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Major trauma service delivery procedures

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Trauma

About

What is covered

This interactive flowchart covers the:
  • assessment and initial management of major trauma, including airway management, chest trauma, haemorrhage, pain and temperature control
  • assessment and initial management of spinal injury
  • assessment and management of complex and non-complex fractures
  • organisation and delivery of major trauma services.
Recommendations apply to children, young people and adults unless otherwise specified. Pre-hospital and hospital settings are covered.

Updates

Updates to this interactive flowchart

28 March 2018 Trauma (NICE quality standard 166) added.
20 March 2018 Thopaz+ portable digital system for managing chest drains (NICE medical technology guidance 37) added to chest trauma management in a pre-hospital setting and chest trauma management in hospital.
10 November 2017 Recommendation in management in the pre-hospital setting amended to change wording from 'administer prophylactic antibiotics' to 'consider administering prophylactic antibiotics'.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on assessing and managing trauma in an interactive flowchart

What is covered

This interactive flowchart covers the:
  • assessment and initial management of major trauma, including airway management, chest trauma, haemorrhage, pain and temperature control
  • assessment and initial management of spinal injury
  • assessment and management of complex and non-complex fractures
  • organisation and delivery of major trauma services.
Recommendations apply to children, young people and adults unless otherwise specified. Pre-hospital and hospital settings are covered.

Updates

Updates to this interactive flowchart

28 March 2018 Trauma (NICE quality standard 166) added.
20 March 2018 Thopaz+ portable digital system for managing chest drains (NICE medical technology guidance 37) added to chest trauma management in a pre-hospital setting and chest trauma management in hospital.
10 November 2017 Recommendation in management in the pre-hospital setting amended to change wording from 'administer prophylactic antibiotics' to 'consider administering prophylactic antibiotics'.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Major trauma: service delivery (2016) NICE guideline NG40
Fractures (complex): assessment and management (2016 updated 2017) NICE guideline NG37
Pre-hospital initiation of fluid replacement therapy in trauma (2004) NICE technology appraisal guidance 74
Translaryngeal tracheostomy (2013) NICE interventional procedures guidance 462
Low-intensity pulsed ultrasound to promote fracture healing (2010) NICE interventional procedures guidance 374
Thopaz+ portable digital system for managing chest drains (2018) NICE medical technologies guidance 37
Ambu aScope2 for use in unexpected difficult airways (2013) NICE medical technologies guidance 14
CardioQ-ODM oesophageal doppler monitor (2011) NICE medical technologies guidance 3
Trauma (2018) NICE quality standard 166

Quality standards

Trauma

These quality statements are taken from the trauma quality standard. The quality standard defines clinical best practice for assessing and managing trauma and should be read in full.

Quality statements

Airway management

This quality statement is taken from the trauma quality standard. The quality standard defines clinical best practice for assessing and managing trauma and should be read in full.

Quality statement

People with major trauma who cannot maintain their airway and/or ventilation have drug-assisted rapid sequence induction (RSI) of anaesthesia and intubation within 45 minutes of the initial call to the emergency services.

Rationale

Failure to provide an adequate airway for people who cannot maintain one can result in brain injury, with long-term implications for function and quality of life, or death. Performing drug-assisted RSI of anaesthesia and intubation quickly, and preferably at the scene of the incident rather than by diverting to an emergency department, improves ventilation, increasing the probability of survival and reducing long-term morbidity.

Quality measures

Structure
a) Evidence of the availability of healthcare professionals trained to perform drug-assisted RSI of anaesthesia and intubation at the scene, or of systems to transport people to the nearest emergency department where it can be performed.
Data source: Local data collection, for example from local protocols.
b) Evidence of local arrangements to support decision-making about whether to dispatch trained healthcare professionals to the scene to deliver drug-assisted RSI of anaesthesia and intubation, or transport the person to the nearest emergency department where it can be performed.
Data source: Local data collection, for example from local protocols.
Process
a) Proportion of people with major trauma who cannot maintain their airway and/or ventilation who have drug-assisted RSI of anaesthesia and intubation.
Numerator – the number in the denominator who have drug-assisted RSI of anaesthesia and intubation.
Denominator – the number of people with major trauma who cannot maintain their airway and/or ventilation.
Data source: Local data collection, for example, audit of patient records. The Trauma Audit and Research Network collects data on intubation ventilation and use of drugs at the scene and in the emergency department.
b) Proportion of people with major trauma who cannot maintain their airway and/or ventilation who have drug-assisted RSI of anaesthesia and intubation within 45 minutes of the initial call to the emergency services.
Numerator – the number in the denominator who have drug-assisted RSI of anaesthesia and intubation within 45 minutes of the initial call to the emergency services.
Denominator – the number of people with major trauma who cannot maintain their airway and/or ventilation and have drug-assisted RSI of anaesthesia and intubation.
Data source: Local data collection, for example, audit of patient records. The Trauma Audit and Research Network collects data on intubation ventilation and use of drugs at the scene and in the emergency department.
Outcomes
a) Mortality rates from major trauma.
Data source: Local data collection, for example using the Office for National Statistics mortality database. The Trauma Audit and Research Network also collects data on deaths of trauma patients.
b) Rates of brain injury resulting from lack of oxygen caused by major trauma.
Data source: Local data collection, for example local audit of patient records.

