional Hospital Mullingar had a ‘transfer failed’ recorded – they are not included in Table 6.1.

13 6133 refers to the number of submissions, i.e. a patient could have been admitted to one or more hospitals and could be counted twice in Table 6.1

CHAPTER 6


FIGURE 6.5: PERCENTAGE OF ‘TRANSFERS OUT’ BY HOSPITAL (n=6135)14

FFIIGGUURREE 66..55:: PPEERRCCEENNTTAAGGEE OOFF ''TTRRAANNSSFFEERRSS OOUUTT'' OOFF HHOOSSPPIITTAALL ((nn==66113355))

31%

35%

33%

26%

23%

28%

12%

5%

10%

7% 7%7% 7%

4% 4%5%

3% 2% 1 2%3% 3%

2% 1%

15%

11%

7%

13%

12%

7%

9%

15%8%

9%7% 8%

7%

7%

9%

5% 5%

5% 5%5% 4% 3% 2%

2%2%

0%

10%

20%

30%

40%

50%

Wex

ford

Cav

an

Sout

h Ti

pper

ary

Mer

cy

Mul

linga

r

Kilk

enny

Slig

o

Lett

erke

nny

Lim

eric

k

Con

nolly

Ker

ry

Dro

ghed

a

Port

laoi

se

Naa

s

Tem

ple

Stre

et

Wat

erfo

rd

May

o

Tulla

mor

e

St V

ince

nt's

Gal

way

St J

ames

's

Mat

er

Talla

ght

Bea

umon

t

Cor

k

PERC

ENTA

GE

HOSPITALS

Low-or moderate-severity injury Severe injury

14 6135 refers to the number of submissions, i.e. a patient could have been admitted to one or more hospitals and could be counted twice in Figure 6.5. Patients who were transferred in and out are not included.


CHAPTER 6


FIGURE 6.6: PERCENTAGE OF ‘TRANSFERS IN’ BY HOSPITAL (n= 6135)15

FFIIGGUURREE 66..66:: PPEERRCCEENNTTAAGGEE OOFF ''TTRRAANNSSFFEERRSS IINN'' BBYY HHOOSSPPIITTAALL ((nn== 66113355))

44%

2%

25%

15%

2%

12%9% 8%

10% 9%4% 4% 6%

3% 1% 1%

12%

28%

3%

2%

14%

2%4%

4%

1%1%

3% 3%1%

2%1%

0%

10%

20%

30%

40%

50%

60%

Cru

mlin

Tem

ple

Stre

et

Wat

erfo

rd

Tulla

mor

e

Bea

umon

t

Dro

ghed

a

Talla

ght

Mat

er

Gal

way

St J

ames

's

Cor

k

St V

ince

nt's

Lim

eric

k

Con

nolly

Naa

s

May

o

Slig

o

Ker

ry

PERC

ENTA

GE

HOSPITALS


CHAPTER 6


GENDER AND TRANSFERS

Out of all transfers, 66% (n=709) were male and 34% (n=368) were female (Figure 6.7).

66%

34%

FIGURE 6.7: PERCENTAGE OF TRANSFERS BY GENDER (n=1077)

66% 34%

MaleFemale


CHAPTER 6

AGE AND TRANSFERS

Figure 6.8 shows the percentage of patients within each age group who were transferred as a proportion of all patients within that age group. Younger patients are more likely to be transferred; for example, 44% (n=79) of children aged 0–14 years were transferred, compared with just 9% (n=60) of patients aged 85 years and over.FFIIGGUURREE 66..88:: PPRROOPPOORRTTIIOONN OOFF EEAACCHH AAGGEE BBAANNDD TTHHAATT WWAASS TTRRAANNSSFFEERRRREEDD ((nn==55442299))

56%

71% 72% 73%79% 78%

83%88% 91%

80%

44%

29% 28% 27%21% 22%

17%12% 9%

20%

0%

20%

40%

60%

80%

100%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total

PERC

ENTA

GE

AGE GROUP

Not transferred Transferred

FIGURE 6.8: PROPORTION OF EACH AGE GROUP THAT WAS TRANSFERRED (N=5429)

CHAPTER 6


ISS AND TRANSFERS

Major trauma patients who were severely injured (ISS >15) were more likely to be transferred (27%, n=469) than patients who had a low- or moderate-severity injury (Figure 6.9).

FFIIGGUURREE 66..99:: PPEERRCCEENNTTAAGGEE OOFF PPAATTIIEENNTTSS TTRRAANNSSFFEERRRREEDD VVEERRSSUUSS NNOOTT TTRRAANNSSFFEERRRREEDD BBYY IISSSS ((NN==55442299))

83% 84%73%

17% 16%27%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


PERC

ENTA

GE

ISS


FIGURE 6.9: PERCENTAGE OF PATIENTS TRANSFERRED VERSUS NOT TRANSFERRED BY ISS (N=5429)


CHAPTER 6

MECHANISM OF INJURY AND TRANSFERS

Major trauma patients who were involved in road trauma (30%, n=258), falls of greater than 2 m (27%, n=150) and blows (25%, n=132) were more likely to be transferred, whereas those who had a fall of less than 2 m were less likely to be transferred (Figure 6.10).

FFIIGGUURREE 66..1100:: PPEERRCCEENNTTAAGGEE OOFF PPAATTIIEENNTTSS TTRRAANNSSFFEERRRREEDD VVEERRSSUUSS NNOOTT TTRRAANNSSFFEERRRREEDD BBYY MMEECCHHAANNIISSMM OOFF IINNJJUURRYY((NN==55442299))

75%85%

73% 71% 75%

25%15%

27% 29% 25%

0%

20%

40%

60%

80%

100%

Blow(s) Fall less than 2 m Fall more than 2 m Road trauma Other

PERC

ENTA

GE

MECHANISM OF INJURY


FIGURE 6.10: PERCENTAGE OF PATIENTS TRANSFERRED VERSUS NOT TRANSFERRED BY MECHANISM OF INJURY (N=5429)

CHAPTER 6


BODY REGION INJURED AND TRANSFERS

Major trauma patients who had a spine injury (28%, n=252) were more likely to be transferred than patients who had other injuries (Figure 6.11).

FFIIGGUURREE 66..1111:: PPEERRCCEENNTTAAGGEE OOFF PPAATTIIEENNTTSS TTRRAANNSSFFEERRRREEDD VVEERRSSUUSS NNOOTT TTRRAANNSSFFEERRRREEDD BBYY BBOODDYY RREEGGIIOONN IINNJJUURREEDD ((NN==55442299))

76%

90%81%

76%84%

76% 76% 72%80%

24%

10%19%

24%16%

24% 24% 28%20%

0%

20%

40%

60%

80%

100%

Abdomen Chest Face Head Limbs Multiple Other Spine Total

PERC

ENTA

GE

BODY REGION INJURED


FIGURE 6.11: PERCENTAGE OF PATIENTS TRANSFERRED VERSUS NOT TRANSFERRED BY BODY REGION INJURED (N=5429)


CHAPTER 6

LOCATION OF INJURY AND TRANSFERS

Major trauma patients who were injured in an industrial incident (31%, n=33), farming incident (29%, n=56), or on a public area or road (25%, n=498) were more likely to be transferred from one hospital to another to receive definitive care, as the first hospital did not have the required services (Figure 6.12).

REASON FOR TRANSFERS

As expected, the most common reason for both transfers in (98%) and transfers out (85%) was for specialist care; the remainder of transfers were largely repatriations.

FFIIGGUURREE 66..1122:: PPEERRCCEENNTTAAGGEE OOFF PPAATTIIEENNTTSS TTRRAANNSSFFEERRRREEDD VVEERRSSUUSS NNOOTT TTRRAANNSSFFEERRRREEDD BBYY LLOOCCAATTIIOONN OOFF IINNJJUURRYY ((NN==55442299))

84%75%

91%

71% 69%79%

16%25%

9%

29% 31%21%

0%

20%

40%

60%

80%

100%


PERC

ENTA

GE

LOCATION OF INJURY


FIGURE 6.12: PERCENTAGE OF PATIENTS TRANSFERRED VERSUS NOT TRANSFERRED BY LOCATION OF INJURY (N=5429)

CHAPTER 6


KEY FINDINGS FROM CHAPTER 6• Road ambulance was the most common mode of transportation to hospital in 2018

(75%, n=3666).

• Of those major trauma patients attended to by a pre-hospital professional (n=3754), 51% (n=1921) were attended to by a paramedic and 31% (n=1161) were attended to by an advanced paramedic.

• In 2018, there were 1,221 patients with TBI with an AIS of 3 or higher. Of these, 18% (n=220) were admitted directly to a neurosurgical unit. A further 19% (n=234) were subsequently transferred to a neurosurgical unit following reception to hospital.

• There were 179 patients with a severe TBI (AIS ≥3, GCS <9); of those, 17% (n=31) were admitted directly to a neurosurgical unit.

• In 2018, 20% (n=1077) of patients were transferred at least once to another hospital for further care.

• There is a variance in the percentage of ‘transfers in’ across hospitals, ranging from 0% to 56%, similarly there is a variance in the percentage of ‘transfers out’ across hospitals, ranging from 0% to 47%.

CHAPTER 7CARE OF MAJOR

TRAUMA PATIENTS IN THE ACUTE

HOSPITAL SERVICE


CHAPTER 7

CARE OF MAJOR TRAUMA PATIENTS IN THE ACUTE HOSPITAL SERVICEReception, reconstruction and rehabilitation are key process measures in the MTA that contribute to patient outcomes.

PRESENTATION BY TIME OF DAY

There is very little variation in the rate of presentation of major trauma patients by day of the week or month of the year. However, 59% of patients arrive between 4.00pm and 8.00am (Figure 7.1).

FIGURE 7.1: PRESENTATION BY TIME OF DAY (N=5413)16

FFIIGGUURREE 77..11:: PPRREESSEENNTTAATTIIOONN BBYY TTIIMMEE OOFF DDAAYY ((NN==66111188))

0%

1%

2%

3%

4%

5%

6%

7%

.00

1.00

2.0

0

3.0

0

4.0

0

5.0

0

6.0

0

7.0

0

8.0

0

9.0

0

10.0

0

11.0

0

12.0

0

13.0

0

14.0

0

15.0

0

16.0

0

17.0

0

18.0

0

19.0

0

20.0

0

21.0

0

22.0

0

23.0

0

PERC

ENTA

GE

HOUR

16% 43% 41%

00.00 - 07.59 08.00 - 15.59 16.00 - 23.59

16 Patients with missing information on time point of admission (n=16) are excluded.


CHAPTER 7

PRE-ALERT

Pre-alert is a system whereby the ambulance service communicates to the receiving hospital that it is bringing a patient to the emergency department (ED), the nature of the patient’s injuries, the patient’s physiology, their expected requirements on arrival and the expected time of arrival.

Figure 7.2 includes analysis of the pre-alert to the initial hospital the patient is brought to after having sustained traumatic injury. Younger patients continue to be more likely to be pre-alerted than older patients There continues to be a very low percentage of patients documented as having been pre-alerted (10%, n=531). This is in part due to issues with the pre-hospital documentation not being either legible or accessible by the audit coordinators. The National Ambulance Service (NAS) has developed an electronic patient care report (ePCR) which is currently being rolled out across the health service. This will improve data collection for pre-alert. Younger patients are more likely to be pre-alerted than older patients (Figure 7.2). Major trauma patients who suffered severe injuries were also more likely to have been pre-alerted (Figure 7.2A).

17 Figure 7.2 refers to direct admissions only* Please note: Percentages may not sum to 100% due to rounding.

FFIIGGUURREE 77..22:: PPRREE--AALLEERRTTEEDD BBYY AAGGEE GGRROOUUPP ((nn==55008855))

75%

58%65% 62%

73% 73%78% 81% 86%

74%

12%

18%

17% 20%

13% 9%7% 6%

5%

10%

12%24%

18% 18% 15% 18% 15% 13% 9%15%

0%

20%

40%

60%

80%

100%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total

PERC

ENTA

GE

AGE GROUP


FIGURE 7.2: PRE-ALERTED BY AGE GROUP (n=5085)17*


CHAPTER 7

FFIIGGUURREE 77..22AA:: PPRREE--AALLEERRTTEEDD WWIITTHH IISSSS >>1155 BBYY AAGGEE GGRROOUUPP ((nn==11559966))

59%

39%

53% 53% 57% 56%

71%77% 80%

64%

30%

38%

31% 34% 27%22%

11%10%

9%

20%

11%

23%16% 13% 16%

22% 18% 14% 11% 16%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total

PERC

ENTA

GE

AGE GROUP


FIGURE 7.2A: PRE-ALERTED WITH ISS >15 BY AGE GROUP (n=1596)*



CHAPTER 7

RECEPTION BY A TRAUMA TEAM

Time to critical interventions and outcomes is improved when a trained trauma team is present on the arrival of a severely injured patient (Driscoll and Vincent, 1992). The National Health Service (NHS) Clinical Advisory Group (2010) recommended that trauma teams in MTCs should be led by a consultant, or by a registrar with the necessary seniority, experience and training at trauma units. In Ireland, the lack of clear national standards on what should constitute a trauma team or when such a team should be activated makes this challenging to measure. Currently, it is up to participating hospitals to define their trauma team and report whether this definition of a trauma team was activated.

