Major Trauma Centres In England Research Articles

Retrospective Observational Study of the Management of Blunt Traumatic Splenic Injury 2017-2022 at Major Trauma Centres in England. What is the Current Role of Splenic Artery Embolisation?

PURPOSE: To compare the treatment and outcomes of blunt splenic injury (BSI) management strategy within Major Trauma centres in England between 2017 and 2022. Data was extracted from UK TARN (Trauma Audit Research Network) identifying all splenic injuries admitted to English Major Trauma Centres (MTCs) between 01/01/17 and 31/12/21. Mechanism, injuries, treatment and outcomes were compared between management strategies according to American Association of Surgery in Trauma (AAST) grade over the period. The main endpoints of splenic salvage rate, along with mortality and length of stay were compared between the treatment options. 3,723 patients sustained BSI; 2,906 (78.1%) were managed conservatively, 491 (13.2%) underwent embolisation while 326 (8.8%) underwent splenectomy. There were 1895 (50.9%) AAST grade 2 injuries, 1019 (27.4%) grade 3, 592 (15.9%) grade 4 and 247 (6.6%) grade 5. Embolisation was successful (i.e. no subsequent splenectomy) for 465/491 (94.7%). The length of stay of discharged patients in the splenectomy group was longer than in those receiving embolisation (p = 0.001) or conservative management (p < 0.001) (median (IQR) of 12 (7, 27), 10 (6, 19), 10 (6, 20) days, respectively). Mortality at 30days was not significantly different in those who underwent splenectomy (12.3%) compared to embolisation (8.6%) and conservative management (11.5%) (p = 0.129). Splenic embolisation results in a high rate of splenic salvage.

Improving communication during damage control surgery: a survey of adult major trauma centres in England.

Deficiencies in non-technical skills can severely impede the functioning of teams in high-intensity scenarios, such as in damage control surgery for the critically injured trauma patient. Truncated preoperative checklists, modified from the standard World Health Organization preoperative checklist, and situational reporting at intervals during surgery are long-established practices in the military, and are recommended in the National Health Service guidelines on major incidents. These tools allow the multiprofessional team to create a shared mental model of the anaesthetic and operative plan, thereby improving team efficiency. Our aim was to establish whether adult major trauma centres in England are using truncated preoperative checklists and situational reporting for damage control surgery. An online survey was devised and distributed via the national programme of care for trauma in November 2020. Responses were received from all 23 adult major trauma centres in England. Nine centres (39.1%) reported using a truncated preoperative checklist for damage control surgery albeit in a variety of formats. Common components were blood products received and/or available, presence of allergies, tranexamic acid and antibiotic administration, availability of viscoelastic tests, equipment required, availability of cell saver, role allocation and reference to other personnel needed, and discussion of the plan. Twelve centres (52.2%) have formal policies in place for situational reporting. Again, these were in multiple formats but all focused on patient physiology to direct surgical planning. We have identified key components to advanced communication aids for damage control surgery, providing a foundation on which other major trauma centres can build their own versions of these potentially lifesaving tools.

Early vocational rehabilitation and psychological support for trauma patients to improve return to work (the ROWTATE trial): study protocol for an individually randomised controlled multicentre pragmatic trial