What the quality statement means for different audiences

Service providers (ambulance services, major trauma centres and trauma units) ensure that there are protocols operating in ambulance control to identify people with major trauma who need drug-assisted RSI of anaesthesia and intubation and deliver it at the scene, or transport people to the nearest emergency department if this is not possible, so that it is received within 45 minutes of the initial call to the emergency services.
Healthcare professionals (paramedics, advanced pre-hospital doctors and anaesthetists) trained in RSI deliver drug-assisted RSI of anaesthesia and intubation at the scene of the major trauma within 45 minutes of the initial call to the emergency services. If a trained professional is not available at the scene, healthcare professionals decide whether to call out someone trained in RSI to the scene, or transport the person to the nearest emergency department. They maintain the person’s airway using a suitable technique until trained healthcare professionals arrive at the scene, or until the person arrives at the emergency department. Drug-assisted RSI of anaesthesia and intubation is performed by anaesthetists or other doctors in emergency departments within 45 minutes of the initial call to the emergency services if it cannot be performed at the scene.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that have local protocols on performing drug-assisted RSI of anaesthesia and intubation at the scene of the major trauma, or, if this is not possible, at the nearest emergency department within 45 minutes of the initial call to the emergency services. They monitor contracts and seek evidence that service providers have this in place.
People who have had a major injury and are not able to breathe on their own are given a general anaesthetic (a drug that puts a person to sleep) by a doctor at the scene of the injury. A breathing tube is then placed into their mouth and down into their windpipe to help them breathe. If a doctor is not available at the scene of the injury, or if the breathing tube doesn't work well enough, the ambulance team should use other methods to help the person breathe until they can be taken to a major trauma centre or a trauma unit.

Source guidance

Definitions of terms used in this quality statement

People with major trauma who cannot maintain their airway and/or ventilation
Major trauma describes serious and often multiple injuries that may require lifesaving interventions. People might not be able to maintain their airway and/or ventilation if they are in a coma (Glasgow Coma Score less than 9), if they are not breathing adequately or their mouth is obstructed, for example by vomit, their tongue or debris.
[Expert opinion and NICE’s full guideline on major trauma: assessment and initial management]
Rapid sequence induction (RSI) of anaesthesia and intubation
A medical procedure involving prompt administration of general anaesthesia and subsequent intubation of the trachea. The procedure results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis) and is used to maintain a patient’s airway following a traumatic incident.
[NICE’s full guideline on major trauma: assessment and initial management, glossary]

Image reporting

This quality statement is taken from the trauma quality standard. The quality standard defines clinical best practice for assessing and managing trauma and should be read in full.

Quality statement

People who have had urgent 3D imaging for major trauma have a provisional written radiology report within 60 minutes of the scan.

Rationale

Obtaining the results of 3D imaging for chest trauma, haemorrhage and spinal injury as soon as possible allows for earlier diagnosis and decisions to be made on management, for example whether interventions such as surgery or interventional radiology are needed. Earlier treatment can reduce mortality and length of hospital stay, and improve health-related quality of life.

Quality measures

Structure
Evidence of local arrangements to ensure that provisional written radiology reports of urgent 3D imaging for chest trauma, haemorrhage and spinal injury are available within 60 minutes of the scan.
Data source: Local data collection, for example staff rotas.
Process
a) Proportion of urgent 3D images for chest trauma with a provisional written radiology report available within 60 minutes of the scan.
Numerator – the number in the denominator with a provisional written radiology report available within 60 minutes of the scan.
Denominator – the number of urgent 3D images for chest trauma.
Data source: Local data collection, for example, local audit of radiology reporting. The Trauma Audit and Research Network collects data on the timing of CT and when the CT report is issued.
b) Proportion of urgent 3D images for haemorrhage with a provisional written radiology report available within 60 minutes of the scan.
Numerator – the number in the denominator with a provisional written radiology report available within 60 minutes of the scan.
Denominator – the number of urgent 3D images for haemorrhage.
Data source: Local data collection, for example, local audit of radiology reporting. The Trauma Audit and Research Network collects data on the timing of CT and when the CT report is issued.
c) Proportion of urgent 3D images for spinal injury with a provisional written radiology report available within 60 minutes of the scan.
Numerator – the number in the denominator with a provisional written radiology report available within 60 minutes of the scan.
Denominator – the number of urgent 3D images for spinal injury.
Data source: Local data collection, for example, local audit of radiology reporting. The Trauma Audit and Research Network collects data on the timing of CT and when the CT report is issued.
Outcomes
a) Mortality rates from major trauma.
Data source: Local data collection, for example using the Office for National Statistics mortality database. The Trauma Audit and Research Network also collects data on deaths of trauma patients.
b) Length of hospital stay for people with major trauma.
Data source: Local data collection, for example using Hospital Episode Statistics data from NHS Digital. The Trauma Audit and Research Network also collects data on length of stay in hospital for trauma patients.
c) Health-related quality of life for people who have experienced major trauma.
Data source: Local data collection, for example patient surveys.

