Timothy Hodgetts

Trauma governance in the UK defence medical services

Introduction Clinical governance is concerned with the application and enforcement of good clinical practice [1-4] and the management of military trauma patients is no exception. To this end, a framework of governance has been implemented to facilitate best practice, and to ensure that Service personnel who are seriously injured on deployed operations receive exemplary care. This paper describes the processes in place to capture data, interpret the data, and audit the process of trauma management in the UK Defence Medical Services.

Benchmarking the UK Military Deployed Trauma System

Corresponding Author: Colonel TJ Hodgetts QHP Honorary Professor of Emergency Medicine Academic Department of Military Emergency Medicine Institute of Research and Development, Vincent Drive, Birmingham B15 2SQ T: +44 121 415 8848 E: Prof.ADMEM@rcdm.bham.ac.uk Comparing Civilian and Military Performance In November 2007 the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published a report [1] that identified that almost 60% of major trauma patients (Injury Severity Score ≥16) receive care that is “less than good practice” in a representative sample of hospitals across England, Wales, Northern Ireland and the Offshore Islands. The report represents one of a series of Royal College sponsored reports over almost 2 decades that have consistently criticized the quality of acute trauma care in the NHS [2,3]. A core function of the Defence Medical Services (DMS) is the effective assessment, treatment and evacuation of Service personnel injured on deployed operations. Service clinicians would argue that the organization and delivery of acute trauma care that has developed to support contemporary combat operations is significantly advanced compared to the NHS. The publication of the NCEPOD report is an opportunity to objectively benchmark DMS trauma system performance against the NHS. The DMS has audited its clinical effectiveness in major trauma management in detail since 1999 [4] and has deployed personnel in a Trauma Nurse Co-ordinator role to collect relevant data throughout the contemporary conflicts in Iraq and Afghanistan, generating periodic reports of major trauma performance [5,6]. A Joint Theatre Trauma Registry (JTTR) is maintained at the Royal Centre for Defence Medicine (RCDM) in Birmingham. NCEPOD determined that under half (42%) of sampled NHS hospitals undertake detailed audit through subscription to the national Trauma Audit Research Network (UK TARN). Many NHS hospitals sampled treated less than one major trauma case per week, and some treated only 1-2 cases in the entire 12 week sampling period. Only 12/183 (6.6%) hospitals treated >1 major trauma case per week. Experience in dealing with major trauma was related to performance as those with a higher caseload (>20 major trauma in 12 weeks) were judged to deliver a higher percentage of care assessed as good practice. A benchmark of trauma system performance is provided by comparing NCEPOD findings with JTTR for the period 01 April 2006 to 30 September 2007.While including casualties treated by UK DMS in both Iraq and Afghanistan, the first date coincides with the start of UK combat operations in Southern Afghanistan. For this period there were 314 major trauma cases (calculated using the Abbreviated Injury Scale 2005, USMilitary version [7]), which is an average of 4.25 per week (51.0 over 12 weeks). Injury mechanisms and injury severity are different between the NHS and DMS patient cohorts: 56.3% of NHS major trauma patients are a result of motor vehicle collision (blast or gunshot are not coded and are included in 10.3% of “other” mechanisms); in the DMS cohort only 5.1% of major trauma is from MVC, with 53.8% blast/fragmentation and 29.9% gunshot. Banding the Injury Severity Scores demonstrated that the DMS cohort was significantly (p<0.0001) more severely injured than the NHS cohort (ISS 16-24, NHS = 56.5%, DMS = 26.4%; ISS 25-35, NHS = 35.1%, DMS = 22.3%; ISS 36-75, NHS = 8.4%, DMS = 51.3%). However, the injury severity must be interpreted with caution as AIS 05 (Military) has been adjusted from AIS 98 (UK civilian coding standard) to take account of injuries inflicted by military mechanisms. The lack of availability of senior clinical staff to direct the Trauma Team was identified as the norm in the NHS: 118/183 (64.5%) hospitals did not have a consultant Trauma Team leader during a specific sample period (early hours of Sunday morning) and in only 6/183 (3.3%) hospitals was the consultant team leader resident. This was considered to contribute to incorrect clinical decision making and lack of appreciation of the severity of injury. Independently, the National Patient Safety Agency has expressed concern that trainees are less able than consultants to recognize seriously ill or deteriorating patients and that this may have a detrimental effect on outcome [8]. In the deployed field hospital there is a full consultant-based team (consultants from each of the specialties of emergency medicine [team leader], anaesthesia, general surgery and orthopaedic surgery) resident in the hospital 24 hours a day and immediately available for the reception of any seriously injured patient. Specific criticism was made by NCEPOD of the lack of standardized transfer documentation, and the compliance with published guidelines. Secondary transfers were felt to be “conducted in haphazard fashion with little consultant oversight”. This contrasts with UK DMS policy where strategic movement of the seriously injured from the field hospital to RCDM relies on a consultant in intensive care as part of a Critical Care Air Support Team (CCAST): the mobilization of CCAST follows a standardized process and is the responsibility of the Air Evacuation Liaison Officer (AELO, usually a nurse) embedded with the field hospital. NCEPOD has commented on performance against a raft of clinical performance indicators (PIs) and the requirement to monitor PIs was highlighted by Royal College of Surgeons of England in 2000 [3]. The UK DMS continuous quality improvement programme for the seriously injured is referred to as ‘MACE’ (Major Trauma Audit for Clinical Effectiveness) and over 60 clinical PIs are tracked from point of wounding through to rehabilitation. Airway management in the pre-hospital setting is often challenging and a high incidence of partially obstructed or obstructed airways on arrival at hospital has prompted the GOVERNANCE AND DATA COLLECTION

