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Chelsey Smith was 15 when she was left with life-threatening injuries, following a road traffic accident in February last year.
After an initial assessment at the University Hospital in Wishaw, Lanarkshire, Chelsey was rushed to the West of Scotland’s Paediatric Major Trauma Centre in Glasgow for specialist treatment.
Consultant Paediatric Neurosurgeon Roddy O’Kane performed the surgery, to reduce the swelling and pressure on Chelsey’s brain, with part of her skull being removed and stored in her stomach to keep it sterile.
Following intensive rehab with the team at the RHC, Chelsey, who is now 16, has made a remarkable recovery and, less than a year after her final surgery, was a guest of honour at the Major Trauma Centre’s training day this week.
She said: “I just can’t thank all of the team here at the Royal Hospital for Children in Glasgow for everything they have done for me, they have saved my life and given me my life back too.
“I don’t remember much about the day of the accident to be honest, but I’m here now and that’s what matters. I have had so much support from Roddy, my Major Trauma Co-ordinator Lynsay Stewart, all of the staff at the hospital and of course my family.
“Roddy was able to magically take a part of my skull and put it in my stomach to let the swelling reduce in my brain, I don’t really know how it works but it’s amazing. It was a long journey and I would tell anyone who is in a similar situation to keep going, to make this recovery you have to be mentally prepared for it too and thankfully I had so many positive people around me to help with that.”
Chelsey is now back preparing for her exams at Brannock High in Newarthill, has been able to get a part-time job and is hoping to go on to study accountancy.
She said: “Obviously everything that happened was not good, but thanks to the Royal Hospital for Children team in Glasgow I have been able to get back to school and have also started a part-time job.
“I just want to say thank you again to everyone for all they have done for me. Even after my follow-up appointments are finished, I’ll keep coming back to visit, I have missed them all.”
The procedure which involves removing part of the skull is not common, but after other medical interventions were unsuccessful it was the last option to save Chelsey’s life.
Roddy said: “This procedure is not something that we do every day but it gave Chelsey the best chance of surviving the injuries she had sustained during the accident.
“We take part of the skull out and store it in the stomach in order to keep it sterile, this is usually re-attached after a couple of months once swelling has reduced.
“Chelsey’s recovery is absolutely remarkable, based on her condition when she arrived it is incredible to see how well she is doing. There was a real danger to her life and we also anticipated that there would be more of lasting impact on her life.
“We are all so proud of Chelsey and all of the hard work she has put in during her rehab with our specialist teams. We’re delighted for her and her family and were all beaming from ear to ear when we got to see her again today.”
The development of the Major Trauma Service in the West of Scotland came with significant resource to provide rehabilitation in order to achieve the Scottish Trauma Networks stated aim of: Saving Lives. Giving Life Back.
The rehabilitation team within the Major Trauma ward in the Queen Elizabeth University Hospital are delivering early, intensive, multidisciplinary rehabilitation to patients who are multiply injured and have complex rehabilitation needs. The team consists of speech and language therapists, physiotherapists, occupational therapists, clinical psychologists, dietitians, therapy support workers and major trauma co-ordinators.
Initial results are extremely positive and a number of QI projects have also been carried out. An analysis of the data collated since the Major Trauma ward opened in August 2021 shows that the median length of stay in the ward is 10 days. It also showed that 69.4% of patients were discharged straight home from the ward and 20.6% required repatriation to their local hospital. This has contributed to an improved patient journey and in these times of significant pressure on the NHS, is reducing the requirement for ambulance transfers and beds in trauma units.
“a set of measures that assist individuals, who experience or are likely to experience disability, to achieve and maintain optimum functioning in interaction with their environments”
(WHO, 2011)
Evidence shows that the earlier rehabilitation is provided and the greater the intensity, the better the outcomes for the patient (Hartley, Keevil, Alushi et al, 2019). It was with this evidence in mind that the ethos of the STN was developed.
