Regionalisation of trauma care in England

Financial analysis of revision hip surgery at a tertiary referral centre as classified using the British Hip Society Revision Hip Complexity Classification

Aims

The burden of revision total hip arthroplasty (rTHA) continues to grow. The surgery is complex and associated with significant costs. Regional rTHA networks have been proposed to improve outcomes and to reduce re-revisions, and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for a rTHA service, and to assess the financial impact of case complexity at a tertiary referral centre within the NHS.

Methods

A retrospective analysis of all revision hip procedures was performed at this centre over two consecutive financial years (2018 to 2020). Cases were classified according to the Revision Hip Complexity Classification (RHCC) and whether they were infected or non-infected. Patients with an American Society of Anesthesiologists (ASA) grade ≥ III or BMI ≥ 40 kg/m² are considered "high risk" by the RHCC. Costs were calculated using the Patient Level Information and Costing System (PLICS), and remuneration based on Healthcare Resource Groups (HRG) data. The primary outcome was the financial difference between tariff and cost per patient episode.

Results

In all, 199 revision episodes were identified in 168 patients: 25 (13%) least complex revisions (H1); 110 (55%) complex revisions (H2); and 64 (32%) most complex revisions (H3). Of the 199, 76 cases (38%) were due to infection, and 78 patients (39%) were "high risk". Median length of stay increased significantly with case complexity from four days to six to eight days (p = 0.006) and for revisions performed for infection (9 days vs 5 days; p < 0.001). Cost per episode increased significantly between complexity groups (p < 0.001) and for infected revisions (p < 0.001). All groups demonstrated a mean deficit but this significantly increased with revision complexity (£97, £1,050, and £2,887 per case; p = 0.006) and for infected failure (£2,629 vs £635; p = 0.032). The total deficit to the NHS Trust over two years was £512,202.

Conclusion

Current NHS reimbursement for rTHA is inadequate and should be more closely aligned to complexity. An increase in the most complex rTHAs at major revision centres will likely place a greater financial burden on these units.

Severe trauma with associated pelvic fractures: The impact of regional trauma networks on clinical outcome

Lately, the care of severely injured patients in the United Kingdom has undergone a significant transformation. The establishment of regional trauma networks (RTN) with designated Major Trauma Centers (MTCs) and satellite hospitals called Trauma Units (TUs) has centralized the care of severely injured patients in the MTCs. Pelvic fractures are notoriously linked with hypovolemic shock or even death from excessive blood loss. The aim of this prospective cohort study is to compare the profile of severely injured patients with combined pelvic fractures and their mortality between two different distinct eras of an advanced healthcare system. Anonymized consecutive patient records submitted to TARN UK between 2002 and 2017 by NHS England hospitals were analyzed. Records of patients without a pelvic fracture, or with isolated pelvic fractures (no other serious injury with abbreviated injury scale AIS >2) were excluded. All patients with known outcomes were included and were divided into 2 distinct periods (pre-RTN era: between January 2002 and March 2008 (control group); and RTN era April 2013 to June 2017 (study group)). Data from the transition period from April 2008 to March 2013 were excluded to minimize the effect of variations between the developing networks and MTCs during that era. Overall, the study group included 10,641 patients, whereas the control group was 3152 patients, with a median age of 52.4 and 35.1 years and an ISS of 24 and 27 respectively. A systolic blood pressure below 90mmHg was observed in 7.2% of patients in the study group and 10.4% in the control group. A significant increase of the median time to death (from 8hrs to 188hrs) was observed between the two eras. The cumulative mortality of severely injured patients with pelvic fractures decreased significantly from 17.8% to 12.4% (p<0.0001). The recorded improvement of survivorship in the subgroup of severely injured patients with a pelvic fracture (32% lower in the post-RTN than in the pre-RTN period: OR 1.32  (95% CI 1.21 - 1.44), following the first 5 years of established regional trauma networks in NHS England, is encouraging, and should be attributed to a wide range of factors that translate to all levels of trauma care.

