TRAUMA UNIT OPERATIONAL POLICY

Title: Trauma Unit Operational Policy Version 1.0 Page 1 of 25

TRAUMA UNIT OPERATIONAL POLICY

Policy Type Clinical

Directorate Acute

Policy Owner

Chief Operating Officer Acute & Ambulance

Policy Author

TARN Coordinator

Next Author Review Date

1st July 2021

Approving Body

Corporate Governance & Risk Sub-Committee 13th December 2016

Version No.

1.0

Policy Valid from date

1st December 2016

Policy Valid to date:

31st December 2021

‘During the COVID19 crisis, please read the policies in conjunction with any updates

provided by National Guidance, which we are actively seeking to incorporate into policies through the Clinical Ethics Advisory Group and where necessary other

relevant Oversight Groups’


DOCUMENT HISTORY (Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing a procedural document for the first time – the initial draft will be version 0.1)

Date of Issue

Version No.

Date Approved

Director Responsible for Change

Nature of Change Ratification / Approval

28/08/16 0.1 Medical Director New Policy

25/11/16 0.1 Medical Director New Policy for ratification

Clinical Standards Group

13/12/16 1.0 13/12/2016 Medical Director New Policy for ratification/approval

Corporate Governance & Risk Sub-Committee

26/03/20 1.0 26/03/2020 Medical Director Extension to review date approved until 13/09/2020 via Chairs action at

Policy Management Sub-Committee

24/09/20 1.0 Medical Director Extension to review date until 31/12/2020 approved by

Policy Lead Director – Medical Director

29/01/21 1.0 26/03/2020 Chief Operating Officer Acute and Ambulance

12 month blanket policy extension due to covid 19 applied with author review date set 180 days prior to Valid to Date

Quality & Performance Committee

23/05/21 1.0 26/03/2020 Chief Operating Officer Acute and Ambulance

Extended policy uploaded and linked back with new cover sheet

Corporate Governance

NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust


Contents 1 Executive Summary ....................................................................................................... 4

2 Introduction .................................................................................................................... 4

3 Definitions ...................................................................................................................... 4

4 Scope ............................................................................................................................ 4

5 Purpose ......................................................................................................................... 4

6 Roles and Responsibilities ............................................................................................. 5

7 Policy detail/Course of Action......................................................................................... 6

9 Training ........................................................................................................................ 12

10 Monitoring Compliance and Effectiveness.................................................................... 13

11 Links to other Organisational Documents ..................................................................... 13

12 References .................................................................................................................. 13

13 Appendices .................................................................................................................. 13


1 Executive Summary This policy defines the standards required by the Isle of Wight Trust to operate as a Trauma unit and how to work to achieve these standards within the existing structure. The policy clearly defines what provision we have available and how we would respond to deliver the highest standards of trauma care to the multiply injured patient.

2 Introduction Major Trauma is defined as isolated or multiple serious injuries that may result in death or disability. Common causes include road incidents, sporting injurues and acts of violence. It remains as the most common cause of death in the under 40 age group. St Marys is a trauma unit within the Southern Trauma network system and is a satellite service associated with Southampton NHS Trust. The Trust Trauma unit is over 45 mins from the Trauma centre in Southampton General Hospital, this would usually result in the Trust unit being bypassed and the seriously ill trauma patients being taken straight to the Trauma centre at Southampton, however the Trust is separated from the mainland by the Solent and this makes the Trust geographically different to other units. The Trust Trauma unit is staffed, trained and equipped to receive Major trauma patients from The Isle of Wight Ambulance and also the Hampshire and Isle of Wight Air ambulance, St Marys also provides care and preparation for secondary transfers by HIOWAA and the Coastguard Helicopter.

3 Definitions Major Trauma is defined as isolated or multiple serious injuries that may result in death or disability. Common causes include road incidents, sporting injuries and acts of violence. It remains as the most common cause of death in the under 40 age group.

4 Scope This policy pertains to all members of staff within the Trust involved with Major Trauma not only the Emergency Department staff but all who form part of the Trauma team. This policy defines the standards required by the Isle of Wight Trust to operate as a Trauma Unit and how we work to achieve those standards within in the structure of our Trust. The policy clearly defines what provision we have available and how we would respond to deliver the highest standards of trauma care to the multiply injured patient.

5 Purpose This policy sets out the standards required by the Isle of Wight Trust in order to operate a Trauma unit and how to achieve these standards within the existing structure. The policy clearly defines what provision we have available and how we would respond to deliver the highest standards of trauma care to the multiple injured patient.