BackgroundModerately severe or major trauma (injury severity score (ISS) > 8) is common, often resulting in physical and psychological problems and leading to difficulties in returning to work. Vocational rehabilitation (VR) can improve return to work/education in some injuries (e.g. traumatic brain and spinal cord injury), but evidence is lacking for other moderately severe or major trauma.MethodsROWTATE is an individually randomised controlled multicentre pragmatic trial of early VR and psychological support in trauma patients. It includes an internal pilot, economic evaluation, a process evaluation and an implementation study. Participants will be screened for eligibility and recruited within 12 weeks of admission to eight major trauma centres in England. A total of 722 participants with ISS > 8 will be randomised 1:1 to VR and psychological support (where needed, following psychological screening) plus usual care or to usual care alone. The ROWTATE VR intervention will be provided within 2 weeks of study recruitment by occupational therapists and where needed, by clinical psychologists. It will be individually tailored and provided for ≤ 12 months, dependent on participant need. Baseline assessment will collect data on demographics, injury details, work/education status, cognitive impairment, anxiety, depression, post-traumatic distress, disability, recovery expectations, financial stress and health-related quality of life. Participants will be followed up by postal/telephone/online questionnaires at 3, 6 and 12 months post-randomisation. The primary objective is to establish whether the ROWTATE VR intervention plus usual care is more effective than usual care alone for improving participants’ self-reported return to work/education for at least 80% of pre-injury hours at 12 months post-randomisation. Secondary outcomes include other work outcomes (e.g. hours of work/education, time to return to work/education, sickness absence), depression, anxiety, post-traumatic distress, work self-efficacy, financial stress, purpose in life, health-related quality of life and healthcare/personal resource use. The process evaluation and implementation study will be described elsewhere.DiscussionThis trial will provide robust evidence regarding a VR intervention for a major trauma population. Evidence of a clinically and cost-effective VR intervention will be important for commissioners and providers to enable adoption of VR services for this large and important group of patients within the NHS.Trial registrationISRCTN: 43115471. Registered 27/07/2021.

ARE NEUROVASCULAR CHARTS APPROPRIATE FOR DIAGNOSING COMPARTMENT SYNDROME?

IntroductionCompartment syndrome can be a life changing consequence of injury to a limb. If not diagnosed and treated early it can lead to permanent disability. Neurovascular observations done on the ward by nursing staff, are often our early warning system to those developing compartment syndrome. But are these adequate for detecting the early signs of compartment syndrome? Our aim was to compare the quality and variability of charts across the UK major trauma network.Materials &amp; MethodsAll major trauma centres in England and Scotland were invited to supply a copy of the neurovascular chart routinely used. We assessed how such charts record relevant information. Specific primary data points included were pain scores, analgesia requirements, pain on passive stretch and decreased sensation in the first web space specifically. As secondary objectives, we assessed how late signs were recorded, whether clear instructions were included, quantitative scores and the use of regional blocks recorded.ResultsA response rate of 46% was achieved. Of the charts reviewed, 25% documented pain scores or pain on passive movement. Pain on movement and analgesia requirements were documented in 33% and 8% respectively. Specific sensation within the 1st webspace was recorded in 16%. No charts recorded use of regional block. All charts recorded global sensation, movement (unspecified), pulse and colour whilst 66% documented capillary refill and 83% temperature. Instructions were included in 41% of charts.ConclusionsIn 2016, the BOA supported publication of an observation chart for this purpose however, it is not widely used. In our study, late signs of compartment syndrome were generally well recorded. However, documentation of early signs and regional blocks was poor. This may lead to delays in diagnosis with significant clinical and medicolegal consequences. Standardisation of documentation by updating and promoting the use of the pre-existing chart would ensure highest quality care across the network.

Development and validation of the MAnchester Needs Tool for Injured Children (MANTIC).

To develop a measure of the needs injured children and their families' needs throughout recovery; The MAnchester Needs Tool for Injured Children (MANTIC). Tool development, psychometric testing. Five children's major trauma centres in England. Children aged 2 to 16 years with any type of moderate/severe injury(ies) treated in a major trauma centre within 12 months of injury, plus their parents. Stage 1a (Item generation): Interviews with injured children and their parents to generate draft items. Stage 1b (Co-production): Feedback about item clarity, relevance and appropriate response options was provided by parents and the patient and public involvement group. Stage 2 (Psychometric development): Completion of the prototype MANTIC by injured children and their parents with restructuring (as necessary) to establish construct validity. Concurrent validity was assessed by correlation with quality of life (EQ-5D-Y). MANTICs were repeated 2 weeks later to assess test-retest reliability. Stages 1a,b: Interviews (13 injured children, 19 parents) generated 64 items with semantic differential four-point response scale (strongly disagree, disagree, agree, strongly agree). Stage 2: One hundred and forty-four participants completed MANTIC questionnaires (mean age 9.8 years, SD 3.8; 68.1% male). Item responses were strong requiring only minor changes to establish construct validity. Concurrent validity with quality of life was moderate (r = 0.55, P < 0.01) as was test-retest reliability (ICC = 0.46 and 0.59, P < 0.001). Uni-dimensionality was strong (Cronbach's α > 0.7). The MANTIC is a feasible, acceptable, valid self-report measure of the needs of injured children and their families, freely available for clinical or research purposes.

