Major Trauma Presentation

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• Major Trauma Presentation
• Matt Thompson, Clinical Director, Major Trauma
  Project

Presentation to JCPCT - 27 January 2009
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Project objective
To design and implement an inclusive trauma
system that assures the care of all injured
patients and ensures that optimal care is
provided at all stages
of the patient journey
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Case for change

• Poor co-ordination across London means the time
  to definitive care is unacceptably long
• The standard of care delivered to the majority of
  trauma patients across the UK has been shown to
  be sub-standard
• Governance and accountability are poor in London
  centres treating severely injured patients

4
International experiences should be used

• In a regionalised system, trauma patients are
  triaged to the most appropriate centre according
  to protocol
• Chicago reduction in mortality of 25 when care
  is provided in a level 1 trauma centre
• Florida Trauma centre counties had significantly
  lower MVC death rates (50)
• Regionalised trauma systems show a continuous
  improvement in results over time
• Quebec Integrated trauma system showed a
  reduction in mortality from 52 to 19
• Orange County reduction in preventable deaths
• US-wide study mortality falls when volumes
  increase

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Scope of the Project - three phases

• Phase 1 Exploration Until August 2008
• Design a trauma system and optimal care pathway
  for London
• Run a preliminary phase to determine provider
  interest
• Develop designation criteria and process
• Phase 2 Preparation August 2008 Summer 2009
• Run designation process
• Public Consultation on options
• Implementation planning
• Phase 3 Implementation Summer 2009 onwards
• If the response to the proposals in the
  consultation is positive, implement the trauma
  plan and commission agreed trauma care pathways

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Phase 1 A trauma system made up of networks
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Benefits of a London trauma system

• Improved patient outcomes
• A system-wide prevention strategy to reduce the
  number of people suffering severe injury
• Improved education and training of those
  delivering trauma care
• Increased ability to deliver a pan-London Major
  Incident Plan
• More people surviving injury and returning to
  optimum social and economic functioning
• Costs per life saved and per life-year saved are
  very low compared with other comparable medical
  interventions

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Stakeholder engagement

• Clinical Expert Panel (monthly)
• 20 clinicians from trauma specialities including
  rehabilitation, LAS, public health, social
  services
• Patient Panel (monthly)
• PPAG member
• Relevant charities e.g. Headway, Spinal Injuries
  Association
• Commissioning Panel (monthly)
• PCT representatives in and adjoining areas of
  London
• Stakeholder event 120 attendees
• Focus group with the public to test proposals
• Linkage with NHS London Department of Emergency
  Preparedness (monthly)
• On-going conversations with surrounding PCTs and
  SHAs
• Gateway Review cited an outstanding level of
  clinical engagement

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Phase 2 - Bid evaluation outcome

• An exhaustive set of designation criteria drawn
  up and agreed by all the expert panels supporting
  the project
• Site visits were conducted as part of the bid
  evaluation, to meet with bidding Major Trauma
  Networks (MTNs)
• 3 bids demonstrated the ability to deliver the
  required level of service by April 2010
• East London Essex Trauma Network MTC Royal
  London Hospital
• South East London Trauma Network MTC Kings
  College Hospital
• South West London Surrey Trauma Network MTC
  St Georges Hospital
• An additional designation process in January 2009
  to assess the viability of a 4th MTN to cover
  North and North West London
• The 2 bids received demonstrated the ability to
  deliver the required level of service for North
  and North West London by April 2012
• MTC Royal Free
• MTC St Marys

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Potential configuration options

• The MT project board has recommended ruling out
• 2-MTN systems because of
• High risk that MTCs would not be able to cope
  with demand. This would have a significant
  negative impact on clinical quality and
  potentially destabilise other services
• Low coverage of incidents and population
• 5-MTN system because of
• Significant risk of poorer clinical outcomes
  compared to a 3- or 4-MTN system
• Increased incremental cost compared to a 3- or
  4-MTN system, it would not significantly improve
  journey time or coverage.
• The JCPCT therefore has three options to consider
• 3-MTN system based on Royal London, Kings and
  Georges (LKG)
• 4-MTN system based on Royal London, Kings and
  Georges and Royal Free (LKGF)
• 4-MTN system based on Royal London, Kings and
  Georges and St Marys (LKGM)

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Summary of possible options
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Factors to differentiate between options

• The MT project team has developed nine factors to
  assess configuration options through the
• Original options development process (patient and
  clinical expert Panel)
• Viability testing of the outcome of the first
  clinical evaluation stage
• The evaluation criteria from the additional
  designation process for N NW London
• The factors that the MT Board recommended to use
  to inform the choice of a preferred option are

These factors have been applied to each of the
options to identify a preferred option
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3-MTN vs 4-MTN summary of assessment against the
9 factors

• Although a 3-MTN system is stronger in terms of
  clinical quality (as measured by the designation
  criteria) and critical mass, there is
  considerable concern over MTC resilience in
  delivering MTC capacity and network size above
  that described in their original bids
• The MT Board considers factors 7 and 8 compelling
  enough to recommend a 4-MTN system, which could
  be implemented with support from the London
  trauma system for less developed networks

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LKGF vs LKGM summary of assessment against the 9
factors

• Of the 4-MTN systems, LKGM gives a greater
  proportion of Londons population covered by
  April 2010, creates a more sustainable system
  with networks capacity aligned to MT incidence
  and provides a better fit with Londons major
  incident planning
• It is acknowledged that alternative ways of
  redistributing PCTs to St George's or Kings
  exist, which would change MT
• incidence and number of TCs in the Royal Free
  network and could affect the assessment of
  criteria 7, 8 and 9.

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Conclusion MT Board recommended preferred option

• A trauma system using the LKGM networks is
  preferred because
• There is concern in a 3-MTN system, over MTC
  resilience in delivering capacity above that
  described in their original bids
• A 4-MTN system addresses this concern and gives
  better coverage, major incident compatibility,
  and networks of a more sustainable size
• Of the two possible 4-MTN systems, LKGM gives a
  greater proportion of Londons population covered
  at the earlier implementation date (April 2010)
• LKGM creates networks of more sustainable size
• LKGM provides a better fit with Londons major
  incident planning