Chapter 1 - Severn Major Trauma Network

The Severn Trauma Network serves an adult population of around 2.3 million. The South West has a greater proportion of inhabitants of pensionable age than any other English region (19.6%) and this is reflected in network data. The average age of major trauma patients treated in the network is 65. The majority of major trauma patients across the network are treated as the result of a fall from less than 2m. Road traffic collisions are the second most common cause of injury, followed by falls more than 2m.

Following the introduction of Regional Major Trauma Networks, Major Trauma Centres are required to have an automatic acceptance policy for patients requiring treatment for major trauma injuries. The purpose of this policy is to provide direction and guidance for actions from key individuals and organisations within the Severn Major Trauma Network to improve the patient pathway and quality of care. To do this it will: ‣ Ensure the automatic acceptance of major trauma patients after consultant to Trauma Team Leader (TTL) referral within the Severn Trauma Network from Trauma Units to the Major Trauma Centre ‣ Ensure that all relevant parties are aware of their specific roles and responsibility, and prevent the acceptance and transfer of patients being delayed ‣ Describe the procedure where capacity to accept severely injured patients is exceeded.

This policy will relate to patients from Trauma Units and Local Emergency Hospitals within the Severn Major Trauma Network area following a major trauma injury. This policy applies to referring trusts hospitals, ambulance trusts and local air ambulances. It is the responsibility of North Bristol NHS Trust staff to ensure that that this policy is followed from first contact by an outside agency. The policy will be implemented by personnel in the Emergency Department, Intensive Care, High Dependency Units and General Wards. The final responsibility for the implementation of this policy lies with the on call Major Trauma Consultant (TTL) who accepts the patient. The trauma team leader can be contacted on 07703 886400. Departure from the policy would have to be justified to the Executive On call manager with clear and compelling reasons. Any departure from the policy must be documented in the patient notes and flagged through the major trauma governance process – MTGovernance@nbt.nhs.uk

This policy applies 7 days a week, 24 hours a day All relevant clinical information is to be given to the receiving Trust The Retrieve Adult Critical Care Transfer Service provides triage and coordination of all adult critical care transfer referrals 24/7 and should be contacted whenever a critical care transfer is required. All adult critical care transfer referrals should be made to Retrieve via their single point of contact telephone number (0300 030 2222) In certain circumstances (at night and when the Retrieve team are committed elsewhere), the referring Trauma Unit will be required to undertake the transfer, providing appropriately trained and experienced clinical escorts and using a 999 ambulance (accessed via Retrieve). The transfer of the patient is to be organised by the referring hospital, providing necessary escort arrangements, together with all necessary documentation including the Severn Major Trauma Network trauma patient record. This policy should be read in conjunction with: ‣ The Severn Major Trauma Network repatriation policy ‣ SWASFT Major Trauma Triage Tool ‣ Inter-Hospital Transfer of Critically Ill Adult Major Trauma Patients ‣ Major Incident Policy

In the case of an emergency transfer the referring hospital must contact the on-duty Major Trauma Consultant (TTL - 07703 886400) with details of the patient. The referring hospital must also inform the Ambulance Service Coordination desk of the transfer and details of the patient. Retrieve should be contacted for any critical care transfers. The transfer procedure must be carried out at TTL level Full patient details including name of referring TTL and time of referral to be recorded in the Major Trauma booklet 15 Patient notes including their Major Trauma booklet should be transferred to the receiving hospital with the patient. On arrival, the patient is met by the major trauma team and trauma call procedures initiated

The Severn Major Trauma Centre has a duty of care to the population covered by the Severn Major Trauma Network and must accept all severely injured patients in a timely manner. Timely is defined as according to the urgency of transfer as defined by the Trauma Team Leader only. Where there are problems with capacity in specific areas of NBT (such as critical care) to accept patients from the Severn Major Trauma Network, it is the responsibility of the affected unit/department to inform the TTL in a timely manner and to work together to resolve the situation expediently. Capacity constraints cannot be used over clinical priority to turn-down or delay patients. In the unlikely event that a patient at a Severn Trauma Unit required a Major Trauma Centre Bed and the patient cannot be accepted at NBT because of capacity (such as during a major incident) it is the responsibility of the NBT TTL to ensure that an alternative bed can be sourced in another Major Trauma Centre (in conjunction with the Ambulance Service Coordination centre). The decision of whether a patient requires immediate major trauma centre care (and therefore must be accepted) is made by the TTL. If no other Major Trauma Centre within clinically acceptable transfer time can accept the patient then North Bristol NHS Trust must accept the patien

