Benchmarking the UK Military Deployed Trauma System

Corresponding Author: Colonel TJ Hodgetts QHP Honorary Professor of Emergency Medicine Academic Department of Military Emergency Medicine Institute of Research and Development, Vincent Drive, Birmingham B15 2SQ T: +44 121 415 8848 E: Prof.ADMEM@rcdm.bham.ac.uk Comparing Civilian and Military Performance In November 2007 the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published a report [1] that identified that almost 60% of major trauma patients (Injury Severity Score ≥16) receive care that is “less than good practice” in a representative sample of hospitals across England, Wales, Northern Ireland and the Offshore Islands. The report represents one of a series of Royal College sponsored reports over almost 2 decades that have consistently criticized the quality of acute trauma care in the NHS [2,3]. A core function of the Defence Medical Services (DMS) is the effective assessment, treatment and evacuation of Service personnel injured on deployed operations. Service clinicians would argue that the organization and delivery of acute trauma care that has developed to support contemporary combat operations is significantly advanced compared to the NHS. The publication of the NCEPOD report is an opportunity to objectively benchmark DMS trauma system performance against the NHS. The DMS has audited its clinical effectiveness in major trauma management in detail since 1999 [4] and has deployed personnel in a Trauma Nurse Co-ordinator role to collect relevant data throughout the contemporary conflicts in Iraq and Afghanistan, generating periodic reports of major trauma performance [5,6]. A Joint Theatre Trauma Registry (JTTR) is maintained at the Royal Centre for Defence Medicine (RCDM) in Birmingham. NCEPOD determined that under half (42%) of sampled NHS hospitals undertake detailed audit through subscription to the national Trauma Audit Research Network (UK TARN). Many NHS hospitals sampled treated less than one major trauma case per week, and some treated only 1-2 cases in the entire 12 week sampling period. Only 12/183 (6.6%) hospitals treated >1 major trauma case per week. Experience in dealing with major trauma was related to performance as those with a higher caseload (>20 major trauma in 12 weeks) were judged to deliver a higher percentage of care assessed as good practice. A benchmark of trauma system performance is provided by comparing NCEPOD findings with JTTR for the period 01 April 2006 to 30 September 2007.While including casualties treated by UK DMS in both Iraq and Afghanistan, the first date coincides with the start of UK combat operations in Southern Afghanistan. For this period there were 314 major trauma cases (calculated using the Abbreviated Injury Scale 2005, USMilitary version [7]), which is an average of 4.25 per week (51.0 over 12 weeks). Injury mechanisms and injury severity are different between the NHS and DMS patient cohorts: 56.3% of NHS major trauma patients are a result of motor vehicle collision (blast or gunshot are not coded and are included in 10.3% of “other” mechanisms); in the DMS cohort only 5.1% of major trauma is from MVC, with 53.8% blast/fragmentation and 29.9% gunshot. Banding the Injury Severity Scores demonstrated that the DMS cohort was significantly (p<0.0001) more severely injured than the NHS cohort (ISS 16-24, NHS = 56.5%, DMS = 26.4%; ISS 25-35, NHS = 35.1%, DMS = 22.3%; ISS 36-75, NHS = 8.4%, DMS = 51.3%). However, the injury severity must be interpreted with caution as AIS 05 (Military) has been adjusted from AIS 98 (UK civilian coding standard) to take account of injuries inflicted by military mechanisms. The lack of availability of senior clinical staff to direct the Trauma Team was identified as the norm in the NHS: 118/183 (64.5%) hospitals did not have a consultant Trauma Team leader during a specific sample period (early hours of Sunday morning) and in only 6/183 (3.3%) hospitals was the consultant team leader resident. This was considered to contribute to incorrect clinical decision making and lack of appreciation of the severity of injury. Independently, the National Patient Safety Agency has expressed concern that trainees are less able than consultants to recognize seriously ill or deteriorating patients and that this may have a detrimental effect on outcome [8]. In the deployed field hospital there is a full consultant-based team (consultants from each of the specialties of emergency medicine [team leader], anaesthesia, general surgery and orthopaedic surgery) resident in the hospital 24 hours a day and immediately available for the reception of any seriously injured patient. Specific criticism was made by NCEPOD of the lack of standardized transfer documentation, and the compliance with published guidelines. Secondary transfers were felt to be “conducted in haphazard fashion with little consultant oversight”. This contrasts with UK DMS policy where strategic movement of the seriously injured from the field hospital to RCDM relies on a consultant in intensive care as part of a Critical Care Air Support Team (CCAST): the mobilization of CCAST follows a standardized process and is the responsibility of the Air Evacuation Liaison Officer (AELO, usually a nurse) embedded with the field hospital. NCEPOD has commented on performance against a raft of clinical performance indicators (PIs) and the requirement to monitor PIs was highlighted by Royal College of Surgeons of England in 2000 [3]. The UK DMS continuous quality improvement programme for the seriously injured is referred to as ‘MACE’ (Major Trauma Audit for Clinical Effectiveness) and over 60 clinical PIs are tracked from point of wounding through to rehabilitation. Airway management in the pre-hospital setting is often challenging and a high incidence of partially obstructed or obstructed airways on arrival at hospital has prompted the GOVERNANCE AND DATA COLLECTION