Major trauma: service delivery

Provide a pre‑hospital major trauma triage tool to differentiate between patients who should be taken to a major trauma centre and those who should be taken to a trauma unit for definitive management.

Choose a pre‑hospital major trauma triage tool that includes assessment of physiology and anatomical injury and takes into account the different needs of older patients, children and other high‑risk populations (such as patients who take anticoagulants, pregnant women and patients with comorbidities).

Support pre‑hospital care providers using the major trauma triage tool with immediate clinical advice from the ambulance control centre.

Train pre‑hospital care providers to use the major trauma triage tool.

Monitor and audit use of the major trauma triage tool as part of the major trauma network's quality improvement programme.

Be aware that the optimal destination for patients with major trauma is usually a major trauma centre. In some locations or circumstances intermediate care in a trauma unit might be needed for urgent treatment, in line with agreed practice within the regional trauma network.

Spend only enough time at the scene to give immediate life‑saving interventions.

Divert to the nearest trauma unit if a patient with major trauma needs a life‑saving intervention, such as drug‑assisted rapid sequence induction of anaesthesia and intubation, that cannot be delivered by the pre‑hospital team.

Spend only enough time to give life‑saving interventions at the trauma unit before transferring patients for definitive treatment.

Be aware that the major trauma centre is the ultimate destination for definitive treatment.

Provide a structured system for recording and receiving pre‑alert information. Ensure that the information recorded includes:

• age and sex of the injured person

• time of incident

• mechanism of injury

• injuries suspected

• signs, including vital signs, and Glasgow Coma Scale

• treatment so far

• estimated time of arrival at emergency department

• special requirements

• the ambulance call sign, name of the person taking the call and time of call.

Ensure that pre‑hospital documentation, including the recorded pre‑alert information, is made available to the trauma team quickly and placed in the patient's hospital notes.

Ensure that a senior nurse or trauma team leader receives the pre‑alert information and determines the level of trauma team response according to agreed and written local guidelines.

Ensure that the trauma team leader is easily identifiable to receive the handover and the trauma team is ready to receive the information.

Ensure that multispecialty trauma teams are activated immediately in trauma units to receive patients with major trauma.

Do not use a tiered team response in trauma units.

Have a paediatric trauma team available immediately for children (under 16s) with major trauma.

Consider a tiered team response to receive patients in major trauma centres. This may include:

• a standard multispecialty trauma team or

• a standard multispecialty trauma team plus specialist involvement (for example, code red for major haemorrhage) and mobilisation of supporting departments and services such as transfusion, interventional radiology and surgery.

Have a paediatric trauma team available immediately for children (under 16s) with major trauma.

Provide a protocol for the safe and rapid transfer of patients who need definitive specialist intervention.

Train clinical staff involved in the care of patients with major trauma in the transfer protocol.

Review the transfer protocol regularly.

Ensure that patients with major trauma who need critical interventions at a major trauma centre leave the sending emergency department within 30 minutes of the decision to transfer.

Hospital major trauma services should have responsibility and authority for the governance of all major trauma care in hospital.

Provide a dedicated major trauma service for patients with major trauma that consists of:

• a dedicated trauma ward for patients with multisystem injuries

• a designated consultant available to contact 24 hours a day, 7 days a week who has responsibility and authority for the hospital trauma service and leads the multidisciplinary team care

• acute specialist trauma rehabilitation services

• acute specialist services for the paediatric and elderly populations

• a named member of clinical staff (a key worker, often a senior nurse) assigned at each stage of the care pathway who coordinates the patient's care.

The key worker should:

• act as a single point of contact for patients, family members and carers, and the healthcare professionals involved in their care

• provide information on how the hospital and the trauma system works (major trauma centres, trauma units and teams)

• attend ward rounds and ensure that all action plans from the ward round are carried out in a timely manner

• provide patient advocacy

• ensure that there is a management plan and identify any conflicts

• organise ongoing care including discharge planning, transfers and rehabilitation.

Ensure that pre‑hospital documentation is standardised within a trauma network, for example using the Royal College of Physicians' professional guidance on the structure and content of ambulance records.

Ensure that hospital documentation is standardised within a trauma network and there are systems that allow healthcare professionals access to all relevant and current clinical data at different points in the care pathway. This could be by using compatible electronic medical records such as a picture archiving and communication system (PACS) and an image exchange portal.

Ensure that there is a major trauma audit programme to evaluate systems, services and processes as part of the major trauma network's quality improvement programme.

Ensure that a major trauma audit programme includes:

• regular review of audits undertaken locally and regionally

• registration with the Trauma Audit and Research Network (TARN)

• accurate and complete data submission to TARN

• quarterly review of TARN reports.

A national trauma audit system should collect and analyse data to enable providers of major trauma services to review their local, regional and national major trauma performance.

Establish a protocol for providing information and support to patients, family members and carers.

The trauma team structure should include a clear point of contact for providing information to patients, family members and carers.

Document all key communications with patients, family members and carers about the management plan.

Allocate a dedicated member of staff to contact the next of kin and provide support for unaccompanied children and vulnerable adults.

For patients who are being transferred from an emergency department to another centre, provide verbal and written information that includes:

• the reason for the transfer

• the location of the receiving centre and the patient's destination within the receiving centre

• the name and contact details of the person who was responsible for the patient's care at the initial hospital.

Ensure that each healthcare professional within the trauma service has the training and skills to deliver, safely and effectively, the interventions they are required to give, in line with the NICE guidelines on non-complex fractures, complex fractures, major trauma and spinal injury.

Enable each healthcare professional who delivers care to patients with major trauma to have up‑to‑date training in the interventions they are required to give.

Provide education and training courses for healthcare professionals who deliver care to children (under 16s) with major trauma that include the following components:

• safeguarding

• taking into account the radiation risk of CT to children when discussing imaging for them

• the importance of the major trauma team, the roles of team members and the team leader, and working effectively in a major trauma team

• managing the distress families and carers may experience and breaking bad news

• the importance of clinical audit and case review.

Ensure that people with major trauma have access to services that can provide the interventions recommended in this guideline and in the NICE guidelines on non-complex fractures, complex fractures, major trauma and spinal injury. See the appendix for the recommendations for pre‑hospital and hospital management of major trauma that might have particular implications for service delivery.

Ensure that drug‑assisted rapid sequence induction of anaesthesia and intubation (RSI) is available for patients with major trauma who cannot maintain their airway and/or ventilation, and be aware that RSI should:

• be performed as soon as possible and within 45 minutes of the initial call to the emergency services and

• preferably be provided at the scene of the incident and not by diverting to a trauma unit.
  
  (For more information see the section on airway management in pre-hospital and hospital settings in the NICE guideline on major trauma.)

Ensure that interventional radiology and definitive open surgery are equally and immediately available for haemorrhage control in all patients with active bleeding. (For more information see the section on interventional radiology in the NICE guideline on major trauma and the section on controlling pelvic haemorrhage in the NICE guideline on complex fractures.)