Health system costs of in-hospital cardiac arrest

This paper reports on the health system resources used in the treatment of in-hospital cardiac arrests in a British district general hospital. The resources used in resuscitation attempts were recorded prospectively by observation of a convenience sample of 30 cardiac arrests. The post-resuscitation resource use by survivors was collected through a retrospective record review (n = 37) and by following survivor members in the prospective sample (n = 6). Financial data were used to translate resource use into costs (1999 prices). There was a non-significant trend for more resources to be used in daytime resuscitations than at night. Survivors had significantly fewer diagnostic tests during resuscitation than those who died (P = 0.004). Length of resuscitation attempt was positively and significantly related to resource use (P < 0.05). The average variable cost per resuscitation attempt (1999 prices) was 195.66 pounds sterling; 76.5% was for staff, and 13.1% for drugs and fluids. Emergency calls were attended by an average of 10.11 staff. The average fixed cost per resuscitation attempt was 928.81 pounds sterling; 12% for capital equipment and 73% for staff training. The average post-resuscitation costs attributable to the cardiac arrest of the 29 people surviving more than 24 h after cardio-pulmonary resuscitation (CPR) were estimated to be 1,589.72 pounds sterling. This is lower than other studies which estimated total costs of post-CPR lengths of stay. Reducing avoidable cardiac arrests would generate in-hospital savings in direct resuscitation care of survivors. Scope for reducing capital and training costs is discussed.

Combat “Category A” Calls: Evaluating The Prehospital Timelines in a Military Trauma System

Aim To establish the pre-hospital timelines for seriously injured UK military casualties on OP HERRICK. Population All consecutive MERT and MERT-E mobilizations from Camp Bastion, Helmand Province, between 04 May 06 and 18 Jun 07. Methods Interrogation of MS Access database compiled from paper patient report forms for each casualty transported. Results 528 patients were transported. 84.6% (456) were battle casualties. There were 192 GSW and 233 casualties with blast/fragmentation injuries. 189 of 528 (35.7%) were UK Service personnel. Median time from injury to handover at the emergency department for UK military T1 casualty subset was 99 minutes. Conclusion The public perception of excessive timelines for pre-hospital care in Afghanistan has been distorted. The ground truth is a pre-hospital time less than one quarter of the cited 7 hours for the seriously injured subset of UK Service personnel.

What is the Ideal Pre-Hospital Analgesic? – A Questionnaire Study

Aim To determine clinical opinion of effectiveness of current battlefield analgesia and the realistic options to improve future analgesia in hostile environments. Methods Structured electronic questionnaire distributed to selected individuals in UK and on operations. Population 122 UK Defence Medical Services and US Medical Corps doctors, nurses and combat medical technicians involved in the early management of severe trauma on deployment. Results 54 (44%) agreed and 63 (52%) disagreed that intramuscular morphine had the ideal analgesic properties for the military pre-hospital environment. Over half of those with operational experience reported multiple instances of intramuscular morphine providing inadequate analgesia. 86 (70%) desired a more potent analgesic than morphine in the first hour following injury. 101 (83%) identified simplicity and reliability of use by a soldier as of high importance. 99 (81%) identified rapid onset of action of high importance. With regard to an acceptable route of drug self-administration, 88 (72%) supported a nasal spray; 78 (64%) supported a sustained release buccal tablet (adhesive to the gum); 61 (50%) supported a disposable inhaler of volatile gas (although 91%had no experience of the currently available drug in this formulation); and 55 (45%) supported a skin patch. Conclusion Intramuscular morphine does not meet the needs of the majority of clinical stakeholders. Alternative routes of self-administration are acceptable, but support for available commercial solutions is clouded by incomplete awareness. Anaesthetists and emergency physicians desire a multimodal approach to battlefield analgesia within the evacuation chain.