Protocol for the development of a core outcome set for studies on centralisation of healthcare services

INTRODUCTION

Centralisation defined as the reorganisation of healthcare services into fewer specialised units serving a higher volume of patients is a potential measure for healthcare reforms aiming at reducing costs while improving quality. Research on centralisation of healthcare services is thus essential to inform decision-makers. However, so far studies on centralisation report a variability of outcomes, often neglecting outcomes at the health system level. Therefore, this study aims at developing a core outcome set (COS) for studies on centralisation of hospital procedures, which is intended for use in observational as well as in experimental studies.

METHODS AND ANALYSIS

We propose a five-stage study design: (1) systematic review, (2) focus group, (3) interview studies, (4) online survey, (5) Delphi survey. The study will be conducted from March 2022 to November 2023. First, an initial list of outcomes will be identified through a systematic review on reported outcomes in studies on minimum volume regulations. We will search MEDLINE, EMBASE, CENTRAL, CINHAL, EconLIT, PDQ-Evidence for Informed Health Policymaking, Health Systems Evidence, Open Grey and also trial registries. This will be supplemented with relevant outcomes from published studies on centralisation of hospital procedures. Second, we will conduct a focus group with representatives of patient advocacy groups for which minimum volume regulations are currently in effect in Germany or are likely to come into effect to identify outcomes important to patients. Furthermore, two interview studies, one with representatives of the German medical societies and one with representatives of statutory health insurance funds, as well as an online survey with health services researchers will be conducted. In our analyses of the suggested outcomes, we will largely follow the categorisation scheme developed by the Cochrane EPOC group. Finally, a two-round online Delphi survey with all stakeholder groups using predefined score criteria for consensus will be employed to first prioritise outcomes and then agree on the final COS.

ETHICS AND DISSEMINATION

This study has been approved by the Research Ethics Committee at the Brandenburg Medical School Theodor Fontane (MHB). The final COS will be disseminated to all stakeholders involved and through peer-reviewed publications and conferences.

Improvements over time for patients following liver trauma: A 17-year observational study

Background

Centralisation of trauma care has been shown to be associated with improved patient outcomes. The establishment of Major Trauma Centres (MTC) and networks in England in 2012 allowed for centralisation of trauma services and specialties including hepatobiliary surgery. We aimed to investigate the outcomes for patients with hepatic injury over the last 17 years at a large MTC in England in relation to the MTC status of the centre.

Methods

All patients who sustained liver trauma between 2005 and 2022 were identified using the Trauma Audit and Research Network database for a single MTC in the East Midlands. Mortality and complications were compared between patients before and after establishment of MTC status. Multivariable logistic regression models were used to determine the odds ratio (OR) and 95% confidence interval (95% CI) for complications according to MTC status, accounting for the potentially confounding variables of age, sex, severity of injuries and comorbidities for all patients, and the subgroup with severe liver trauma (AAST Grade IV and V).

Results

There were 600 patients; the median age was 33 (IQR 22-52) years and 406/600 (68%) were male. There were no significant differences in 90-day mortality or length of stay between the pre- and post-MTC patients. Multivariable logistic regression models showed both lower overall complications [OR 0.24 (95% CI 0.14, 0.39); p < 0.001] and lower liver-specific complications [OR 0.21 (95% CI 0.11, 0.39); p < 0.001] in the post-MTC period. This was also the case in the severe liver injury subgroup (p = 0.008 and p = 0.002 respectively).

Conclusions

Outcomes for liver trauma were superior in the post-MTC period even when adjusted for patient and injury characteristics. This was the case even though patients in this period were older with more comorbidities. These data support the centralisation of trauma services for those with liver injuries.

SUS management in interstate health regions: assessment of the government’s capacity

Abstract This study displays an assessment of SUS management in a Brazilian interstate health region. An evaluative study was conducted with levels of regional analysis and data production, combining interviews with key informants and documentary analysis. Sources and data were compared and linked to analytical categories of the Government Triangle, showing a cutout of the outcomes and the government’s capacity assessment. There is a low capacity for government in interstate health regions when managers and co-management spaces are unable to influence regional political decisions, limiting themselves to normative and ratifying government strategies. Disparities in the management capacity among the border states prevent the sustainability of coordinating state decision-making goals, exposing that management strategies are not enough to institutionalize interstate regionalization. There is a predominance of low SUS governance capacity in interstate health regions, and its political pattern becomes an unclear project restricted to the ideological level. The broad documentary appreciation with the use of powerful theoretical referential are methodological contributions of this research for the political analysis of SUS management in spaces that were the least examined, such as interstate borders.