The overall percentage of major trauma patients received by a trauma team at the first receiving hospital remains low, at 8% (n=425) (Table 7.1). Of those received by a trauma team, patients in the younger age groups were more likely to be received by a trauma team, with a steady decline in the likelihood of receipt by a trauma team as patient age increased (Figure 7.3). Major trauma patients who suffered severe injuries were also more likely to be received by a trauma team, especially in the younger age groups (Figure 7.3A).

18 Figure 7.3 refers to direct admissions only

FFIIGGUURREE 77..33:: RREECCEEPPTTIIOONN BBYY AA TTRRAAUUMMAA TTEEAAMM BBYY AAGGEE GGRROOUUPP ((nn==55008855))

86% 85% 89% 85%91% 92% 92% 96% 97%

92%

14% 15% 11% 15%9% 8% 8% 4% 3%

8%

0%

20%

40%

60%

80%

100%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total

PERC

ENTA

GE

AGE GROUP

Not received by a trauma team Received by a trauma team

FIGURE 7.3: RECEPTION BY A TRAUMA TEAM BY AGE GROUP (n=5085)18


CHAPTER 7

FFIIGGUURREE 77..33AA:: RREECCEEPPTTIIOONN BBYY AA TTRRAAUUMMAA TTEEAAMM WWIITTHH IISSSS >>1155 BBYY AAGGEE GGRROOUUPP ((nn==11559966))

70% 74%81% 77%

83% 84% 86%93% 94%

85%

30% 26%19% 23%

17% 16% 14%7% 6%

15%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total

PERC

ENTA

GE

AGE GROUP

Not received by a trauma team Received by a trauma team

FIGURE 7.3A: RECEPTION BY A TRAUMA TEAM WITH ISS >15 BY AGE GROUP (n=1596)19

19 Figure 7.3A refers to direct admissions only

TABLE 7.1: RECEPTION BY A TRAUMA TEAM

2017

All patients received by trauma team 8% (n=425/508518)

Received by a trauma team led by a consultant (at 30 minutes) 46% (n=196/425)

All severely injured patients (ISS >15) received by a trauma team 15% (n=235/1596)

Severely injured patients (ISS >15) received by a trauma team led 53% by a consultant (n=124/235)


CHAPTER 7

GRADE OF MOST SENIOR DOCTOR TREATING PATIENT ON ARRIVAL

Increasing age correlates with a reduced likelihood of patients being seen by a consultant and a greater likelihood of patients being seen by a doctor at Senior House Officer (SHO) grade (Figure 7.4).

20 Figure 7.4 refers to direct admissions only The category ‘Other’ includes information that was not recorded, as well as other senior treating doctor.* Please note: Percentages may not sum to 100% due to rounding.

FIGURE 7.4: GRADE OF MOST SENIOR DOCTOR TREATING PATIENT ON ARRIVAL BY AGE GROUP (n=5085)20*

FFIIGGUURREE 77..44:: GGRRAADDEE OOFF MMOOSSTT SSEENNIIOORR DDOOCCTTOORR TTRREEAATTIINNGG PPAATTIIEENNTT OONN AARRRRIIVVAALL BBYY AAGGEE GGRROOUUPP ((nn==55008855))

35%28% 25% 28%

19% 20% 21% 21% 17%22%

39%

38%38%

39%48% 43% 45% 45%

42%43%

7%

5% 7%

10% 11%15%

14% 16%21% 13%

15%

17% 20%16% 16% 18% 14% 12% 15%

15%

4% 12% 9% 7% 6% 5% 6% 7% 5% 7%

0%

20%

40%

60%

80%

100%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total

PERC

ENTA

GE

AGE GROUP

Consultant Registrar SHO Specialist registrar Other


CHAPTER 7

TIME TO SEE PATIENTS ON ARRIVAL AT HOSPITALS

Patient outcomes are better when they are seen by senior clinicians in a timely manner. In 2018, only 9% (n=450) of major trauma patients were documented as having been reviewed by a consultant within 30 minutes of arrival to ED.

Consultant 450 (9%) 1110 (22%) 264 (17%) 499 (31%)

Associate Specialist 0 (-) 26 (1%) 0 (-) <5 (0%)

Specialist Registrar 11 (0%) 788 (15%) 0 (-) 270 (17%)

Registrar 352 (7%) 2173 (43%) 159 (10%) 595 (37%)

SHO 982 (19%) 678 (13%) 399 (25%) 160 (10%)

Intern 176 (3%) 5 (0%) 44 (3%) <5 (0%)

Other (not recorded) 22 (<1%) 60 (1%) <5 (0%) 13 (1%)

Detail not captured at time point 3092 (61%) 245 (5%) 729 (46%) 54 (3%)

Most senior Most senior Most senior Most senior doctor seeing doctor seeing doctor seeing doctor seeing patient on patient in patient on patient in arrival in the ED ED after arrival arrival with ED with <30mins ISS>15 in the ED ISS>15 after <30mins arrival (n=5,085) (n=5,085) (n=1,596) (n=1,596)

TABLE 7.2: MOST SENIOR DOCTOR SEEING THE PATIENT IN THE ED AND THOSE WITH AN ISS >15


CHAPTER 7

SURGERY

In 2018, 2,348 surgeries were recorded; some patients had multiple surgeries while other patients had surgery at more than one hospital and therefore generated more than one submission. There were 1,698 surgeries at the first hospital to which the patient was brought; a further 650 surgeries were performed at the hospital to which the patients were transferred. The most common type of surgery performed was limb surgery (60%, n=1403) (Figure 7.5).

In recent years there has been a change in the treatment of major trauma patients in relation to some surgeries; for example, abdominal surgery (4%, n=89) is becoming a more uncommon treatment as interventional radiologists are increasingly employed to address bleeding in the spleen, liver, pelvis, retroperitoneum and non-compressible vessels. The MTA will work towards reporting the detail of these procedures in future reports.

21 Of the 5,429 patients, 2,348 had major surgery this represents 6,135 admissions to hospitals. Figure 7.5 refers to the main surgery performed in the hospital to which the patient was admitted; subsequent surgeries in the same hospital are not included here. A patient may have had two or more surgeries performed in two or more hospitals and therefore be counted more than once in Figure 7.5.


FIGURE 7.5: SURGICAL INTERVENTION BY BODY REGION (n=2348)21*

FFIIGGUURREE 77..55:: SSUURRGGIICCAALL IINNTTEERRVVEENNTTIIOONN BBYY BBOODDYY RREEGGIIOONN ((nn==22334488))

2% 3% 4%5%

7% 8%

12%

60%

0%

10%

20%

30%

40%

50%

60%

General Thoracic Abdomen Skin/softtissue

Head andbrain

Spine Face Limb(s)

PERC

ENTA

GE

BODY REGION


CHAPTER 7

Figure 7.6 shows the breakdown of ISS by the body region on which surgery was performed. Almost all of the patients who had head or brain surgery had an ISS >15 (99%, n=165).

FIGURE 7.6: SURGICAL INTERVENTION BY BODY REGION AND ISS (n=2348)

FFIIGGUURREE 77..66:: SSUURRGGIICCAALL IINNTTEERRVVEENNTTIIOONN BBYY BBOODDYY RREEGGIIOONN AANNDD IISSSS ((nn==22334488))

51%

96%

51%

1%

85%79%

60%52%

49%

4%

49%

99%

15%21%

40%48%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Abdomen Face General Head andbrain

Limb(s) Skin/softtissue

Spine Thoracic

PERC

ENTA

GE

BODY REGION



CHAPTER 7

Figure 7.7 shows that of those patients who had surgery, males were more likely to require surgery in all body regions except in limb surgery which should a slightly higher percentage of females. FFIIGGUURREE 77..77:: SSUURRGGIICCAALL IINNTTEERRVVEENNTTIIOONN BBYY BBOODDYY RREEGGIIOONN AANNDD GGEENNDDEERR ((nn==22334488))

18%11%

26% 24%

51%

37% 36%31%

40%

82%89%

74% 76%

49%

63% 64%69%

60%

0%

20%

40%

60%

80%

100%

Abdomen Face General Head andbrain

Limb(s) Skin/softtissue

Spine Thoracic Total

PERC

ENTA

GE

BODY REGION

Female Male

FIGURE 7.7: SURGICAL INTERVENTION BY BODY REGION AND GENDER (n=2348)

FFIIGGUURREE 77..88:: AAIIRRWWAAYY MMAANNAAGGEEMMEENNTT OOFF PPAATTIIEENNTTSS WWIITTHH AA GGCCSS <<99 ((nn==223399))

72%

0%

11%

2%

16%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Intubated – ED Intubated – pre-hospital Intubated – both ED and pre-hospital

No intubation Not known

PERC

ENTA

GE

AIRWAY MANAGEMENT


CHAPTER 7

HOSPITAL SYSTEMS PERFORMANCE

The Trauma Audit & Research Network (TARN) audit is underpinned by clinical standards and systems indicators, which are intended to provide opportunities for learning and quality improvement.

1. AIRWAY MANAGEMENT IN PATIENTS WITH GCS<9

International guidelines use a GCS of <9 as a criterion for the requirement of definitive airway management, i.e. endotracheal or tracheal intubation, on arrival at an ED (Royal College of Surgeons of England, 1999).

In 2018, there were 239 patients with a recorded GCS of <9. Of these, 72% (n=171) were documented as being intubated in the ED. Sixteen per cent (n=37) had ‘not known’ recorded for their airway support status (Figure 7.8). It is hoped that with the continued roll-out of TraumaDoc, which captures the intubation process, documentation of this will improve.

FIGURE 7.8: AIRWAY MANAGEMENT OF PATIENTS WITH A GCS <9 (n=239)22*

22 This refers to direct admissions only.* Please note: Percentages may not sum to 100% due to rounding.


CHAPTER 7

2. MANAGEMENT OF SHOCKED PATIENTS

Patients with blunt trauma admitted with a systolic blood pressure of less than 110 mmHg have a significantly increased risk of mortality (Hasler et al., 2011). The crude survival rate does not attempt to adjust for differences in age, gender, comorbidities, etc., which contribute to survival. A total of 649 shocked patients were recorded in 2018, representing 12% of all MTA patients. Of those, 90% (n=587) survived and 10% (n=62) died (Figure 7.9).

FIGURE 7.9: SURVIVAL OF SHOCKED PATIENTS (n=649)

DeadAlive

90%

10%


CHAPTER 7

3. TIME TO CT FOR HEAD INJURY PATIENTS AT INITIAL TREATING HOSPITAL

Head injury patients with an initial GCS of <13 should have a CT head scan within one hour of admission to hospital (National Institute for Health and Care Excellence, 2014). In 2018, of the 288 patients who required a CT (having head injuries and an initial GCS of <13), 48% (n=132) received it within one hour, an increase of seven percentage points from the Major Trauma Audit National Report 2017 (Figure 7.10). This is based on the patients’ presentation to the initial treating hospital. The median time to CT scan was 1.1 hours (interquartile range (IQR) 0.7–1.7 hours).

Although there is considerable variance demonstrated at hospital level, rapid access pathways have been established in some hospitals and appear to facilitate more patients meeting this target (Figure 7.10A).

FIGURE 7.10: PERCENTAGE OF PATIENTS TO RECEIVE A CT SCAN WITHIN 1 HOUR (n=273)23

Within one hourAfter one hour

23 15 patients did not have time to CT recorded

52% 48%


CHAPTER 7

FIGURE 7.10A: PROPORTION OF ELIGIBLE PATIENTS RECEIVING CT SCAN WITHIN 1 HOUR WITH A GCS <13 BY HOSPITAL (n=273)

FFIIGGUURREE 77..1100AA:: PPRROOPPOORRTTIIOONN OOFF EELLIIGGIIBBLLEE PPAATTIIEENNTTSS RREECCEEIIVVIINNGG CCTT SSCCAANN WWIITTHHIINN OONNEE HHOOUURR WWIITTHH AA GGCCSS <<1133 BBYY HHOOSSPPIITTAALL ((nn==227733))

100% 100%

90%

83% 82%80%

75%

65%

60%57%

56%52%

33% 33%32%

29%

23% 22%19%

13%

48%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Cav

an

Tem

ple

Stre

et

St V

ince

nt's

Slig

o

Mat

er

Wat

erfo

rd

Ker

ry

St J

ames

's

Gal

way

Lett

erke

nny

Cor

k

Dro

ghed

a

Kilk

enny

Talla

ght

Bea

umon

t

May

o

Lim

eric

k

Wex

ford

Con

nolly

Mul

linga

r

Nat

iona

l

PERC

ENTA

GE

HOSPITALS


CHAPTER 7

4. INTENSIVE CARE UNIT ADMISSION

Patients sustaining major trauma are admitted to a critical care service for many reasons, including ongoing resuscitation, organ support and/or closer monitoring. Critical care encompasses both intensive care and high-dependency care. In practice, level two is the high dependency care and level three is the intensive care level of critical care (National Standards for Adult Critical Care Services, 2011). The length of stay (LOS) in an intensive care unit (ICU) can be influenced by the availability of ICU beds, the needs of the patient and/or the availability of step-down beds.

Table 7.3 shows that 15% (n=827) of MTA submissions were admitted to an ICU, with a median LOS in the unit of three days for all submissions. Some patients generate multiple MTA submissions during their patient journey, as they are transferred between hospitals. The MTA should be used to help inform national ICU bed capacity requirements.

Figure 7.11 shows the median ICU LOS by hospital; this figure illustrates that there is variation in median ICU LOS at hospital level. Demand for ICU beds varies, as some hospitals offer a national service and have mandatory acceptance requirements for certain conditions. Figure 7.11A shows the number of ICU bed days occupied by hospital in 2018, which ranges from six days to 1,877 days.