What the quality statement means for different audiences

Service providers (major trauma centres and trauma units) ensure that healthcare professionals trained in image reporting are available to interpret urgent 3D imaging for chest trauma, haemorrhage and spinal injury and deliver a provisional written radiology report within 60 minutes of the scan.
Healthcare professionals (radiologists, radiographers and other trained reporters) interpret urgent 3D imaging for chest trauma, haemorrhage and spinal injury and deliver a provisional written radiology report within 60 minutes of the scan.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that have the capacity and expertise to interpret urgent 3D imaging for chest trauma, haemorrhage and spinal injury and deliver a provisional written radiology report within 60 minutes of the scan. They monitor contracts and seek evidence that service providers have this in place.
People who have had an urgent CT or MRI scan for a chest injury, serious bleeding or a spinal injury have the first result of their scan reported to their doctor in writing within 1 hour of having the scan.

Source guidance

Definitions of terms used in this quality statement

Urgent 3D imaging for major trauma
3D imaging that takes place immediately on arrival at hospital for chest trauma, haemorrhage and spinal injury. This includes CT for chest trauma, haemorrhage and spinal injury and MRI for spinal injury.
[NICE’s guideline on major trauma: assessment and initial management, recommendations 1.4.5 and 1.5.31, and NICE’s guideline on spinal injury: assessment and initial management, recommendations 1.5.2, 1.5.6, 1.5.7 and 1.5.10, and expert opinion]

Open fractures

This quality statement is taken from the trauma quality standard. The quality standard defines clinical best practice for assessing and managing trauma and should be read in full.

Quality statement

People with open fractures of long bones, the hindfoot or midfoot have fixation and definitive soft tissue cover within 72 hours of injury if this cannot be performed at the same time as debridement.

Rationale

Delays in the fixation and cover of open fractures of the long bones of the lower and upper limbs, hindfoot or midfoot can lead to infections and further complications, such as amputations. Ideally fixation and soft tissue cover should be performed at the same time as first debridement, but this might not be possible if it would prevent completion of debridement within the recommended time scales. In these circumstances, ensuring that fixation and soft tissue cover are completed within 72 hours of injury should result in fewer complications, reductions in unplanned surgery and length of hospital stays, and faster return to normal activities.

Quality measures

Structure
Evidence that orthopaedic and plastic surgery specialities have a joint orthoplastic surgery service that allows for fixation and definitive soft tissue cover of open fractures of long bones, the hindfoot or midfoot within 72 hours of injury if this cannot be performed at the same time as debridement.
Data source: Local data collection, for example local protocols.
Process
a) Proportion of open fractures of long bones, the hindfoot or midfoot with fixation and definitive soft tissue cover performed within 72 hours of injury if this cannot be performed at the same time as debridement.
Numerator – the number in the denominator with fixation and definitive soft tissue cover performed within 72 hours of injury.
Denominator – the number of open fractures of long bones, the hindfoot or midfoot where fixation and soft tissue cover cannot be performed at the same time as debridement.
Data source: Local data collection.
b) Proportion of open fractures of long bones, the hindfoot or midfoot with fixation and definitive soft tissue cover performed within 72 hours of injury.
Numerator – the number in the denominator with fixation and definitive soft tissue cover performed within 72 hours of injury.
Denominator – the number of open fractures of long bones, the hindfoot or midfoot.
Data source: The Trauma Audit and Research Network collects data on BOAST4 patients who received soft tissue coverage within the target of 72 hours.
Outcomes
a) Rates of unplanned surgery after surgery on open fractures.
Data source: Local data collection, for example local audit of patient records.
b) Non-emergency amputation rates for people with open fractures.
Data source: Local data collection, for example local audit of patient records.
c) Length of hospital stay for people with open fractures.
Data source: Local data collection, for example using Hospital Episode Statistics data from NHS Digital. The Trauma Audit and Research Network also collects data on length of stay in hospital for trauma patients.
d) Time taken to return to normal activities for people with open fractures.
Data source: Local data collection, for example patient surveys.

