MAJOR TRAUMA AUDIT

MAJOR TRAUMA AUDITPAEDIATRIC REPORT 2014–2019

Prof Conor DeasyMajor Trauma Audit Clinical Lead

Louise BrentIrish Hip Fracture Database and Major Trauma Audit Manager National Office of Clinical Audit

Olga BrychData analyst National Office of Clinical Audit

Dr Ciara MartinPaediatric Emergency Medicine – Children’s Health Ireland

Dr Caroline Mason MohanPublic Health – Royal College of Physicians of Ireland

Naomi Fitzgibbon Major Trauma Audit Public and Patient Interest Representative

REPORT PREPARED WITH ASSISTANCE FROM MEMBERS OF THE MTA GOVERNANCE COMMITTEE

NATIONAL OFFICE OF CLINICAL AUDIT (NOCA)

NOCA was established in 2012 to create sustainable clinical audit programmes at national level. NOCA is funded by the Health Service Executive Quality Improvement Team and operationally supported by the Royal College of Surgeons in Ireland.

The National Clinical Effectiveness Committee (NCEC, 2015, p.2) defines national clinical audit as “a cyclical process that aims to improve patient care and outcomes by systematic, structured review and evaluation of clinical care against explicit clinical standards on a national basis”. NOCA supports hospitals to learn from their audit cycles.

Electronic copies of this report can be found at: https://www.noca.ie/publicationsBrief extracts from this publication may be reproduced provided the source is fully acknowledged.

Citation for this report:National Office of Clinical Audit, (2021)Major Trauma Audit Paediatric Report 2014-2019. Dublin: National Office of Clinical Audit.

ISSN 2009-9673 (Print)ISSN 2009-9681 (Electronic)

This report was published on 10 March 2021

National Office of Clinical Audit, 2nd Floor, Ardilaun House, 111 St Stephen’s Green, Dublin 2, D02 VN51

Tel: + (353) 1 402 8577Email: [email protected]

DESIGNED BY For more information about this report, contact:

ACKNOWLEDGMENTS

This work uses data provided by patients and collected by their healthcare providers as part of their care. NOCA would like to thank the valuable contribution of all participating hospitals, in particular the Major Trauma Audit coordinators and clinical leads. Without their continued support and input, this audit could not continue to produce meaningful analysis of trauma care in Ireland. We would like to thank Philip Dunne, IT Systems Support from the Healthcare Pricing Office, who provides ongoing support for the HIPE portal. We wish to also thank our peer reviewers for their input and constructive feedback for this report.

NATIONAL CLINICAL EFFECTIVENESS COMMITTEE (NCEC)

The National Clinical Effectiveness Committee (NCEC) is a Ministerial committee of key stakeholders in patient safety and clinical effectiveness. Its mission is to provide a framework for endorsement of guidelines and audit to optimise patient and service user care. The NCEC’s remit is to establish and implement processes for the prioritisation and quality assurance of clinical guidelines and clinical audit and subsequently recommend them to the Minister for Health for endorsement and mandating for national implementation. Major Trauma Audit

NCEC National Clinical Audit No. 1

NOCA would like to thank Mr Kieran Minihane; Mrs Aoife Minihane and The National Ambulance Service for supplying imagery used throughout this report.

ACKNOWLEDGING SIGNIFICANT CONTRIBUTIONS FROM THE FOLLOWING:

NOCA has engaged the internationally recognised Trauma Audit and Research Network (TARN) to provide its methodological approach for MTA in Ireland. TARN has been in operation in the UK since the 1990s and has been at the forefront of quality and research initiatives in trauma care. It is the largest trauma registry in Europe and is clinically led, academic and independent.

TARN use a standardised dataset for trauma patients, allowing review of care at both organisational and national level, thereby assuring the quality of and ultimately improving trauma care.

The Quality Improvement Team (QIT) was established to support the development of a culture that ensures improvement of quality of care is at the heart of all services that the HSE delivers. HSE QIT works in partnership with patients, families and all who work in the health system to innovate and improve the quality and safety of its care.

Major Trauma AuditPaediatric Report 2014-2019

Prof Conor DeasyClinical LeadMajor Trauma AuditNational Office of Clinical Audit2nd Floor, Ardilaun House111 St. Stephen’s GreenDublin 2

25th January 2021

Dear Dr Deasy,

I wish to acknowledge receipt of the Major Trauma Audit National Report 2019. Following your presentation to the NOCA Quality Assurance Committee on the 17th December 2020 we are delighted to endorse this report.