Number of patients 827 555 136

Median (IQR) 4 (2-9) 4 (2-10) 6 (1.50-13)

ICU bed days 5829 4224 1199

TABLE 7.3: ICU LENGTH OF STAY (LOS)

ICU LOS FOR ALL ICU LOS FOR MTA ICU LOS FOR MTA PATIENTS MTA PATIENTS PATIENTS (ISS>15) WITH SEVERE TBI


CHAPTER 7

24 875 refers to the number of submissions, i.e. a patient could have been admitted to one or more hospitals and could be counted twice in Figure 7.11. In Table 7.3, 827 refers to patients only, i.e. each patient is counted once.

FIGURE 7.11: MEDIAN ICU LOS BY HOSPITAL (n=875)24

FFIIGGUURREE 77..1111:: MMEEDDIIAANN IICCUU LLEENNGGTTHH OOFF SSTTAAYY BBYY HHOOSSPPIITTAALL ((nn==887755))

7

6

5

4 4

3 3 3 3 3 3 3 3

2 2 2 2 2 2 2 2 2

1 1 1

3

0

1

2

3

4

5

6

7

8

Bea

umon

t

Mer

cy

St J

ames

's

Cor

k

Mat

er

May

o

Tulla

mor

e

Slig

o

Gal

way

Ker

ry

Con

nolly

Dro

ghed

a

Lim

eric

k

Cav

an

Cru

mlin

Port

laoi

se

Naa

s

Tipp

erar

y

Kilk

enny

St V

ince

nt's

Talla

ght

Wat

erfo

rd

Wex

ford

Lett

erke

nny

Mul

linga

r

Tem

ple

Stre

et

Nat

iona

l

ICU

LO

S

HOSPITAL

FIGURE 7.11A: TOTAL NUMBER OF ICU BED DAYS OCCUPIED PER HOSPITAL (n=5829)

FFIIGGUURREE 77..1111AA:: TTOOTTAALL NNUUMMBBEERR OOFF IICCUU BBEEDD DDAAYYSS OOCCCCUUPPIIEEDD PPEERR HHOOSSPPIITTAALL

1877

1206

495

327 305

182 178 151 122 121 117 112 87 74 67 66 64 54 51 46 45 40 20 8 8 60

200

400

600

800

1000

1200

1400

1600

1800

2000

Mat

er

Bea

umon

t

Cor

k

Dro

ghed

a

Gal

way

St V

ince

nt's

St J

ames

's

Wat

erfo

rd

Ker

ry

Con

nolly

Tem

ple

Stre

et

Talla

ght

Kilk

enny

Tulla

mor

e

Wex

ford

Lim

eric

k

Tipp

erar

y

Slig

o

May

o

Mul

linga

r

Cav

an

Lett

erke

nny

Cru

mlin

Port

laoi

se

Naa

s

Mer

cy

ICU

LO

S

HOSPITAL


CHAPTER 7

5. HOSPITAL LOS

Hospital LOS for trauma patients is dependent on the nature and severity of the injuries sustained, the baseline health of the patient, the efficiency of the hospital in delivering care and the ability of the hospital to discharge the patient to an appropriate setting when they have recovered. Access to rehabilitation, step-down facilities, and home and community supports influence the LOS at the acute hospital for severely injured patients. The median LOS for all major trauma patients in 2018 was nine days (Table 7.4). Figure 7.12 shows the median LOS for major trauma patients by age group, and demonstrates that the LOS increases with age. There is variation in median LOS at hospital level, as illustrated by Figure 7.12A. Capacity and demand vary considerably at hospital level. Figure 7.12B shows the number of bed days occupied by hospital, which ranges from 203 days to 11,404 days in 2018. A total of 87,768 hospital bed days were occupied by major trauma patients in 2018.

Median LOS for all major trauma patients (IQR): 9 (5–18)

Median LOS for major trauma patients with an ISS >15 (IQR): 10 (5–22)

TABLE 7.4: HOSPITAL LOS FOR MAJOR TRAUMA PATIENTS

FIGURE 7.12: HOSPITAL LOS BY AGE GROUP (N=5429)

FFIIGGUURREE 77..1122:: HHOOSSPPIITTAALL LLEENNGGTTHH OOFF SSTTAAYY BBYY AAGGEE GGRROOUUPP ((NN==55442299))

5 56

7 78

10

13

14

0

2

4

6

8

10

12

14

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

MED

IAN

LO

S (D

AYS

)

AGE GROUP

FFIIGGUURREE 77..1122AA:: MMEEDDIIAANN LLEENNGGTTHH OOFF SSTTAAYY BBYY HHOOSSPPIITTAALL ((nn==66113355))

10 10 10 10

9 9 9

8 8 8 8 8 8

7 7

6 6 6 6 6

5 5

4 4 4

3

8

0

2

4

6

8

10

12

Bea

umon

t

May

o

Naa

s

St V

ince

nt's

Cor

k

Mat

er

Gal

way

Tulla

mor

e

Dro

ghed

a

Slig

o

Ker

ry

Wat

erfo

rd

Lett

erke

nny

Con

nolly

Talla

ght

Cru

mlin

Mer

cy

St J

ames

's

Lim

eric

k

Tipp

erar

y

Mul

linga

r

Port

laoi

se

Cav

an

Kilk

enny

Tem

ple

Stre

et

Wex

ford

Nat

iona

l

MED

IAN

LO

S (D

AYS

)

HOSPITAL

FFIIGGUURREE 77..1122BB:: TTOOTTAALL NNUUMMBBEERR OOFF BBEEDD DDAAYYSS OOCCCCUUPPIIEEDD PPEERR HHOOSSPPIITTAALL

1140

4

1083

2

960

4

7052

6326

5799

4722

4191

4169

4160

3784

2251

2168

1796

1493

1441

1074

1026

1016

905

786

740

310

290

226

203

0

2000

4000

6000

8000

10000

12000

Bea

umon

t

Cor

k

Mat

er

St V

ince

nt's

St J

ames

's

Dro

ghed

a

Talla

ght

Con

nolly

Lim

eric

k

Gal

way

Wat

erfo

rd

Ker

ry

Tulla

mor

e

Cav

an

Slig

o

May

o

Lett

erke

nny

Mul

linga

r

Kilk

enny

Tipp

erar

y

Wex

ford

Naa

s

Tem

ple

Stre

et

Mer

cy

Cru

mlin

Port

laoi

se

NU

MBE

R O

F BE

D D

AYS

HOSPITAL


CHAPTER 7

FIGURE 7.12A: MEDIAN LOS BY HOSPITAL (n=6135)25

FIGURE 7.12B: TOTAL NUMBER OF BED DAYS OCCUPIED PER HOSPITAL (n=87768)

25 6135 refers to all submissions.

KEY FINDINGS FROM CHAPTER 7• Younger patients continue to be more likely to be pre-alerted than older patients. This is

largely because mechanisms of injury, in particular low falls sustained by older persons, may seem low risk but are often associated with very significant injuries.

• The overall percentage of major trauma patients received by a trauma team at the first receiving hospital remains low, at 8% (n=425).

• Patients in the younger age groups were more likely to be received by a trauma team, with a steady decline in the likelihood of receipt by a trauma team as patient age increased.

• Increasing age correlates with fewer patients being seen by a consultant and a greater likelihood of patients being seen by a more junior doctor (i.e. at SHO grade).

• Nine per cent (n=450) of major trauma patients were documented as having been reviewed by a consultant within 30 minutes of arrival to ED.

• There were 2,348 surgeries recorded out of all submissions (n=6135). The most common type of surgery performed was limb surgery (60%, n=1403).

• Almost all of the patients who had head or brain surgery had an ISS >15 (99%, n=165).

• There were 239 patients with a recorded GCS of <9. Of these, 72% (n=171) were documented as being intubated in the ED and 11% (n=25) were documented as being intubated both in ED and pre-hospital. Sixteen per cent (n=37) had ‘not known’ recorded for their airway support status.

• A total of 649 shocked patients were recorded in 2018, representing 12% of all MTA patients. Of those, 90% (n=587) survived and 10% (n=62) died.

• In 2018, of the 273 patients who required a CT scan (i.e. those with head injuries and an initial GCS of <13), 48% (n=132) received it within 1 hour, an increase of seven percentage points from the Major Trauma Audit National Report 2017.

• Although there is considerable variance in the percentage of patients receiving a CT scan within 1 hour demonstrated at hospital level, rapid access pathways have been established in some hospitals and appear to facilitate more patients meeting this target.

• A total of 87,768 hospital bed days were occupied by major trauma patients in 2018.


CHAPTER 7

CHAPTER 8OUTCOMES

CHAPTER 8

This chapter will describe the outcomes of major trauma patients in terms of mortality, discharge destination and case-mix-standardised rate of survival. Mortality is reported at 30 days post-discharge.

MORTALITY AT 30 DAYS POST-DISCHARGE

Mortality is a crude measure of quality of care in major trauma patients; quality of survival and return to independent living is a far more patient-centred measure. The NOCA MTA is working towards developing these outcome measures. That said, in 2018, 5% (n=286) of patients were recorded as having died during their hospital admission.

MORTALITY AND AGE

Figure 8.1 shows the percentage of patients within each age group who died from their injuries as a proportion of the total number of patients who died (n=286). The highest proportion of deaths occurred in patients aged 75 years and over.

OUTCOMES


FIGURE 8.1: MORTALITY BY AGE GROUP (n=286)

FFIIGGUURREE 88..11:: MMOORRTTAALLIITTYY BBYY AAGGEE GGRROOUUPP ((nn==228866))

1%

7%6% 6%

8%

10%

9%

26%25%

0%

10%

20%

30%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

PERC

ENTA

GE

AGE GROUP

MORTALITY BY GENDER AND AGE

Out of all deaths at 30 days post-discharge in 2018, 63% (n=179) were male and 37% (n=107) were female (Figure 8.2).

CHAPTER 8


FIGURE 8.2: MORTALITY BY GENDER (n=286)

MaleFemale

37%

63%

CHAPTER 8


MORTALITY BY MECHANISM OF INJURY

The highest proportion of deaths continues to be attributable to falls less than 2 m (59%, n=170) (Figure 8.3). Figure 8.3A shows that the leading causes of mortality in major trauma patients in the younger age groups are ‘other’ (which includes asphyxiation, drowning, and amputation) and road trauma.


FIGURE 8.3: MORTALITY BY MECHANISM OF INJURY (n=286)*

FFIIGGUURREE 88..33:: MMOORRTTAALLIITTYY BBYY MMEECCHHAANNIISSMM OOFF IINNJJUURRYY ((nn==228866))59%

10% 10%

20%

0%

10%

20%

30%

40%

50%

60%

Fall less than 2 m Fall more than 2 m Road trauma Other

PERC

ENTA

GE

MECHANISM OF INJURY

CHAPTER 8


FIGURE 8.3A: MORTALITY BY MECHANISM OF INJURY AND AGE GROUP (n=286)*


FFIIGGUURREE 88..33AA:: MMOORRTTAALLIITTYY BBYY MMEECCHHAANNIISSMM OOFF IINNJJUURRYY AANNDD AAGGEE GGRROOUUPP ((nn==228866))

6%

38%

50%

76%84% 88%

59%

10%

18%

11%

8%

23%

12%

12% 3%

10%

38%

29%

6%

13%

13%

8%1%

7%

10%

100%

52%47%

83%

42%

13%4% 3% 3%

20%

0%

20%

40%

60%

80%

100%

0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Total

PERC

ENTA

GE

AGE GROUP

Fall less than 2 m Fall more than 2 m Road trauma Other

CHAPTER 8


MORTALITY BY ISS

Of those patients who died in 2018, 75% (n=214) had an ISS >15, indicating severe injury (Figure 8.4).

FIGURE 8.4: MORTALITY BY ISS CATEGORY (n=286)

FFIIGGUURREE 88..44:: MMOORRTTAALLIITTYY BBYY IISSSS CCAATTEEGGOORRYY ((nn==228866))

9%

16%

75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


PERC

ENTA

GE

ISS CATEGORY

CHAPTER 8



MORTALITY BY BODY REGION INJURED

Figure 8.5 shows that head injuries were the cause of death in 55% (n=156) of all major trauma patients who died in 2018.

FIGURE 8.5: MORTALITY BY BODY REGION MOST SEVERLY INJURED (n=286)*

FFIIGGUURREE 88..55:: MMOORRTTAALLIITTYY BBYY BBOODDYY RREEGGIIOONN MMOOSSTT SSEEVVEERREELLYY IINNJJUURREEDD ((nn==228866))

55%

14%

10%8% 7%

5%2%

0%0%

10%

20%

30%

40%

50%

60%

Head Other Limbs Spine Chest Multiple Abdomen Face

PERC

ENTA

GE

BODY REGION INJURED

CHAPTER 8


DISCHARGE DESTINATION

Figure 8.6 shows that 59% (n=3229) of major trauma patients were discharged directly home from hospital. Thirteen per cent (n=686) were discharged to a nursing home and 9% (n=513) were discharged to a rehabilitation setting. Access to rehabilitation, step-down facilities, and home and community supports influence the LOS at the acute hospital for severely injured patients.

In 2018, it was identified that there is a lack of meaningful rehabilitation data being captured through the audit for Ireland. A rehabilitation subcommittee was established by the MTA Governance Committee, and a pilot data collection tool focused on rehabilitation data was developed. This was distributed to 10 hospitals and the findings from this pilot are currently being reviewed. The aim of this work will be to incorporate these fields into the main audit once this work is complete.