Improvements over time for patients following liver trauma: A 17-year observational study.

Centralisation of trauma care has been shown to be associated with improved patient outcomes. The establishment of Major Trauma Centres (MTC) and networks in England in 2012 allowed for centralisation of trauma services and specialties including hepatobiliary surgery. We aimed to investigate the outcomes for patients with hepatic injury over the last 17 years at a large MTC in England in relation to the MTC status of the centre. All patients who sustained liver trauma between 2005 and 2022 were identified using the Trauma Audit and Research Network database for a single MTC in the East Midlands. Mortality and complications were compared between patients before and after establishment of MTC status. Multivariable logistic regression models were used to determine the odds ratio (OR) and 95% confidence interval (95% CI) for complications according to MTC status, accounting for the potentially confounding variables of age, sex, severity of injuries and comorbidities for all patients, and the subgroup with severe liver trauma (AAST Grade IV and V). There were 600 patients; the median age was 33 (IQR 22-52) years and 406/600 (68%) were male. There were no significant differences in 90-day mortality or length of stay between the pre- and post-MTC patients. Multivariable logistic regression models showed both lower overall complications [OR 0.24 (95% CI 0.14, 0.39); p < 0.001] and lower liver-specific complications [OR 0.21 (95% CI 0.11, 0.39); p < 0.001] in the post-MTC period. This was also the case in the severe liver injury subgroup (p = 0.008 and p = 0.002 respectively). Outcomes for liver trauma were superior in the post-MTC period even when adjusted for patient and injury characteristics. This was the case even though patients in this period were older with more comorbidities. These data support the centralisation of trauma services for those with liver injuries.

SP5.2.5 Optimising Communication during Damage Control Surgery- a survey of adult Major Trauma Centres in England

Abstract Aims Snap briefs (truncated WHO checklists) and Sit Reps (situational reporting), are long established practices within the military, developed from their vast experience in treating patients requiring Damage Control Surgery (DCS)[1,2]. Our aim was to establish if formal systems like these are in place in Major Trauma Centres (MTCs) in England, and gather staff's experiences of using these systems. Methods An online survey was devised and distributed to MTCs in England via the Major Trauma Network. It consisted of 14 questions, relating to use of modified WHO checklists and Sit Reps during DCS. Results Results were received from all 23 adult MTCs in England. Eight centres (34.8%) reported using a modified WHO checklist for DCS. Most commonly these were modified to include reference to blood products used and available, other specialties needed, and presence of surgical equipment prior to start (eg. thoracotomy.) 12 centres (52.2%) are using Sit Reps during DCS. Many respondents from centres without a formal policy in place stated that they personally endeavor to maintain communication when they are involved in DCS cases, and recognised that a formal system would be greatly beneficial. Conclusion Many MTCs are not using truncated WHO checklists and Sit Reps for DCS. From the centres who have adopted these methods, staff have reported they improve shared decision making. Wider implementation of these techniques could therefore lead to both improved patient care and staff experiences.

A national study of 23 major trauma centres to investigate the effect of frailty on clinical outcomes in older people admitted with serious injury in England (FiTR 1): a multicentre observational study