On behalf of the NOCA Governance Board, I wish to congratulate you and your committee on an excellent report which gives assurance to the major trauma patients that their care is being carefully monitored in Irish hospitals.

Please accept this as formal endorsement from the NOCA Governance Board.

Yours sincerely,

Dr Brian CreedonClinical DirectorNational Office of Clinical Audit

National Office of Clinical Audit2nd Floor

Ardilaun House, Block B111 St Stephen’s Green

Dublin 2, D02 VN51Tel: + (353) 1 402 8577

Email: [email protected]

MAJOR TRAUMA AUDIT PAEDIATRIC REPORT 2014-2019 5

All those involved in the care of children and young people will welcome the focus on trauma in childhood in the Major Trauma Audit Paediatric Report 2014–2019.

The Major Trauma Audit (MTA) is a key example of how services can be improved and further developed through the use of clinical audit. It reflects the importance of work being done by the National Office of Clinical Audit and the MTA Governance Committee.

Paediatric healthcare in Ireland is undergoing change with the reconfiguration of services and the building of the new children’s hospital in Dublin, which will be the location of Ireland’s Major Paediatric Trauma Centre. A National Model of Care for Paediatric Healthcare Services in Ireland (Health Service Executive, 2015) provides the framework for service configuration, and implementation of the model of care is underway.

This report examines the landscape of Irish paediatric major trauma. Children accounted for a significant proportion of the major trauma population from 2014 to 2019, and of those, 4% died. Boys are more likely to be injured than girls, and the home is the commonest place where injuries occur. Most injuries are preventable. Thirty four percent of injuries in infants under one year were suspected to be non-accidental. Society needs to look out for and protect these vulnerable children.

Many children arrive to hospital by car, which has implications for pre-hospital care, pre-alert systems and the preparedness of the emergency department team. More than half (57%) of paediatric major trauma patients were transferred to another unit for further management; however, transport of injured children is not without its risks.

Road trauma is a major cause of death and disability in children. This report highlights the necessity of access to rehabilitation in the hospital setting. While Ireland has had commendable success in reducing child deaths due to road trauma, more needs to be done to make our roads safer while protecting children’s rights to play, walk and cycle in their communities.

Trauma in children is everyone’s responsibility; society must do all it can to protect children. The preventable nature of devastating injuries to children highlights the crucial importance of education programmes, public awareness, parental support, and legislation where needed.

Data from the Major Trauma Audit Paediatric Report 2014–2019 will inform decision-making in the areas of paediatric trauma prevention, child protection and service configuration – including transport and rehabilitation – in order to ensure that all children and young people receive the right care in the right place at the right time.

It is welcome that a Paediatric lead for Trauma has been approved as part of 2021 new development funding. The Paediatric lead will work with the two Trauma Networks Clinical Leads as part of the Trauma System Implementation Programme.

I commend the National Office of Clinical Audit, the MTA Governance Committee and the editorial team on producing this Major Trauma Audit Paediatric Report 2014–2019. This report is highly relevant at this time and will be used to develop major trauma care pathways and drive improvements in the prevention and management of childhood trauma.

Dr Ellen CrushellClinical Lead, National Clinical Programme for Paediatrics and Neonatology

FOREWORD

DR ELLEN CRUSHELL

NOCA NATIONAL OFFICE OF CLINICAL AUDIT6

CONTENTS

01

02

03

0405

06

NOCA ENDORSEMENT LETTER 4FOREWORD 5GLOSSARY OF TERMS AND DEFINITIONS 10EXECUTIVE SUMMARY 12KEY FINDINGS 14KEY FINDINGS PAEDIATRIC INFOGRAPHIC 16KEY RECOMMENDATIONS 18CAPTURING PATIENT PERSPECTIVES 19WHAT IS MAJOR TRAUMA? 20 CHAPTER 1: INTRODUCTION 23Who is this report aimed at? 26