26 Mortuary figures do not equate to mortality figures, as mortality is reported at 30 days post-discharge.

FIGURE 8.6: DISCHARGE DESTINATION (N=5429)26

FFIIGGUURREE 88..66:: DDIISSCCHHAARRGGEE DDEESSTTIINNAATTIIOONN ((NN==55442299))

59%

13% 12%9%

6%

1%0%

10%

20%

30%

40%

50%

60%

Home Nursing home Other acutehospital

Rehabilitation Mortuary Not known

PERC

ENTA

GE

DISCHARGE DESTINATION

CHAPTER 8


RISK-ADJUSTED BENCHMARKING

Risk adjustment is a process that allows data to be compared by adjusting for confounding factors (i.e. age, gender, severity of injury, pre-existing comorbidities and GCS) that influence the outcome. Within TARN, this is done at an individual patient level as well as at a hospital level. From approved TARN submissions, a risk-adjusted survival rate was calculated for Ireland for 2018. This was based on all approved submissions from participating hospitals and was adjusted for case mix. This risk-adjusted survival rate is referred to as the Ws value.

Ireland’s Ws value of 1.15 (95% confidence interval (CI), 1.02–2.23) (Table 8.1) means that for every 100 major trauma patients treated in Ireland, there are 1.15 more survivors than the TARN statistical model predicts (Bouamra et al., 2015).

95 - 100 3460 3431 3411.58 0.56 0.67 0.38

90 - 95 786 754 730.75 2.96 0.16 0.46

80 - 90 502 451 430.06 4.17 0.08 0.35

65 - 80 174 146 127.68 10.53 0.04 0.40

45 - 65 117 58 65.33 -6.27 0.02 -0.14

25 - 45 67 22 24.64 -3.94 0.02 -0.06

0 - 25 46 14 6.05 17.28 0.01 0.04

Total 5152 4876 4796.10 1.55 1.62 (1.02-2.23)

TABLE 8.1: CASE-MIX-STANDARDISED RATE OF SURVIVAL FOR IRELAND, 2018

PS Band n Survivors Expected W TARN Ws 95% CI Survivors Fraction

CHAPTER 8


Note: Patients who died at or were discharged from a hospital are eligible for Ws calculations. Patients who were transferred out from a hospital and not readmitted are included in the receiving (final) hospital’s Ws.

The hospital Ws value is calculated where there are more than 50 approved TARN submissions for that hospital, but becomes more reliable as more cases are added. In 2018, 22 hospitals with more than 50 approved submissions were included. The number of discharges ranged from 23 to 625 per hospital, with 13 hospitals having less than 200 approved submissions (Figure 8.7). The funnel plot shows the individual hospitals’ positions in relation to the average Ws value, e.g. whether the hospital is two standard deviations (SD) above (+2 SD) or three SD below (−3 SD).

Risk-adjusted survival does not take into account the potential high personal and societal costs when patients are delayed or prevented from returning to their pre-trauma functional status or quality of life.

The Irish Rehabilitation Outcomes Collaborative (IROC) Proposal is a major national clinical audit commissioned by the Clinical Strategy and Programme division within the HSE and conducted in partnership with the National Clinical Programme for Rehabilitation Medicine, the Irish Association of Rehabilitation Medicine (IARM), the Royal College of Physicians of Ireland (RCPI) and the Road Safety Authority (RSA).

The IROC will develop a comprehensive audit system embedded within routine clinical care which will be used to determine the scope, provision, quality and efficiency of specialist rehabilitation services across Ireland and improve the quality of care for people with complex rehabilitation needs following neurological injury/illness or major trauma.

FIGURE 8.7: IRISH HOSPITAL WS SCORES, 2018

SD = Standard deviation

HOSPITAL

Ws Average Ws -3 SD+2 SD +3 SD -2 SD

10

-15

-10

-5

0

5

15

RATE

OF

SURV

IVA

L

Wex

ford

Lett

erke

nny

Clo

nmel

St L

ukes

Mul

linga

r

Tulla

mor

e

May

o

Cav

an

Slig

o

Kerr

y

Talla

ght

Lim

eric

k

Wat

erfo

rd

Gal

way

St J

ames

’s

St V

ince

nt’s

Con

nolly

Mat

er

Dro

ghed

a

Bea

umon

t

Cor

k


CHAPTER 8

The work is undertaken against a background of the publication of A Trauma System for Ireland: Report of the Trauma Steering Group (Department of Health, 2018) and the work of the MTA in NOCA, and also the implementation of the National Strategy & Policy for the Provision of Neuro-Rehabilitation Services in Ireland and the National Clinical Programme for Rehabilitation Medicine Model of Care.

It will describe how specialist rehabilitation services are currently delivered in the context of rehabilitation and trauma networks, and will support the further development and implementation of the relevant national standards and clinical guidelines.

Ultimately, a key priority will be to create data linkages between the MTA database and the IROC database. This will allow tracking of patients discharged from major trauma care centres in order to identify those who subsequently receive specialist rehabilitation, and also those who do not reach specialist services.

CHAPTER 8


KEY FINDINGS FROM CHAPTER 8• The highest proportion of deaths occurred in patients who were aged 75 years and over

(n=147).

• The highest percentage of deaths continues to occur in males (63%, n=179).

• The highest proportion of deaths continues to be attributable to falls less than 2 m (59%, n=170).

• Of those patients who died in 2018, 75% (n=214) had an ISS >15, indicating severe injury.

• Head injuries were the cause of death in 55% of all major trauma patients who died in 2018.

• Fifty-nine per cent (n=3213) of major trauma patients were discharged directly home from hospital. Further work on rehabilitation, step-down facilities and outcomes for these patients is ongoing.

CHAPTER 9AUDIT UPDATE

CHAPTER 9

In 2018, the MTA made significant progress in data coverage. Part of the reason for such an improvement in the data coverage has been the increased visibility and use of the data within the health system. The MTA will continue to provide the health system with relevant, accurate data and capture key data as the new trauma system evolves.

The Major Trauma Audit National Report 2017 findings were presented at many national and international conferences during 2018: nationally at conferences for the Irish Gerontological Society (IGS), the National Falls and Bone Health Project (2018–2023) (AFFINITY), the Irish Association for Emergency Medicine (IAEM) and the Irish Society of Chartered Physiotherapists (ISCP), and internationally at the 7th Fragility Fracture Network Global Congress in the Royal College of Surgeons in Ireland (RCSI).

Throughout the year, monthly teleconferences are held between the MTA Manager and the coordinators. In addition, the MTA Manager attended several hospital meetings. Two TARN workshops were held in 2018 in the RCSI, primarily for the audit coordinators and clinical leads.

In 2019, several key developments will be taking place for the audit, including:

• completion of the MTA data dictionary• updated quarterly Hospital Group reports• completion of an in-depth report on Health Information and Quality Authority

(HIQA) data quality dimensions• development of further validation reports• implementation of the new data analytical portal by TARN• further public and patient involvement.

AUDIT UPDATE


CHAPTER 10RECOMMENDATIONS

AND CONCLUSION

CHAPTER 10

RECOMMENDATIONS AND CONCLUSION


• The MTA continues to highlight the need for a coordinated trauma system that can deliver direct and timely access to established and properly resourced trauma teams, key interventions such as CT, and well-coordinated multidisciplinary rehabilitation, as well as promote injury prevention.

• The MTA will continue to support the implementation of the Trauma System for Ireland strategy report in partnership with the National Clinical Lead for Trauma Services and the HSE Trauma Review Implementation Group (TRIG).

• The MTA continues to highlight the need for a multi-agency, multidisciplinary and coordinated strategy to address prevention and management of the most common mechanism of injury in Ireland: low falls.

STRATEGIC

• Each hospital should have an active MTA hospital governance committee engaged in using the reports from this audit to actively engage in quality improvement and reduce the variation in performance across all hospital sites.

• NOCA will conduct a survey of MTA hospital governance committees and will provide guidance and tools to support this.

GOVERNANCE

• NOCA will continue to work with hospitals to improve data quality e.g. matching patient cases that have been transferred from one hospital to another.

DATA QUALITY

• The MTA will progress the development of key data fields in order to capture meaningful data for rehabilitation in Ireland through the rehabilitation subcommittee and MTA Governance Committee.

• The MTA will continue to progress the development of longer-term outcome measures for the audit.

OUTCOMES

KEY RECOMMENDATIONS


CHAPTER 10

CONCLUSION

This report has shown that, as a maturing audit, the MTA is now facilitating changes in the health system on a national and local scale. The engagement and continued interest of healthcare staff with this audit is growing. The recognition and use of data from the MTA to facilitate and inform the development of the national trauma system in Ireland has been a milestone in the progress of the audit. Some other key achievements include the greatly improved data coverage and improvements in access to CT scans.

Thanks to the clinical leadership of the hospital clinical leads, and the data collection and dedication of the audit coordinators, this audit is now on par with other international major trauma audits.

Next steps for the MTA will include supporting hospitals to improve their local governance arrangements for major trauma, and helping them to progress the use of data from this audit in order to engage in quality improvement. On a countrywide scale, the MTA will continue to highlight the areas where injury prevention opportunities can be achieved through better home and work safety, and by encouraging the public to ‘Think Safety First’.

REFERENCES

REFERENCES

Baker, S.P., O’Neill, B., Haddon, W. Jr and Long, W.B. (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. Journal of Trauma and Acute Care Surgery, 14(3), pp. 187-196.

Bouamra, O., Wrotchford, A., Hollis, S., Vail, A., Woodford, M. and Lecky, F. (2015) A new approach to outcome prediction in trauma: A comparison with the TRISS model. Journal of Trauma and Acute Care Surgery, 61(3), pp. 701-710.

Charlson, M.E., Pompei, P., Ales, K.L. and MacKenzie, C.R. (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of Chronic Diseases, 40(5), pp. 373-383.

Department of Health (2018) Sláintecare Implementation Strategy [Internet]. Available from: https://assets.gov.ie/22607/31c6f981a4b847219d3d6615fc3e4163.pdf [Accessed Day Month 2019].

Department of Health (2018) A Trauma System for Ireland: Report of the Trauma Steering Group [Internet]. Available from: https://health.gov.ie/wp-content/uploads/2018/02/Report-of-the-Trauma-Steering-Group-A-Trauma-System-for-Ireland.pdf [Accessed 20 November 2018].

Dreinhöfer, K.E., Mitchell, P.J., Bégué, T., Cooper, C., Costa, M.L., Falaschi, P., Hertz, K., Marsh, D., Maggi, S., Nana, A. and Palm, H., 2018. A global call to action to improve the care of people with fragility fractures. Injury, 49(8), pp.1393-1397.

Driscoll, P.A. and Vincent, C.A. (1992) Variation in trauma resuscitation and its effect on patient outcome. Injury, 23(2), pp. 111-115.

Hasler, R.M., Nuesch, E., Jüni, P., Bouamra, O., Exadaktylos, A.K. and Lecky, F. (2011) Systolic blood pressure below 110 mm Hg is associated with increased mortality in blunt major trauma patients: multicentre cohort study. Resuscitation, 82(9), pp. 1202-1207.

Health Information and Quality Authority (2018) Guidance on a data quality framework for health and social care [Internet]. Available from: https://www.hiqa.ie/sites/default/files/2018-10/Guidance-for-a-data-quality-framework.pdf [Accessed 20 November 2018].

Health Service Executive, National Council on Ageing and Older People, Department of Health and Children (2008) Strategy to Prevent Falls and Fractures in Ireland’s Ageing Population [Internet]. Available from: https://www.hse.ie/eng/services/publications/olderpeople/executive-summary---strategy-to-prevent-falls-and-fractures-in-irelands-ageing-population.pdf [Accessed 04 Secember 2019].

Moran, C.G., Lecky, F., Bouamra, O., Lawrence, T., Edwards, A., Woodford, M., Willett, K. and Coats, T.J. (2018) Changing the system – major trauma patients and their outcomes in the NHS (England) 2008–17. EclinicalMedicine, 2–3, pp. 13-21.

National Clinical Effectiveness Committee (2015) Prioritisation and Quality Assurance for National Clinical Audit [Internet]. Available from: http://health.gov.ie/patient-safety/ncec/national-clinicalaudit/ [Accessed 05 November 2019].

National Institute for Health and Care Excellence (2014) Head injury: assessment and early management: Clinical guideline [CG176] [Internet]. Available from: https://www.nice.org.uk/guidance/cg176 [Accessed 23 October 2019].

National Office of Clinical Audit (2019) Major Trauma Audit National Report 2017. Dublin: National Office of Clinical Audit. Available from: http://s3-eu-west-1.amazonaws.com/noca-uploads/general/MAJOR_TRAUMA_AUDIT_NATIONAL_REPORT_2017_FINAL.pdf[Accessed 04 December 2019].

NHS Clinical Advisory Group (2010) Regional Networks for Major Trauma: NHS Clinical Advisory Groups Report [Internet]. Available from: http://www.uhs.nhs.uk/Media/SUHTInternet/Services/Emergencymedicine/Regionalnetworksformajortrauma.pdf [Accessed 14 November 2018].

REFERENCES


REFERENCES

Royal College of Physicians (2015) National Hip Fracture Database (NHFD) Annual Report 2015. London: Royal College of Physicians. Available from: http://www.nhfd.co.uk/nhfd/nhfd2015reportPR1.pdf [Accessed 23 October 2019].