NBT Trauma Team Leader (Consultant): 07703 886 400 SWASFT Ambulance Co-ordination Desk: 0845 1206342 Retrieve: 0300 030 2222

The Trust is notified of a major incident by the Ambulance Service via an automated system to the Emergency Department. Information regarding the incident is communicated using the METHANE mnemonic which provides key information needed to inform the Trust’s response: 1. Major Incident Standby / Declared 2. Exact Location 3. Type of Incident 4. Hazards—both present and potential 5. Access and egress to the incident 6. Number of casualties and a breakdown of types i. Priority 1 (P1), life threatening injuries, resus ii. Priority 2 (P2), urgent, non life threatening, majors iii. Priority 3 (P3), delayed, minors iv. Number of children, burns etc 7. Emergency Services already at scene or involved in responding to the incident On receipt of the Major Incident Notification, the Emergency Department documents the METHANE and initiates the appropriate response as outlined in the Major Incident Plan. 17 INITIAL MASS CA

Principles Influencing Triage: ‣ Number and type of casualties ‣ Location of the incident within the network ‣ Neurosurgery only at NBT, cardiothoracic services at UHBW (one thoracic surgeon will receive patients at NBT). Specialised children’s services at BCH.

Severn Casualty Capability Chart: Pre-determined capacity for the first 2 hours

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Total capacity for Severn (200). Ideally: ‣ Priority 1s to MTC ‣ Priority 2s to trauma units (but TUs may also have to take priority 1s) ‣ Priority 3s to TU’s, LEH’s and other appropriate facilitates. These figures relate to the first 2 hours and should be viewed in the context of incidents producing mass casualties: within small incidents the figures for each unit will be lower.

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All receiving hospitals should ensure they enact plans to enable them to free up 20% of their total bed base, 10% of which should be in the first six hours, and a further 10% within 12 hours of the incident declaration, allowing patients from the incident scene to be rapidly placed and ensure patient flow. In addition to this, hospitals with level 3 Intensive Care capability should prepare to surge to double their normal level 3 ventilated bed capacity and maintain this for a minimum period of 96 hours. Trauma Units should be prepared to manage patients who they would usually treat and transfer for extended periods, along with preparing to receive additional repatriations from the MTC. During a mass casualty incident, it may be necessary for receiving hospitals to expand their emergency capacity into space not usually occupied by the emergency pathway. This will require the activation of business continuity measures. Organisations will need to consider activation of their lockdown arrangements to support site security and the need to protect access to health care facilities to those in need of treatment. In the event of being in a scene cordon the hospital may be asked to act as a temporary rest centre or reception centre.

Trusts should be prepared to provide the information required on the NHS England National Incident Situation Report Template, or specific incident template issued during the incident to the appropriate time scales.

National arrangements for the identification of victims are likely to be invoked. These may include the activation of National Emergency Mortuary Arrangements (NEMA) or the designation of a Designated Disaster Mortuary (DDM) which may be on NHS premises but operated by the local authority. It may be the case that the mortuary space in NHS hospitals has to be managed carefully, and coordinated with the appropriate HM Coroner’s Office, HM Police and Local Authority to maintain capacity. This will be important where deceased are to be held for a period of time, and there will be delays in taking hospital mortuary bodies to the designated disaster mortuaries