SUS management in interstate health regions: assessment of the government's capacity

This study displays an assessment of SUS management in a Brazilian interstate health region. An evaluative study was conducted with levels of regional analysis and data production, combining interviews with key informants and documentary analysis. Sources and data were compared and linked to analytical categories of the Government Triangle, showing a cutout of the outcomes and the government's capacity assessment. There is a low capacity for government in interstate health regions when managers and co-management spaces are unable to influence regional political decisions, limiting themselves to normative and ratifying government strategies. Disparities in the management capacity among the border states prevent the sustainability of coordinating state decision-making goals, exposing that management strategies are not enough to institutionalize interstate regionalization. There is a predominance of low SUS governance capacity in interstate health regions, and its political pattern becomes an unclear project restricted to the ideological level. The broad documentary appreciation with the use of powerful theoretical referential are methodological contributions of this research for the political analysis of SUS management in spaces that were the least examined, such as interstate borders.

A comparative study of hip fracture care and outcomes in major trauma centres versus trauma units

INTRODUCTION

There is good evidence to support that major trauma networks significantly reduce morbidity and mortality in severely injured patients. However, following the introduction of major trauma centres (MTCs) in England in 2012, early concerns were raised regarding the effect on hip fracture patients. The aim of our study was to review data from the National Hip Fracture Database for fractured neck of femur (FNOF) patients, comparing patient outcomes between MTCs and trauma units (TUs), and the national regions of the UK.

METHODS

NHFD data from 2018 for all hospitals in England, Wales and NI was collected using the charts and dashboards available online. We recorded data for the following outcomes: time to surgery, acute hospital length of stay, overall hospital length of stay, discharge to original residence within 120 days, crude 30-day mortality and adjusted 30-day mortality. We conducted a one-way ANOVA test to calculate statistical differences for each outcome measure by MTC vs TU and then separately for the regions of the UK divided into England, Wales and Northern Ireland (NI).

RESULTS

Data for 175 hospitals are included in this study; 22 of which were MTCs. The total number of operative cases were 65,848. 9668 of these occurred in MTC compared to 56,180 in TUs. This equates to an annual average of 439 per MTC and 367 per TU. Despite this, there was no statistically significant difference observed in all outcomes for MTC vs TU. Patients in NI waited longer for their surgery (60.3 h, p < 0.001), whilst patients in Wales had the longest overall hospital length of stay (31.6 days, p < 0.001). However, there was no difference in patients' crude 30-day mortality (p = 0.480) or adjusted 30-day mortality (p = 0.191).

CONCLUSION

These findings are reassuring for MTCs in England. We found no evidence to suggest that FNOF patients are treated inferiorly, or have worse outcomes, at MTCs vs TUs. FNOF patients in NI waited longer for their surgery but this did not have any significant difference on 30-day mortality rates. The care of FNOF patients in NI may warrant further study.

Revision total knee replacement: A two-year review of complexity data and regional workload in South West England

BACKGROUND

The GIRFT report (2012) sought to address the need for sustainable orthopaedic treatment delivered through regional "networks"; the aim being improved care, decreased cost and reduced revision rate. The aims of this study were to record the number and complexity of revision total knee replacements within a regional network using a validated classification over a two-year period and audit this against National Joint Registry (NJR) records.

METHODS

A region-wide network model where revision TKR cases are assessed locally using the Revision Knee Complexity Classification (RKCC) and local multi-disciplinary team (MDT) was introduced. Data was collected from 8 revision centres over a two-year period using the RKCC. The case volume was audited against the NJR records.

RESULTS

In year 1 (01/01/2018-31/12/2018) 237 RKCC forms were collected from eight centres. 46% of R2s and 63% of R3s were carried out at the higher volume centre. 211 K2 forms were received by the NJR. In year 2 (01/01/2019-31/12/2019) 252 RKCC forms were collected. 46% of R2s and 64% of R3s were carried out at the higher volume centre. 267 K2 forms were received by the NJR.