The rehabilitation needs of medical inpatients is changing. Development of community based, admission avoidance schemes means that patients admitted to hospital tend to be more unwell and have more complex rehabilitation needs. This has been exacerbated by the COVID-19 pandemic: patients are more frail, deconditioned, present later in disease course and a significant proportion have underlying neurological diagnosis.
Ongoing challenges around bed capacity and ‘front door’ performance forced the opening of additional medical beds in the QEUH in October 2021. The current staffing complement within the medical sector is not able to meet the rehabilitation needs of the patients (Staff to patient ratios: Physiotherapy (PT) = 1:41, Occupational therapy (OT) = 1:56). This means that patients who are assessed as requiring rehabilitation, are seen on average twice a week.
Current staffing resource within the AHP team does not meet the rehabilitation needs of the patients who are located within medical, resulting in longer lengths of stay and reduced independence on discharge requiring significant packages of care and equipment provision. This has financial implications for the NHS in terms of bed days and equipment provision, and for Social Care in terms of ongoing provision of support at home, in addition to the detrimental effects for patients who they are not being facilitated to achieve their maximal functional potential.
Ward 11D was turned fully into a medical ward in October 2021. As no additional AHP staff were provided for these additional bed numbers, and with medical AHP staffing numbers already being low, the AHP Team from the Major Trauma ward were asked to cover these additional medical beds.
This situation was used as an opportunity to collect data on what therapy input and therapy resource was required by the patients within this area to ensure the best quality of care was provided to patient and service and assess the impact of enhanced staffing levels on patient length of stay and outcome.
PT and OT staff from the Major Trauma ward team were assigned to cover the additional medical beds, these staff had experience in neurorehabilitation and were a mix of bands from 6 to 8B.
Increased staff to patient ratio was made available compared to ‘normal’ staffing levels on established general medical wards.
All patients referred to PT/OT over a 6 week period were included.
Patients were provided with daily therapy input as required.
Rehabilitation need and complexity were quantified using the standardised Rehabilitation Complexity Scale (RCS-E)
Data on number of referrals, diagnosis, reason for admission, number of treatment sessions, hours of treatment and number of therapists required for each treatment session was collected in addition to length of stay, and requirement for onward referral to community teams or for packages of care at point of discharge.
Data was collected from both the intervention ward (with enhanced AHP staffing levels) and a comparator ward (with ‘normal’ medical AHP staffing).
The data gathered from both areas is summarised in the following table:
Specific case studies and anecdotal evidence from the Major Trauma team’s time covering 11D showed that it was not only the number of staff available to treat patients that had a positive impact on LOS and patient outcomes. They also found that having staff who were knowledgeable and had experience treating patients with neurological diagnosis with complex rehabilitation needs, was beneficial.
The data highlights that the right number of staff and experience has a significant impact on reducing patients LOS and improving patient outcomes. In this audit LOS was reduced by 6.29days and less patients were referred onto community rehabilitation teams therefore suggesting they achieved their rehabilitation potential in hospital as they received the right amount of specialist treatment. Additionally, significantly fewer packages of care were required for the patients discharged home. This evidence suggests that early and adequate provision of OT/PT intervention is beneficial not only for patients but also for the hospital.
Overall, the data gathered supports the conclusion that improved PT and OT staffing levels can have a positive impact on length of stay and patient outcomes for patients with complex rehabilitation needs, currently managed within medical wards. Ultimately this could result in reduced spend on bed days, equipment provision and care needs for these patients.
The planning and finance department calculated that based on the proposed figure of 416 patients being discharged each year, with an average reduction in length of stay of 6 days per patient, this could potentially save 2496 bed days per year. Based on a cost of £1,200 per day for a general medical bed, this would equate to a saving of £2,995,200 for bed days.
Implementation of the Major Trauma service in the West of Scotland came with significant allocation of resource for rehabilitation. This is to provide early, intensive rehabilitation in line with the British Society for Rehabilitation Guidelines (BSRM, 2015) in order to meet the networks aim of ‘Giving Life Back’.
There is a growing body of evidence which links at least daily multidisciplinary rehabilitation provision with an improvement in long term functional ability (Fan et al, 2020), particularly in patients following acquired brain injury (Konigs et al, 2018).
