VOL: 97, ISSUE: 39, PAGE NO: 39
Captain Lee Turner, RGN, QARANC, is trauma nurse coordinator at Frimley Park Hospital, Camberley
Colonel Timothy Hodgetts, FRCP, FRCSEd, FFAEM, FIMC, FRGS, Dip MedEd, L/RAMC, is professor of emergency medicine and trauma, University Hospital, Birmingham
Major trauma is a high-profile aspect of any district general hospital’s activity. In 1988 the Royal College of Surgeons of England (RCS) estimated that 20% of hospital trauma deaths and 40% of prehospital trauma deaths were avoidable. Hussain and Redmond (1994) confirmed that up to 39% of prehospital trauma deaths were avoidable, and in 1997 the British Orthopaedic Association (BOA) went so far as to state that an alarming 70% of hospital trauma deaths were considered avoidable.
To find out what could be done to improve such alarming statistics, the Major Trauma Clinical Effectiveness Project (MTCEP) was established in October 1997. Since then it has been appraising the clinical management of each seriously injured patient entering Frimley Park Hospital in Camberley, Surrey. The project is funded by the Defence Secondary Care Agency, an executive agency of the Ministry of Defence that provides hospital-trained staff to support the armed forces.
Management of trauma is judged against predetermined standards - or performance indicators - in four areas of activity: prehospital care, resuscitation, definitive care and documentation. Areas of strength are identified and reinforced as good practice, while any failures are investigated and education is provided to reduce the chance of recurrences. In particular, trends in poor management are sought that demand a change in the system of care. This is in line with the recommendations of Better Care for the Severely Injured (RCS and BOA, 2000). The process of audit and education must be continuous to help clinical staff make critical decisions in the early management of severe trauma.
Trauma nurse coordinator
The MTCEP is led by a military trauma nurse coordinator (TNC) and supervised by the military professor of emergency medicine and trauma. The role of the TNC within this project is divided into three main areas: audit, education and clinical, although there are other aspects to the role.
Audit is perhaps the largest element of the TNC’s role. A computerised registry of all seriously injured patients is maintained. All patients who fulfil the criteria for trauma team activation (see box) are tracked, as are more than 40 performance indicators. The injuries of trauma patients are recorded and coded using the Abbreviated Injury Scale (Association for the Advancement of Automotive Medicine, 1998) and then ‘scored’ using a series of internationally accepted tools. Injury diagnosis can be obtained from the clinical notes, X-ray reports, surgeons’ notes at operation, and post-mortem findings. The scoring systems give a probability of survival, which enables both ‘unexpected survivors’ and ‘unexpected deaths’ to be identified. This allows good practice to be reinforced and poor practice to be improved. The results are disseminated to all those involved in the care of trauma patients, so closing the audit loop.
There are various educational initiatives, including lunchtime clinical case conferences. All those involved with the clinical care of trauma patients, together with hospital managers and audit personnel, are invited to debate the care given to the anonymous cases presented.
The benefits of the project have been presented nationally and internationally to nursing and medical audiences. A one-day trauma foundation course for nurses has also been established, which introduces the principles and practice of advanced trauma life support (Committee on Trauma, 1993). The project funds the individual issue of trauma handbooks to A&E senior house officers and specialist registrars, and supports A&E nursing staff to attend trauma-related study days.
The TNC attends trauma calls to act as the ‘scribe nurse’ within the trauma team to ensure high-quality documentation and the release of A&E nurses from an administrative task. The TNC also regularly visits the major trauma patients on the wards, documenting any delayed diagnoses, operative diagnoses or complications.
In addition, the TNC acts as a point of contact for liaison between departments and keeps in contact with tertiary referral hospitals to which our major trauma patients have been transferred for definitive care. This facilitates feedback to A&E staff about patients’ progress.
Military clinical governance
As the project has been sponsored by the Defence Secondary Care Agency, it understandably has an additional military dimension. Collection of data from military deployments has allowed, for example, the detailed analysis of injured soldiers and civilians treated in 22 Field Hospital in Kosovo during 1999 (Hodgetts et al, 2000).
The value of a trauma nurse coordinator is poorly exploited within UK trauma systems development. The TNC post at the MTCEP has evolved to meet the needs of the host trust and the Defence Medical Services. It is a challenging position that has helped to elevate the profile of nursing in conjunction with improving the care of seriously injured patients.