CONCLUSION

This is the first published set of revision knee data showing complexity percentages across a region. The RKCC has been successfully introduced into the region and this has been sustained. The findings show that a successful network has been established and majority of complex revision knee surgery is occurring in the high-volume centre. NJR data suggests that the RKCC is capturing the complexity and volume of our work accurately.

The effectiveness of trauma care systems at different stages of development in reducing mortality: a systematic review and meta-analysis

BACKGROUND

Traumatic injury remains the leading cause of death, with more than five million deaths every year. Little is known about the comparative effectiveness in reducing mortality of trauma care systems at different stages of development. The objective of this study was to review the literature and examine differences in mortality associated with different stages of trauma system development.

METHOD

A systematic review of peer-reviewed population-based studies retrieved from MEDLINE, EMBASE, and CINAHL. Additional studies were identified from references of articles, through database searching, and author lists. Articles written in English and published between 2000 and 2020 were included. Selection of studies, data extraction, and quality assessment of the included studies were performed by two independent reviewers. The results were reported as odds ratio (OR) with 95 % confidence intervals (CI).

RESULTS

A total of 52 studies with a combined 1,106,431 traumatic injury patients were included for quantitative analysis. The overall mortality rate was 6.77% (n = 74,930). When patients were treated in a non-trauma centre compared to a trauma centre, the pooled statistical odds of mortality were reduced (OR 0.74 [95% CI 0.69-0.79]; p < 0.001). When patients were treated in a non-trauma system compared to a trauma system the odds of mortality rates increased (OR 1.17 [95% CI 1.10-1.24]; p < 0.001). When patients were treated in a post-implementation/initial system compared to a mature system, odds of mortality were significantly higher (OR 1.46 [95% CI 1.37-1.55]; p < 0.001).

CONCLUSION

The present study highlights that the survival of traumatic injured patients varies according to the stage of trauma system development in which the patient was treated. The analysis indicates a significant reduction in mortality following the introduction of the trauma system which is further enhanced as the system matures. These results provide evidence to support efforts to, firstly, implement trauma systems in countries currently without and, secondly, to enhance existing systems by investing in system development.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019142842 .

Effectiveness of trauma care systems at different stages of development in reducing mortality: a systematic review and meta-analysis protocol

INTRODUCTION

The introduction of trauma systems that began in the 1970s resulted in improved trauma care and a decreased rate of morbidity and mortality of trauma patients. Worldwide, little is known about the effectiveness of trauma care system at different stages of development, from establishing a trauma centre, to implementing a trauma system and as trauma systems mature. The objective of this study is to extract and analyse data from research that evaluates mortality rates according to different stages of trauma system development globally.

METHODS AND ANALYSIS

The proposed review will comply with the checklist of the 'Preferred reporting items for systematic review and meta-analysis'. In this review, only peer-reviewed articles written in English, human-related studies and published between January 2000 and December 2020 will be included. Articles will be retrieved from MEDLINE, EMBASE and CINAHL. Additional articles will be identified from other sources such as references of included articles and author lists. Two independent authors will assess the eligibility of studies as well as critically appraise and assess the methodological quality of all included studies using the Cochrane Risk of Bias for Non-randomised Studies of Interventions tool. Two independent authors will extract the data to minimise errors and bias during the process of data extraction using an extraction tool developed by the authors. For analysis calculation, effect sizes will be expressed as risk ratios or ORs for dichotomous data or weighted (or standardised) mean differences and 95% CIs for continuous data in this systematic review.

ETHICS AND DISSEMINATION

This systematic review will use secondary data only, therefore, research ethics approval is not required. The results from this study will be submitted to a peer-review journal for publication and we will present our findings at national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42019142842.

Revision knee replacement surgery in the NHS: A BASK surgical practice guideline

BACKGROUND

Revision knee replacement (KR) is both challenging for the surgical team and expensive for the healthcare provider. Limited high quality evidence is available to guide decision-making.

AIM

To provide guidelines for surgeons and units delivering revision KR services.

