London trauma system launch: TARN

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Healthcare
for London
The London
Trauma System Launch
The TRAUMA
Audit & Research
NETWORK
The Trauma Audit & Research Network
Maralyn Woodford
The Trauma Audit & Research Network
1.
Background
2.
Measuring trauma severity
3.
Performance comparisons of trauma care
4.
Data Coordination across Networks
The London Trauma System Launch
10th September 2009
TARN
The TRAUMA
Audit & Research
NETWORK
Universities of Manchester & Leicester
• Established in 1990
• Non Profit making organisation
- self funded through hospital membership fees in
England, Wales, Ireland, Denmark & Switzerland
• Core work
- supporting improvements in trauma care through
audit & research
The Role of
The Trauma Audit & Research Network
 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 Benefits of TARN
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
Measuring and monitoring
trauma care
Assessment of Trauma Severity
Logistic regression modelling‘ – ‘weights’ those
parameters that predict survival.
Anatomical
Injury
ISS
Physiological
Measure
GCS
Age / Gender
Probability of survival of individual patients
Case mix standardised
comparisons of actual and predicted outcome
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).
Comparing Outcomes
2005 - 2008
10
8
Average top 10 TARN
Hospitals (+2.5)
6
4
More
survivors
Ws & 95% CI
2
0
More
deaths
-2
-4
95% Confidence Intervals
-6
-8
Incomplete
-10
data collection
Average bottom
10 TARN Hospitals (-3)
The Trauma Centre:
A Speciality Hospital, not
a Hospital of Specialities
R. A. Davenport et al
BJS 2009
accepted for publication
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
TARN Developments
• Improved data collection & reporting - eDCR
• Successful publication of performance comparisons
of standards of trauma care
www.tarn.ac.uk
The Trauma Audit & Research Network
Accessing a hospital from region
Completeness of Data
Data Accreditation
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
Data Coordination
The Electronic Data Collection & Reporting system
the eDCR System
• online system requiring no specialist software
• data is instantly validated
• Confidential, Secure, Encrypted data, Backup service
• PIAG approval
Data coordination across a network
Requirements:
• Resources
- membership fees
- data collection
• Comprehensive data collection dependant on:
- skills
- management
- time
- geography
Data Quality………..
 is Important
 √√√√ - indicators of data
completeness and accreditation
 Outcome and Process
measures reviewed with confidence
Inequality in Trauma Care?

Royal College of Surgeons 1988
Working Party on the Management of Patients with Major Injury

“….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
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
Healthcare
for London
The London
Trauma System Launch
Questions?
Acknowledgements
• TARN staff
• Executive Committee and Board
• Clinicians and data co-ordinators at TARN participating hospitals
10th September 2009
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