Aim and objectives 27

CHAPTER 2: METHODOLOGY 29Data collection 30

Data entry 30

Injury scoring 31

Data analysis 31

Hospitals included in the MTA 32

CHAPTER 3: DATA QUALITY 35Data for this MTA report 36

Data quality statement 36

Data coverage 42

Data accreditation 44

CHAPTER 4: KEY HIGHLIGHTS 2019 (INFOGRAPHIC) 47 CHAPTER 5: WHO WAS INJURED AND HOW WERE THEY INJURED? 51Age 52

Mechanisms of injury 54

Injury severity score 56

Place of injury 57

Body regions injured 60

Key findings from chapter 5 62

CHAPTER 6: THE PATIENT JOURNEY 63Presentation by time of day 65

Presentation by month and season 66

Mode of arrival 67

Most senior healthcare professional 68

Admissions by hospital 69

Transfers 70

Transfers by mechanism of injury 73



CHAPTER 7: CARE OF PAEDIATRIC MAJOR TRAUMA PATIENTS IN THE ACUTE HOSPITAL SERVICE 77Pre-alert 78

Reception by a trauma team 79

Grade of most senior doctor treating patient on arrival 81

Time to see patients on arrival at hospitals 82

Surgery 83

Hospital systems performance 84


CHAPTER 8: OUTCOMES 89Mortality at 30 days post-discharge 90

Mortality and age 90

Mortality by mechanism of injury 91

Mortality by body region injured 92

Discharge destination 93


CHAPTER 9: AUDIT UPDATE 95Updates on audit recommendations from 2018 96

Audit developments 98

Publications 99

Future developments 100

CHAPTER 10: RECOMMENDATIONS 101 CHAPTER 11: CONCLUSION 113 REFERENCES 115APPENDICES 119APPENDIX 1: INCLUSION CRITERIA 120APPENDIX 2: ABBREVIATED INJURY SCALE (AIS) 123APPENDIX 3: MTA GOVERNANCE COMMITTEE 124APPENDIX 4: FREQUENCY TABLES 125

08

07

09

1011


FIGURES

FIGURE 3.1: Data coverage percentages by hospital, 2019 43

FIGURE 3.2: Data coverage for major trauma audit paediatric report 2014-2019 43

FIGURE 3.3: Data accreditation percentages by hospital, 2019 44

FIGURE 3.4: Data accreditation by key data fields for major trauma audit 2019 45

FIGURE 3.5: Data accreditation by for major trauma audit paediatric report 2014-2019 45

FIGURE 5.1: Percentage of major trauma audit paediatric patients by age group (N=1382) 52

FIGURE 5.2: Percentage of paediatric major trauma audit patients by gender and age group (N=1382) 53

FIGURE 5.3: Mechanism of injury of major trauma audit paediatric patients by age group (N=1382) 54

FIGURE 5.4: Intent/activity at time of injury of major trauma audit paediatric patients by age group (N=1382) 55

FIGURE 5.5: Injury severity score of paediatric major trauma audit paediatric patients by age group (N=1382) 56

FIGURE 5.6: Place of injury for major trauma audit paediatric patients by age group (N=1382) 57

FIGURE 5.6A: Type of road trauma for major trauma audit paediatric patients (n=579) 58

FIGURE 5.6B: Position in vehicle for road traffic collisons (n=85) 59

FIGURE 5.7: Body region injuries all paediatric patients (N=1382) 60

FIGURE 5.7A: Body region injuries paediatric patients ISS>15 (n=488) 60

FIGURE 5.7B: Body region injuries paeditatric patients aged under <1 years old (n=138) 61

FIGURE 5.7C: Body region injuries paeditatric patients aged under 15 years old (n=109) 61

FIGURE 6.1: Presentation by time of day for major trauma audit paediatric patients (n=1360) 65

FIGURE 6.2: Presentation by month and season (N=1382) 66

FIGURE 6.3: Mode of arrival at hospital (n=1059) 67

FIGURE 6.4: Most senior pre-hospital healthcare professional (n=624) 68

FIGURE 6.5: Number of paediatric major trauma patient admissions by hospital (n=1174) 69

FIGURE 6.6: Number of patients who were transferred, by hospital model & childrens hospital (N=1737) 72

FIGURE 6.7: Percentage of paediatric major trauma patients who were transferred versus not transferred by mechanism of injury (N=1382) 73

FIGURE 6.8: Percentage of paediatric major trauma patients who were transferred versus not transferred by location of injury (N=1382) 74

FIGURE 6.9: Percentage of paediatric major trauma patients who were transferred versus not transferred by body region injured (N=1382) 75

FIGURE 7.1: Pre-alerted by age group (n=1174) 78

FIGURE 7.2: Reception by a trauma team by age group (n=1174) 79

FIGURE 7.2A: Reception by a trauma team for paediatric patients with an ISS >15 by age group (n=391) 80

FIGURE 7.3: Grade of most senior doctor treating paediatric patients on arrival by age group (n=1174) 81

FIGURE 7.4: Surgical intervention by body region injured and agr group (n= 689) 83

FIGURE 7.5: Airway management of paediatric major trauma patients with a GCS <9 (n=98) 84

FIGURE 7.6: Percentage of paediatric major trauma patients to receive a CT scan within 1 hour (n=114) 85