For patients not on the Major Trauma pathway, this level of daily intervention is not possible due to limited AHP and clinical/neuropsychology rehabilitation resource within the acute neurosurgical service at the Institute of Neurological Sciences (INS). The project compares the rehab provision in INS to major trauma who are staffed at an appropriate level.
Aims
Six patients with a diagnosis of brain injury who did not follow the MT pathway were identified and compared with six patients with similar demographics and initial presentation who followed the MT pathway.
Patients were highlighted for the comparison project by the Head Injury Advanced Practitioners at the QEUH.
Outcome measures used: Rehabilitation Complexity Scale (RCS) and the Functional Independence Measure + Functional Assessment Measure (FIM+FAM).
Data was collected on length of stay, disciplines involved, therapy attendances/hours and discharge destination.
Although a small sample size it highlights the variation for patients with similar presentations.
Outcome measures: Improvement in both outcome measures with average FIM+FAM score increasing (by 94 compared to 49) and RCS score decreasing (-9 compared to -5) for MT patients.
In addition to the significantly better patient outcomes on the major trauma pathway it also highlights:
The results of preliminary examination appear to support the hypothesis that patients following the MT pathway, who receive early, intensive, daily input from a multidisciplinary team, have a reduced length of stay and improved functional outcomes compared with those who are not on the MT pathway.
Ongoing research in conjunction with INS colleagues is indicated to yield a larger sample size and determine the reliability of these results and the associated cost savings in relation to bed days in an inpatient bed and long term care needs.
In addition to the findings from the two pilot projects completed, an analysis of the data collated since the Major Trauma ward opened in August 2021 shows that the median length of stay in the ward is 10 days.
It also showed that 69.4% of patients were discharged straight home from the ward and 20.6% required repatriation to their local hospital. This has contributed to an improved patient journey and in these times of significant pressure on the NHS, is reducing the requirement for ambulance transfers and beds in trauma units.
Of the patients that were discharged home, only 24% of them required onward referral for community follow up (Community Rehab Teams, MSK services, Brain injury Teams). Additionally only 6% of patients required a Package of Care at point of discharge.
These results are further evidence that having adequate rehabilitation resource which allows early, specialist multi-disciplinary rehabilitation to be carried out result in shorter length of stay, improved patient flow, improved patient outcomes and a reduction in the requirement for packages of care and community rehabilitation on discharge. The provision of this resource is therefore a benefit to both major trauma patients and the service.
What is it?
HECTOR began as the Heartlands Elderly Care Trauma and Ongoing Recovery course that was established to develop a training programme for clinicians and independent practitioners who are responsible for looking after older people who have injuries.
These injuries that an individual sustains often play second fiddle to the complex comorbidities, frailty, and the challenges of caring for them within an ever-pressured emergency care system.
The 2-day course mixes practical scenarios, moulages, lectures and discussions, focusing on the specific care needs of this group of patients.
Who is it for?
Healthcare professionals working with elderly people in the first 24-72 hours after sustaining traumatic injury either as part of the initial assessment or the early stages of rehabilitation.
Previous course participants have included advanced physiotherapists, occupational therapists, consultants and registrars in emergency medicine, geriatric medicine, general surgery and orthopaedics; general practitioners and prehospital responders; major trauma coordinators; nursing staff working with trauma patients; paramedics and rehabilitation staff.
Who is running it?
An interspecialty and multidisciplinary faculty from the Scottish (STN) and Northern Trauma Networks (NTN). The NTN have kindly supported the setting up of this course.
When is it?
The inaugural HECTOR Scotland course is being held on the 20th and 21st March 2023 at the Scottish Centre for Simulation and Clinical Human Factors (SCSCHF).
How do I apply?
Click this link or scan the QR code: HECTOR Application Form
If the link doesn’t work, then please contact fv.scschf@nhs.scot for an application form.
Closing date for applications:
27th January 2023.
Cost:
£350 for doctors, £100 for NMAHPs.
The difference in price is based on availability of study budgets for non-mandatory courses between staff groups.