NHS England will form a Clinical Cell with the Duty Clinical Director along with representatives of the NHS England EPRR Clinical Reference Group, with additional specialist representation as required. This cell will act to ensure that the NHS England Incident Management Team (National) has the appropriate access to clinical advice to inform the response. NHS England may make use of Medical Directors from Regional Offices and DCO teams to support the clinical cell in a protracted incident or where they have specialist subject advice required of the response. In addition to this, NHS England may contact individual experts to offer advice based on available known staff in organisations. Clinical Impact Assessment Call Within the first twenty-four hours of an incident, the Lead National Medical Director will establish a clinical call with responding centres to ascertain the likely impact to services and patient management across all services. An agenda for this is provided in Annex 6: Clinical Impact Assessment Call Agenda Where possible this call will be held on the secure teleconferencing facilities accessible through the NHS England EPRR Duty Officer (NHS05). Ethical Decisions It may become necessary to enact decisions relating to the ceilings of care during a mass casualty incident to ensure the greatest number of survivors possible. This may include the decision by the Clinical Cell to invoke the expectant triage category at the scene. This decision will be time limited, continually under review and only used at a time when NHS resources are overwhelmed Patient Placement The Clinical Cell will advise on the placement of patients who need to be transferred out of the incident response areas to ensure they receive the most appropriate definitive care. Clinical Debrief The Clinical Cell will establish a clinical debrief for the incident, the hot debrief will be held within two weeks of the incident, with a structured clinical debrief within one month. Recovery Cell Nationally a Recovery Cell will be established to coordinate with the response and ensure work is undertaken to manage the recovery of NHS England and the NHS in England. This group will look at the recovery support required and ensure liaison between recovery groups at all levels of the organisation and out to those groups established as part of SCG response.

Decision making for return to normal working ultimately rests with Incident Director (National). This may be delegated as the incident response evolves and recovery commences to regional leads; however, the option to refer to the designated national lead should remain in the case of local/regional dispute or unacceptable variation in recovery actions occurs. ‣ Financial implications must be transparent, and principles applied consistently across the system by providers and commissioners ‣ Recovery should be led by a senior Regional Recovery Lead and coordinated nationally across the health economy to ensure continued application of mutual aid principles, effective use of resources and to facilitate repatriations ‣ National, regional and local recovery leads should liaise at an early stage and throughout the process with ODNs. The ODNs will provide local intelligence and advise on actions to be taken at system level (local/regional/national) ‣ Return to organisational business as usual may take considerably longer than normal. ‣ Trauma cases may require multiple and prolonged returns to surgery and/or stays in critical care. ‣ Specialist services may need to be commissioned or expanded to deal with additional demand on a medium to long term basis ‣ Patients may need to be repatriated into their own health economy a long way from the incident location and may require medium to long term care and rehabilitation. Commissioners will need to agree the provision of additional resources. ‣ National support will be required to recover costs from overseas patients and national arrangements should be set out in advance. Costs may be for short, medium or long term care and treatment and could include; emergency and/or specialist treatment and care, rehabilitation services and repatriation. ‣ Discussions around the reduction, alteration, suspension or cancellation of services by organisations supporting the incident that impact on their national standards should be conducted between regulators at a national level. ‣ Proactive capture of points to inform learning from response and facilitate recovery should be achieved.

All NHS organisations involved in the response will be expected to undertake a debrief as per the requirements of the NHS England EPRR Framework and Core Standards. Trusts may be invited to multiple debriefs by many agencies and should attend these where possible.

Psychosocial support should be offered to patients and staff as needed they should also be made aware of those symptoms that are normal during the initial period following a traumatic event, An NHS England post incident leaflet is available ‘Access to post incident mental health services leaflet’. NEED HYPERLINK TO THE LEAFLET

Risk factors and likely injury types National planning assumptions state the likely split across triage categories will be 25% Priority 1 (casualties needing immediate intervention), 25% Priority 2 (casualties needing early treatment but delay acceptable), 50% Priority 3 (casualties needing treatment but a longer delay is acceptable). The cause of the incident is likely to dictate the type of injury from a Mass Casualty event however there is likely to be: ‣ Severe Blunt Force or Ballistic Trauma (especially in firearms and bomb related incidents) across specialties. ‣ Burns ‣ Acoustic Injuries (where blasts have occurred) Environmental Local conditions can impact on the ease to get to medical facilities and the ease of access to patients requiring a greater response from the hospital. Weather conditions can impact on the number of casualties in an incident and the type of treatment and staff required to respond, extremes of temperature can increase the risk of shock, and bring about exposure related illness. Water Supplies Water supplies could be the cause of a mass casualty incident or impacted upon by an incident. The Trust has in place utility disruption plans to allow services to continue in the event of a disruption or contamination to supplies. Advice should be sought from Public Health England during any incident of this nature. Lack of water supplies may require a change in the way patients are cared for and effect immediate treatment. VIP Visits It is likely during and/or following a mass casualty incident there will be significant interest from VIPs to visit hospitals and those affected. This may need to be coordinated nationally to ensure that appropriate arrangements are in place. Visits from VIPs can require extensive resourcing and organisations need to carefully consider these against the need to deliver ongoing patient care.

