Impact case study database

Context and Pathways to Impact

In the UK, prior to 2012, major trauma patients were invariably taken to the nearest hospital, regardless of whether it had appropriate specialists. UoM research showed that patients treated in local hospitals were more likely to have adverse outcomes than those treated in specialist centres and that specialist treatment was potentially more cost-effective. Our evidence was presented to the National Audit Office (NAO) in 2010 leading to reorganisation of NHS trauma care. In 2012, major trauma networks (MTNs) were introduced to address the variability in service and patient outcomes, with a GBP30,000,000 investment. The reorganisation enabled paramedics to take severely injured patients directly to specialist Major Trauma Centres (MTCs). All MTCs provided on-site neurosurgical services, as indicated by our research, and 24/7 access to senior clinicians and early investigation.

Policy Impacts

Policy changes, underpinned by UoM research, are now embedded in the NHS commissioning system. The 2013 NHS Standard Contract for Major Trauma included the aim of treatment through trauma networks with MTCs at the heart. It confirmed an MTC “ has all the facilities and specialties required to be able to treat patients with any type of injury in any combination.” The contract also mandated that submission of data for measurement through the Trauma Audit and Research Network (TARN) should underpin the Best Practice Tariff (distributing GBP60,000,000 to GBP80,000,000 per annum) [A]. TARN was founded by UoM and Salford Royal NHS Foundation Trust to enable hospitals to collect and evaluate their data on trauma care using the measurement tools that we developed. Treatment at an MTC and use of TARN remain as criteria for major trauma best practice payments in 2020/21 tariffs [B]. TARN also enables our researchers to create a direct link between their research and the national quality standards through the NHS England Major Trauma Clinical Advisor Group and the National Clinical Director for Major Trauma.

In January 2014, the National Institute for Health and Care Excellence (NICE) published updated guidance on head injury, which recommended, as a key priority, transporting “patients who have sustained a head injury directly to a hospital that has the resources to further resuscitate them and to investigate and initially manage multiple injuries”. It further recommended local guidelines on the transfer of patients with head injuries from hospital to a neuroscience centre should be drawn up and should recognise that “ transfer would benefit all patients with serious head injuries…irrespective of the need for neurosurgery” [Ci]. UoM reference 3 (Patel et al.) was cited as evidence supporting the NICE guidance [Cii] and Lecky was a chair of the 2014 NICE guideline development group [Ciii].

Patient Impacts

The reorganisation of NHS England’s trauma system and introduction of MTNs and MTCs has improved both the quality of care provided and has lowered mortality risk for trauma victims:

A study of care within England’s MTNs during 2013-2016 showed time-critical interventions were delivered more rapidly when patients were transported directly to MTCs (compared to trauma units or secondary transfers). CT scans and urgent surgery were delivered on average an hour sooner in MTCs than in trauma units (CT median time 2 hours versus 3.15 hours, urgent surgery 4.37 hours versus 5.37 hours).The crude and adjusted odds of death for patients directly admitted to MTCs were also lower than those treated in trauma units and those admitted to MTC via secondary transfer [D].

A study of outcomes from April 2008 to March 2017 included >110,000 patients and 35 hospitals. It found that in five years after launch, MTNs had led to improved treatment systems e.g. 36.5% increase in consultant-led care and the proportion of patients having CT imaging increased from 50% to 72%. It also confirmed that MTNs were associated with beneficial changes in clinical practice. For instance, massive transfusion protocols and use of tranexamic acid, which reduces risk of death in bleeding trauma cases, have become routine practice during resuscitation for major trauma [E]. The number of patients needing critical care reduced from 31% to 24% and average length of stay on critical care wards reduced from four to three days [E]. From 2012/13 to 2016/17 there was an increase from 66% to 72% in the percentage of patients taken directly to MTCs across the 35 reporting hospitals [E]. Importantly the study demonstrated a 19% improvement in adjusted mortality [E], equating to approximately 3,600 additional survivors between 2013 and 2020.

A 2018 NHS England press release highlighted the study results, confirming “ The NHS in England has saved an additional 1,600 patients with severe injuries since major trauma centres were established in 2012” [Fi]. The story was covered widely in nationwide press [Fii]. NHS England’s National Clinical Director for Trauma Care said, “ This study shows that changes to trauma care…are saving hundreds of lives every year” [Fi] and Clinical Director for a trauma network in England said in commentary “ The results…demonstrate the successful national introduction of clinically led networks to reduce trauma mortality” and confirmed “ The implementation of the English trauma system has been an example of a successful clinically led process” [G].

Impacts in the Republic of Ireland

A Trauma Care Policy Steering Group was developed in Ireland during 2015. This group reported in February 2018, recommending the establishment of two MTCs within two regional networks [H]. UoM research was reviewed as evidence by the group [6]. Complete implementation is expected to take between five and seven years. However, the Irish National Office of Clinical Audit’s (NOCA) 2018 annual major trauma audit report indicated that implementation work has already produced positive results. NOCA reported a “ significant increase in access to CT within 1 hour for head injury patients from only 33% in 2016…to 48% (n=132) in 2018, with a median time of 1.1 hours” [I] and a decrease in secondary transfers from “ 28% in 2016…to 20% in 2018 indicating that more patients are getting to the right place at the right time than previously” [I].