Older people are the largest group admitted to hospital with serious injuries. Many older people are living with frailty, a risk factor for poor recovery. We aimed to examine the effect of preinjury frailty on outcomes. In this multicentre observational study (FiTR 1), we extracted prospectively collected data from all 23 adult major trauma centres in England on older people (aged ≥65 years) admitted with serious injuries over a 2·5 year period from the Trauma Audit and Research Network (TARN) database. Geriatricians assessed the preinjury Clinical Frailty Scale (CFS), a 9-point scale of fitness and frailty, with a score of 1 indicating a patient is very fit and a score of 9 indicating they are terminally ill. The primary outcome was inpatient mortality, with patients censored at hospital discharge. We used a multi-level Cox regression model fitted with adjusted hazards ratios (aHRs) to assess the association between CFS and mortality, with CFS scores being grouped as follows: a score of 1-2 indicated patients were fit; a score of 3 indicated patients were managing well; and a score of 4-8 indicated patients were living with frailty (4 being very mild, 5 being mild, 6 being moderate, and 7-8 being severe). Between March 31, 2019, and Oct 31, 2021, 193 156 patients had records were held by TARN, of whom 16 504 had eligible records. Median age was 81·9 years (IQR 74·7-88·0), 9200 (55·7%) were women, and 7304 (44·3%) were men. Of 16 438 patients with a CFS score of 1-8, 11 114 (67·6%) were living with frailty (CFS of 4-8). 1660 (10·1%) patients died during their hospital stay, with a median time from admission to death of 9 days (IQR 4-18). Compared in patients with a CFS score of 1-2, risk of inpatient death was increased in those managing well (CFS score of 3; aHR 1·82 [95% CI 1·39-2·40]), living with very mild frailty (CFS score of 4: 1·99 [1·51-2·62]), living with mild frailty (CFS score of 5: 2·61 [1·99-3·43]), living with moderate frailty (CFS score of 6: 2·97 [2·26-3·90]), and living with severe frailty (CFS score of 7-8: 4·03 [3·04-5·34]). Our findings support inclusion of the CFS in trauma pathways to aid patient management. Additionally, people who exercise regularly (CFS of 1-2) have better outcomes than those with lower activity levels (CFS of ≥3), supporting exercise as an intervention to improve trauma outcomes. None.

A national study of 23 major trauma centres to investigate the effect of a geriatrician assessment on clinical outcomes in older people admitted with serious injury in England (FiTR 2): a multicentre observational cohort study

Older people are at the greatest risk of poor outcomes after serious injury. Evidence is limited for the benefit of assessment by a geriatrician in trauma care. We aimed to determine the effect of geriatrician assessment on clinical outcomes for older people admitted to hospital with serious injury. In this multicentre observational study (FiTR 2), we extracted prospectively collected data on older people (aged ≥65 years) admitted to the 23 major trauma centres in England over a 2·5 year period from the Trauma Audit and Research Network (TARN) database. We examined the effect of a geriatrician assessment within 72 h of admission on the primary outcome of inpatient mortality in older people admitted to hospital with serious injury, with patients censored at discharge. We analysed data using a multi-level Cox regression model and estimated adjusted hazard ratios (aHRs). Between March 31, 2019, and Oct 31, 2021, 193 156 patients had records held by TARN, of whom 35 490 were included in these analyses. Median age was 81·4 years (IQR 74·1-87·6), 19 468 (54·9%) were female, and 16 022 (45·1%) were male. 28 208 (79·5%) patients had experienced a fall from less than 2 m. 16 504 (46·5%) people received a geriatrician assessment. 4419 (12·5%) patients died during hospital stay, with a median time from admission to death of 6 days (IQR 2-14). Of those who died, 1660 (37·6%) had received a geriatrician assessment and 2759 (62·4%) had not (aHR 0·43 [95% CI 0·40-0·46]; p<0·0001). Geriatrician assessment was associated with a reduced risk of death for seriously injured older people. These data support routine provision of geriatrician assessment in trauma care. Future research should explore the key components of a geriatrician assessment paired with a health economic evaluation. None.

The effectiveness and cost-effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma patients with uncontrolled torso haemorrhage: study protocol for a randomised clinical trial (the UK-REBOA trial)

