Healthcare The Londonfor London Trauma System Launch

Maralyn Woodford

The TRAUMA

Audit & Research

NETWORK

The Trauma Audit & Research Network

The Trauma Audit & Research Network

1. Background

2. Measuring trauma severity

3. Performance comparisons of trauma care

4. Data Coordination across Networks

The London Trauma System Launch 10 th September 2009

TARNUniversities of Manchester & Leicester

• Non Profit making organisation - self funded through hospital membership fees in England, Wales, Ireland, Denmark & Switzerland

The TRAUMA

Audit & Research

NETWORK

• Established in 1990

• Core work - supporting improvements in trauma care through audit & research

ensure Quality Data coordination

provide regular and informative Feedback with adherence to Benchmarks & Standards

maintain a statistical base to support clinical governance offer responsive local reports & specific local improvement publish National reports to inform the planning of trauma services

Improvements in Trauma Care

The Role of The Trauma Audit & Research Network

Improvement in trauma care locally by:

• Reviewing outlier patients unexpected survivors – what did we do right? unexpected deaths – what did we do wrong?

• Compare outcomes through case-mix standardisation

• Compare processes of care through clinically-defined standards of trauma care

The Benefits of TARN

Measuring and monitoring trauma care

Assessment of Trauma Severity

Logistic regression modelling‘ – ‘weights’ those parameters that predict survival.

Anatomical Injury

ISSISS

Physiological Measure

GCSGCS

Age / Gender

Probability of survival of individual patients

Case mix standardised comparisons of actual and predicted outcome

An improved approach to outcome predictions

Where:GCS = Glasgow Coma Scale scoreISS = Injury Severity Scoreb0……..b26 are coefficients derived from regression analysis applied to data from TARN 2001 - 2006.b0 = constant 4.729b1 = 0 and applies when the GCS = 13 - 15b2 = -1.076 and applies when the GCS = 9 - 12b3 = -1.543 and applies when the GCS = 6 – 8b4 = -2.446 and applies when the GCS = 4 - 5b5 = -3.413 and applies when the GCS = 3b6 = -2.046 and applies when Intubatedb7 = -3.867b8 = -3.313b9 = 0 and applies when gender = maleb10 = -0.089 and applies when gender = femaleb11 = -0.083 and applies when Age = 0 – 5b12= 0.676 and applies when Age = 6 - 10b13 = 0.329 and applies when Age = 11 – 15b14 = 0 and applies when Age = 16 - 44b15 = -0.533 and applies when Age = 45 – 54b16 = -1.101 and applies when Age = 55 - 64b17 = -1.755 and applies when Age = 65 – 74b18 = -3.221 and applies when Age = > 74b19 = -0.237 and applies when Age = 0 – 5 and gender = femaleb20 = -0.216 and applies when Age = 6 – 10 and gender = femaleb21 = 0.042 and applies when Age = 11 – 15 and gender = femaleb22 = 0 and applies when Age = 16 - 44 and gender = female (or male)b23= 0.274 and applies when Age = 45 - 54 and gender = femaleb24 = 0.184 and applies when Age = 55 - 64 and gender = femaleb25 = 0.095 and applies when Age = 65 - 74 and gender = femaleb26 = 0.366 and applies when Age >74 and gender = femaleThe constant e = 2.718282 (the base of Napierian logarithms).

Comparing Outcomes

2005 - 2008

-10

-8

-6

-4

-2

0

2

4

6

8

10

Ws

& 9

5% C

I

Moresurvivors

Moredeaths

Average bottom10 TARN Hospitals (-

3)

95% Confidence Intervals

Average top 10 TARN Hospitals

(+2.5)

Incomplete

data collection

The Trauma Centre: A Speciality Hospital, not a Hospital of Specialities

R. A. Davenport et alBJS 2009accepted for publication

Current TARN Reports & Feedback

• Every 3 months - in depth analysis - themed: head, thoracic, orthopaedic, abdomen & spine- monitors the RCS / BOA & NICE Guidelines

- senior input in trauma team- timeliness and transfers- regional organisation

- role of the local hospital

• Electronic Reports & self production using the eDCR

• Network Reports

TARN Developments

• Improved data collection & reporting - eDCR

• Successful publication of performance comparisons

of standards of trauma care

The Trauma Audit & Research Network

www.tarn.ac.uk

Accessing a hospital from region

Completeness of Data

Data Accreditation

Standards of Trauma Care

• Injuries to the Brain & Skull Time to CT Transfer to Neurosurgical centres

• Injuries to the Spine Transfer rates of unstable spinal injuries

• Injuries to the Chest Most senior Cardiothoracic clinician attending patient

• Injuries to the Limbs & Pelvis Time to theatre for open limb injuries Most senior Surgeon attending to patient

Data Coordination The Electronic Data Collection & Reporting system

the eDCR System

• online system requiring no specialist software

• data is instantly validated

• Confidential, Secure, Encrypted data, Backup service

• PIAG approval

Data coordination across a networkRequirements:

• Resources - membership fees- data collection

• Comprehensive data collection dependant on:- skills- management- time - geography

Data Quality………..

is Important

√√√√ - indicators of data

completeness and accreditation

Outcome and Process

measures reviewed with confidence

Inequality in Trauma Care?

Royal College of Surgeons 1988

“….this report reveals significant deficiencies in the management of seriously injured patients…..”

“…..up to one third of trauma deaths potentially avoidable.”

Royal College of Surgeons 1988

Working Party on the Management of Patients with Major Injury

Royal College of Surgeons 1988

Proposals for change:

• Improve pre-hospital care• Introduce ATLS principles to improve resuscitation, especially

shock control• Invest in rehabilitation services

• Integrate trauma services• Clinical audit & research to review efficacy of care

Questions?

Acknowledgements• TARN staff

• Executive Committee and Board

• Clinicians and data co-ordinators at TARN participating hospitals

10th September 2009

Healthcare The Londonfor London Trauma System Launch