6 Roles and Responsibilities

6.1 Chief Executive In line with the requirements of Governance, the Chief Executive carries ultimate responsibility for assuring the quality of the services provided by the Trust that is included within this policy document.

6.2 Executive Director of Nursing and Quality The Chief Executive Officer has delegated responsibility for ensuring the quality of services to the Executive Director of Nursing and Quality

6.3 Chief Operating Office The Chief Operating Officer will work with the named Lead Clinician for Trauma Care and the Clinical Leads to deliver to the clinical standards defined in the NHS IOW Trauma Unit standards document.

6.4 Lead Clinician for Trauma Care The Lead Clinician for Trauma Care will:

Establish the overall principles within this policy

Represent the Trust at local and National Trauma Network meetings

Work with Clinical Business Unit management to ensure the necessary standards are met within their clinical discipline

Oversee the necessary trauma training provision for all staff

Lead on ensuring that the trauma unit Incident reporting process and Critical Incident investigations review through the Datix system is robust.

Feed back to the Executives on all issues relating to trauma care within our TU and the Trauma Network

Liaise with Trust CQUIN lead for any indicator related to Emergency Trauma care

6.5 Clinical Specialty Leads The Clinical Specialty Leads will work with Clinical Business Unit to ensure that the necessary standards are met within their clinical discipline.

6.6 Consultants All consultants in the key disciplines in the Trauma Pathway are expected to support the Trust in delivering trauma care to the standards required.

6.7 Trauma Leads for St Marys Hospital Executive Director Chief Operating Officer Medical Director Director of Nursing, and Quality


Clinical Lead for Business Unit Operational Manager for Emergency Care Lead Clinician for Trauma Care Head of Nursing and Quality for the business unit Matron Specialty Leads Emergency Medicine Trauma and Orthopaedics General Surgery Anaesthesia and Intensive Care Radiology Transfusion Lead Clinician Paediatrics Trauma Coordinator Rehabilitation Co-ordinator TARN co-ordinator

7 Policy detail/Course of Action

Operational Policy standard for the Trauma Unit

7.1 RECEPTION and RESUSITATION T14-2B-302 – Trauma Team Activation Protocol. In the event of a pre-alert by paramedics to the Emergency Department (ED), the senior member of nursing and medical staff should be informed and the trauma team activation protocol should be consulted (Appendix 1). If the criteria are met then a trauma call should be activated by dialing 2222 via switchboard. If the patient is less than 16 years of age a paediatric trauma call should be requested. If the patient is known to be pregnant of duration greater than 20 weeks then an obstetric emergency call should be activated in addition. Patients who self-present should be assessed at triage, any patient presenting with a mechanism that may result in a spinal cord injury should be triple immobilized and consideration of the trauma call activation protocol should be considered as above. The Consultant on call in the Emergency Department should also be informed if not already present. A minimum of one ED Consultant is present in the department from 0800 to 1700 five days a week. 24 hour Middle grade cover is available. 24 hour Orthopaedic cover is provided by a junior grade. The Middle grade Orthopaedic on call doctor is not resident on site out of hours and therefore must be notified by long range bleep and by the Orthopaedic on call doctor. All Trauma team members should report to the resuscitation room in anticipation of the arrival of the patient.

7.1.1 Trauma Team Leader T14-2B-301 - The Emergency Department staff grade will be the trauma team leader initially. All Trauma team leaders will be Advanced Trauma Life support and Advanced Paediatric life support providers or equivalently trained as evidenced by CPD logs. The Emergency Medicine Middle grade is required to inform the Consultant on call if not present who should be in attendance within 30 minutes of contact. The on call radiographer will notify the resident CT radiographer on receipt of a trauma call.

7.1.2 Trauma Team Composition Staff Expected to respond to the trauma call activation:


Emergency Department middle grade

Emergency Department Consultant if present (to be contacted when on call)

Anaesthetic Middle Grade

Surgical Registrar/Middle Grade

Trauma Coordinator (when on site) Additional Supportive staff also notified:

Emergency Department Porter

Transfusion Services

Senior Nurse on call for Theatres

Radiographer on call. Additional Staff required to respond in event of a Paediatric Trauma Call: (Paediatric Consultant to be informed)

Paediatric Middle Grade Additional Staff required to respond in event of an Obstetric Trauma Call:

Neonatal Senior Doctor on call

Neonatal Nurse

7.2 T14-2B-303 Agreement to Network Transfer Protocol form Trauma Units to Major Trauma Centres In the event of a patient either self-presenting or arriving at St Marys Trauma unit by ambulance identified after primary survey as having pathology that cannot be treated at the trauma unit or may require damage limitation surgery that cannot be provided within thirty minutes, should be transferred to the Major Trauma Centre Emergency Department after initial stabilization under the secondary transfer protocol (available on the CBU website).