METHODS

A formal consensus process was followed by BASK's Revision Knee Working Group, which included surgeons from England, Wales, Scotland and Northern Ireland. This was supported by analysis of National Joint Registry data.

RESULTS

There are a large number of surgeons operating at NHS sites who undertake a small number of revision KR procedures. To optimise patient outcomes and deliver cost-effective care high-volume revision knee surgeons working at high volume centres should undertake revision KR. This document outlines practice guidelines for units providing a revision KR service and sets out: The current landscape of revision KR in England, Wales and Northern Ireland. Service organisation within a network model. The necessary infrastructure required to provide a sustainable revision service. Outcome metrics and auditable standards. Financial mechanisms to support this service model.

CONCLUSIONS

Revision KR patients being treated in the NHS should be provided with the best care available. This report sets out a framework to both guide and support revision KR surgeons and centres to achieve this aim.

Financial analysis of revision knee surgery at a tertiary referral centre as classified according to the Revision Knee Complexity Classification (RKCC)

BACKGROUND

Revision total knee arthroplasty (rTKA) can be complex, with greater costs to the treating hospital than primary TKA. A rTKA regional network has been proposed in England. The aim of this work was to accurately quantify current costs and reimbursement for the rTKA service and to assess whether costs are proportional to case complexity at a tertiary referral centre within the National Health Service (NHS).

METHODS

A review of all rTKA performed at our institution over two consecutive financial years (2017-2019) was performed. Cases were classified according to the Revision Knee Complexity Classification (RKCC) and by mode of failure; "infected" and "non-infected". Financial data was acquired through Patient-Level Information and Costing System (PLICS). The primary outcome was the financial difference between tariff and cost per episode. Comparisons between groups were analysed using analysis of variance and two-tailed unpaired t-test as appropriate.

RESULTS

159 patients underwent 188 rTKA procedures. Length of stay and cost significantly increased between complexity groups (p < 0.0001) and for infected revisions (p < 0.0001). All groups sustained a mean deficit but this significantly increased with revision complexity (from £1,903 to £5,269 per case) and for infected revisions. The total deficit to the Trust for the two-year rTKA service was £667,091.

CONCLUSIONS

The current level of NHS reimbursement are inadequate for centres that offer rTKA and should be more closely aligned to case complexity. An increase in the most complex rTKA at major revision centres will undoubtedly place an even greater strain on the finances of these units.

Provision of revision knee surgery and calculation of the effect of a network service reconfiguration: An analysis from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

BACKGROUND

Revision knee replacement (KR) is technically challenging, expensive, and outcomes can be poor. It is well established that increasing surgeon and unit volumes results in improved outcomes and cost-effectiveness for complex procedures. The aim of this study was to 1) describe the current provision of revision KR in England, Wales and Northern Ireland at the individual surgeon and unit level and 2) investigate the effect on workload of case distribution in a network model.

METHODS

Current practice was mapped using NJR summary statistics containing all revision KR procedures performed over a three-year period (2016-2018). Units were identified as revision centres based on threshold volumes. Units undertaking <20 revisions per year were classified as Primary Arthroplasty Units (PAUs) in calculations on the effect of workload centralisation.

RESULTS

Revision KR was performed by 1353 surgeons at 232 NHS sites. The majority of surgeons and units were low-volume; >1000 surgeons performed <7 and 125 sites performed <20 procedures per year. Reallocation of work from these 125 PAUs (1235 cases, 21% of total workload) to a network model with even redistribution of cases between centres undertaking revision surgery would result in an additional average annual case increase of 11 per unit per year (range six to 14).

CONCLUSIONS

Revision KR workload re-allocation would lift all revision centres above a 30 per year threshold and would appear to be a manageable increase in workload for specialist revision KR centres. Case complexity and local referral agreements will significantly affect the real increase in workload; these factors were not incorporated here.

Time to definitive care within major trauma networks in England

BACKGROUND

Significant mortality improvements have been reported following the implementation of English trauma networks. Timely transfer of seriously injured patients to definitive care is a key indicator of trauma network performance. This study evaluated timelines from emergency service (EMS) activation to definitive care between 2013 and 2016.