BackgroundHaemorrhage is the most common cause of preventable death after injury. REBOA is a novel technique whereby a percutaneously inserted balloon is deployed in the aorta, providing a relatively quick means of temporarily controlling haemorrhage and augmenting cerebral and coronary perfusion, until definitive control of haemorrhage can be attained. The aim of the UK-REBOA trial is to establish the clinical and cost-effectiveness of a policy of standard major trauma centre treatment plus REBOA, as compared with standard major trauma centre treatment alone, for the management of uncontrolled torso haemorrhage caused by injury.MethodsPragmatic, Bayesian, group-sequential, randomised controlled trial, performed in 16 major trauma centres in England. We aim to randomise 120 injured patients with suspected exsanguinating haemorrhage to either standard major trauma centre care plus REBOA or standard major trauma centre care alone. The primary clinical outcome is 90-day mortality. Secondary clinical outcomes include 3-h, 6-h, and 24-h mortality; in-hospital mortality; 6-month mortality; length of stay (in hospital and intensive care unit); 24-h blood product use; need for haemorrhage control procedure (operation or angioembolisation); and time to commencement of haemorrhage control procedure (REBOA, operation, or angioembolisation). The primary economic outcome is lifetime incremental cost per QALY gained, from a health and personal social services perspective.DiscussionThis study, which is the first to randomly allocate patients to treatment with REBOA or standard care, will contribute high-level evidence on the clinical and cost-effectiveness of REBOA in the management of trauma patients with exsanguinating haemorrhage and will provide important data on the feasibility of implementation of REBOA into mainstream clinical practice.Trial registrationISRCTN16184981

A survey-based review of psychology provision in major trauma centres (MTCs) in England

Introduction Following major trauma, individuals frequently experience psychological or neuropsychological consequences of their injuries. Clinical psychologists are well-placed to provide support for these individuals and the multidisciplinary teams that work with them. It is currently unclear as to the level of psychology provision in major trauma centres (MTCs), and the input they can provide. This study therefore aimed to identify psychology provision in major trauma centres in England to facilitate discussion and support service development. Method Electronic surveys were distributed via a mailing list to psychologists in MTCs to gather data on the role and resource of psychology provision in major trauma centres in England. Data were analysed quantitatively and qualitatively. Results Psychologists from 21/40 MTCs in England responded. Significant gaps in psychology service provision were found across all services, including not being able to provide consistent input throughout the week and not being able to provide a combination of assessment, formulation and intervention, amongst others. Common barriers to providing psychology input included lack of integration into multidisciplinary teams and reduced knowledge of patient transfers, underpinned by staff resource. These issues also contributed to psychologists in MTCs limiting the types of referrals they accept. Conclusions Psychology is presently under-resourced in MTCs in England, particularly in services for children. Recommendations for major trauma psychology roles and level of resource need to be provided in national service specifications in order improve service delivery and prioritise psychosocial outcomes of individuals with potentially life-changing injuries.

The use of smartphone-application based medical photography for open fractures: A national survey of orthoplastic affiliated Major Trauma Centres in England

IntroductionBAPRAS/BOAST 4 guidelines recommend the use of medical photography for peri-operative management of open fractures. Smartphones are a common commodity for the modern day plastic surgeon and there is evidence their utilization improves guideline compliance at Major Trauma Centres (MTCs). AimTo capture national data assessing the prevalence and intricacies of smartphone app-based photography systems used for open fractures in plastic surgery units at MTCs in England. MethodA structured questionnaire survey was used to collate and analyze the responses of plastic surgeons and trainees at all MTCs in England. The survey included participant demographics, type and use of medical photography systems, and opinions on the usefulness of integrating a dedicated app in practice. We later explore the background, costs, download process, functionality and NHS governance applicability of each application. ResultsThe most popular clinical imaging modalities included professional photographers (65%) and departmental cameras (60%). Only 6 (26%) of MTCs use the following four smartphone app-based photography systems: Oxford University Hospital FotoApp, Medical Data Solutions and Services, Haiku and Secure Clinical Image Transfer. All systems are GDPR compliant and three systems auto upload images onto hospital databases. Five units report using messaging apps (Forward, Siilo, Whatsapp) with photography functionality. All participants agreed that a dedicated imaging smartphone app would be useful in open fracture management. ConclusionPlastic surgery is a highly visual specialty and clinical photography complements patient care. In the era of COVID-19 where resources are finite and professional photography not always available, this national survey highlights a demand for integrating smartphone app-based photography to improve guideline compliance, inter- and intra-disciplinary team communication and patient care.