7. 3 RADIOLOGY T14-2B-304, T14-2B-305 The trust has 24/7 access to a CT scanner and on site radiographer. The radiographer is on the trauma call. There is a 24/7 consultant led radiology rota for reporting via Medica Whole body CT (WBCT) requests indications pathway from A&E referrals for CT. A single positive parameter from any of the three categories leads to the possibility of serious internal injury and WBCT should be considered.


Mechanism Apparent Injury Vital Signs Any high speed RTA, e.g.

>30mph

Trapped > 30 min Car v pedestrian/cyclist (high energy) Fall > 3m (use judgment) Significant assault to trunk Blast or burn + trauma Other high energy mechanism

Evidence of blunt thoraco-abdominal trauma Evidence of open thoraco-abdominal trauma 2 or more long bone # Significant CNS trauma suspected Intubated at scene

GCS < 9 Sys BP < 90mmHg (guide) Persistent tachycardia >100 Resp Rate <10 or > 29 SaO2 < 93%

7.3.1 T14-2B-306 and T14-2B 307 The Trust aims to provide the CT scan within 30 minutes of the request being received and approved, subject to the patient being promptly transferred to the CT scan suite in a suitable condition. A report will be provided in accordance with the IOW Standard Operating Procedure for Patient CT Referrals from Accident and Emergency. The report should aim to be available within 60 minutes of the completion of the scan wherever practicable, as agreed in principle by the Clinical Director of Radiology. Images can be transferred via the Image Exchange Portal to the PACS. Requests for imaging of the head or cervical spine are made in accordance with the NICE guidance via the duty Radiologist. CT for trauma in paediatrics is requested in accordance with the Royal College of Radiologists Paediatric Trauma Protocols (Royal College of Radiologists, 2014).

7.4 SURGERY T14-2B-308 and T14-2B-309

The following staff are available on site on a 24/7 cover rota:

A general surgeon of ST3 level or above

An anaesthetist of ST3 level or above

The following staff are available within 30 minutes on a 24/7 cover rota

A trauma and orthopaedic surgeon of ST3 or above The IOW NHS Trust has no dedicated trauma operating theatre but can accommodate urgent surgery; staff are available 24 hours a day, 7 days a week. Scheduled lists for theatres run from 0930 until 1800 but are available for emergency work outside of these hours.

7.5 T14-2B-310 Trauma Management Guidelines Where appropriate the Regional Trauma Network guidelines will be followed for initial management and secondary transfer protocol followed for major trauma presentations.


7.6 Penetrating Cardiac Injuries Severe or penetrating injuries should be discussed with the Emergency Department Consultant or the Major Trauma Centre as to whether transfer under the secondary transfer protocol is appropriate or whether discussion with the cardiothoracic surgical team is required. In severe and unstable injury cardiothoracic surgeons should be contacted with regard to the team travelling to the Trauma Unit for consideration of haemorrhage control surgery locally. In the event of a cardiac arrest from penetrating trauma the Network protocol for traumatic cardiac arrest should be followed (Resuscitative thoracotomy). This should be undertaken by the most experienced doctors, with appropriate training, available within the timeframe. Training for this procedure has been highlighted as a requirement locally and throughout the region for Trauma Units and at present is acknowledged as a risk in this pathway

7.7 Unstable Pelvic Fractures. Pelvic injuries will be managed in accordance with ATLS principles and in accordance with IOW guidelines for the management of Haemodynamically unstable pelvic fractures.

7.8 Chest Drain Insertion The Trust has an existing policy on the insertion of Chest drains. Chest drains will be inserted independently by those Middle Grade staff or junior staff who have demonstrated appropriate competence through previous supervision. If a doctor with this competency is not immediately available the on call Consultant of the concerned Directorate should be informed as necessary and assistance sought from an appropriate middle grade Doctor on call. It is the Consultant’s responsibility to identify adequately trained doctors to perform the procedure. All doctors expected to be able to insert a chest drain should be trained using a combination of didactic lecture, simulated practice and supervised practice until considered competent. Chest drain insertion is a core competency expected of doctors doing A&E, Medical, Surgical, Anaesthetics and Intensive Care training. Each Business Unit should review the provision of training and assessment of competence relevant to the specialty.

7.9 Severe Traumatic Brain Injury Head injured patients are investigated according to NICE head and cervical spine injury guidance. Patients with positive CT should be discussed with the Emergency Medicine Consultant or Middle Grade and considered for either transfer under the secondary transfer protocol or management under The IOW Critical Care Network guidance for management of the Trauma Patients with GCS equal or less than 13.