What the quality statement means for different audiences

Service providers (major trauma centres, specialist orthoplastic centres, trauma units and district general hospitals) ensure that orthoplastic surgery lists and joint working arrangements are in place for consultants in orthopaedic and plastic surgery to perform fixation and definitive soft tissue cover of open fractures of long bones, the hindfoot or midfoot concurrently and within 72 hours of injury if this cannot be performed at the same time as debridement.
Healthcare professionals (orthopaedic and plastic surgery consultants) perform fixation and definitive soft tissue cover of open fractures of long bones, the hindfoot or midfoot concurrently and within 72 hours of injury if this cannot be performed at the same time as debridement.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that have an orthoplastic surgery list and a combined orthoplastic approach to performing fixation and definitive soft tissue cover of open fractures of long bones, the hindfoot or midfoot within 72 hours of injury if this cannot be performed at the same time as debridement.
People with breaks in a bone complicated by a wound have their broken bones fixed using wires, plates, screws or rods (known as internal fixation) or an external frame (known as external fixation). The wound then needs to be repaired to reduce the chance of infection. When possible all of these steps should be done during a single operation. When more than 1 operation is needed, the steps should be completed within 72 hours.

Source guidance

Fractures (complex): assessment and management (2016, updated 2017) NICE guideline NG37, recommendations 1.2.27 and 1.2.29

Definitions of terms used in this quality statement

Open fractures of long bones, the hindfoot or midfoot
A fracture of long bones, the hindfoot or midfoot associated with an open wound. The skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound. This term is synonymous with ‘compound fracture’.
[NICE’s full guideline on fractures (complex): assessment and management, glossary]
Fixation
The final surgical implantation of internal or external metalwork for the purposes of repairing a bone and fixing it into place.
[NICE’s full guideline on fractures (complex): assessment and management, glossary]
Definitive soft tissue cover
Final closure of the open fracture wound, using a local flap of skin, or skin grafted from another part of the body.
[NICE’s full guideline on fractures (complex): assessment and management, glossary]
Debridement
The whole process of opening up of a wound, or pathological area (for example, bone infection), together with the surgical excision of all avascular, contaminated, infected, or other undesirable tissue. Debridement should be performed:
  • immediately for highly contaminated open fractures
  • within 12 hours of injury for high‑energy open fractures (likely Gustilo–Anderson classification type IIIA or type IIIB) that are not highly contaminated
  • within 24 hours of injury for all other open fractures.
[NICE’s full guideline on fractures (complex): assessment and management, glossary and recommendation 1.2.28]

Assessment for cervical spine injury

This quality statement is taken from the trauma quality standard. The quality standard defines clinical best practice for assessing and managing trauma and should be read in full.

Quality statement

People with full in-line spinal immobilisation have their risk of cervical spine injury assessed using the Canadian C-spine rule.

Rationale

If a person might have a spinal injury, it is important to immobilise their spine during assessment to prevent any damage. However, continuing immobilisation for longer than necessary can lead to avoidable adverse effects, such as discomfort and skin breakdown. Using a risk assessment tool as soon as possible to determine whether to carry out, maintain or remove immobilisation will reduce the risk of spinal cord injury and minimise discomfort for the person. It will also help to determine whether further investigations, such as prompt imaging, are needed.

Quality measures

Structure
Evidence of the documented use of checklists to ensure that the Canadian C-spine rule is used to assess people with full in-line spinal immobilisation for their risk of cervical spine injury.
Data source: Local data collection, for example service specifications.
Process
Proportion of people with full in-line spinal immobilisation who have had their risk of cervical spine injury assessed using the Canadian C-spine rule.
Numerator – the number in the denominator who have had their risk of cervical spine injury assessed using the Canadian C-spine rule.
Denominator – the number of people with full in-line spinal immobilisation.
Data source: Local data collection, for example, local audit of patient records. The Trauma Audit and Research Network collects data on spinal immobilisation.
Outcomes
a) Rates of neurological deterioration caused by inappropriate removal of spinal immobilisation.
Data source: Local data collection, for example, local audit of patient records.
b) Rates of appropriate removal of full in-line spinal immobilisation.
Data source: Local data collection, for example patient surveys.