METHODS

An observational study was conducted on data collected from the UK national clinical audit of major trauma care of patients with an Injury Severity Score above 15. Outcomes included time from EMS activation to: arrival at a trauma unit (TU) or major trauma centre (MTC); to CT; to urgent surgery; and to death.

RESULTS

Secondary transfer was associated with increased time to urgent surgery (median 7·23 (i.q.r. 5·48-9·28) h versus 4·37 (3·00-6·57) h for direct transfer to MTC; P < 0·001) and an increased crude mortality rate (19·6 (95 per cent c.i. 16·9 to 22·3) versus 15·7 (14·7 to 16·7) per cent respectively). CT and urgent surgery were performed more quickly in MTCs than in TUs (2·00 (i.q.r. 1·55-2·73) versus 3·15 (2·17-4·63) h and 4·37 (3·00-6·57) versus 5·37 (3·50-7·65) h respectively; P < 0·001). Transfer time and time to CT increased between 2013 and 2016 (P < 0·001). Transfer time, time to CT, and time to urgent surgery varied significantly between regional networks (P < 0·001).

CONCLUSION

Secondary transfer was associated with significantly delayed imaging, delayed surgery, and increased mortality. Key interventions were performed more quickly in MTCs than in TUs.

Current trauma care system in Saudi Arabia: A scoping literature review

BACKGROUND

Trauma is one of the leading causes of death worldwide with millions of people dying each year, particularly in low or middle-income countries. This paper describes and evaluates the current trauma system (TS) in Saudi Arabia (SA).

METHODS

A scoping literature review was performed, incorporating an extensive search of Medline and Embase databases for refereed literature, as well as a search of grey literature to locate unpublished articles or reports in English or Arabic. All publications were assessed against the World Health Organization (WHO) Trauma System Maturity Index (TSMI) and American College of Surgeon's (ACS) criteria.

RESULTS

Despite local injury prevention efforts, Motor Vehicle Crashes (MVC) remain the primary cause of injuries in SA. Prehospital trauma care in SA aligns with level III care as described in the WHO TSMI classification system, based on the presence of formal emergency medical services and universal access to care. With respect to the ACS classification, no clear written guidelines, either for field triage or trauma destination protocols such as trauma bypass, were identified in prehospital trauma care. The role of secondary and tertiary facilities in treating trauma patients is unclear, with no clear referral linkages, suggesting a level I to III grading of SA's trauma care facilities. Currently, there is no national or regional electronic trauma registry, no quality assurance program, and active involvement in research projects related to injuries is limited.

CONCLUSION

The current SA TS has strengths but there are key features missing in comparison to other systems globally. As MVCs remain a leading cause of death/ disability, efforts to reduce the prevalence and impact of MVC burden in SA through development of a stronger national TS are warranted.

The volume-outcome relationship among severely injured patients admitted to English major trauma centres: a registry study

BACKGROUND

Many countries have centralized and dedicated trauma centres with high volumes of trauma patients. However, the volume-outcome relationship in severely injured patients (Injury Severity Score (ISS) > 15) remains unclear. The aim of this study was to determine the association between hospital volume and outcomes in Major Trauma Centres (MTCs).

METHODS

A retrospective observational cohort study was conducted using the Trauma Audit and Research Network (TARN) consisting of all English Major Trauma Centres (MTCs). Severely injured patients (ISS > 15) admitted to a MTC between 2013 and 2016 were included. The effect of hospital volume on outcome was analysed with random effects logistic regression models with a random intercept for centre and was tested for nonlinearity. Primary outcome was in-hospital mortality.

RESULTS

A total of 47,157 severely injured patients from 28 MTCs were included in this study. Hospital volume varied from 69 to 781 severely injured patients per year. There were small between-centre differences in mortality after adjusting for important demographic and injury severity characteristics (adjusted 95% odds ratio range: 0.99-1.01). Hospital volume was found to be linear and not associated with in-hospital mortality (adjusted odds ratio (aOR) 1.02 per 10 patients, 95% confidence interval (CI) 0.68-1.54, p = 0.92).

CONCLUSIONS

Despite the large variation in volume of the included MTCs, no relationship between hospital volume and outcome of severely injured patients was found. These results suggest that centres with similar structure and processes of care can achieve comparable outcomes in severely injured patients despite the number of severely injured patients they treat.