7.10 Drowning and Hypothermia Patients who have drowned and are hypothermic should be discussed with the cardiothoracic surgeons on call at the major trauma centre for consideration of cardiopulmonary bypass at Southampton University Hospital

7.11 TRANSFUSION T14-2B-311and T14-2b-312 There is a named Consultant Haematologist designated as clinical lead for transfusion. The Trust has on-site Haematology service support 24/7 in addition to available Consultant Haematologists throughout the day and on-call out of hours 24/7 to provide transfusion advice.

7.11.1 T14-2B-313 The Trust has a massive transfusion protocol which is being updated to parallel the massive transfusion protocol used at Southampton University Hospital. This is currently


an ongoing process. A network protocol has not been agreed due to the difference in availability of blood products at different trauma units. The IOW currently holds 2 units of platelets for use with Major trauma patients. (Trust guidelines) 7.11.2 T14-2B-314 In patients with significant haemorrhage, Tranexamic acid should be given within 3 hours of injury and receive a second dose in accordance with the CRASH-2 protocol. Tranexamic acid is available for trauma patients as part of the major haemorrhage protocol.

7.12 DEFINITIVE CARE MEASURES T14-2C-301 Major Trauma Lead Clinician There is a named Emergency Medicine Consultant designated for major trauma. The Lead Clinician has managerial responsibility for the service and allocated programmed activity specified in their Job Plan.

7.13 T14-2C-302 Designated Specialty Patients who attend with traumatic head injuries not requiring secondary transfer to the Major trauma Centre are currently admitted under the care of the General Surgical Consultant on call

7.14 T14-2C-303 Trauma Coordinator Service There is currently no trauma coordinator service; it should be available Monday to Friday for the coordination of trauma patients The purpose of the role is:

To enhance the patient’s experience and to ensure a multi-disciplinary approach to the care and management of patients undergoing trauma surgery and outpatient fracture management – focusing upon improved quality and enhanced access.

To integrate into part of the clinical team to ensure care is performed in a timely manner, that patients are transferred to the MTC as per protocol. Liasing with MTC for timely repatriations and rehabilitation service for trauma plans

To ensure that trauma patients are managed in a most timely and appropriate fashion according to their needs.

7.15 T14-2C-303 Management of Spinal Injuries Inpatient care of spinal injuries is overseen by the Orthopaedic team. Spinal injuries should be managed in consultation on a consultant to consultant basis with the Spinal Cord Injury Centre Service at Southampton University Hospital. Liaison with this service is the responsibility of the Orthopaedic team. Any spinal injured patient with definite neurology on presentation to the Emergency Department meeting the criteria outlined by the National Spinal Cord Injury Strategy Board recommendations will be transferred to the Major Trauma Centre under the secondary transfer protocol. All patients with a spinal fracture should have imaging of the whole spine as 10% will have a noncontiguous fracture (ATLS, 9th Edition).

7.16 T14-2C-305 Management of Multiple Rib Fractures. Chest trauma requiring admission but not requiring cardiothoracic intervention should be admitted under the surgical team to either the admissions ward or high dependency unit. Penetrating trauma should be discussed with the Emergency Department Consultant and review if transfer under the secondary transfer protocol is indicated or further discussion with Cardiothoracic Surgical team is required.


Chest trauma should be managed in accordance with our MTC rib injury management guidance. Consider admission to high dependency area for patients with multiple rib fractures for pain control and monitoring.

Patients with 4 or more displaced or flail rib fractures that are intubated or likely to require intubation with no other life threatening conditions should be discussed with rib fracture fixation service at SouthamptonUniversity Hospital.

7.17 T14-2C-306 Management of Musculoskeletal Trauma All long bone fractures associated with major trauma are to be seen and assessed by the orthopaedic junior grade and discussed with a senior grade.

7.17.1 Neck of Femur Management All patients with suspected Neck of Femur injuries are to be rapidly assessed and managed in accordance with the Neck of Femur Fast track Pathway. Transfer should not be delayed by Orthopaedic team review in the Emergency Department unless a specific need is identified.

7.17.2 Open Fractures of Lower Limbs Open lower limb fractures this includes all grades of open fracture (I to IV). Gustello Fracture classification should be documented in accordance with BOAST4 requirements. Management should be as recommended in BOAST 4 guidance. (available on the CBU website)

7.17.3 T14-2C-307 Fixation of Fractures There are on site facilities for the management of patients with isolated long bone fractures - a 24/7 Trauma operating theatre, fully staffed, with an Orthopaedic Consultant on call and available on site during working hours. There is also an Orthopaedic Consultant or above on call 24/7 who can be on site within 30 minutes.

