Outcome measurements in major trauma—Results of a consensus meeting
Introduction
For more than 20 years there have been multiple reports advocating the need for change in the care provided for the seriously injured patient in England. The issues were highlighted by the joint report from the Royal College of Surgeons (RCS) and the British Orthopaedic Association (BOA) in July 2000.1 These include the low numbers of patients, heterogenicity of injuries and varied outcomes. Seriously injured patients are acutely ill and require complex co-ordinated care, which will often exceed the capabilities of local services. Rehabilitation services are often inadequate and there is little information on morbidity following major trauma.
There is significant international evidence that centralisation of services and development of networks for severely injured patients improves outcome. Following the National Clinical Enquiry report; NCEPOD: Trauma Who Cares? in 2007,2 a commitment was made by Government to improve trauma services in England by the development of Regional Trauma Networks (RTNs). This process was given greater momentum by the National Audit Office (NAO) public spending reviews on Major Trauma in February 2010 and the subsequent Public Accounts Committee hearings in March 2010.3, 4
In May 2010 the new coalition government revised the NHS Operating Framework for 2011–2012, which states that all regions should move towards networks for trauma, with networks being in place by the end of the financial year 2011–12.5 In response to this all regions of England are making significant progress and are on track to have networks in place to meet this deadline.
The White Paper “Liberating the NHS” states five priorities: patient centred care, a focus on outcomes, accountability and responsibility, empowering clinicians to lead, reform and service development.6 As part of the focus on outcomes the NHS Outcomes Framework was developed.7 This framework will be the means by which the NHS Commissioning Board will be held to account by the Secretary of State for Health. One of the five framework domains recognises the importance of helping adults and children to recover from injury and the need for improvement in recording outcomes in trauma. A specific indicator is to be developed to monitor outcomes from injuries and trauma as part of that Domain 3. There is also a requirement to ensure a positive patient experience and to develop indicators to show this.
To date outcomes in major trauma have been measured in terms of mortality and short term health process measures. As RTNs mature the emphasis on performance will need to expand from case-mix adjusted mortality alone to measures of long-term morbidity, functional deficit and well-being.
To address this challenge a systematic review was performed jointly by TARN and the Cochrane Injury Group bringing together available evidence regarding outcome measures utilised in major trauma.
A multiprofessional group of senior leaders in the medical, nursing, allied health professional, public health and social care fields were brought together along with researchers and policy leads from the Department of Health (DH) and Department for Works and Pensions (DWP). They were asked to consider the report and using their personal knowledge and presentations given on the day to deliberate and reach a consensus on the way forward.
Section snippets
Objectives
This report will summarise the deliberations of the group, on the outcome measurements available in major trauma and to present recommendations for the selection of outcome measurements in major trauma patients.
Methodology
The objectives of the group were to make recommendations for a limited selection of outcome measures that could be usefully adopted to compare patient outcomes at one or two years following injury, and that could be both integrated into National Clinical Audit data collection and be considered for the Outcomes Framework. These outcome measures should be appropriate for use by RTNs as part of their clinical governance requirements and be measures by which RTNs performance improvement could be
Recommendations and discussion
The group generally agreed with the process indicators and risk adjusted mortality measures presented in the TARN and Cochrane systematic review with some additional comments:
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The children's group called for a study on the use of tranexamic acid in children.
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The children's group agreed that although severe head injuries in patients <65 years of age should be treated in a neurosurgical unit within 6 h of injury; they were concerned this may cause problems in children due to the very limited numbers
Conclusion
There is still work needed on outcome measures especially in the paediatric setting, but also in major trauma in general. Whilst there are no perfect measures available it was agreed as most important to make that large step to assess the outcomes of patients after major trauma other than survival. Patient experience is also key both politically and in ensuring that services are designed, improved and maintained with the needs and wants of patients central. This area is still in development and
Conflict of interest statement
There are no financial or personal relationships with other people or organisations that could inappropriately influence (bias) the work of the three authors. There are no conflicts of interest.
Acknowledgements
The following were members of the consensus group:
Arun Bhoopal (Statistician, Outcomes Framework Team, Department of Health); Professor Bipin Bhakta (Charterhouse Professor of Rehabilitation Medicine, University of Leeds); Mr Tim Chesser (Consultant Trauma & Orthopaedic Surgeon, Frenchay Hospital); Antoinette Edwards (Projects and Research Manager, Trauma Audit and Research Network); Dr Phil Edwards (Senior Lecturer, London School of Hygiene and Tropical Medicine and Cochrane Injuries Group);
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2021, International Emergency NursingCitation Excerpt :Despite the magnitude of nonfatal injuries that require health care, few trauma registries routinely collect outcomes other than mortality [3]. At present, there is also a growing interest to capture patient-reported outcomes as well as patients’ experiences, in order to gain a comprehensive picture of outcome after trauma and to ensure care is designed, improved and maintained according to their wants and needs [4–7]. A systematic review by Polinder et al. [8] shows that health-related quality of life (HRQoL) in the general injury population overall improved during the year following a trauma.