A comparative study of hip fracture care and outcomes in major trauma centres versus trauma units

IntroductionThere is good evidence to support that major trauma networks significantly reduce morbidity and mortality in severely injured patients. However, following the introduction of major trauma centres (MTCs) in England in 2012, early concerns were raised regarding the effect on hip fracture patients. The aim of our study was to review data from the National Hip Fracture Database for fractured neck of femur (FNOF) patients, comparing patient outcomes between MTCs and trauma units (TUs), and the national regions of the UK. MethodsNHFD data from 2018 for all hospitals in England, Wales and NI was collected using the charts and dashboards available online. We recorded data for the following outcomes: time to surgery, acute hospital length of stay, overall hospital length of stay, discharge to original residence within 120 days, crude 30-day mortality and adjusted 30-day mortality. We conducted a one-way ANOVA test to calculate statistical differences for each outcome measure by MTC vs TU and then separately for the regions of the UK divided into England, Wales and Northern Ireland (NI). ResultsData for 175 hospitals are included in this study; 22 of which were MTCs. The total number of operative cases were 65,848. 9668 of these occurred in MTC compared to 56,180 in TUs. This equates to an annual average of 439 per MTC and 367 per TU. Despite this, there was no statistically significant difference observed in all outcomes for MTC vs TU. Patients in NI waited longer for their surgery (60.3 h, p < 0.001), whilst patients in Wales had the longest overall hospital length of stay (31.6 days, p < 0.001). However, there was no difference in patients’ crude 30-day mortality (p = 0.480) or adjusted 30-day mortality (p = 0.191). ConclusionThese findings are reassuring for MTCs in England. We found no evidence to suggest that FNOF patients are treated inferiorly, or have worse outcomes, at MTCs vs TUs. FNOF patients in NI waited longer for their surgery but this did not have any significant difference on 30-day mortality rates. The care of FNOF patients in NI may warrant further study.

National audit to assess standards of care for deliberate self-harm patients presenting to trauma centres with penetrating wounds and recommendations for action

The authors assessed the standard of care for patients presenting with deliberate self-harm (DSH) injuries to major trauma centres (MTCs) in England as well as hospitals within the major trauma network in Scotland. This was to generate an understanding of current practice, identify any shortfall and develop recommendations to improve safety and patient care. We contacted all MTCs in England and hospitals in the major trauma network in Scotland, asking their permission to be included in this study. Emergency department (ED) consultants at each unit were then invited to complete a telephone questionnaire clarifying their current management policies of DSH patients against NICE guidance. The telephone questionnaire was carried out by the same author to ensure interpretation was consistent. Twenty-seven MTCs within England as well as the four hospitals in the major trauma network within Scotland were contacted. There was a total of 15 responses - 14 responses from MTCs within England and 1 response from a hospital in the trauma network in Scotland. The clear deficit in practice was identified and recommendations were generated. Our study has shown that patients are transferred following DSH without a clear review of their physical, psychological and social needs. We hope to share our recommendations for the implementation of a local protocol to improve standards and safety.

Speech and language therapy service provision in spinal injury units compared to major trauma centres in England: Are services matched?

National UK guidance makes recommendations for speech and language therapy staffing levels in critical care and rehabilitation settings. Traumatic spinal cord injury patients often require admission primarily to critical care services within a major trauma centre prior to transfer to a specialist spinal injury unit but may not receive similar levels of care. Dysphagia and communication difficulties are recognised features of cervical spinal cord injury; however, little is known about access to speech and language therapy services to provide rehabilitation and improve outcomes. The aim of this study was to compare the workforce and clinical practices of speech and language therapy services in eight spinal injury units and four major trauma centres in England through an online survey. An online survey was created with 26 multiple-choice questions across seven sub-sections, with options for free-text comments. These were sent to a named speech and language therapy contact at each of the specified units. Responses were uploaded into Excel for analyses, which included descriptive statistics and analysis of themes. Responses were received from 92% (11/12) speech and language therapy services invited, which included seven out of eight spinal injury units and all four major trauma centres. No units met national staffing recommendations. Staff in spinal injury units provided an average of 27h per week input to the unit compared to 80h in a major trauma centre. Despite caseload variations, speech and language range of therapy involvement and prioritisation process were equivalent. Access to instrumental assessment varied, with less use of Fibreoptic Endoscopic Evaluation of Swallowing in spinal injury units despite its clinical value to the spinal cord injury caseload. Speech and language therapy services delivering post-acute and long-term rehabilitation to spinal cord injury patients are limited by their resources and capacity, which restricts the level of therapy delivered to patients. This may have an impact on clinical outcomes for communication and swallowing impairments. Further evidence is needed of the interventions delivered by speech and language therapists and outcomes will be beneficial alongside benchmarking similar services. What is already known on this subject In England, people who sustain a spinal cord injury are admitted to a major trauma centre prior to transfer to a specialist spinal injury unit. Dysphagia and communication impairments are recognised as a complication of cervical spinal cord injury and benefit from speech and language therapy intervention. National recommendations exist for staffing levels, expertise and competencies for speech and language therapists working in critical care and rehabilitation units. What this study adds This study identified variations in the levels of speech and language therapy staffing, seniority, service delivery and access to instrumental assessments for dysphagia between major trauma centres and spinal injury units. None of the services complied with national staffing recommendations. Clinical implications of this study Speech and language therapy services in spinal injury units are often available part-time or have limited access to diagnostic tools which limits the range and intensity of rehabilitation input available. This has clinical implications for outcomes for swallowing and communication as well as long-term consequences for integrating back into community.