Royal College of Surgeons of England (1999) Report of the working party on the management of patients with head injuries. London: Royal College of Surgeons of England.

The Irish Longitudinal Study on Ageing (2014) The Over 50s in a Changing Ireland: Economic Circumstances, Health and Well-Being [Internet]. Dublin: The Irish Longitudinal Study on Ageing. Available from: http://www.ucd.ie/t4cms/Wave2-Key-Findings-Report%20-%20The%20Over%2050s%20in%20a%20Changing%20Ireland.pdf [Accessed 23 October 2019].

World Health Organization (2015) World Report on Ageing and Health [Internet]. Available from: http://www.who.int/ageing/publications/world-report-2015/en/ [Accessed 23 October 2019].

World Health Organization (2018) Falls [Internet]. Available from: http://www.who.int/mediacentre/factsheets/fs344/en/ [Accessed 23 October 2019].


APPENDICES

The decision to include a patient should be based on the following 3 points:1. ALL TRAUMA PATIENTS IRRESPECTIVE OF AGE2. WHO FULFIL ONE OF THE FOLLOWING LENGTH OF STAY CRITERIA

DIRECT ADMISSIONS

Trauma admissions whose length of stay is 3 days or more

ORTrauma patients admitted to a High

Dependency Area regardless of length of stayOR

Deaths of trauma patients occurring in the hospital including the Emergency Department

(even if the cause of death is medical)OR

Trauma patients transferred to other hospital for specialist care or for an ICU/HDU bed.

PATIENTS TRANSFERRED IN

Trauma patients transferred into your hospital for specialist care or ICU/HDU bed whose

combined hospital stay at both sites is 3 days or more

ORTrauma admissions to a ICU/HDU area

regardless of length of stayOR

Trauma patients who die from theirinjuries (even if the cause of death is medical)

Patients transferred in for rehabilitation only should not be submitted to TARN.

APPENDIX 1: INCLUSION CRITERIA


3. AND WHOSE ISOLATED INJURIES MEET THE FOLLOWING CRITERIA

BODY REGION OR SPECIFIC INJURY

INCLUDED – IN ISOLATION (EXCEPT WHERE SPECIFIED)

EXCLUDED – IN ISOLATION (EXCEPT WHERE SPECIFIED)

HEAD All brain or skull injuries LOC or injuries to scalp

THORAX All internal injuries

ABDOMEN All internal injuries

SPINE Cord injury, fracture, dislocation Spinal strain or sprain. or nerve root injury.

FACE Fractures documented as: Significantly Fractures documented as Closed and Displaced, open, compound or comminuted. simple or stable. All Lefort fractures All panfacial fractures. All Orbital Blowout fractures

NECK Any Organ or vascular injury or hyoid fracture Nerve Injuries Skin Injuries

FEMORAL All Shaft, Distal, Head or Subtrochanteric Isolated Neck of femur or Inter/Greater FRACTURE fractures, regardless of Age. trochanteric fractures ≥ 65 years. Isolated Neck of Femur or Inter/ Greater trochanteric fractures <65 years old

FOOT OR HAND: Crush or amputation only. Any fractures &/or dislocations, JOINT OR BONE even if Open &/or multiple

FINGER OR TOE None All injuries to digits, even if Open fractures, amputation or crush &/or multiple injuries.

BODY REGION OR SPECIFIC INJURY

INCLUDED – IN ISOLATION (EXCEPT WHERE SPECIFIED)

EXCLUDED – IN ISOLATION (EXCEPT WHERE SPECIFIED)

LIMB – UPPER Any Open injury. Any Closed unilateral injury fractures, (EXCEPT Any 2 limb fractures &/or dislocations. (including multiple closed fractures & or HAND/FINGERS) dislocations or the same limb)

LIMB – BELOW Any Open injury. Any Closed unilateral injury fractures, KNEE (EXCEPT Any 2 limb fractures &/or dislocations. (including multiple closed fractures & or FEET/TOES) dislocations or the same limb)

PELVIS All isolated fractures to Ischium, Sacrum, Single pubic rami fracture >65 years old. Coccyx, Ileum, acetabulum. Multiple pubic rami fractures. Single pubic rami fracture <65 years old. Any fracture involving SIJ or Symphysis pubis.

NERVE Any injury to sciatic, facial, femoral or All other nerve injuries, single or multiple. cranial nerve.

VESSEL All injuries to femoral, neck, facial, cranial, Intimal tear or superficial laceration or thoracic or abdominal vessels. perforation to any limb vessel. Transection or major disruption of any other vessel.

SKIN Laceration or penetrating skin injuries Simple skin lacerations or penetrating injuries with with blood loss >20% (1000mls) blood loss < 20% (1000mls); single or multiple. Major degloving injury. (>50% body region) Contusions or abrasions: single or multiple. Minor degloving injury. (<50% body region)

BURN Any full thickness burn or Partial/superficial Partial or superficial burn <10% body surface area. burn >10% body surface area

INHALATION All included

FROSTBITE Severe frostbite Superficial frostbite

ASPHYXIA All None

DROWNING All None

EXPLOSION All None

HYPOTHERMIA Accompanied by another TARN eligible injury Hypothermia in isolation

ELECTRICAL All None


INJURY DETAIL

Injury detail is of paramount importance to any TARN submission, therefore all injuries sustained by a patient must be recorded on every submission.

Information relating to injuries should be obtained from the following sources: clinician’s notes, nursing notes, radiology reports, operative notes, discharge summaries and post mortem reports.

Guidelines to help with injury documentation, record:• Length, depth or grade of lacerations (especially to internal organs)• Depth, size and location of haemorrhages and contusions (especially in the brain)• Open or closed fractures• Stability & site of fractures (e.g. comminuted/displaced shaft/proximal/distal fracture)• Articular (joint) involvement (e.g. intra-articular, extra-articular)• Blood loss• Vessel damage• Location & number of rib fractures• Compression or effacement of ventricles/brain stem cisterns• Neurology associated with spinal cord injuries• Instability, blood loss, joint involvement or vascular damage associated with pelvic fractures• Cardiac arrest associated with asphyxia or drowning

UNCONFIRMED INJURIES

Injuries should only be recorded when the diagnosis is confirmed.Never record possible, probable or suspected injuries.

RADIOLOGY REPORTS AND POST-MORTEMS

The user should paste a radiology report into the relevant imaging section of any electronic data collection and reporting (EDCR) submission.

When a report is pasted into an EDCR submission, it will automatically appear on the AIS coding section, thus ensuring that the TARN coder has all the information in front of them before assigning AIS codes.

Post mortem results should be used whenever available even if this results in a delay in dispatching your submission.

All injury coding using AIS is done centrally at TARN, but users can see every AIS code issued by TARN by clicking into the AIS coding section once a submission has been approved.

Accurate and detailed injury descriptions will enable a more precise Injury Severity Score and therefore a more accurate Probability of Survival calculation.


ANATOMICAL INJURY DESCRIPTIONS

CODING STRUCTURE EXPLAINED

BODY TYPE OF SPECIFIC SPECIFIC LEVEL LEVEL AIS REGION ANATOMICAL ANATOMICAL ANATOMICAL STRUCTURE STRUCTURE STRUCTURE 4 5 0 2 0 2 2

All existing codes on the TARN database that were coded with AIS98 (previous version of Dictionary) were successfully mapped to corresponding AIS2005 codes, so continuing comparisons can be made.

BACKGROUND INFORMATION

A.I.S. was first published in 1969 by the Association for the Advancement of Automotive Medicine (A.A.A.M.). The latest edition (AIS2005) is now available from the AAAM website: www.AAAM..org at cost of $250 per dictionary.

STRUCTURE

• Based on anatomical injury.• A single AIS score for each injury.• More than 1500 injuries listed.• Scores range from 1 to 6, the higher the score the more severe the injury.• The intervals between the scores are not always consistent e.g. the difference between AIS3 and AIS4 is not

necessarily the same as the difference between AIS1 and AIS2.

EXAMPLE AIS CODES

INJURY NUMERICAL IDENTIFIER AIS SEVERITYFracture 1 rib 450201 1 MinorFractured 2 ribs 450202 2 ModerateHaemopneumothorax 442205 3 SeriousBilateral lung lacerations 441450 4 SevereBilateral flail chest 450214 5 CriticalMassive chest crush 413000 6 Maximum


ABBREVIATED INJURY SCALE (AIS)

NOCA NATIONAL OFFICE OF CLINICAL AUDIT100 NOCA NATIONAL OFFICE OF CLINICAL AUDIT146

ROLE NAME

Dr Conor Deasy Clinical Lead and Chair – National Board for Ireland of the College of Emergency Medicine

Ms Louise Brent NOCA Irish Hip Fracture Database and Major Trauma Audit Manager

Dr Tomás Breslin Irish Association for Emergency Medicine

Ms Ann Calvert Emergency Medicine Nursing Interest Group

Mr Darach Crimmins Royal College of Surgeons in Ireland – Neurosurgery Programme

Ms Marina Cronin NOCA Head of Quality & Development (RESIGNED 2019)

Mr Vincent Daly National Ambulance Service (RESIGNED 2019)

Ms Rachael Doyle HSE National Clinical Programme for Older People

Ms Anna Duffy MTA Audit Coordinator Representative

Mr Gordon Dunne Senior Accountable Health Manager (RESIGNED 2019)

Ms Jacqueline Egan Pre-Hospital Emergency Care Council

Ms Orlaith Ferguson Public Representative – Sage Advocacy

Dr Joan Fitzgerald Royal College of Physicians of Ireland – Pathology

Ms Naomi Fitzgibbon PPI Representative, Spinal Injuries Ireland

Dr Una Geary National Emergency Medicine Programme Lead (RESIGNED 2019)

Dr Jennifer Hasting College of Anaesthetists

Ms Nora Hourigan Hospital In-Patient Enquiry Manager

Mr Macartan Hughe National Ambulance Service

Mr Dara Kavanagh Royal College of Surgeons in Ireland – General Surgery

Ms Marion Lynders MTA Audit Coordinator Representative

Dr Ciara Martin Paediatric Emergency Medicine

Mr Morgan McMonagle Royal College of Surgeons in Ireland – Irish Association of Vascular Surgeons

Dr Peter MacMahon Royal College of Surgeons in Ireland – Faculty of Radiologists

Dr Caroline Mason Mohan Royal College of Physicians of Ireland – Public Health

Dr Jacinta McElligott Royal College of Physicians of Ireland – Rehabilitation Medicine

Dr Jeanne Moriarty Joint Faculty of Intensive Care Medicine of Ireland Nominee – Critical Care

Dr Gerry Lane Irish Committee for Emergency Medicine Training Chair/Nominee

Dr George Little National Emergency Medicine Programme Nominee for MTA

Mr Brendan O’Daly Irish Institute of Trauma and Orthopaedic Surgery – Trauma and Orthopaedic Programme

Ms Rosie Quinn Therapy Representative

Ms Geraldine Shaw HSE Office of Nursing and Midwifery Services

Ms Collette Tully NOCA Executive Director (BY INVITATION)

APPENDIX 2: MTA GOVERNANCE COMMITTEE

MAJOR TRAUMA AUDIT NATIONAL REPORT 2015-2016 101MAJOR TRAUMA AUDIT NATIONAL REPORT 2018 147

APPENDIX 3: FREQUENCY TABLES

N %

Female 2346 43.2%Male 3083 56.8%Total 5429 100.0%

Figure 4.1: Percentage of MTA patients by gender (N=5429)

N %

No significant pre-existing comorbidities 2501 46% Mild comorbidities (1–5) 2009 37% Moderate comorbidities (6–10) 660 12% Severe comorbidities (>10) 220 4% Not recorded 39 1% Total 5429 100%

Figure 4.2 CCI score of MTA patients (N=5429)

FEMALE MALE TOTAL N % N % N %

0–14 87 48.3% 93 51.7% 180 100.0%15–24 89 21.2% 331 78.8% 420 100.0%25–34 97 21.9% 345 78.1% 442 100.0%35–44 117 24.8% 354 75.2% 471 100.0%45–54 169 28.5% 424 71.5% 593 100.0%55–64 357 43.9% 457 56.1% 814 100.0%65–74 395 49.4% 404 50.6% 799 100.0%75–84 562 55.4% 452 44.6% 1014 100.0%85+ 473 68.0% 223 32.0% 696 100.0%Total 2346 43.2% 3083 56.8% 5429 100.0%

Figure 4.1A: Percentage of MTA patients by gender and age group (N=5429)

AGE GROUP 0-14 15–24 25–34 35–44 45–54 N % N % N % N % N %

No significant pre-existing 167 92.8% 349 83.1% 327 74.0% 285 60.5% 312 52.6% condition Mild comorbidities (1–5) 6 3.3% 67 16.0% 100 22.6% 150 31.8% 210 35.4%Moderate comorbidities (6–10) <5 0.6% 0 0.0% 5 1.1% 17 3.6% 45 7.6% Severe comorbidities (>10) 0 0.0% 0 0.0% <5 0.9% 17 3.6% 22 3.7%Not recorded 6 3.3% <5 1.0% 6 1.4% <5 0.4% <5 0.7%Total 180 100.0% 420 100.0% 442 100.0% 471 100.0% 593 100.0%