What the quality statement means for different audiences

Service providers (ambulance services, major trauma centres, trauma units and district general hospitals) train staff in using the Canadian C-spine rule and implement its use in pre hospital and hospital settings to carry out risk assessment for cervical spine injury for people with full in-line spinal immobilisation.
Healthcare professionals (paramedics and trauma teams) use the Canadian C-spine rule to carry out risk assessment for people with full in-line spinal immobilisation, and document this. A digital reference tool that contains the Canadian C-spine rule, such as MDCalc, can be used when doing the assessment. The level of risk of cervical spine injury should be used to make decisions on whether spinal immobilisation and prompt imaging are needed.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that have checklists to document the use of the Canadian C-spine rule to assess the risk of cervical spine injury for people with full in-line spinal immobilisation, and inform decisions about when to carry out or continue with spinal immobilisation and request prompt imaging.
People with a possible spinal injury who have their spine immobilised to prevent further injury, using a special collar and head supports, are asked questions by the ambulance team to try to find out how likely it is that they have a spinal injury, and which part of the spine might be injured. These questions include their age, the type of injury they have had and how they became injured. The same questions are asked again when the person arrives at the hospital. If the hospital staff think the person might have a spinal injury, they offer a scan. If the spine is unlikely to be injured, hospital staff remove the collar and head supports.

Source guidance

Spinal injury: assessment and initial management (2016) NICE guideline NG41, recommendations 1.1.5 and 1.4.5

Definitions of terms used in this quality statement

People with full in-line spinal immobilisation
Full in-line spinal immobilisation usually involves fitting the person with a collar, placing them on a scoop stretcher, and using head blocks and tape to keep their head still.
[NICE’s information for the public in its guideline on spinal injury: assessment and initial management]
Canadian C-spine rule
The person with suspected spine injury should be assessed as having high, low or no risk of cervical spine injury using the following rule:
  • the person is at high risk if they have at least one of the following high‑risk factors:
    • age 65 years or older
    • dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the head – for example diving, high‑speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)
    • paraesthesia in the upper or lower limbs
  • the person is at low risk if they have no high-risk features and at least one of the following low‑risk factors:
    • involved in a minor rear‑end motor vehicle collision
    • comfortable in a sitting position
    • ambulatory at any time since the injury
    • no midline cervical spine tenderness
    • delayed onset of neck pain
  • the person remains at low risk if they are:
    • unable to actively rotate their neck 45 degrees to the left and right (the range of the neck can only be assessed safely if the person is at low risk and there are no high‑risk factors).
  • the person has no risk if they:
    • have one of the above low‑risk factors and
    • are able to actively rotate their neck 45 degrees to the left and right.
Applying the Canadian C‑spine rule to children is difficult and the child's developmental stage should be taken into account.
[Expert opinion and NICE’s guideline on spinal injury: assessment and initial management, recommendations 1.1.5 and 1.1.6]

Major trauma service

This quality statement is taken from the trauma quality standard. The quality standard defines clinical best practice for assessing and managing trauma and should be read in full.

Quality statement

Major trauma centres have a dedicated trauma ward for patients with multisystem injuries and a designated consultant available to contact 24 hours a day, 7 days a week.

Rationale

People with major trauma frequently have multisystem injuries that need management input from more than one specialist. This can mean that management is spread across multiple settings and specialities, which can lead to delays in treatment and a lack of coordinated care, resulting in a poorer outcome for the person. Having a consultant-led multidisciplinary service with input from all the relevant specialties can improve continuity of care, prevent delays in treatment and result in shorter hospital stays, lower mortality and improved patient experience.

Quality measures

Structure
a) Evidence of a dedicated trauma ward for patients with multisystem injuries.
Data source: Local data collection, for example from service specifications.
b) Evidence of the availability of a designated consultant 24 hours a day, 7 days a week, who has responsibility and authority for the hospital trauma service and leads the multidisciplinary team care.
Data source: Local data collection, for example from staff rotas.
Outcomes
a) Mortality rates from major trauma.
Data source: Local data collection, for example using the Office for National Statistics mortality database. The Trauma Audit and Research Network also collects data on deaths of trauma patients.
b) Length of hospital stay for people who have had major trauma.
Data source: Local data collection, for example using Hospital Episode Statistics data from NHS Digital. The Trauma Audit and Research Network also collects data on length of stay in hospital for trauma patients.
c) Patient experience of major trauma services.
Data source: Local data collection, for example patient surveys.

What the quality statement means for different audiences

Service providers (major trauma centres) ensure that they have a dedicated multidisciplinary trauma ward led by a consultant 24 hours a day, 7 days a week, to treat patients with multisystem injuries.
Healthcare professionals (doctors, nurses and allied health professionals) work together to treat patients with multisystem injuries in a dedicated trauma ward. A consultant is available to lead the multidisciplinary team 24 hours a day, 7 days a week. A key worker (often a senior nurse) coordinates care at each stage of the care pathway.
Commissioners (NHS England) ensure that they commission services using a service specification that states that there should be a dedicated trauma ward for patients with multisystem injuries and a designated consultant available to contact 24 hours a day, 7 days a week. They monitor contracts and seek evidence that service providers have these available.
People who have serious injuries to different areas of the body can have all of their injuries treated in a special trauma ward. A consultant doctor is available who can be contacted 24 hours a day, 7 days a week and is in charge of the ward. Each person also has a named key worker, such as a senior nurse, who coordinates their care in hospital. The key worker stays in contact with the person, their family and carers, and the other healthcare professionals who are providing their care.