Pelvic and acetabular fracture care in England: current workload and future directions.

Fractures of the pelvis and acetabulum (PAFs) are challenging injuries, requiring specialist surgical input. Since implementation of the major trauma network in England in 2012, little has been published regarding the available services, workforce organisation and burden of PAF workload. The aim of this study was to assess the recent trends in volume of PAF workload, evaluate the provision of specialist care, and identify variation in available resources, staffing and training opportunity. Data on PAF volume, operative caseload, route of admission and time to surgery were requested from the Trauma Audit and Research Network. In order to evaluate current workforce provision and services, an online survey was distributed to individuals known to provide PAF care at each of the 22 major trauma centres (MTCs). From 2013 to 2019, 23,823 patients with PAF were admitted to MTCs in England, of whom 12,480 (52%) underwent operative intervention. On average, there are 3,971 MTC PAF admissions and 2,080 operative fixations each year. There has been an increase in admissions and cases treated operatively since 2013. Three-quarters (78%) of patients present directly to the MTC while 22% are referred from regional trauma units. Annually, there are on average 37 operatively managed PAF injuries per million population. Notwithstanding regional differences in case volume, the average number of annual PAF operative cases per surgeon in England is 30. There is significant variation in frequency of surgeon availability. There is also variation in rota organisation regarding consistent specialist surgeon availability. This article describes the provision of PAF services since the reorganisation of trauma services in England. Future service development should take into account the current distribution of activity, future trends for increased volume and casemix, and the need for a PAF registry.

The impact of injury: The experiences of children and families after a child’s traumatic injury

Objective: To explore the experiences of children and families after a child’s traumatic injury (Injury Severity Score >8). Design: Qualitative interview study. Setting: Two children’s major trauma centres in England. Participants: 32 participants: 13 children with traumatic injuries, their parents/guardians (n = 14) and five parents whose injured child did not participate. Methods: Semi-structured interviews exploring the emotional, social, practical and physical impacts of children’s injuries, analysed by thematic analysis. Results: Interviews were conducted a median of 8.5 months (IQR 9.3) post-injury. Injuries affected the head, chest, abdomen, spine, limbs or multiple body parts. Injured children struggled with changes to their appearance, physical activity restrictions and late onset physical symptoms, which developed after hospital discharge when activity levels increased. Social participation was affected by activity restrictions, concerns about their appearance and interruptions to friendships. Psychological impacts, particularly post-traumatic stress type symptoms often affected both children and parents. Parents’ responsibilities suddenly increased, which affected family relationships and roles, their ability to work and carry out daily tasks. Rapid hospital discharge was wanted, but participants often felt vulnerable on return home. They valued continued contact with a healthcare professional and practical supports from family and friends, which enabled resumption of their usual lives. Conclusions: Injured children experience changes to their appearance, friendships, physical activity levels and develop new physical and mental health symptoms after hospital discharge. Such challenges can be addressed by the provision of advice about potential symptoms, alternative activities during recovery, strategies to build resilience and how to access services after hospital discharge.