AGE GROUP 55–64 65–74 75–84 85+ Total N % N % N % N % N %

No significant pre-existing 367 45.1% 305 38.2% 236 23.3% 153 22.0% 2501 46.1% condition Mild comorbidities (1–5) 321 39.4% 339 42.4% 471 46.4% 345 49.6% 2009 37.0%Moderate comorbidities (6–10) 69 8.5% 115 14.4% 247 24.4% 161 23.1% 660 12.2%Severe comorbidities (>10) 52 6.4% 37 4.6% 55 5.4% 33 4.7% 220 4.1%Not recorded 5 0.6% <5 0.4% 5 0.5% <5 0.6% 39 0.7%Total 814 100.0% 799 100.0% 1014 100.0% 696 100.0% 5429 100.0%

Figure 4.2A: CCI score of MTA patients by age group (N=5429)


N %

Blow(s) 523 9.6%Burn 66 1.2%Crush 40 0.7%Fall less than 2 m 3169 58.4%Fall more than 2 m 557 10.3%Other 142 2.6%Stabbing 57 1.0%Road trauma 875 16.1%Total 5429 100.0%

Figure 4.3: Mechanism of injury (N=5429)

Figure 4.3A: Mechanism of injury by age group (N=5429)

0-14 15–24 25–34 35–44 45–54 N % N % N % N % N %

Blow(s) 20 11.1% 144 34.3% 124 28.1% 72 15.3% 59 9.9% Fall less than 2 m 80 44.4% 52 12.4% 81 18.3% 130 27.6% 271 45.7%Fall more than 2 m 16 8.9% 44 10.5% 58 13.1% 73 15.5% 87 14.7%Road trauma 40 22.2% 141 33.6% 133 30.1% 127 27.0% 130 21.9%Other 24 13.3% 39 9.3% 46 10.4% 69 14.6% 46 7.8%Total 180 100.0% 420 100.0% 442 100.0% 471 100.0% 593 100.0%

55–64 65–74 75–84 85+ Total N % N % N % N % N %

Blow(s) 43 5.3% 33 4.1% 21 2.1% 7 1.0% 523 9.6% Fall less than 2 m 517 63.5% 555 69.5% 836 82.4% 647 93.0% 3169 58.4%Fall more than 2 m 111 13.6% 83 10.4% 68 6.7% 17 2.4% 557 10.3%Road trauma 115 14.1% 103 12.9% 68 6.7% 18 2.6% 875 16.1%Other 28 3.4% 25 3.1% 21 2.1% 7 1.0% 305 5.6%Total 814 100.0% 799 100.0% 1014 100.0% 696 100.0% 5429 100.0%


N %

All head injuries 1418 17.7%Severe head injuries 1222 86.2%Isolated severe head injuries 656 53.7%Severe head injuries and other associated injuries 566 46.3%All face injuries 766 9.6%Severe face injuries 10 1.3%Isolated severe face injuries <5 20.0%Severe face injuries and other associated injuries 8 80.0%All limb injuries 1960 24.5%Severe limb injuries 1239 63.2%Isolated severe limb injuries 998 80.5%Severe limb injuries and other associated injuries 241 19.5%All spinal injuries 1392 17.4%Severe spinal injuries 708 50.9%Isolated severe spinal injuries 444 62.7%Severe spinal injuries and other associated injuries 264 37.3%All pelvic injuries 653 8.2%Severe pelvic injuries 150 23.0%Isolated severe pelvic injuries 56 37.3%Severe pelvic injuries and other associated injuries 94 62.7%All chest and abdominal injuries 1541 19.2%Severe chest and abdominal injuries 1104 71.6%Isolated severe chest and abdominal injuries 393 35.6%Severe chest and abdominal injuries and other associated injuries 711 64.4%All other injuries 278 3.5%Severe other injuries 96 34.5%Isolated other injuries 75 78.1%Severe other injuries and other associated injuries 21 21.9%

Figure 4.4: Injuries sustained by body region (N=8008)

INJURY SEVERITY N %

Low-severity injury 1367 25.2%Moderate-severity injury 2335 43.0%Severe injury 1727 31.8%Total 5429 100.0%

Figure 4.5: Percentage of patients by ISS (N=5429)


Figure 4.5A: ISS by age group (N=5429)

0-14 15–24 25–34 35–44 45–54 N % N % N % N % N %

Low-severity injury 31 17.2% 163 38.8% 149 33.7% 118 25.1% 120 20.2%Moderate-severity injury 88 48.9% 111 26.4% 138 31.2% 200 42.5% 291 49.1%Severe injury 61 33.9% 146 34.8% 155 35.1% 153 32.5% 182 30.7%Total 180 100.0% 420 100.0% 442 100.0% 471 100.0% 593 100.0%

55–64 65–74 75–84 85+ Total N % N % N % N % N %


Figure 4.6A: Place of injury by age group (N=5429)

0-14 15–24 25–34 35–44 45–54 N % N % N % N % N %

Home 88 48.9% 59 14.0% 89 20.1% 137 29.1% 230 38.8%Public area or road 68 37.8% 321 76.4% 306 69.2% 251 53.3% 264 44.5%Institution 7 3.9% 0 0.0% 6 1.4% 6 1.3% 10 1.7%Farm 8 4.4% 15 3.6% 12 2.7% 20 4.2% 22 3.7%Industrial <5 0.6% <5 1.0% 12 2.7% 23 4.9% 24 4.0%Other 8 4.4% 21 5.0% 17 3.8% 34 7.2% 43 7.3%Total 180 100.0% 420 100.0% 442 100.0% 471 100.0% 593 100.0%

55–64 65–74 75–84 85+ Total N % N % N % N % N %

Home 402 49.4% 473 59.2% 701 69.1% 517 74.3% 2696 49.7%Public area or road 296 36.4% 226 28.3% 187 18.4% 78 11.2% 1997 36.8%Institution 20 2.5% 21 2.6% 70 6.9% 79 11.4% 219 4.0%Farm 37 4.5% 42 5.3% 28 2.8% 10 1.4% 194 3.6%Industrial 26 3.2% 13 1.6% 0 0.0% <5 0.3% 105 1.9%Other 33 4.1% 24 3.0% 28 2.8% 10 1.4% 218 4.0%Total 814 100.0% 799 100.0% 1014 100.0% 696 100.0% 5429 100.0%

N %

Home 2696 49.7%Public area or road 1997 36.8%Institution 219 4.0%Farm 194 3.6%Industrial 105 1.9%Other 218 4.0%Total 5429 100.0%

Figure 4.6: Place of injury (N=5429)


Figure 4.6B: Place of injury by ISS (N=5211)

Home Public Area Institution Farm Industrial Total or road N % N % N % N % N % N %

Low-severity injury 648 24.0% 563 28.2% 47 21.5% 39 20.1% 23 21.9% 1320 25.3%Moderate-severity injury 1256 46.6% 756 37.9% 90 41.1% 82 42.3% 45 42.9% 2229 42.8%Severe injury 792 29.4% 678 34.0% 82 37.4% 73 37.6% 37 35.2% 1662 31.9%Total 2696 100.0% 1997 100.0% 219 100.0% 194 100.0% 105 100.0% 5211 100.0%

N %

Female 1470 55%Male 1226 45%Total 2696 100%

Figure 4.7: Injuries sustained at home by gender (n=2696)

N %

Fall less than 2 m 2100 77.9%Fall more than 2 m 331 12.3%Blow(s) 93 3.4%Burn 58 2.2%Stabbing 28 1.0%Other 86 3.2%Total 2696 100%

Figure 4.8: Injuries sustained at home by mechanism of injury (n=2696)

Figure 4.9: CCI score of patients injured at home by age (n=2678)

0-14 15–24 25–34 35–44 45–54 N % N % N % N % N %

Mild comorbidities (1–5) <5 4.8% 24 41.4% 32 36.0% 64 46.7% 90 39.3%Moderate comorbidities (6–10) <5 1.2% 0 0.0% <5 1.1% 6 4.4% 24 10.5%Severe comorbidities (>10) 0 0.0% 0 0.0% <5 2.2% <5 2.9% 11 4.8% No significant pre-existing comorbidities 79 94.0% 34 58.6% 54 60.7% 63 46.0% 104 45.4%Total 84 100.0% 58 100.0% 89 100.0% 137 100.0% 229 100.0%

55–64 65–74 75–84 85+ Total N % N % N % N % N %

Mild comorbidities (1–5) 179 44.9% 215 45.6% 326 46.8% 255 49.6% 1189 44.4%Moderate comorbidities (6–10) 37 9.3% 72 15.3% 176 25.3% 119 23.2% 436 16.3%Severe comorbidities (>10) 32 8.0% 26 5.5% 33 4.7% 22 4.3% 130 4.9% No significant pre-existing comorbidities 151 37.8% 158 33.5% 162 23.2% 118 23.0% 923 34.5%Total 399 100.0% 471 100.0% 697 100.0% 514 100.0% 2678 100.0%


Figure 4.10: Injuries sustained at home by ISS and age group (n=2696)

0-14 15–24 25–34 35–44 45–54 N % N % N % N % N %


55–64 65–74 75–84 85+ Total N % N % N % N % N %


N %

Dead 170 6.3%Alive 2526 93.7%Total 2696 100.0%

Figure 4.11: Injuries sustained at home by mortality (n=2696)

N %

Car 386 44.1%Cyclist 168 19.2%Pedestrian 160 18.3%Motorcycle 146 16.7%Not known 15 1.7%Total 875 100.0%

Figure 4.12: Type of road trauma (n=875)

Figure 4.12A: Type of road trauma by ISS (n=860)

Car Cyclist Pedestrian Motorcycle Total N % N % N % N % N %


N %

9 179 15.2%GCS 9–12 109 9.3%GCS 13–15 887 75.5%Total 1175 100.0%

Figure 4.13: Severe head injury patients by AIS classification (AIS ≥3) (n=1175), further classified into TBI severity by GCS


Figure 4.13A: TBI severity by GCS score, by age group for patients with severe head injuries (AIS ≥3) (n=1175)

0-14 15–24 25–34 35–44 45–54 N % N % N % N % N %

Severe TBI 5 9.8% 25 32.9% 23 24.5% 18 20.2% 28 22.4%Moderate TBI <5 3.9% 8 10.5% 15 16.0% 11 12.4% 13 10.4%Mild TBI 44 86.3% 43 56.6% 56 59.6% 60 67.4% 84 67.2%Total 51 100.0% 76 100.0% 94 100.0% 89 100.0% 125 100.0%

55–64 65–74 75–84 85+ Total N % N % N % N % N %

Severe TBI 30 20.1% 13 7.9% 21 8.1% 16 9.5% 179 15.2%Moderate TBI 17 11.4% 9 5.5% 23 8.9% 11 6.5% 109 9.3%Mild TBI 102 68.5% 143 86.7% 214 82.9% 141 83.9% 887 75.5%Total 149 100.0% 165 100.0% 258 100.0% 168 100.0% 1175 100.0%

Figure 4.13C: Mortality of MTA patients with severe head injury by AIS classification and by age group (n=1222)

0-14 15–24 25–34 35–44 45–54 N % N % N % N % N %

Dead 2 3.8% 10 12.7% 9 9.5% 4 4.3% 13 10.2%Alive 50 96.2% 69 87.3% 86 90.5% 90 95.7% 114 89.8%Total 52 100.0% 79 100.0% 95 100.0% 94 100.0% 127 100.0%

55–64 65–74 75–84 85+ Total N % N % N % N % N %

Dead 19 12.3% 15 8.8% 49 17.9% 39 22.3% 160 13.1%Alive 136 87.7% 156 91.2% 225 82.1% 136 77.7% 1062 86.9%Total 155 100.0% 171 100.0% 274 100.0% 175 100.0% 1222 100.0%

N %

Fall less than 2 m 68 38.0%Fall more than 2 m 31 17.3%Road trauma 56 31.3%Other 24 13.4%Total 179 100.0%

Figure 4.13B: Cause of injury in patients with severe TBI (AIS ≥3 AND GCS <9) (n=179)

Figure 5.1 Falls by gender (n=3726)

Fall less than 2 m Fall more than 2 m Total N % N % N %

Male 1397 44.1% 390 70.0% 1787 48.0%Female 1772 55.9% 167 30.0% 1939 52.0%Total 3169 100.0% 557 100.0% 3726 100.0%


00.00-07.59 08.00-15.59 16.00-23.59 Total N % N % N % N %

0-14 5 5.3% 40 42.1% 50 52.6% 95 100.0%15-24 32 33.3% 26 27.1% 38 39.6% 96 100.0%25-34 37 26.6% 41 29.5% 61 43.9% 139 100.0%35-44 42 20.7% 80 39.4% 81 39.9% 203 100.0%45-54 47 13.1% 164 45.8% 147 41.1% 358 100.0%55-64 114 18.2% 262 41.8% 251 40.0% 627 100.0%65-74 96 15.1% 274 43.1% 265 41.7% 635 100.0%75-84 133 14.8% 411 45.8% 353 39.4% 897 100.0%85+ 98 14.8% 312 47.1% 253 38.2% 663 100.0%Total 604 16.3% 1610 43.4% 1499 40.4% 3713 100.0%

Fall less than 2 m Fall more than 2 m Total N % N % N %

0–14 80 83.3% 16 16.7% 96 100.0%15–24 52 54.2% 44 45.8% 96 100.0%25–34 81 58.3% 58 41.7% 139 100.0%35–44 130 64.0% 73 36.0% 203 100.0%45–54 271 75.7% 87 24.3% 358 100.0%55–64 517 82.3% 111 17.7% 628 100.0%65–74 555 87.0% 83 13.0% 638 100.0%75–84 836 92.5% 68 7.5% 904 100.0%85+ 647 97.4% 17 2.6% 664 100.0%Total 3169 85.1% 557 14.9% 3726 100.0%