What effect has the major trauma network had on perceptions of trauma care delivery amongst trauma teams in major trauma centres and neighbouring trauma units?

INTRODUCTION

The Trauma network was established in April 2012 in England to improve the care of patients with trauma. The care of major trauma was centralised to major trauma centres. This article aims to survey trauma team members (TTM) to compare perceptions of trauma care delivery in major trauma centres (MTC) and trauma units (TU) from where major trauma care has been diverted.

METHODS

Trauma team members (TTM) from six hospitals were interviewed between June and July 2016. This included three MTCs and their neighbouring TU. Data were also gathered to determine appropriate trauma qualifications of TTMs.

RESULTS

TTMs in MTCs perceived the standard of trauma service improved (90% increased, 10% same) since April 2012 in comparison to TUs (10% increased, 63% same, 27% decreased) (p ≤ 0.001). In MTCs, TTMs felt their skills improved more (66% improved, 34% unchanged) compared to TU's (24% improved, 64% unchanged, 12% regressed) (p ≤ 0.001). TTM's in MTCs were more satisfied with their trauma teams training (p ≤ 0.001), leader's communication (p ≤ 0.001) and handover process (p ≤ 0.01) in comparison to TTMs in TUs. 69% of doctors in MTCs held valid trauma qualifications as compared to only 37% in TUs (p ≤ 0.001).

CONCLUSION

The centralisation of major trauma care to MTCs allows care for severely injured patients in specialised hospitals with allocated resources. This survey shows the effect of this reorganisation where diversion of major trauma from TUs may have led to their TTMs perceiving their standard of care to be less than TTMs in MTCs. This study recommends training support for TUs using modalities such as simulation-based training and regular audits to ensure improved perceptions and adequate qualifications. Multidisciplinary meetings between MTCs and TUs can allow information to be exchanged and shared to ensure reciprocal support and engagement to improve perception of trauma care delivery.

Prognostic model for traumatic death due to bleeding: cross-sectional international study

OBJECTIVE

To develop and validate a prognostic model and a simple model to predict death due to bleeding in trauma patients.

DESIGN

Cross-sectional study with multivariable logistic regression using data from two large trauma cohorts.

SETTING

274 hospitals from 40 countries in the Clinical Randomisation of Anti-fibrinolytic in Significant Haemorrhage (CRASH-2) trial and 24 hospitals in the Northern French Alps Trauma registry.

PARTICIPANTS

13 485 trauma patients in the CRASH-2 trial and 9945 patients in the Northern French Alps Trauma registry who were admitted to hospital within 3 hours of injury.

MAIN OUTCOME MEASURE

In-hospital death due to bleeding within 28 days.

RESULTS

There were 815 (6%) deaths from bleeding in the CRASH-2 trial and 102 (1%) in the Northern French Alps Trauma registry. The full model included age, systolic blood pressure (SBP), Glasgow Coma Scale (GCS), heart rate, respiratory rate and type of injury (penetrating). The simple model included age, SBP and GCS. In a cross-validation procedure by country, discrimination and calibration were adequate (pooled C-statistic 0.85 (95% CI 0.81 to 0.88) for the full model and 0.84 (95% CI 0.80 to 0.88) for the simple model).

CONCLUSION

This prognostic model can identify trauma patients at risk of death due to bleeding in a wide range of settings and can support prehospital triage and trauma audit, including audit of tranexamic acid use.

Revision knee complexity classification-RKCC: a common-sense guide for surgeons to support regional clinical networking in revision knee surgery

PURPOSE

There is considerable variation in practice throughout Europe in both the services provided and in the outcomes of Revision Knee Surgery. In the UK, a recent report published called get it right first time (GIRFT) aims to improve patient outcomes through providing high quality, cost-effective care, and reducing complications. This has led to the development of a classification system that attempts to classify the complexity of revision knee surgery, aiming to encourage and support regional clinical networking.

METHODS

The revision knee classification system (RKCC) incorporates not only complexity, but also patient factors, the presence of infection, the integrity of the extensor mechanism, and the soft tissues. It then provides guidance for clinical network discussion. Reliability and reproducibility testing have been performed to establish the inter- and intra-observer variabilities using this classification.