Major trauma centre Lead Clinicians: An evaluation of current practice in major trauma centres in England

Background NHS England requires there to be a clinical consultant with managerial responsibility for the Major Trauma Centre (MTC) service, who holds the title of MTC Lead Clinician. The objective of this study was to investigate the role of MTC Lead Clinician in England. Firstly, identifying the parent speciality of the current cohort and their background and training. Further aims were to ascertain what attracted clinicians to the position and to explore ideas about how to train the next generation of MTC Lead Clinicians. Methods Survey-based data collection was performed. Included were current MTC Lead Clinicians, or those with equivalent job descriptions, for adult major trauma. Paediatric MTCs and Trauma Units were excluded. Fixed choice questions were analysed using descriptive statistics. Open-ended questions were interpreted using thematic analysis. Results The response rate for the survey was 81.81%. The largest proportion of respondents were Emergency Medicine Physicians (38.9%). Previous senior leadership roles were identified as valuable previous experience. Regular attendance at conferences was deemed to be of more importance than specific training courses. Leadership, management, and financial skills were identified as key areas for further training. There was variance in both the job role and the time allocated for these duties between centres. Conclusion Currently there is variation in the parent specialty, role responsibilities and preparation for MTC Lead Clinicians in England. Our findings suggest that guidance on appropriate training, clarity in responsibilities and fostering leadership and managerial skills are important as the role develops for the future.

The role of plastic surgery in major trauma in the United Kingdom and workforce recommendations

The 22 major trauma centres (MTCs) in England were appointed in 2012 to provide care to severely injured patients despite variation in existing infrastructure, resources, culture and skillset. Six MTCs remain unsupported by a co-located plastic surgery department. We describe the plastic surgical major trauma workload in England, the plastic surgical workforce and skillset available in each centre, and suggest what plastic surgical skills are required in an MTC. A multi-centre, prospective cohort study was performed to collect operative workload data. Eleven MTCs in England submitted complete datasets. Workforce data were provided by the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS). Fifty-three percent (n = 1582) of Trauma and Audit Research Network (TARN)-eligible patients admitted during the study period underwent at least one operation during their index admission. Of these, 14% (n = 227) required plastic surgery. The majority of plastic surgical operative work involved the extremities: 62% of index procedures involved the lower limb and 38% involved the upper limb. The number of full-time plastic surgical consultants per MTC ranged from 1 to 22. Only 10 MTCs had at least one plastic surgeon with a primary interest in lower limb trauma. Plastic surgery contributes substantially to major trauma care and the majority of this workload relates to extremity trauma. However, there is significant variability in the size, accessibility and skillset of the workforce available. On the basis of these data, we suggest a plastic surgical skillset which should be represented in plastic surgical departments supporting an MTC.

The use of cognitive screens within major trauma centres in England: A survey of current practice

IntroductionMajor trauma centres are effective in reducing morbidity and mortality rates following serious injury. Many patients attending major trauma centres present with traumatic brain injuries, requiring specialist assessment in screening for potential cognitive deficits. Numerous cognitive screens exist but it is currently unclear which are used most frequently within major trauma centres. This study aimed to identify which screening tools are used most frequently in major trauma centres in England to enable discussion around their suitability for this clinical population.MethodElectronic surveys were distributed via a mailing list to Clinical Psychologists and Clinical Neuropsychologists in major trauma centres across England to gather data on the use of cognitive screens.ResultsFourteen Clinical Psychologists in Neuropsychology participated. Results suggest major trauma centres in England are currently using the ACE-III (50%) or MoCA (42%) as the most frequently used screens for cognitive difficulties following traumatic brain injury. Cognitive screening pathways are multi-disciplinary involving OTs (86%), psychologists (qualified 79%; assistant 57%) psychiatrists (36%), mental health nurses (7%) and therapy assistants (7%).ConclusionsMajor trauma centres are using evidence-based cognitive screens at present, but further work is needed to develop more effective, better validated cognitive screens for traumatic brain injury populations. Increased inter-professional discussion on the practice of cognitive screening would be beneficial for patients seen within major trauma centres.