Figure 5.2 Falls by age (n=3726)

Chest Head Limbs Multiple Spine Total N % N % N % N % N % N %

Fall less 407 13.3% 747 24.4% 1140 37.2% 156 5.1% 616 20.1% 3066 100.0% than 2 m Fall more 96 17.7% 132 24.4% 106 19.6% 77 1 4.2% 130 24.0% 541 100.0% than 2 m Total 503 13.9% 879 24.4% 1246 34.5% 233 6.5% 746 20.7% 3607 100.0%

Figure 5.4 Falls and most severely injured body area (n=3607)

Low-severity injury Moderate-severity injury Severe injury Total N % N % N % N %

Fall less than 2 m 724 22.8% 1568 49.5% 877 27.7% 3169 100.0% Fall more than 2 m 106 19.0% 208 37.3% 243 43.6% 557 100.0%Total 830 22.3% 1776 47.7% 1120 30.1% 3726 100.0%

Figure 5.5 Falls and injury severity score (n=3726)

Figure 5.3 Falls by presentation by time of day and age band n=(3713)


Figure 5.6 Falls with ISS >15 by pre-alert status (n=1041)

Not pre-alerted Not recorded Pre-alerted Total N % N % N % N %

0–14 15 83.3% <5 11.1% <5 5.6% 18 100.0%15–24 17 50.0% 7 20.6% 10 29.4% 34 100.0%25–34 33 67.3% 6 12.2% 10 20.4% 49 100.0%35–44 29 56.9% 5 9.8% 17 33.3% 51 100.0%45–54 63 64.9% 16 16.5% 18 18.6% 97 100.0%55–64 85 63.9% 24 18.0% 24 18.0% 133 100.0%65–74 129 75.9% 28 16.5% 13 7.6% 170 100.0%75–84 229 78.4% 41 14.0% 22 7.5% 292 100.0%85+ 160 81.2% 22 11.2% 15 7.6% 197 100.0%Total 760 73.0% 151 14.5% 130 12.5% 1041 100.0%

N %

Received by trauma team 97 9.3%Not received by trauma team 944 90.7%Total 1041 100.0%

Figure 5.7 Falls with ISS >15 and reception by trauma team (n=1041)

N %

Ambulance 3666 74.6%Ambulance and helicopter 45 0.9%Car 978 19.9%Helicopter 43 0.9%Walk 179 3.6%Total 4911 100.0%

Figure 6.1 Mode of arrival at hospital (n=4911)

N %

Paramedic 1921 51.2%Advanced paramedic 1161 30.9%Not known 625 16.6%Doctor 41 1.1%Other 6 0.2%Total 3754 100.0%

Figure 6.2 Most senior pre-hospital healthcare professional (n=3754)


N %

Direct admission to neurosurgical unit 220 18.0%Not transferred to neurosurgical unit 767 62.8%Transferred to neurosurgical unit 234 19.2%Total 1221 100.0%

Figure 6.3 Care pathway of patients with severe head injury by AIS (n=1221)

N %

Direct admission to neurosurgical unit 31 17.3%Transfer to neurosurgical unit 58 32.4%Not transferred to neurological unit 90 50.3%Total 179 100.0%

Figure 6.3A Patients with severe TBI and admissions to a neurosurgical unit (AIS ≥3 and GCS <9) (n=179)

N %

Not transferred 4352 80.2%Transferred 1077 19.8%Total 5429 100.0%

Figure 6.4 Percentage of patients transferred to another hospital (N=5429)


Low or moderate Severe Total Total severity injury injury transfers out N % N % N % N %

Beaumont Hospital 10 1.8% 10 1.8% 20 3.6% 552Cavan General Hospital 58 34.9% 19 11.4% 77 46.4% 166Children’s Health Ireland at Crumlin 0 0.0% 0 0.0% 0 0.0% 25Children’s Health Ireland at Temple Street 0 0.0% <5 9.3% <5 9.3% 43Connolly Hospital 21 7.3% 27 9.4% 48 16.7% 288Cork University Hospital 6 0.9% 15 2.2% 21 3.0% 693Letterkenny University Hospital <5 5.1% 12 15.4% 16 20.5% 78Mater Misericordiae University Hospital 14 2.6% 16 2.9% 30 5.5% 546Mayo University Hospital 5 4.5% 5 4.5% 10 9.0% 111Mercy University Hospital 8 25.8% <5 12.9% 12 38.7% 31Midland Regional Hospital, Tullamore 5 2.5% 9 4.5% 14 7.1% 198Regional Hospital Mullingar 28 22.6% 15 12.1% 43 34.7% 124Midland Regional Hospital, Portlaoise <5 6.7% <5 6.7% <5 13.3% 30Naas General Hospital <5 3.7% <5 7.4% 6 11.1% 54Our Lady of Lourdes Hospital, Drogheda 27 6.7% 33 8.2% 60 14.9% 404Sligo University Hospital 15 12.2% 11 8.9% 26 21.1% 123South Tipperary General Hospital 34 32.7% 7 6.7% 41 39.4% 104 St James’s Hospital 7 1.5% 20 4.3% 27 5.8% 466 St Luke’s General Hospital, Kilkenny 33 27.5% 8 6.7% 41 34.2% 120 St Vincent’s University Hospital 8 2.2% 17 4.6% 25 6.8% 368Tallaght University Hospital 10 2.7% 9 2.4% 19 5.2% 368University Hospital Galway and <5 1.1% 15 5.3% 18 6.3% 285 Merlin Park University Hospital University Hospital Kerry 13 7.4% 13 7.4% 26 14.9% 175University Hospital Limerick 40 10.2% 32 8.1% 72 18.3% 393University Hospital Waterford 11 3.9% 15 5.3% 26 9.1% 285Wexford General Hospital 33 31.4% 16 15.2% 49 46.7% 105Total 397 6.5% 338 5.5% 735 12.0% 6135

Figure 6.5 Percentage of transfers out by hospital (n=6135)27



28 6135 refers to the number of submissions, i.e. a patient could have been admitted to one or more hospitals and could be counted twice in Figure 6.5. Patients who were transferred in and out are not included

Low or moderate Severe Total Total severity injury injury transfers in N % N % N % N %

Beaumont Hospital 13 2.4% 75 13.6% 88 15.9% 552Cavan General Hospital 0 0.0% 0 0.0% 0 0.0% 166Children’s Health Ireland at Crumlin 11 44.0% <5 12.0% 14 56.0% 25Children’s Health Ireland at Temple Street <5 2.3% 12 27.9% 13 30.2% 43Connolly Hospital 8 2.8% <5 0.3% 9 3.1% 288Cork University Hospital 27 3.9% 24 3.5% 51 7.4% 693Letterkenny University Hospital 0 0.0% 0 0.0% 0 0.0% 78Mater Misericordiae University Hospital 41 7.5% 23 4.2% 64 11.7% 546Mayo University Hospital <5 0.9% 0 0.0% <5 0.9% 111Mercy University Hospital 0 0.0% 0 0.0% 0 0.0% 31Midland Regional Hospital, Tullamore 29 14.6% <5 2.0% 33 16.7% 198Regional Hospital Mullingar 0 0.0% 0 0.0% 0 0.0% 124Midland Regional Hospital, Portlaoise 0 0.0% 0 0.0% 0 0.0% 30 Naas General Hospital 0 0.0% <5 1.9% <5 1.9% 54Our Lady of Lourdes Hospital, Drogheda 48 11.9% 10 2.5% 58 14.4% 404Sligo University Hospital 0 0.0% <5 0.8% <5 0.8% 123South Tipperary General Hospital 0 0.0% 0 0.0% 0 0.0% 104 St James’s Hospital 41 8.8% <5 0.9% 45 9.7% 466 St Luke’s General Hospital, Kilkenny 0 0.0% 0 0.0% 0 0.0% 120 St Vincent’s University Hospital 16 4.3% 11 3.0% 27 7.3% 368Tallaght University Hospital 33 9.0% 15 4.1% 48 13.0% 368University Hospital Galway and 29 10.2% <5 1.4% 33 11.6% 285 Merlin Park University Hospital University Hospital Kerry <5 0.6% 0 0.0% <5 0.6% 175University Hospital Limerick 22 5.6% 5 1.3% 27 6.9% 393University Hospital Waterford 71 24.9% 9 3.2% 80 28.1% 285Wexford General Hospital 0 0.0% 0 0.0% 0 0.0% 105Total 392 6.4% 202 3.3% 594 9.7% 6135

Figure 6.6 Percentage of transfers in by hospital (n=6135)28

Transferred N %

Female 368 34.2%Male 709 65.8%Total 1077 100.0%

Figure 6.7 Percentage of transfers by gender (n=1077)


Not transferred Transferred Total N % N % N %

0–14 101 56.1% 79 43.9% 180 100.0%15–24 299 71.2% 121 28.8% 420 100.0%25–34 320 72.4% 122 27.6% 442 100.0%35–44 343 72.8% 128 27.2% 471 100.0%45–54 471 79.4% 122 20.6% 593 100.0%55–64 632 77.6% 182 22.4% 814 100.0%65–74 660 82.6% 139 17.4% 799 100.0%75–84 890 87.8% 124 12.2% 1014 100.0%85+ 636 91.4% 60 8.6% 696 100.0%Total 4352 80.2% 1077 19.8% 5429 100.0%

Figure 6.8 Proportion of each age group that was transferred (N=5429)


Blow(s) 391 74.8% 132 25.2% 523 100.0% Fall less than 2 m 2708 85.5% 461 14.5% 3169 100.0% Fall more than 2 m 407 73.1% 150 26.9% 557 100.0%Road trauma 617 70.5% 258 29.5% 875 100.0%Other 229 75.1% 76 24.9% 305 100.0%Total 4352 80.2% 1077 19.8% 5429 100.0%

Figure 6.10 Percentage of patients transferred versus not transferred by mechanism of injury (N=5429)


Abdomen 112 76.2% 35 23.8% 147 100.0%Chest 732 90.0% 81 10.0% 813 100.0%Face 249 81.4% 57 18.6% 306 100.0%Head 878 76.0% 277 24.0% 1155 100.0%Limbs 1298 84.2% 244 15.8% 1542 100.0%Multiple 312 76.5% 96 23.5% 408 100.0%Other 110 75.9% 35 24.1% 145 100.0%Spine 661 72.4% 252 27.6% 913 100.0%Total 4352 80.2% 1077 19.8% 5429 100.0%

Figure 6.11 Percentage of patients transferred versus not transferred by body region injured (N=5429)


Low-severity injury 1138 83.2% 229 16.8% 1367 100.0%Moderate-severity injury 1956 83.8% 379 16.2% 2335 100.0%Severe injury 1258 72.8% 469 27.2% 1727 100.0%Total 4352 80.2% 1077 19.8% 5429 100.0%

Figure 6.9 Percentage of patients transferred versus not transferred by ISS (N=5429)



Home 2270 84.2% 426 15.8% 2696 100.0%Public area or road 1499 75.1% 498 24.9% 1997 100.0%Institution 200 91.3% 19 8.7% 219 100.0%Farm 138 71.1% 56 28.9% 194 100.0%Industrial 72 68.6% 33 31.4% 105 100.0%Other 173 79.4% 45 20.6% 218 100.0%Total 4352 80.2% 1077 19.8% 5429 100.0%

Figure 6.12 Percentage of patients transferred versus not transferred by location of injury (N=5429)

TIME OF DAY N %

.00 170 3.1%1.00 130 2.4%2.00 107 2.0%3.00 108 2.0%4.00 111 2.1%5.00 75 1.4%6.00 71 1.3%7.00 92 1.7%00.00-07.59 864 15.9%8.00 138 2.5%9.00 214 4.0%10.00 268 5.0%11.00 347 6.4%12.00 325 6.0%13.00 337 6.2%14.00 340 6.3%15.00 345 6.4%08.00-15.59 2314 42.6%16.00 360 6.7%17.00 321 5.9%18.00 343 6.3%19.00 309 5.7%20.00 268 5.0%21.00 254 4.7%22.00 207 3.8%23.00 173 3.2%16.00-23.59 2235 41.2%Total 5413 100.0%

Figure 7.1 Presentation by time of day (n=5413)


Figure 7.2 Pre-alerted by age group (n=5085)29


0–14 117 75.5% 19 12.3% 19 12.3% 155 100.0%15–24 222 57.5% 94 24.4% 70 18.1% 386 100.0%25–34 260 64.5% 73 18.1% 70 17.4% 403 100.0%35–44 271 62.4% 78 18.0% 85 19.6% 434 100.0%45–54 409 72.5% 82 14.5% 73 12.9% 564 100.0%55–64 548 72.8% 134 17.8% 71 9.4% 753 100.0% 65–74 581 78.1% 109 14.7% 54 7.3% 744 100.0%75–84 790 81.2% 128 13.2% 55 5.7% 973 100.0%85+ 576 85.6% 63 9.4% 34 5.1% 673 100.0%Total 3774 74.2% 780 15.3% 531 10.4% 5085 100.0%

Figure 7.2A Pre-alerted with ISS >15 by age group (n=1596)