RESULTS

Good correlation between first attempt non-expert and experts, good intra-observer variability of non-expert, and an excellent correlation between second attempt non-expert and experts has been achieved. This supports the use of RKCC by both inexperienced and experienced surgeons.

CONCLUSIONS

The revision knee complexity classification has been proposed that offers a common-sense approach to recognize the increasing complexity in revision TKR cases. It provides a methodological assessment of revision knee cases and support regional clinical networking and triage of appropriate cases to revision units or specialist centres.

LEVEL OF EVIDENCE

Expert opinion, Level V.

Does a dedicated hip fracture unit improve clinical outcomes? A five-year case series

INTRODUCTION

The aim of the study was to establish whether a dedicated hip fracture unit, geographically separate from the local major trauma centre, could improve clinical outcomes for patients sustaining proximal femoral fragility fractures.

MATERIALS AND METHODS

This study was a retrospective case series, using data collected from Brighton and Sussex University Hospitals NHS Trust's submissions to the National Hip Fracture Database between 1 April 2011 and 16 September 2016. The outcomes measured were mortality, length of hospital stay, time from admission to surgical intervention and return to premorbid residence. Patients were compared before and after reconfiguration of services into a separate dedicated hip fracture unit geographically distinct from the major trauma centre.

RESULTS

A total of 2117 patients (2178 injuries) were managed before the existence of the hip fracture unit, while 660 patients (673 injuries) were treated within the hip fracture unit. During the five-year study period, the 30-day mortality rate (pre-hip fracture unit 5.47% vs hip fracture unit 3.13%, P = 0.014), variance in the length of hospital stay (P < 0.001), mean time to surgical intervention (P = 0.044) and return to premorbid residence were significantly improved. An immediate 12-month comparison demonstrated significantly improved variance in length of hospital stay (P = 0.020) and return to premorbid residence (P = 0.015).

DISCUSSION

The reconfiguration of services significantly reduced variance in length of stay, enabling accurate resource planning in future. Multiple incremental improvements in service provision, in addition to the hip fracture unit, may explain the lower mortality observed.

CONCLUSION

While further research is required, replication of the hip fracture unit service model may potentially afford significant clinical and financial gains.

Geographic Distribution of Trauma Burden, Mortality, and Services in the United States: Does Availability Correspond to Patient Need?

BACKGROUND

The association between the need for trauma care and trauma services has not been characterized previously. We compared the distribution of trauma admissions with state-level availability of trauma centers (TCs), surgical critical care (SCC) providers, and SCC fellowships, and assessed the association between trauma care provision and state-level trauma mortality.

STUDY DESIGN

We obtained 2013 state-level data on trauma admissions, TCs, SCC providers, SCC fellowship positions, per-capita income, population size, and age-adjusted mortality rates. Normalized densities (per million population [PMP]) were calculated and generalized linear models were used to test associations between provision of trauma services (higher-level TCs, SCC providers, and SCC fellowship positions) and trauma burden, per-capita income, and age-adjusted mortality rates.

RESULTS

There were 1,345,024 trauma admissions (4,250 PMP), 2,496 SCC providers (7.89 PMP), and 1,987 TCs across the country, of which 521 were Level I or II (1.65 PMP). There was considerable variation between the top 5 and bottom 5 states in terms of Level I/Level II TCs and SCC surgeon availability (approximately 8.0/1.0), despite showing less variation in trauma admission density (1.5/1.0). Distribution of trauma admissions was positively associated with SCC provider density and age-adjusted trauma mortality (p ≤ 0.001), and inversely associated with per-capita income (p < 0.001). Age-adjusted mortality was inversely associated with the number of SCC providers PMP. For every additional SCC provider PMP, there was a decrease of 618 deaths per year.

CONCLUSIONS

There is an inequitable distribution of trauma services across the US. Increases in the density of SCC providers are associated with decreases in mortality. There was no association between density of trauma admissions and location of Level I/Level II TCs. In the wake of efforts to regionalize TCs, additional efforts are needed to address disparities in the provision of quality care to trauma patients.