Abstract
Background
There is currently rapid progress in regionalization of trauma care in the UK following recommendations from the RCS(Eng), 1 NCEPOD 2 and the ‘Darzi’ Report. 3 This process will result in groups of hospitals cooperating together to provide comprehensive trauma care within a region. The policy framework within the Department of Health (DoH) is also changing. Trauma care has become a priority area, and the recent appointment of a National Clinical Director for Trauma Care will help to align DoH policy with clinical need.
This change in the configuration of services for the severely injured means that the quality system for trauma care also has to change. In the past, trauma audit has been based on individual hospital provider units, with about half of UK hospitals opting into the Trauma Audit and Research Network (TARN) system. This system is directed to clinicians at hospital trust level, providing information about individual hospital performance in the form of quarterly reports and other analyses, which are then used as the basis for multidisciplinary trauma audit meetings.
There is significant variation in the attention paid to the quality of trauma care among Hospital Trusts. Those with a greater interest in trauma care hold regular (usually quarterly) multidisciplinary trauma meetings where information provided by the TARN trauma audit system is reviewed and individual cases presented to highlight areas for improvement or areas of good practice. These meetings usually rotate between a series of themes (head, limb, abdominal, thoracic and spinal injury). In contrast many (probably most) hospitals do not have a multidisciplinary trauma audit system and, at best, undertake trauma audit within specific departments (usually the Emergency Department).
The regionalization of trauma care means that trauma audit will have to change its focus from the individual hospital trust to the whole regional trauma system, and will have to consider other stakeholders such as patients, regional trauma system managers, purchasers and regulators. Each of these groups will have their own perspective – so fulfilling such diverse needs will be a challenge. We will have to move further away from the American concept of a ‘trauma registry’ towards a very practical focus on the information needs of the quality assurance process within the regionalized trauma systems.
In the future the quality system will need to be based on the whole regional trauma system rather than simply looking at individual hospitals. Future patient pathways are likely to involve several different healthcare providers and outcomes are likely to be crucially dependent on performance at the interfaces (patient handovers and transfers of care). The future need for a trauma quality system will therefore be on three levels: The first part of a future trauma quality system will be a ‘core’ of information. It will need to be continuously collected to look at long-term trends in overall trauma care and to identify patients for case review. A recent European agreement has established the ‘Utstein Trauma Template’ as an internationally agreed core trauma data-set;
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The second part of future trauma audit will concentrate on particular clinical or policy areas with shorter-term (one or two year) data collection. Many different groups are likely to feel that ‘their’ area of trauma care should be audited, however relatively few trauma care standards can be measured each year. There will therefore need to be a prioritization system. There will be the need for a national group to decide which specific standards should be part of the national trauma audit each year (a role that may be undertaken by the newly formed Intercollegiate Trauma Standards Group); The third area of data collection will be at a regional level concentrating on particular issues that are a priority for that particular local regional trauma system. These areas may not be a national priority, however due to local circumstances they may be important to the local providers or purchasers of trauma care.
The collection of trauma data is likely to remain time intensive, so it is important that the data collection is manageable within trauma systems. The number of variables collected across these three areas will have to be balanced, so that an appropriately sized data-set is specified each year.
Multiple sets of clinical standards/guidelines for trauma care have been developed by NICE, the Royal Colleges, and various specialist associations and societies. In the past these standards have sometimes not had multidisciplinary input, and in some cases can be difficult to audit due to a lack of specificity. Future standards will need to be important to patients, clinically credible and measurable.
Following high-profile failures of the quality control systems in medicine there is a demand for openness in clinical performance analysis. At present it is not certain how much the information needs of the public/patients will shape the future trauma quality assurance system. Outcome data accessible to the general public were initially pioneered by cardiac surgery, followed in 2007 when trauma care became the second area of medical practice to make individual hospital performance data available, which can be viewed on a website (www.tarn.ac.uk). This seems to have satisfied the needs of patients and the public as there has been little demand for this system to change over the past two years.
In conclusion, the current regionalization of trauma care in the UK will require a new approach to the system for benchmarking quality of trauma care. This is likely to move further away from the rather passive concept of a ‘trauma registry’ to a more flexible and dynamic way of providing relevant information about the quality of care to the many different groups that contribute to the care of the severely injured patient.
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