7.17.4 T14-2C-308 Specialist Burns care All non-complex burns are managed and followed up as per the Regional Burn Care Network management protocol. Complex burns are referred to the local burns units Salisbury District Hospital (Appendix 4)

7.17.5 T14-2C-309 Discharge Summary A discharge summary detailing a list of all injuries, any operations (including date), instructions for follow up and instructions for community rehabilitation should be available for all trauma patients.

REHABILITATION MEASURES

7.18 T14-2D-301 – Rehabilitation Coordinator The named Rehabilitation Coordinators are a physiotherapist and a registered nurse. The rehabilitation coordinator is responsible for coordination and communication regarding the patient’s current and future rehabilitation.

7. 18.1 T14-2d-302 – Trauma Unit Agreement to Network Repatriation Policy Agreed protocol for acceptance of patients from the major trauma centre as outlined in the MTC – TU policy. 7.18.2 T14-2D-303 Physiotherapy Services


Trauma specific physiotherapists provide a service seven days a week with extended working day shift patterns and an on call rota to cover 24/7.

7.18.3 T14-2D-304 Access to Rehabilitation Specialists The Discharge Liaison Team that aims to facilitate effective, efficient and timely discharge of patients from hospital. Particular emphasis is placed upon complex multi-disciplinary assessments and case conferences including patients with complex needs, palliative care and rehabilitation needs. The role involves working across professional boundaries with multi agencies including local health and social care staff. There are Speech and Language Therapy and Occupational Heath Therapists available. These services are available from 8.30 to 16.30 Monday to Friday. The Trust has an Emergency Care Therapy Team, composed of Physiotherapists and Occupational Therapists to assist in the discharge planning of low severity trauma with access to physiotherapy and rehabilitation beds in the community. At present there is no pathway for referral to neuro-rehabilitation services for traumatic head injury patients not requiring surgery but with positive CT changes, the service is operated on an individual need basis

7.19 Patient transfer to Major Trauma Centre Level 2 and Level 3 patient transfers will be facilitated by the IOW NHS Trust .A transfer callout alert is in operation for suitably trained staff to escort patients to receiving hospitals when required.(Link available on Trust intranet))

8 Consultation The Trauma unit operational policy defines the standards required by the IOW Trust to operate as a Trauma unit and how to work to achieve these standards within the existing structure of our Trust. All members of the existing Trauma team respondees should be made aware of this document and have the opportunity to respond.

9 Training

9.1 In House Teaching Programs Trauma management is a regular part of the annual mandatory training Emergency Department nursing teaching programme. All band 6 nurses have attended the ATNC and all ED staff attended the locally delivered TILS as part of their mandatory training. All medical staff attend the ATLS course and have the opportunity to attend the TILS as part of the multi- disciplinary team.

9.2 Trauma Simulation Drills As part of Emergency Department formal teaching programs medical staff should have simulation suite based trauma teaching. There should be a weekly program of in situ simulation training for nursing and medical staff. This simulation program includes core skill drill training four times per year including adult, paediatric major trauma and obstetric trauma/cardiac arrest. These drills will test the trauma call out procedure and attendance will be monitored.


10 Monitoring Compliance and Effectiveness Audit and Governance TARN submission The Trust supports the Trauma Audit Research Network (TARN) database with all suitable cases submitted by our TARN Coordinator. A summary of IOW NHS Trust data is outlined in the Annual report document. Regional Trauma Network Collaborative Group Trauma Lead clinician or Trauma nurse co-ordinator attends the bi monthly Regional Trauma CAG meeting. Trauma Network Morbidly and Mortality Meeting Trauma Lead clinician or nominated deputy attends the M&M meeting held at IOW NHS Trust and other Consultant representation are encouraged to attend and present cases when appropriate. Trust MDT Trauma Group Trust MDT Trauma Group meets a minimum of four times per year. Emergency Surgery Morning Meeting An Emergency Surgery meeting takes place every day at 8am where all new admissions in the last 12 hours to the on call surgical team are discussed, and plans for treatment agreed for those patients potentially requiring surgery. For major laparotomy procedures the consultant responsible for the patient should take part in the surgery whenever possible. Peer review Annual peer review either by TQuins or/and self-assessment.