Any questions, then email the centre fv.scschf@nhs.scot
Many thanks,
Joel, Claire, Jon and Sarah (HECTOR Scotland faculty)
“To treat patients with injuries and not injuries on patients”
D Raven, course founder
#HectorOverTheWall #SilverTrauma
Paediatric trauma pathways in the NoSTN have been rolled out and developed since August 2019 across Grampian and Highland.
Over this time, service improvement projects have been carried out to improve delivery of care to these patients. Of significance are the number of patients to benefit from the trauma pathway within RACH who do not meet STAG inclusion criteria. The trauma pathway, which includes psychology and trauma coordinator input alongside relevant specialties and therapies, has allowed for a greater cohort of patients to access enhanced care following a traumatic injury. Services have also been extended to include burns patients where appropriate. We continue to promote our service and pathway by regular face to face promotion and posters throughout RACH to ensure familiarity and an easy referral process for staff.
Data collected for RACH between August 2019 and June 2022 shows that 89 patients have been commenced on the trauma pathway. Of those, 22 patients did not meet STAG inclusion criteria. This equates to roughly 25% of all patients. Comparison of both patient groups shows similar mechanisms of injury and patient/family needs following injury, further justifying the need for inclusion of patients out with audit criteria. Data shows that accidents involving motor vehicles and falls from height were the most common cause of traumatic injury. Numbers are also currently being collected to identify how many patients required psychology input following traumatic injury, with or without a rehab need. The intention has always been to improve patient care for all patient groups by creating a robust pathway which can be replicated. These figures highlight the far reaching benefits of this pathway, showing that clinical reasoning for individual cases ensures the most appropriate patients are encompassed.
Patient experience questionnaires have been developed for paediatric patients and their families. There are 3 different questionnaires aimed at 7-11 year olds, 12+ years and parents/carers. These are designed to gain positive feedback regarding service delivery as well as to identify areas of improvement. Comments received from recently completed questionnaires are below:
The paediatric trauma coordinator role recently adapted to include cross working over paediatric and adults MTCs. There have been many advantages to this. When an adult is admitted to hospital, their children’s lives are significantly disrupted. The child may not directly be involved in the trauma themselves. However, the dual role enables additional areas of support to be highlighted and provided for these families. Following education for adult colleagues, there is an increased awareness of child protection concerns. Links with paediatric services are now stronger and more efficient. There are times when a child/children and adult/s from the same family are admitted simultaneously. Having links with both hospitals enables smooth communication and visiting, joined up care and a consistent point of contact for the family. There is also a group of young people who may fall under adult services but whose needs very much lie within paediatric services. This can be dependent on age and stage, whether they are still a dependent living at home and whether they still attend school. Strong links with both teams ensures these patients have access to the appropriate professionals and that links can be made with schools/nurseries, families and third parties to ensure tailored support.
CBIT in Hand
We have recently established excellent links with our colleagues at the Child Brain Injury Trust. As a result, we have joined forces and launched the CBIT in hand app in RACH. This app is designed to provide information and advice following head injury to patients and families, professionals and third parties who come into contact with the child. Head injury may range from mild concussion through to traumatic brain injury. The app has been well received throughout the hospital by staff and patients alike. Details are being collected of those signposted to the app in order to gain feedback.
RACH Website
During the 2020 Covid pandemic, patients were contacted to gain information on preferred communication methods and access to information/resources. The responses overwhelmingly pointed to the need for online, electronic and easily accessible information. This was true from both patient and parent perspectives. It was identified that a platform for sharing such information was missing. Following research and networking around the hospital, it was found that this was a widely supported idea. Fast forward a few years and we are in the midst of RACH website development, having been lucky enough to secure the support and funding from the Archie Foundation. Once complete, this will feature a section for the Major Trauma Centre, helping to promote the identity of our service and provide easy access to online information for families.
