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Quality Statement

The way major trauma services are provided in the UK and Wales has changed significantly during the last 20 years, with the development of major trauma networks. These compile of centres that enable more people with life-threatening injuries to seek appropriate help in the right place even if remote to their home county. The increasingly complex nature of major trauma procedures has led to a need for those who are most severely injured to be cared for at specialist centres, concentrating resources and expertise. This has been shown to have several benefits, most importantly improved mortality and morbidity statistics.

Historically, the recognition of major trauma syndromes and the subsequent management has been evidenced to be poor. This was coincided with a lack of regional organisation and poor consultant level involvement in decision-making resulting in preventable deaths. People with major trauma frequently have multisystem injuries requiring management from multiple specialities leading to care delays in a system that lacks coordination and oversight. Having a consultant-led multidisciplinary service with input from all the relevant specialties can improve continuity of care, prevent delays in treatment and result in shorter hospital stays, lower mortality and improved patient experience.

Major trauma can be defined as multiple and serious injuries resulting in disability or death. These may include, but are not limited to: serious head injuries, multiple injuries caused by road traffic accidents, industrial accidents, falls, mass casualty events, and knife and gunshot wounds. It is the leading cause of death in people under the age of 45 and a significant cause of short and long-term illness or poor health. Major Trauma services are supported closely by other services such as emergency medicine, vascular, plastic surgery, orthopaedics, cardiothoracic, critical care and rehabilitation to provide supported optimum care for patients.

Experience across the UK and evidence shows that a major trauma network saves lives and provides better outcomes for patients. The network will facilitate timely and co-ordinated care including rehabilitation as close to home as possible. The vision is to develop national and regional pathways to provide an overarching framework for the delivery of care for major trauma patients throughout their entire journey, from injury to rehabilitated recovery and an emphasis on prevention. The pathways aim to drive system-wide improvement through a reduction in unwarranted variation of care and improved outcomes.

Major trauma, in both adults and children, is measured on a scale known as the Injury Severity Score (ISS) which scores injuries from 1 to 75 (ascending with severity). Patients who have an ISS>15 are defined as having suffered from major trauma. Patients with an ISS of 9-15 have moderately severe trauma. It is estimated there are approx. 2,500 cases of major or moderate trauma in South, West Wales and South Powys each year. There around 700 major trauma cases in North Wales.

In the last 10 years, the average age of the Welsh population has increased with a 54% increase predicted in the over 65s by 2036. Evidence shows the majority of major trauma occurs in patients older than 65 years (usually those with frailty and multiple co-comorbidities, caused by falls, resulting in neurological and musculoskeletal damage) – so called 'Trauma in the Older Person' (TOP).

The North West Midlands and North Wales Major Trauma network has served the population of North Wales and North Powys since 2012, as there is no major trauma centre in North Wales. Due to the remote and mountainous terrain in North Wales, major trauma cases are often transferred directly by Wales Air Ambulance/Emergency Medical and Retrieval Service or National Coastguard Agency.

The South Wales Trauma Network (SWTN) was designed to achieve the common goal and purpose of enhancing patient outcomes and experience across the entire patient pathway from the point of wounding to rehabilitated recovery and including injury prevention. The continued challenge is to build on the existing major trauma regional networks with national leadership, local engagement and collaboration with the third sector. This aims to deliver real improvements ensuring there is a long-term and consistent approach to improving outcomes as envisaged in the Wellbeing of Future Generations Act and demonstrated by international experience.

The introduction of quality statements were signalled in ‘A Healthier Wales’ and has been described in the National Clinical Framework as the next level of national planning for specific clinical services. Quality statements form part of the enhanced focus on quality and will be integral to the future planning and accountability arrangements for the NHS in Wales.

There is a need to ensure that equity of access is provided for those people who have faced inequality, such as, for example, ethnic minority communities and the LGBQT+ communities and pathways will need incorporate more flexibility to deliver this. The Welsh Government’s “More than just words” plan to strengthen Welsh language in health and care services through the ‘active offer’ principle should become an integral part of service provision. Service providers should build on current best practice and plan, commission and provide care based on this principle.