11 Links to other Organisational Documents

Trauma Team call out criteria (available on AUCCBU website) Wessex Major Trauma Secondary transfer protocol (available on AUCCBU website) Wessex Orthoplastic Trauma referral tool. (Available on AUCCBU website) Burns triage tool (available on AUCCBU website) Major incident Policy (available on Trust Intranet) Advanced Trauma Life Support (available on Trust intranet) Advanced Paediatric Life Support (available on Trust intranet)

12 References Royal College of Radiologists 2014 Advanced Trauma Life Support 9th edition.

13 Appendices Appendix 1 Self assessment matrix Appendix 2 Financial and Resourcing Impact Assessment on Policy Implementation Appendix 3 Equality Impact Assessment (EIA) Screening Tool


Appendix 1 15 T-QUINS SELF ASSESSMENT MATRIX

PLEASE NOTE: Previous measures were numbered T13-xx-xxx (2013). The revised measures included herewith are numbered T14-xx-xxx (2014). Where the number for the measure for T13 and T14 remains the same no indication of change is given and the only change is that T14 replaces T13. However, where any measure now numbered T14 was previously included under a different number as T13 this is indicated for ease of reference to assist with the identification of previous evidence supplied against the previous T13 measure number.

Network Governance Measures

Adults MTC

Children’s Major

Trauma

Trauma Units

Measure

MTN

MTC

Trauma

Unit

Pre-

Hospital

T14-1C-101 Network configuration

T14-1C-102 Network Governance structure

T14-1C-104 Individual Pre-Hospital Provider Feedback

T14-1C-105 New

Network transfer Protocol from Trauma units to MTC

T14-1C-106 (previously T13-1C-105)

Network Transfusion Protocols For Trauma units

T14-1C-107 (previously T13-2B-110)

New (included in

reception and Resuscitation

Measure T14-2B-307)

Teleradiology Facilities

T14-1C-108 New

New (included in

Reception and Resuscitation

Measures T14-2B-306)

Network CT Protocol for Adults

T14-1C-109 New

Network imaging Protocol for Children

T14-1C-111 New

Trauma Management Guidelines

T14-1C-112 New

Management of severe Head injury

T14-1C-113 New

Management of Spinal injuries


Emergency planning

T14-1C-115 (Also rehab

measure T14-2D-101) (previously T13-2D-101)

T14-2D-201 New

The Trauma Network Director of Rehabilitation

T14-1C-116 (previously T13-2D-110)

T14-2D-210

New

Directory of Rehabilitation Services

T14-1C-117 (also rehab

measure T14-2D-109) (previously T13-2D-111)

T14-2D-211

New

Referral Guidelines to Rehabilitation Services



measure T14-2D-110)

T14-2D-212

New

Patient Transfer


measure T14-2D-111)

Network Patient Repatriation Policy

Pre-Hospital Care Measures

Adults MTC

Children’s Major

Trauma

Trauma Units

Measure

MTN

MTC

Trauma

Unit

Pre-

Hospital

T14-2A-101

Pre-Hospital Care Clinical Governance

T14-2A-102

Trauma Triage Tool and immediate transfer policy

T14-2A-103

24/7 Consultant Medical advice for the Ambulance control room

T14-2A-104

24/7 Paramedic advice in the control room

T14-2A-105 (previously T13-2A-106)

Enhanced care teams available 24/7

T14-2A-106 (previously T13-2A-107)

Pain management protocol for Adults

T14-2A-107 New

Pain management Protocol for Children

T14-2A-108

Pre-Hospital Administration of Tranexamic Acid for Adults

T14-2A-109

Application of Pelvic Binders

T14-2A-110

Hospital pre-alert and handover


Reception and Resuscitation Measures

Adults MTC

Children’s Major

Trauma

Trauma Units

Measure

MTN

MTC

Trauma

Unit

Pre-

Hospital

T14-2B-101

T14-2B-201

New

T14-2B-301

New

Trauma Team leader

T14-2B-103

T14-2B-203

New

T14-2B-302

New

Trauma Team Activation Protocol

T14-2B-303 New

Agreement to Network Transfer Protocol from TUs to MTCs

T14-2B-104

T14-2B-204

New

24/7 Surgical and Resuscitative Thoracotomy Capability

T14-2B-105

T14-2B-205

New

T14-2B-304

New

24/7 CT Scanner Facilities and on-site Radiographer

T14-2B-106

T14-2B-206

New

T14-2B-305

New

CT Reporting

Included in Network Measures T14-1C-108)

Included in Network Measures T14-1C-109)

T14-2B-306

New

Network CT Protocols

Included in Network

Measures T14-1C-107)

T14-2B-307

New

Teleradiology Facilities

T14-2B-107 New

T14-2B-207

New

24/7 MRI Scanning Facilities

T14-2B-108 New

T14-2B-208

New

24/7 Interventional Radiology

T14-2B-109 New

T14-2B-209

New

Interventional Radiology Facilities

T14-2B-110 (previously T13-2B-111)