The repatriation of major trauma patients to their local hospitals has the potential to be challenging for the patient, carers and organisations involved. Unnecessary delays are unhelpful in a number of ways: ‣ They can impede care packages for patients ‣ They can be inconvenient or distressing for both patients and relatives ‣ They are a source of frustration in relationships between hospitals ‣ They can prevent acutely ill patients being admitted into designated beds ‣ Can affect patient flow and operational running of the Major Trauma Centre (MTC) The purpose of this policy is to provide direction and guidance for actions from key individuals and organisations to reduce the challenge and improve the patient pathway and quality of care for major trauma patients. It also aims to replicate the automatic acceptance principle that ensures acceptance of patients from the Trauma Units (TU) to MTC during the early phase of care. It will provide the MTC with an effective means of returning patients to their original or local Trust following their initial acute treatment and therefore ensure capacity is available in the MTC for any further patients requiring major trauma care.

The policy will be formally agreed and accepted amongst all organisations within the Severn Trauma Operational Delivery Network (ODN) and relate to those patients admitted to North Bristol NHS Trust (MTC) following major trauma. This policy applies only to TARN inclusion criteria major trauma patients. For operational purposes, major trauma patients are those that have been received following triage according to the Major Trauma Triage Tool (Page 45). It does not apply to patients other than those deemed to have major trauma injuries at time of transfer.

The policy will ensure that all patients are repatriated to their local health care provider when they are medically fit or have completed specific treatment at the MTC. It will ensure that all relevant parties are aware of their specific roles and responsibilities and prevents delay to patient transfer. It will provide clear guidance for action when patient pathways become blocked.

The process outlined in this policy applies twenty-four hours, seven days a week to all organisations within the Severn Trauma Network. ‣ The MTC is committed to automatically accepting major trauma patient transfers into the centre. As such to maintain flow it is critical that there is a robust and reliable process for repatriation to TU. A principle of automatic acceptance for repatriations needs to be approved by TU. ‣ MTC clinical teams will make contact with the receiving Trust clinical team and agree the transfer and acceptance of care using the Repatriation Notification Form (Page 26). ‣ The MTC and other hospitals should maintain communication throughout the patient’s stay at MTC as appropriate. ‣ The MTC will provide as much notice as is reasonably possible of repatriation and endeavour that this is no less than 48 hours before repatriation is required. ‣ All relevant clinical and social information is to be provided to the receiving Trust upon referral. ‣ An escalation policy will be triggered if a bed is not allocated to a major trauma patient within 24 hours of them being ready for transfer. ‣ Transport will be organised by the MTC, providing necessary escort arrangements, together with all necessary documentation including a formal typed discharge summary to accompany the patient. ‣ If the patient has critical care needs, transport arrangements can be discussed with Retrieve – 0300 030 2222. ‣ Lack of rehabilitation facilities within the receiving organisation should not affect the repatriation of patients. 24 ‣ A patient must be accepted by a senior doctor (ST3 and above) doctor within the specialty required before the repatriation process can begin. Please note that for quadriplegic patients returning to hospitals within the Network an accepting consultant in the receiving specialty is required.

24 Hours If repatriation has not occurred within 24 hours of patient being fit for transfer, then the Operations Manager at the MTC will be informed and will communicate with the Operational Lead at the receiving Trust. Out of hours this will be the site team lead or the manager on call. 48 Hours If repatriation has not occurred within 48 hours of patient being fit for transfer, then the Deputy Director of Operations at the MTC is to be informed and communicate with their equivalent at the receiving Trust. 72 Hours If following discussion between Directors of Operations, no agreement can be reached, a time for repatriation will be established by the MTC approximately 72 hours from patient being ready for transfer and this will be confirmed with the Trauma Unit, who must identify a receiving team and ward, the patient will then be transferred.

This policy will be monitored jointly by all Trauma Unit clinical and managerial leads and the Severn Major Trauma Operational Delivery Network Board. A formal review will be undertaken annually, and amendments will be made as necessary.

Major Trauma Repatriation Notification Form

Major Trauma Centre Coordinators to Complete Top Section and Email to Receiving Trust nominated email address.

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