This approach aligns with the National Clinical Framework which places specific emphasis on the development of national clinical pathways and the Quality Safety Framework which emphasises the importance of systemic local use of the quality assurance cycle. It also enables a focus on cross-working with other groups to address areas such as prevention, rehabilitation, pain management, care for those who are critically ill or at end of life as well as collaboration with other conditions such as vascular.

Health boards – as integrated healthcare organisations – are responsible for the delivery of major trauma services in line with professional standards and the quality attributes set out below.  They will respond to this Quality Statement through the integrated medium term planning process. The Wales Critical Care, Emergency Medicine and Major Trauma Strategic Network will support health boards to improve the quality, consistency, and value of healthcare delivery. Detailed service specifications will also be developed to support the commissioning and accountability arrangements including key metrics for delivering high quality and sustainable major trauma services that meet the needs of the population. These will be set out in Annex A as they become available.

Quality attributes of services for people who have suffered a major trauma in Wales

Equitable

  1. National approach led by the Wales Critical Care, Emergency Medicine and Major Trauma strategic Network supported by the major trauma operational delivery networks to deliver service improvement with the NHS Executive.
  2. National major trauma pathways will ensure transparency, support equity of access, consistency in standards of care and address unwarranted variation.
  3. Services for people with a major trauma will be measured and held accountable using metrics, clinical audit such as TARN, PROMs and peer review recommendations that reflect the quality of care and its outcomes.
  4. Major trauma workforce is supported and developed, to address staff retention and ensure it is sustainable, equitably distributed, grown to meet increased demand with focus on key areas such as radiology and rehabilitation to meet the exponential increase in demand.

Safe

  1. A system-level focus on transforming pathways to further build in resilience by streamlining cross specialty working and adopting the learning in line with national and professional guidance such as NICE.
  2. Effective multi-disciplinary team working which enables appropriate, timely and constructive discussion with supportive collaboration and clinical decision making.
  3. Effective integrated care with appropriate MDT involvement, discharge planning (rehabilitation, community health and social care) including follow up and aftercare plans.
  4. Decisions relating to patient care are appropriately documented showing the decisions made and rationale behind them including appropriate consideration of the risk and benefits and potential prognosis.
  5. Evidenced patient safety improvement programmes are embedded utilising the all Wales incident reporting system to identify themes and share collective learning points.

Effective

  1. Nationally optimised evidence-based pathways for people who suffer a major trauma are embedded in local service delivery to improve outcomes and survival, including access to diagnostics, local review of patients, clear referral, assessment, transfer/repatriation and rehabilitation pathways.
  2. Children and young people should be provided with care appropriate to their age and needs with the transition to adult services appropriately supported to ensure a smooth transition of care.
  3. A culture where all patient’s needs, are understood ensuring the right support is provided at the right time, utilising a whole system approach including other specialties such as critical care, cardiothoracic, orthopaedics, vascular, plastic surgery, pain management, care of the elderly and services such as peer support provided by third sector.
  4. High quality research should be undertaken into methods of preventing and treating major trauma to aid the delivery of improved outcomes and identification optimum treatments or therapies.

Efficient

  1. A national approach to informatics systems and data that enables greater integration of care and provides relevant, high quality, standardised data to drive service improvement.
  2. Building on new ways of working by using technology to free up more time to care such as the electronic patient records and prescribing enabling the safe and efficient management of patients.

Person centred

  1. Patients are communicated with effectively and compassionately, with them actively involved in decision making processes regarding treatment following a major trauma
  2. Patient’s wishes are listened to and respected that they are supported to understand the severity of their injury, treatment options and prognosis including, where appropriate, information and support about Advanced Care Plans to enable them to record appropriate escalation decision and if appropriate how they would wish to be cared for at the end of life.
  3. Collaborative approach to person-centred care is culturally embedded and supported by a common approach to treatment and care provided as locally as possible where appropriate.
  4. Improved insight into patient experience such as use of rehabilitation prescriptions, PROMS and PREMs to better understand care and service needs to aid service improvement and ensure people affected by a major trauma achieve the outcomes that matter to them.

Timely

  1. Reduce deaths and disabilities in people with serious injuries by improving the quality and timeliness of their care in line with professional standards including ensuring they are taken to an appropriate and optimal destination e.g. major trauma centre or trauma unit.

 

ANNEX A - Service Specifications

The major trauma networks will develop service specifications for major trauma to inform accountability discussions and commissioning decisions. These will be added as they become available.