T14-2B-210

New

24/7 Access to Emergency, Theatre and Surgery


T14-2B-211

New

Damage control Training for Emergency Trauma Consultant Surgeons


24/7 Access to on-site Surgical Staff

T14-2B-308

New 24/7 Access to Surgical Staff


T14-2B-309

New

Dedicated Orthopaedic Trauma Operating Theatre


T14-2B-213

New

Provision of Surgeons and Facilities for Fixation of pelvic Ring Injuries


T14-2B-214 New

T14-2B-310

New

Trauma Management Guidelines as specified in T14-1C-111, MTC and TU should include relevant local details


T14-2B-215

New

On-Site Intensive Care Unit


T14-2B-119 (previously T13-2A-120)

T14-2B-217

New

24/7 Specialist Acute pain Service


T14-2B-218

New

T14-2B-311

New

Transfusion Lead Clinician


T14-2B-219

New

T14-2B-312 New

24/7 Specialist Transfusion Advice


T14-2B-220

New

Massive Transfusion Protocol For the Major Trauma Centre

T14-2B-313

New

Network Transfusion Protocol


T14-2B-221

New

T14-2B-314

New

Administration of Tranexamic Acid


Definitive Care Measures

Adults MTC

Children’s Major

Trauma

Trauma Units

Measure

MTN

MTC

Trauma

Unit

Pre-

Hospital

T14-2C-101

T14-2C-201

New

Major Trauma Centre Lead Clinician

T14-2C-301

New

Major Trauma Lead Clinician

T14-2C-302

New

Designated Speciality

T14-2C-102

T14-2C-202

New

Major Trauma Service

T14-2C-103

T14-2C-203

New

Major Trauma Coordinator Service

T14-2C-303

New

Trauma Coordinator Service

T14-2C-104

T14-2C-204

New

Major Trauma MDT Meeting

T14-2C-105

T14-2C-205

New

MDT Conference Facilities

T14-2C-106

T14-2C-206

New

Dedicated Major Trauma Ward or Clinical Area

T14-2C-107

T14-2C-207

New

Protocol for Formal Tertiary

T14-2C-108

T14-2C-208

New

Management of Neurosurgical Trauma

T14-2C-109

T14-2C-209

New

Management of Craniofacial Trauma

T14-2C-110

T14-2C-210

New

T14-2C-304

New

Management of Spinal injuries

T14-2C-305

New

Management of Multiple Rib Fractures

T14-2C-111

T14-2C-211

New

T14-2C-306

New

Management of Multiple Musculoskeletal Trauma

Facilities for Fixation of Fractures

T14-2C-112

T14-2C-212

New

Management of Hand Trauma

T14-2C-113

T14-2C-213 New

Management of Complex Peripheral Nerve Injuries

T14-2C-114

T14-2C-214

New

Management of Maxillofacial Trauma


Vascular and Endovascular Surgery


T14-2C-215

New

T14-2C-308

New

Designated Specialist Burns Care



T14-2C-216

New

Nutritional Management Policy


T14-2C-217

New

T14-2C-309

New

Discharge Summary


Rehabilitation Measures

Adults MTC

Children’s Major

Trauma

Trauma Units

Measure

MTN

MTC

Trauma

Unit

Pre-

Hospital

T14-2D-101 (also Network Measure T14-1C-115) previously T13-2D-101

The Trauma Network Director of Rehabilitation

T14-2D-201

New

Clinical Lead for Acute Trauma Rehabilitation

T14-2D-102 (previously T1432D-103)

T14-2D-202 New

T14-2D-301

New

Rehabilitation Coordinator Post

T14-2C-103

New

T14-2D-203

New

Specialist Rehabilitation service

T14-2D-104 (previously T13-2D-105)

T14-2D-204

New

Key Worker


T14-2D-205

New

T14-2D-305

New

Rehabilitation Prescriptions


T14-2D-206

New

Rehabilitation for Traumatic Amputation

T14-2D-107

(previously T13-2D-108)

T14-2D-207

New

Facilities for Families / Carers


T14-2D-208

New

Patient Information

T14-2D-109 (also Network Measure T14-

1C-117) previously T13-2D-111

T14-2D-209

New

Referral Guidelines to Rehabilitation Services

T14-2D-110 (also Network Measure T14-1C-118) previously T13-2D-112

T14-2D-210

New

Patient Transfer

T14-2D-111 (also Network Measure T14-1C-119)