Follow-up Phone Call Audit
Patients who are commenced on the RACH trauma pathway will receive a follow-up phone call from the trauma coordinator after discharge. The purpose of the call is to provide safety netting, advice and action any outstanding issues which the family may have. An audit was completed to identify potential improvements to the follow up process for paediatric patients. Findings were as follows:
In October 2021 a team from RACH travelled to Orkney to undertake 2 days of paediatric trauma training. This involved lecture based education, multidisciplinary team simulation training with in situ practical procedures as well as question and answer sessions. Topics covered included chest and abdominal trauma, traumatic brain injury as well as child protection concerns and child death. The team thoroughly enjoyed their time there and the feedback was good. A similar trip is planned for September 2022 to Caithness General Hospital.
During Covid, the inpatient responsibility for those with head injuries moved from ED staff to the paediatric general surgeons. To try and ensure consistency with who was being admitted from ED, a proforma was created in accordance with SIGN guidelines. This has meant that decision making about who receives scans, who is observed, who is admitted etc is more streamlined and has led to clearer communication between the ED team and general surgery staff who look after these patients on the ward. The document has now been in circulation for over a year and we are looking at auditing its compliance in the near future. The remote and rural sites across the North of Scotland have also adopted this document. A similar inpatient proforma is also in circulation.
TRiM (Trauma Risk Management) is a trauma-focused peer support system developed to provide early help and information to staff who have experienced a traumatic/adverse/distressing event. Staff working in major trauma settings can be affected by a single distressing event or an accumulation of difficult/challenging situations. Indeed, this is relevant to working in a hospital setting more broadly and certainly not limited to major trauma. Enhanced staff support structures have been developed within RACH (and across NHSG) over the last few years. TRiM is one such development with an established pathway to request TRiM input following adverse events. Funding provided by the NoS Trauma Network enabled the Clinical Psychologist within the MTC pathway to complete TRiM training (practitioner and TRiM manager training) and contribute to the TRiM support available across RACH.
Written by Nina Currie (Paediatric Trauma Coordinator), Ashley Allan (Clinical Psychologist), Gillian Winter (Paediatric MTC Lead NoS/Specialty Doctor
The Scottish Trauma Network (STN) are pleased to announce the publication of the Nursing, Midwifery and Allied Health Professions (NMAHP) NMAHP Development Framework for Major Trauma.
This is hosted within the Education and Training section of the STN website;
https://www.scottishtraumanetwork.com/our-work/education-learning/
The NMAHP Development Framework for Major Trauma will be used by NMAHP practitioners caring for major trauma patients in any in-hospital setting at local, regional and national levels for identifying, planning and supporting learning needs, identifying career pathways and enhancing workforce planning.
This framework is the result of collaborative working between NHS Education for Scotland (NES) and the STN, working closely with NMAHP practitioners and consulting with the STN Education and Workforce group. It is aligned to the already published NES NMAHP Development Framework.
It is currently for registered practitioners at education levels 5-8 with the Healthcare Support Worker element following later in the year, in conjunction with the national HCSW commission.
Introduction by National Clinical Lead
Annual report time arrives once again, and in this new style of presentation my superlatives for the work of all who support the continued work, development and improvements of the Scottish Trauma Network will be brief. This is just as well, as the resources of my thesaurus begin to abate.
It is now 5 years since we convened and commenced our program of work to build and implement an entirely new clinical network of acute care and long-term rehabilitation for Scotland’s most seriously injured. August 30th 2021 witnessed the completion of Phase I with delivery of the fully operational end product. At time of writing, we run smoothly and successfully in the best traditions of “National Collaborative Pragmatism”.
All of this achieved of course, against the backdrop of complications presented to us by the pandemic. A remarkable achievement now recognised and acclaimed at the highest levels of the NHS, the Scottish Government, and national and international media.
This hard-earned and well-deserved reputation requires stiffening of the sinews and strengthening of resolve to be maintained, for us to progress further as we contribute well beyond our remit to the Remobilisation of the NHS in Scotland.
Thus, now begins Phase II, where we plan to tell the story using data, to raise standards for the future, and to demonstrate the sustained improved outcomes for patients, their families, their communities and the nation as a return on the visionary investment of these past 5 years.
The full report can be seen here
Martin McKechnie
National Clinical Lead
Scottish Trauma Network