Changing the System - Major Trauma Patients and Their Outcomes in the NHS (England) 2008-17

Christopher G Moran, Fiona Lecky, Omar Bouamra, Tom Lawrence, Antoinette Edwards, Maralyn Woodford, Keith Willett, Timothy J Coats, Christopher G Moran, Fiona Lecky, Omar Bouamra, Tom Lawrence, Antoinette Edwards, Maralyn Woodford, Keith Willett, Timothy J Coats

Abstract

Background: Trauma care in England was re-organised in 2012 with ambulance bypass of local hospitals to newly designated Major Trauma Centres (MTCs). There is still controversy about the optimal way to organise health series for patients suffering severe injury.

Methods: A longitudinal series of annual cross-sectional studies of care process and outcomes from April 2008 to March 2017. Data was collected through the national clinical audit of major trauma care. The primary analysis was carried out on the 110,863 patients admitted to 35 hospitals that were 'consistent submitters' throughout the study period. The main outcome was longitudinal analysis of risk adjusted survival.

Findings: Major Trauma networks were associated with significant changes in (1) patient flow (with increased numbers treated in Major Trauma Centres), (2) treatment systems (more consultant led care and more rapid imaging), (3) patient factors (an increase in older trauma), and (4) clinical care (new massive transfusion policies and use of tranexamic acid). There were 10,247 (9.2%) deaths in the 110,863 patients with an ISS of 9 or more. There were no changes in unadjusted mortality. The analysis of trends in risk adjusted survival for study hospitals shows a 19% (95% CI 3%-36%) increase in the case mix adjusted odds of survival from severe injury over the 9-year study period. Interrupted time series analysis showed a significant positive change in the slope after the intervention time point of April 2012 (+ 0.08% excess survivors per quarter, p = 0.023), in other words an increase of 0.08 more survivors per 100 patients every quarter.

Interpretation: A whole system national change was associated with significant improvements in both the care process and outcomes of patients after severe injury.

Funding: This analysis was carried out independently and did not receive funding. The data collection for the national clinical audit was funded by subscriptions from participating hospitals.

Keywords: Major trauma; Trauma systems; Wounds and injuries.

Figures

Fig. 1
Fig. 1
STROBE diagram identifying eligible study patients from TARN database in consistently submitting hospitals. *(Patients submitted from hospitals that began submitting after the study period commenced – these were combined with the study group in sensitivity analyses).
Fig. 2
Fig. 2
Trends in odds of surviving major trauma: April 2008–March 2017. Hospitals with consistent submissions. ISS ≥ 9, missing GCS imputed.
Fig. 3
Fig. 3
Trends in odds of surviving major trauma: April 2008–March 2017. All hospitals. ISS ≥ 9, missing GCS imputed.
Fig. 4
Fig. 4
Interrupted times series analysis of change in excess survival rate per 100 patients (W) around intervention in financial year 2012/13. Hospitals with consistent submissions. ISS ≥ 9, missing GCS imputed.
Fig. 5
Fig. 5
Interrupted times series analysis of change in excess survival rate per 100 patients (W) around intervention in financial year 2012/13. All hospitals. ISS ≥ 9, missing GCS imputed.

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