T14-2D-211

New

Network Patient Repatriation Policy

T14-2D-302

New

Trauma Unit Agreement to the Network Repatriation Policy

T14-2D-112

(also Network Measure T13-1D-113)

T14-2D-212

New

Clinical Psychologist for Trauma Rehabilitation

T14-2D-113

(also Network Measure T13-1D-114)

T14-2D-213

New

24/7 Access to Psychiatric Advice

T14-2D-303

New

Physiotherapy Services

T14-2D-304

New

Access to Rehabilitation Specialists


Appendix 2

Financial and Resourcing Impact Assessment on Policy Implementation

NB this form must be completed where the introduction of this policy will have either a positive or negative impact on resources. Therefore this form should not be completed where the resources are already deployed and the introduction of this policy will have no further resourcing impact.

Document title

Major Trauma Unit Operational Policy

Totals WTE Recurring £

Non Recurring £

Manpower Costs 1.0 £36,250

Training Staff

Equipment & Provision of resources

Summary of Impact: Risk Management Issues:

Benefits / Savings to the organisation: Equality Impact Assessment Has this been appropriately carried out? YES/NO Are there any reported equality issues? YES/NO If “YES” please specify:

Use additional sheets if necessary. Please include all associated costs where an impact on implementing this policy has been considered. A checklist is included for guidance but is not comprehensive so please ensure you have thought through the impact on staffing, training and equipment carefully and that ALL aspects are covered.

Manpower WTE Recurring £ Non-Recurring £

Operational running costs

1.0 £36,250

Totals: £36,250

Staff Training Impact Recurring £ Non-Recurring £

Totals:


Equipment and Provision of Resources Recurring £ * Non-Recurring £ *

Accommodation / facilities needed

Building alterations (extensions/new)

IT Hardware / software / licences £500

Medical equipment

Stationery / publicity

Travel costs £500

Utilities e.g. telephones

Process change

Rolling replacement of equipment

Equipment maintenance

Marketing – booklets/posters/handouts, etc

Totals: £1000

Capital implications £5,000 with life expectancy of more than one year.

Funding /costs checked & agreed by finance:

Signature & date of financial accountant:

Funding / costs have been agreed and are in place:

Signature of appropriate Executive or Associate Director:


Appendix 3

Equality Impact Assessment (EIA) Screening Tool

1. To be completed and attached to all procedural/policy documents created within

individual services.

2. Does the document have, or have the potential to deliver differential outcomes or affect in an adverse way any of the groups listed below? If no confirm underneath in relevant section the data and/or research which provides evidence e.g. JSNA, Workforce Profile, Quality Improvement Framework, Commissioning Intentions, etc. If yes please detail underneath in relevant section and provide priority rating and determine if full EIA is required.

Gender

Positive Impact Negative Impact Reasons

Men √

Women √

Race

Asian or Asian British People

√

Black or Black British People

√

Chinese people

√

People of Mixed Race

√

White people (including Irish people)

√

People with Physical Disabilities, Learning

√

Document Title: Major Trauma Unit Operational Policy

Purpose of document To outline the pupose and scope of the Trauma Unit

Target Audience Trauma Team members.,and Emergency Department personnel

Person or Committee undertaken the Equality Impact Assessment

Mary Bound


Disabilities or Mental Health Issues

Sexual Orientation

Transgender √

Lesbian, Gay men and bisexual

√

Age

Children

√

Older People (60+)

√

Younger People (17 to 25 yrs)

√

Faith Group √

Pregnancy & Maternity √

Equal Opportunities and/or improved relations

√

Notes: Faith groups cover a wide range of groupings, the most common of which are Buddhist, Christian, Hindus, Jews, Muslims and Sikhs. Consider faith categories individually and collectively when considering positive and negative impacts. The categories used in the race section refer to those used in the 2001 Census. Consideration should be given to the specific communities within the broad categories such as Bangladeshi people and the needs of other communities that do not appear as separate categories in the Census, for example, Polish. 3. Level of Impact If you have indicated that there is a negative impact, is that impact:

YES NO

Legal (it is not discriminatory under anti-discriminatory law)

Intended

If the negative impact is possibly discriminatory and not intended and/or of high impact then please complete a thorough assessment after completing the rest of this form. 3.1 Could you minimise or remove any negative impact that is of low significance? Explain how below:

3.2 Could you improve the strategy, function or policy positive impact? Explain how below:

3.3 If there is no evidence that this strategy, function or policy promotes equality of opportunity or


improves relations – could it be adapted so it does? How? If not why not?

Scheduled for Full Impact Assessment Date:

Name of persons/group completing the full assessment.

Date Initial Screening completed