Source guidance

Major trauma: service delivery (2016) NICE guideline NG40, recommendation 1.6.2

Definitions of terms used in this quality statement

Major trauma centre
A specialist hospital responsible for the care of the most severely injured patients involved in major trauma across the region. It provides 24/7 emergency access to consultant-delivered care for a wide range of specialist clinical services and expertise. It is optimised for the definitive care of injured patients.
[NICE’s full guideline on major trauma: assessment and initial management, glossary]
Dedicated trauma ward
A multidisciplinary ward for people with multisystem injuries where different specialties input into the care of the patient.
Designated consultant
A consultant who has responsibility and authority for the hospital trauma service and leads the multidisciplinary team care. This can be a subspecialty consultant who has extensive experience of trauma.

Specialist services

This quality statement is taken from the trauma quality standard. The quality standard defines clinical best practice for assessing and managing trauma and should be read in full.

Quality statement

Major trauma centres have acute specialist services for rehabilitation after major trauma, and for children and older people.

Rationale

People with major trauma might need input from specialist services, but access and provision of these services varies between major trauma centres. This can mean that there are delays in treatment and suboptimal outcomes for the person. Ensuring that major trauma centres provide all the specialist services that a patient might need can reduce length of hospital stay, lower mortality and improve patient experience.

Quality measures

Structure
a) Evidence of the availability of acute specialist services for rehabilitation after major trauma.
Data source: Local data collection, for example, from service specifications.
b) Evidence of the availability of acute specialist services for children.
Data source: Local data collection, for example, from service specifications.
c) Evidence of the availability of acute specialist services for older people.
Data source: Local data collection, for example, from service specifications.
Outcomes
a) Morbidity from major trauma.
Data source: Local data collection, for example, local audit of patient records.
b) Length of hospital stay for people who have had major trauma.
Data source: Local data collection, for example using Hospital Episode Statistics data from NHS Digital. The Trauma Audit and Research Network also collects data on length of stay in hospital for trauma patients.
c) Patient experience of major trauma services.
Data source: Local data collection, for example patient surveys.

What the quality statement means for different audiences

Service providers (major trauma centres) ensure that they have acute specialist services for rehabilitation after major trauma, and for children and older people. Acute specialist services for trauma rehabilitation have a multiprofessional team who have undergone recognised specialist training in rehabilitation, which is led or supported by a consultant trained and accredited in rehabilitation medicine. Acute specialist services for children and older people have a multidisciplinary team that specialises in care for these age groups, and is led or supported by a consultant from the specialty.
Health and social care practitioners (consultants in rehabilitation medicine, geriatricians, paediatricians, nurses, allied health professionals, social workers and safeguarding teams) work together as part of a multidisciplinary trauma service to ensure that people with major trauma receive the specialist input they need to get the best outcomes.
Commissioners (NHS England) ensure that they commission services that have acute specialist services for rehabilitation after major trauma, and for children and older people. They monitor contracts and seek evidence that service providers have these available.
People who have had a major injury have access to specialist rehabilitation services to help them recover and get back to their normal activities as much as possible.
Children and older people who have had a major injury have access to special services that care for their age group.