A 26-year comparative review of United Kingdom helicopter emergency medical services crashes and serious incidents.

BACKGROUND The use of helicopter emergency medical services (HEMS) has increased substantially in the United Kingdom since 1987. There are currently no data on the rate of crashes and serious incidents related to HEMS in the United Kingdom. The aims of this article were to present data from a 26-year period since the start of HEMS operations in the United Kingdom and to compare them with published data from Germany, Australia, and the United States. Factors identified as affecting the safety of HEMS operations will also be discussed. METHODS A PubMed search was performed to retrieve published data on accident rates and safety discussions for international HEMS using the key words HEMS, helicopter, emergency medical services, accident, incident, and crash. The details of every helicopter crash in the United States since the beginning of HEMS operations was obtained and reviewed to identify those that involved HEMS aircraft. This novel UK information was compared with published data from three international systems. RESULTS A total of 13 accidents or serious incidents involving HEMS aircraft were identified from Civil Aviation Authority records, only 1 of which was a fatal accident. It was estimated that approximately 230,000 HEMS missions occurred in the United Kingdom between 1987 and 2013, giving an absolute accident incidence of approximately 0.0057% and a fatal accident incidence of approximately 0.00043%. The accident and fatal accident rate per 10,000 missions in the United Kingdom was 0.57 and 0.04, respectively. This compares with published rates from Germany, Australia, and the United States with accident rate per 10,000 missions ranging between 0.57 and 0.75 and fatal accident rates per 10,000 missions ranging between 0.04 and 0.23. CONCLUSION Accidents and serious incidents relating to HEMS operations in the United Kingdom have been comprehensively identified for the first time, allowing an estimation of overall accident and fatal accident rates and comparison with other countries’ HEMS operations. Data collection and analysis were hampered by obscurity of data sources and poor availability of data. In a time of increasing HEMS use in the United Kingdom, it is essential to be mindful of safety, and standardization of data collection will improve focus in this important area.

Shaped charges and explosively formed penetrators: background for clinicians.

Shaped Charges (SC) have been used in High Explosive Anti-Tank (HEAT) munitions and the mining industry since World War II. An explosive is used to propel a liner material of low mass at speeds in excess of 5 times the speed of sound. The subsequent projectile is capable of penetrating the steel of armoured vehicles and inflicting significant injury to any enclosed personnel. Explosively Formed Penetrators (EFP) are a variant of a SC, using higher mass at lower speed to deliver their kinetic energy. The Iraq conflict has seen the use of Improvised Explosive Devices utilising EFP (IED-EFP) by insurgent groups attacking military vehicles. The major wounding mechanisms are from fragmentation and burns. This article is a brief overview of the history and science behind SC and EFP.

A roadmap for innovation

Medicine has historically advanced during conflict, but military medical services have consistently regressed during peace. As over a decade of campaigning in Iraq and Afghanistan draws to a close, securing the legacy of hard won clinical lessons and retaining flexibility to adapt to new patterns of illness and injury during contingency is critical. Central to sustaining exceptional outcomes for future operations and to maintaining the current position of the Defence Medical Services as providers of clinical excellence is retaining the capability to innovate. This capability must extend across the spectrum of clinical innovation—concepts, guidelines, equipment (invention and adoption), curricula (design, assessment and refinement), research and Defence diplomacy. To achieve this requires a strategy, a ‘roadmap’, with a clear vision, end state and centres of gravity (core strengths that must be protected). The direction for innovation will be guided by emergent analysis of the future character of military medicine. Success will be determined by ensuring the conditions are met to protect and enhance the existing ‘winning culture’.

Evaluation Of Clinician Attitudes To The Implementation Of Novel Haemostatic Techniques

Innovation in industry, stimulated by the perceived requirement of the military customer, has generated a series of recent developments in the domain of external haemorrhage control. In response to tasking from Surgeon General, the Academic Department of Military Emergency Medicine (ADMEM) has guided the operational analysis and staged implementation of three changes to improve haemostasis following injury in combat. Two of these changes involve replacement of existing equipment (a new field dressing and a new arterial tourniquet); the third change is the adoption of a haemostatic agent, QuikClotTM. To enable the implementation, ADMEM developed a predeployment training programme to provide the necessary knowledge, skill and judgement to use the new products safely and effectively. This paper evaluates the confidence of clinicians to treat life-threatening external haemorrhage before and after training in the novel techniques.

UK defence medical services guidance for the use of recombinant factor VIIa (rFVIIa) in the deployed military setting.

Use of recombinant Factor VIIa (rFVIIa) for trauma is currently an ‘off label’ use. There are reports of rFVIIa contributing to the successful outcome of military trauma patients. This paper sets out the current position of the UK Defence Medical Services with regard to using rFVIIa in military trauma.