1. Healthcare The London for LondonTrauma System Launch Maralyn Woodford The TRAUMA Audit & Research NETWORK The Trauma Audit & Research Network

2. 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

3. TARN Universities 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

4. 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

5. 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

6. Measuring and monitoring trauma care

7. Assessment of Trauma Severity Logistic regression modelling‘ – ‘weights’ those parameters that predict survival. Anatomical InjuryISS Physiological MeasureGCS Age / Gender Probability of survival of individual patients Case mix standardised comparisons of actual and predicted outcome

8. An improved approach to outcome predictions Where: GCS = Glasgow Coma Scale score ISS = Injury Severity Score b0……..b26 are coefficients derived from regression analysis applied to data from TARN 2001 - 2006. b0 = constant 4.729 b1 = 0 and applies when the GCS = 13 - 15 b2 = -1.076 and applies when the GCS = 9 - 12 b3 = -1.543 and applies when the GCS = 6 – 8 b4 = -2.446 and applies when the GCS = 4 - 5 b5 = -3.413 and applies when the GCS = 3 b6 = -2.046 and applies when Intubated b7 = -3.867 b8 = -3.313 b9 = 0 and applies when gender = male b10 = -0.089 and applies when gender = female b11 = -0.083 and applies when Age = 0 – 5 b12= 0.676 and applies when Age = 6 - 10 b13 = 0.329 and applies when Age = 11 – 15 b14 = 0 and applies when Age = 16 - 44 b15 = -0.533 and applies when Age = 45 – 54 b16 = -1.101 and applies when Age = 55 - 64 b17 = -1.755 and applies when Age = 65 – 74 b18 = -3.221 and applies when Age = > 74 b19 = -0.237 and applies when Age = 0 – 5 and gender = female b20 = -0.216 and applies when Age = 6 – 10 and gender = female b21 = 0.042 and applies when Age = 11 – 15 and gender = female b22 = 0 and applies when Age = 16 - 44 and gender = female (or male) b23= 0.274 and applies when Age = 45 - 54 and gender = female b24 = 0.184 and applies when Age = 55 - 64 and gender = female b25 = 0.095 and applies when Age = 65 - 74 and gender = female b26 = 0.366 and applies when Age >74 and gender = female The constant e = 2.718282 (the base of Napierian logarithms).

9. Comparing Outcomes 2005 - 2008 -10 -8 -6 -4 -2 0 2 4 6 8 10 Ws & 95% CI More survivors More deaths Average bottom 10 TARN Hospitals (-3) 95% Confidence Intervals Average top 10 TARN Hospitals (+2.5) Incomplete data collection

10. The Trauma Centre: A Speciality Hospital, not a Hospital of Specialities R. A. Davenport et al BJS 2009 accepted for publication

11. 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

12. 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

14. Accessing a hospital from region

15. Completeness of Data Data Accreditation

17. 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

18. Data Coordination The Electronic Data Collection & Reporting system

19. the eDCR System online system requiring no specialist software data is instantly validated Confidential, Secure, Encrypted data, Backup service PIAG approval

20. Data coordination across a network Requirements: Resources - membership fees - data collection Comprehensive data collection dependant on: - skills - management - time - geography

21. Data Quality………..  is Important  √√√√ - indicators of data completeness and accreditation  Outcome and Process measures reviewed with confidence

23. 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

24. 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

25. Questions? Acknowledgements TARN staff Executive Committee and Board Clinicians and data co-ordinators at TARN participating hospitals 10 th September 2009 Healthcare The London for LondonTrauma System Launch