Source guidance

Major trauma: service delivery (2016) NICE guideline NG40, recommendation 1.6.2

Definitions of terms used in this quality statement

Major trauma centre
A specialist hospital responsible for the care of the most severely injured patients involved in major trauma across the region. It provides 24/7 emergency access to consultant-delivered care for a wide range of specialist clinical services and expertise. It is optimised for the definitive care of injured patients.
[NICE’s full guideline on major trauma: assessment and initial management, glossary]
Acute specialist services for rehabilitation after major trauma
Specialist rehabilitation is the total active care of patients with complex disabilities by a multi-professional team who have undergone recognised specialist training in rehabilitation, led or supported by a consultant trained and accredited in rehabilitation medicine.
Acute specialist services for children and older people
Specialist inpatient acute paediatrics, acute ageing and complex medicine multidisciplinary teams that can ensure age appropriate care for children and older people in hospital. They are led or supported by consultants in those specialities, and liaise closely with social workers and safeguarding teams.
[Expert opinion]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Some recommendations on management depend on whether the growth plate of the injured bone has closed (skeletal maturity). The age at which this happens varies. In practice, healthcare professionals use clinical judgement to determine whether a bone is skeletally mature. When a recommendation depends on skeletal maturity this is clearly indicated.
In the non-surgical orthopaedic management of unimalleolar ankle fractures:
  • advise immediate unrestricted weight-bearing as tolerated
  • arrange for orthopaedic follow-up within 2 weeks if there is uncertainty about stability
  • advise all patients to return for review if symptoms are not improving 6 weeks after injury.
If treating an ankle fracture with surgery, consider operating on the day of injury or the next day.
Assess whether the person is at high, low or no risk for cervical spine injury using the Canadian C-spine rule as follows:
  • the person is at high risk if they have at least one of the following high-risk factors:
    • age 65 years or older
    • dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 steps, axial load to the head – for example, diving, high-speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)
    • paraesthesia in the upper or lower limbs
  • the person is at low risk if they have at least one of the following low-risk factors:
    • involved in a simple rear-end motor vehicle collision
    • comfortable in a sitting position
    • ambulatory at any time since the injury
    • no midline cervical spine tenderness
    • delayed onset of neck pain
  • the person remains at low risk if they are:
    • unable to actively rotate their neck 45 degrees to the left and right (the range of the neck can only be assessed safely if the person is at low risk and there are no high-risk factors)
  • the person has no risk if they:
    • have one of the above low-risk factors and
    • are able to actively rotate their neck 45 degrees to the left and right.
Be aware that applying the Canadian C-spine rule to people under 16 is difficult and the child's developmental stage should be taken into account.
Assess the person with suspected thoracic or lumbosacral spine injury using these factors:
  • age 65 years or older and reported pain in the thoracic or lumbosacral spine
  • dangerous mechanism of injury (fall from a height of greater than 3 metres, axial load to the head or base of the spine – for example, falls landing on feet or buttocks, high-speed motor vehicle collision, rollover motor accident, lap belt restraint only, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accidents)
  • pre-existing spinal pathology, or known or at risk of osteoporosis – for example steroid use
  • suspected spinal fracture in another region of the spine
  • abnormal neurological symptoms (paraesthesia or weakness or numbness)
  • on examination:
    • abnormal neurological signs (motor or sensory deficit)
    • new deformity or bony midline tenderness (on palpation)
    • bony midline tenderness (on percussion)
    • midline or spinal pain (on coughing)
  • on mobilisation (sit, stand, step, assess walking): pain or abnormal neurological symptoms (stop if this occurs).
See what NICE says on osteoporosis.
Be aware that assessing people under 16 with suspected thoracic or lumbosacral spine injury is difficult and the child's developmental stage should be taken into account.
Use simple dressings with direct pressure to control external haemorrhage.
In patients with major limb trauma use a tourniquet if direct pressure has failed to control life-threatening haemorrhage.
Make eye contact and be in the patient's eye line to ensure you are visible when communicating with this person to avoid them moving their head.
Assess the person for spinal injury, initially taking into account the factors listed below. Check if the person:
  • has any significant distracting injuries
  • is under the influence of drugs or alcohol
  • is confused or uncooperative
  • has a reduced level of consciousness
  • has any spinal pain
  • has any hand or foot weakness (motor assessment)
  • has altered or absent sensation in the hands or feet (sensory assessment)
  • has priapism (unconscious or exposed male)
  • has a history of past spinal problems, including previous spinal surgery or conditions that predispose to instability of the spine.
See what NICE says on metastatic spinal cord compression.
For people under 16 use a ratio of 1 part plasma to 1 part red blood cells, and base the volume on the child's weight.
For people aged 16 and over use a ratio of 1 unit of plasma to 1 unit of red blood cells to replace fluid volume.
For patients who have haemorrhagic shock and a traumatic brain injury:
  • if haemorrhagic shock is the dominant condition, continue restrictive volume resuscitation or
  • if traumatic brain injury is the dominant condition, use a less restrictive volume resuscitation approach to maintain cerebral perfusion.
Use intravenous tranexamic acidAt the time of publication (February 2016), tranexamic acid did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. as soon as possible in patients with major trauma and active or suspected active bleeding.
Do not use intravenous tranexamic acid more than 3 hours after injury in patients with major trauma unless there is evidence of hyperfibrinolysis.
Minimise ongoing heat loss in patients with major trauma.
A radiologist, radiographer or other trained reporter should deliver the definitive written report of emergency department X-rays of suspected fractures before the patient is discharged from the emergency department.