0–14 27 58.7% 5 10.9% 14 30.4% 46 100.0%15–24 52 39.1% 31 23.3% 50 37.6% 133 100.0%25–34 71 52.6% 22 16.3% 42 31.1% 135 100.0%35–44 76 52.8% 19 13.2% 49 34.0% 144 100.0%45–54 95 56.5% 27 16.1% 46 27.4% 168 100.0%55–64 117 55.7% 47 22.4% 46 21.9% 210 100.0%65–74 155 70.8% 39 17.8% 25 11.4% 219 100.0%75–84 254 76.7% 45 13.6% 32 9.7% 331 100.0%85+ 167 79.5% 24 11.4% 19 9.0% 210 100.0%Total 1014 63.5% 259 16.2% 323 20.2% 1596 100.0%

29 Figure 7.2 refers to direct admissions only30 Figure 7.3 refers to direct admissions only

0-14 15–24 25–34 35–44 45–54 N % N % N % N % N %

Not received by a trauma team 134 86.5% 328 85.0% 358 88.8% 369 85.0% 513 91.0%Received by a trauma team 21 13.5% 58 15.0% 45 11.2% 65 15.0% 51 9.0%Total 155 100.0% 386 100.0% 403 100.0% 434 100.0% 564 100.0%

55–64 65–74 75–84 85+ Total N % N % N % N % N %


Figure 7.3 Reception by a trauma team by age group (n=5085)30


0-14 15–24 25–34 35–44 45–54 N % N % N % N % N %


55–64 65–74 75–84 85+ Total N % N % N % N % N %


Figure 7.3A Reception by a trauma team with ISS >15 by age group (n=1596)

55–64 65–74 75–84 85+ Total N % N % N % N % N %

Associate specialist 6 0.8% 8 1.1% 6 0.6% <5 0.3% 26 0.5%Consultant 149 19.8% 154 20.7% 201 20.7% 112 16.6% 1110 21.8%Intern <5 0.1% <5 0.1% <5 0.1% <5 0.1% 5 0.1%Registrar 322 42.8% 335 45.0% 433 44.5% 285 42.3% 2173 42.7%SHO 111 14.7% 105 14.1% 154 15.8% 142 21.1% 678 13.3%Specialist registrar 137 18.2% 106 14.2% 115 11.8% 98 14.6% 788 15.5%Other 6 0.8% 9 1.2% 5 0.5% <5 0.4% 60 1.2%Detail not captured 21 2.8% 26 3.5% 58 6.0% 30 4.5% 245 4.8% Total 753 100.0% 744 100.0% 973 100.0% 673 100.0% 5085 100.0%

0-14 15–24 25–34 35–44 45–54 N % N % N % N % N %

Associate specialist 0 0.0% 0 0.0% <5 0.5% 0 0.0% <5 0.4%Consultant 54 34.8% 108 28.0% 102 25.3% 121 27.9% 109 19.3%Intern 0 0.0% 0 0.0% 0 0.0% 0 0.0% <5 0.2%Registrar 60 38.7% 147 38.1% 152 37.7% 171 39.4% 268 47.5%SHO 11 7.1% 20 5.2% 30 7.4% 43 9.9% 62 11.0%Specialist registrar 24 15.5% 64 16.6% 82 20.3% 69 15.9% 93 16.5%Other 0 0.0% 9 2.3% 11 2.7% 11 2.5% 6 1.1%Detail not captured 6 3.9% 38 9.8% 24 6.0% 19 4.4% 23 4.1%Total 155 100.0% 386 100.0% 403 100.0% 434 100.0% 564 100.0%

Figure 7.4 Grade of most senior doctor treating patient on arrival by age group (n=5085)31

31 Figure 7.4 refers to direct admissions only


N %

Abdomen 89 3.8%Face 275 11.7%General 39 1.7%Head and brain 167 7.1%Limbs 1403 59.8%Skin/soft tissue 121 5.2%Spine 192 8.2%Thoracic 62 2.6%Total 2348 100.0%

Figure 7.5 Surgical intervention by body region (n=2348)

N %

Intubated – ED 171 71.5%Intubated – pre-hospital 1 0.4%Intubated – both ED and pre-hospital 25 10.5%No intubation 5 2.1%Not known 37 15.5%Total 239 100.0%

Figure 7.8 Airway management of patients with a GCS <9 (n=239)

Low- or moderate-severity injury Severe injury Total N % N % N %

Abdomen 45 50.6% 44 49.4% 89 100.0%Face 264 96.0% 11 4.0% 275 100.0%General 20 51.3% 19 48.7% 39 100.0%Head and brain <5 1.2% 165 98.8% 167 100.0%Limb(s) 1195 85.2% 208 14.8% 1403 100.0%Skin/soft tissue 96 79.3% 25 20.7% 121 100.0%Spine 116 60.4% 76 39.6% 192 100.0%Thoracic 32 51.6% 30 48.4% 62 100.0%Total 1770 75.4% 578 24.6% 2348 100.0%

Figure 7.6 Surgical intervention by body region and ISS (n=2348)

Female Male Total N % N % N %

Abdomen 16 18.0% 73 82.0% 89 100.0%Face 30 10.9% 245 89.1% 275 100.0%General 10 25.6% 29 74.4% 39 100.0%Head and brain 40 24.0% 127 76.0% 167 100.0%Limb(s) 712 50.7% 691 49.3% 1403 100.0%Skin/soft tissue 45 37.2% 76 62.8% 121 100.0%Spine 70 36.5% 122 63.5% 192 100.0%Thoracic 19 30.6% 43 69.4% 62 100.0%Total 942 40.1% 1406 59.9% 2348 100.0%

Figure 7.7 Surgical intervention by body region and gender (n=2348)


N %

Dead 62 9.6%Alive 587 90.4%Total 649 100.0%

Figure 7.9 Survival of shocked patients (n=649)

N %

Within 1 hour 132 45.8%After 1 hour 141 49.0%Not known 15 5.2%Total 288 100.0%

Figure 7.10 Percentage of patients to receive a CT scan within 1 hour (n=273)

Within 1 hour After 1 hour Total N % N % N %

Beaumont Hospital 12 31.6% 26 68.4% 38 100.0%Cavan General Hospital 8 100.0% 0 0.0% 8 100.0%Children’s Health Ireland at Crumlin 0 0.0% 0 0.0% 0 0.0%Children’s Health Ireland at Temple Street 6 100.0% 0 0.0% 6 100.0%Connolly Hospital <5 18.8% 13 81.3% 16 100.0%Cork University Hospital 15 55.6% 12 44.4% 27 100.0%Letterkenny University Hospital <5 57.1% <5 42.9% 7 100.0%Mater Misericordiae University Hospital 14 82.4% <5 17.6% 17 100.0%Mayo University Hospital <5 28.6% 5 71.4% 7 100.0%Mercy University Hospital 0 0.0% <5 100.0% 3 100.0%Midland Regional Hospital, Tullamore 0 0.0% <5 100.0% 3 100.0%Regional Hospital Mullingar <5 12.5% 7 87.5% 8 100.0%Midland Regional Hospital, Portlaoise 0 0.0% <5 100.0% <5 100.0%Naas General Hospital 0 0.0% <5 100.0% <5 100.0%Our Lady of Lourdes Hospital, Drogheda 14 51.9% 13 48.1% 27 100.0%Sligo University Hospital 5 83.3% <5 16.7% 6 100.0%South Tipperary General Hospital 0 0.0% 5 100.0% 5 100.0% St James’s Hospital 11 64.7% 6 35.3% 17 100.0% St Luke’s General Hospital, Kilkenny <5 33.3% 6 66.7% 9 100.0% St Vincent’s University Hospital 9 90.0% <5 10.0% 10 100.0%Tallaght University Hospital <5 33.3% 6 66.7% 9 100.0%University Hospital Galway and 6 60.0% <5 40.0% 10 100.0% Merlin Park University Hospital University Hospital Kerry <5 75.0% <5 25.0% <5 100.0%University Hospital Limerick <5 23.1% 10 76.9% 13 100.0%University Hospital Waterford 8 80.0% <5 20.0% 10 100.0%Wexford General Hospital <5 22.2% 7 77.8% 9 100.0%Total 132 48.4% 141 51.6% 273 100.0%

Figure 7.10A Proportion of eligible patients receiving CT scan within 1 hour with a GCS <13 by hospital (n=273)


Median N

Beaumont Hospital 7 141Cavan General Hospital 2 14Children’s Health Ireland at Crumlin 2 7Children’s Health Ireland at Temple Street 1 17Connolly Hospital 3 24Cork University Hospital 4 77Letterkenny University Hospital 1 12Mater Misericordiae University Hospital 4 213Mayo University Hospital 3 15Mercy University Hospital 6 1Midland Regional Hospital, Tullamore 3 14Regional Hospital Mullingar 1 17Midland Regional Hospital, Portlaoise 2 4Naas General Hospital 2 3Our Lady of Lourdes Hospital, Drogheda 3 46Sligo University Hospital 3 15South Tipperary General Hospital 2 16St James’s Hospital 5 27St Luke’s General Hospital, Kilkenny 2 28St Vincent’s University Hospital 2 24Tallaght University Hospital 2 26University Hospital Galway and Merlin Park University Hospital 3 50University Hospital Kerry 3 11University Hospital Limerick 3 20University Hospital Waterford 2 39Wexford General Hospital 2 14National 3 875

Figure 7.11 Median ICU LOS by hospital (n=875)

Median N

Within 1 hour 132 45.8%0–14 5 18015–24 5 42025–34 6 44235–44 7 47145–54 7 59355–64 8 81465–74 10 79975–84 13 101485+ 14 696Total 9 5429

Figure 7.12 Hospital LOS by age group (N=5429)


Median N

Beaumont Hospital 10 552Cavan General Hospital 4 166Children’s Health Ireland at Crumlin 6 25Children’s Health Ireland at Temple Street 4 43Connolly Hospital 7 288Cork University Hospital 9 693Letterkenny University Hospital 8 78Mater Misericordiae University Hospital 9 546Mayo University Hospital 10 111Mercy University Hospital 6 31Midland Regional Hospital, Tullamore 8 198Regional Hospital Mullingar 5 124Midland Regional Hospital, Portlaoise 5 30Naas General Hospital 10 54Our Lady of Lourdes Hospital, Drogheda 8 404Sligo University Hospital 8 123South Tipperary General Hospital 6 104St James’s Hospital 6 466St Luke’s General Hospital, Kilkenny 4 120St Vincent’s University Hospital 10 368Tallaght University Hospital 7 368University Hospital Galway and Merlin Park University Hospital 9 285University Hospital Kerry 8 175University Hospital Limerick 6 393University Hospital Waterford 8 285Wexford General Hospital 3 105Total 8 6135

Figure 7.12A Median LOS by hospital (n=6135)

N %

0–14 <5 1.4%15–24 21 7.3%25–34 17 5.9%35–44 18 6.3%45–54 24 8.4%55–64 30 10.5%65–74 25 8.7%75–84 75 26.2%85+ 72 25.2%Total 286 100.0%

Figure 8.1 Mortality by age group (n=286)

N %

Female 107 37.4Male 179 62.6Total 286 100.0

Figure 8.2 Mortality by gender (n=286)


N %

Fall less than 2 m 170 59.4%Fall more than 2 m 30 10.5%Road trauma 29 10.1%Other 57 19.9%Total 286 100.0%

Figure 8.3 Mortality by mechanism of injury (n=286)

N %

Low-severity injury 26 9%Moderate-severity injury 46 16%Severe injury 214 75%Total 286 100%

Figure 8.4 Mortality by ISS category (n=286)

55–64 65–74 75–84 85+ Total N % N % N % N % N %

Fall less than 2 m 15 50.0% 19 76.0% 63 84.0% 63 87.5% 170 59.4% Fall more than 2 m 7 23.3% <5 12.0% 9 12.0% <5 2.8% 30 10.5% Road trauma <5 13.3% <5 8.0% <5 1.3% 5 6.9% 29 10.1% Other <5 13.3% <5 4.0% <5 2.7% <5 2.8% 57 19.9% Total 30 100.0% 25 100.0% 75 100.0% 72 100.0% 286 100.0%

0-14 15–24 25–34 35–44 45–54 N % N % N % N % N %

Fall less than 2 m 0 0.0% 0 0.0% <5 5.9% 0 0.0% 9 37.5%Fall more than 2 m 0 0.0% <5 9.5% <5 17.6% <5 11.1% <5 8.3%Road trauma 0 0.0% 8 38.1% 5 29.4% <5 5.6% <5 12.5%Other <5 100.0% 11 52.4% 8 47.1% 15 83.3% 10 41.7%Total <5 100.0% 21 100.0% 17 100.0% 18 100.0% 24 100.0%

Figure 8.3A Mortality by mechanism of injury and age group (n=286)


N %

Abdomen 5 1.7%Chest 21 7.3%Face <5 0.3%Head 156 54.5%Limbs 28 9.8%Multiple 13 4.5%Other 40 14.0%Spine 22 7.7%Total 286 100.0%

Figure 8.5 Mortality by body region most severely injured (n=286)

N %

Home 3229 59.5%Nursing home 686 12.6%Other acute hospital 611 11.3%Rehabilitation 513 9.4%Mortuary 320 5.9%Other 24 0.4%Not known 46 0.8%Total 5429 100.0%

Figure 8.6 Discharge destination (N=5429)

NOTES


Phone: +353 1 4028577Email: [email protected]: @noca_irl

www.noca.ie

MAJOR TRAUMA AUDIT - Amazon S3s3-eu-west-1.amazonaws.com/noca-uploads/general/Major... · 2020. 2....

Documents

Transcript of MAJOR TRAUMA AUDIT - Amazon S3s3-eu-west-1.amazonaws.com/noca-uploads/general/Major... · 2020. 2....