Follow a structured process when handing over care within the emergency department (including shift changes) and to other departments. Ensure that the handover is documented.
Ensure that all patient documentation, including images and reports, goes with patients when they are transferred to other departments or centres.
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 responsible for the patient's care at the receiving centre
  • the name and contact details of the person who was responsible for the patient's care at the initial hospital.
The use of spinal immobilisation devices may be difficult (for example in people with short or wide necks, or people with a pre-existing deformity) and could be counterproductive (for example increasing pain, worsening neurological signs and symptoms). In uncooperative, agitated or distressed people, including children, think about letting them find a position where they are comfortable with manual in-line spinal immobilisation.
When carrying out full in-line spinal immobilisation in people aged 16 and over, manually stabilise the head with the spine in-line using the following stepwise approach:
  • Fit an appropriately sized semi-rigid collar unless contraindicated by:
    • a compromised airway
    • known spinal deformities, such as ankylosing spondylitis (in these cases keep the spine in the person's current position).
  • Reassess the airway after applying the collar.
  • Place and secure the person on a scoop stretcher.
  • Secure the person with head blocks and tape, ideally in a vacuum mattress.
When carrying out in-line spinal immobilisation in people under 16, manually stabilise the head with the spine in-line using the stepwise approach above and consider:
  • involving family members or carers if appropriate
  • keeping infants in their car seat if possible
  • using a scoop stretcher with blanket rolls, vacuum mattress, vacuum limb splints or Kendrick extrication device.
If intravenous access has not been established, consider the intranasal route for atomised delivery of diamorphine or ketamineAt the time of publication (February 2016), neither intranasal diamorphine or intranasal ketamine had a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information..
Consider ketamine in analgesic doses as a second-line agent.
For the initial management of pain in young people and adults with suspected long bone fractures of the legs (tibia, fibula) or arms (humerus, radius, ulna), offer:
  • oral paracetamol for mild pain
  • oral paracetamol and codeine for moderate pain
  • intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.
Consider NSAIDs to supplement the pain relief described above except for frail or older adults.
Use intravenous opioids with caution in frail or older adults.
Do not offer NSAIDs to frail or older adults with fractures.
For the initial management of pain in children with suspected long bone fractures of the legs (femur, tibia, fibula) or arms (humerus, radius, ulna), offer:
  • oral ibuprofen, or oral paracetamol, or both for mild to moderate pain
  • intranasal or intravenous opioids for moderate to severe pain (use intravenous opioids if intravenous access has been established).
Be aware that the optimal destination for people with major trauma is usually an MTC. 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.
For people with major trauma or spinal injury, use intravenous morphine as the first-line analgesic and adjust the dose as needed to achieve adequate pain relief.
For recommendations on the initial pharmacological management of pain in adults with suspected low-energy pelvic fractures, see what NICE says on hip fracture.
For patients with suspected high-energy pelvic fractures, use intravenous morphine as the first-line analgesic and adjust the dose as needed to achieve adequate pain relief.
For people with suspected open fractures, use intravenous morphine as the first-line analgesic and adjust the dose as needed to achieve adequate pain relief.
Offer medications to control pain in the acute phase after spinal injury.
If possible, record information on whether the assessments show that the person's condition is improving or deteriorating.
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.
When needed for distal radius fractures, perform surgery:
  • within 72 hours of injury for intra-articular fractures
  • within 7 days of injury for extra-articular fractures.
When needed for re-displacement of distal radius fractures, perform surgery within 72 hours of the decision to operate.
For patients with active bleeding use a restrictive approach to volume resuscitation until definitive early control of bleeding has been achieved.
Use drug-assisted RSI of anaesthesia and intubation as the definitive method of securing the airway in patients with major trauma who cannot maintain their airway and/or ventilation.
If RSI fails, use basic airway manoeuvres and adjuncts and/or a supraglottic device until a surgical airway or assisted tracheal placement is performed.
One member of the trauma team should be designated to record all trauma team findings and interventions as they occur (take 'contemporaneous notes' ).
The trauma team leader should be responsible for checking the information recorded to ensure that it is complete.
Address issues of non-accidental injury before discharge in people with femoral fractures. This is particularly important for people who are not walking or talking. For more information, see NICE's recommendations on fractures in relation to recognising child abuse and neglect during clinical presentation.
Use whole-body CT (consisting of a vertex-to-toes scanogram followed by a CT from vertex to mid-thigh) in people aged 16 and over with blunt major trauma and suspected multiple injuries. Patients should not be repositioned during whole-body CT.
Use clinical findings and the scanogram to direct CT of the limbs in people aged 16 and over with limb trauma.
Do not routinely use whole-body CT to image people under 16. Use clinical judgement to limit CT to the body areas where assessment is needed.
Produce a written summary, which gives the diagnosis, management plan and expected outcome and:
  • is aimed at and sent to the patient's GP within 24 hours of admission
  • includes a summary written in plain English that is understandable by patients, family members and carers
  • is readily available in the patient's records.

Glossary

American Spinal Injury Association
Bispectral Index
amputation when there is time to delay decision but reconstructive surgery is not involved in the decision
electroencephalography
extended focused assessment with sonography for trauma
focused assessment with sonography for trauma
rapid sequence induction
trauma audit and research network
Medical Research Council
major trauma centre
major trauma centres
non-steroidal anti-inflammatory drugs
picture archiving and communication system

Paths in this pathway

Pathway created: February 2016 Last updated: March 2017

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