FIGURE 8.1: Mortality in paediatric major trauma patients by age group (n=57) 90

FIGURE 8.2: Mortality in paediatric major trauma patients by mechanism of injury (n=57) 91

FIGURE 8.3: Mortality in paediatric major trauma patients by body region most severely injured by age group (n=57) 92

FIGURE 8.4: Discharge destination for paediatric major trauma patients (n=1382) 93


TABLES

TABLE 1: Glossary of terms and definitions 10

TABLE 2.1: Data collection calendar 2019 30

TABLE 2.2: Injury severity score classification 31

TABLE 3.1: Data analysis for Major Trauma Audit Report 2019 36

TABLE 3.2: Data analysis for Major Trauma Audit Paediatric Report 2014-2019 36

TABLE 3.3: Overview of data quality for Major Trauma Audit 2019 37

TABLE 6.1: Hospital Models 71

TABLE 7.1: Most senior doctor seeing a patient in the ED, and seeing those with an ISS >15 82

TABLE 7.2: Intensive care unit length of stay (LOS) for paediatric major trauma patients 86

TABLE 7.3: Hospital length of stay (LOS) for paediatric major trauma patients 87


GLOSSARY OF TERMS AND DEFINITIONS

ACRONYM FULL TERM

AIS Abbreviated Injury Scale; a value between 1 (minor) and 6 (fatal) is assigned to each injury.

BOASTs British Orthopaedic Association Standards for Trauma and Orthopaedics

CCI Charlson Comorbidity Index

CHI Children’s Health Ireland; this statutory body was established on 1 January 2019 to govern and deliver acute paediatric services in Ireland. It currently provides care at Crumlin, Temple Street and Tallaght hospitals in Dublin.

CT computed tomography; a scanning technique that uses X-rays to take highly detailed images of the body.

DFB Dublin Fire Brigade

direct admissions Describes care in the first treating hospital.

ECMO extracorporeal membrane oxygenation

ED emergency department

ePCR electronic patient care report

GCS Glasgow Coma Scale; a measure of consciousness ranging from 3, indicating complete unconsciousness, to 15, indicating a state of normal alertness. The GCS comprises eye, verbal and motor scores.

GOSE Glasgow Outcome Scale Extended

HEMS Helicopter Emergency Medical Service

HIPE Hospital In-Patient Enquiry

HIQA Health Information and Quality Authority

HPO Healthcare Pricing Office

HSE Health Service Executive

ICD 10 International Classification of Diseases, Tenth Revision

ICU intensive care unit

IQR interquartile range

ISS Injury Severity Score; a score ranging from 1 (indicating minor injuries) to 75 (indicating very severe injuries that are very likely to result in death). An ISS between 9 and 15 is considered moderate. An ISS of >15 is considered severe and signifies major trauma.

LOS length of stay; refers to the length of time spent in the acute hospital for each patient.


ACRONYM FULL TERM

major trauma Major trauma describes serious and often multiple injuries where there is a strong possibility of death or disability.

MTA Major Trauma Audit

MTC major trauma centre; a multispecialty hospital, on a single site, which is optimised for the provision of trauma care and integrated with the rest of the trauma network.

NAI Non-Accidental Injury. For brevity this phrase is used in place of the more accurate terms “suspected non-accidental injury’ or ‘suspected physical abuse’

NAS National Ambulance Service

NCEC National Clinical Effectiveness Committee

NHS National Health Service (United Kingdom)

NOCA National Office of Clinical Audit

paediatric The term ‘paediatric’ refers to children aged 0–15 years (up until the eve of their 16th birthday).

PPI Public and Patient Interest

QIP quality improvement project

RTC road traffic collision

SCI Spinal Cord Injury

SHO Senior House Officer

SII Spinal Injuries Ireland

SPC Statistical Process Control

TARN Trauma Audit and Research Network

trauma ‘Trauma’ is a term which refers to physical injuries of sudden onset and severity which require immediate medical attention.

TBI traumatic brain injury

trauma network A trauma network is a coordinated, integrated system within a defined geographical region to deliver care to injured patients from injury to recovery through prevention, pre-hospital care and transportation, emergency and acute hospital care, and rehabilitation.

trauma unit A trauma unit is a major hospital within a trauma network that provides care for most injured patients.

TRIG Trauma Review Implementation Group

UK United Kingdom

WHO World Health Organization


The Major Trauma Audit (MTA) is a clinically led audit established by the National Office of Clinical Audit (NOCA) in 2013. This audit focuses on the care of the more severely injured trauma patients in Ireland’s healthcare system. The methodological approach for the MTA is provided by the Trauma Audit and Research Network (TARN) based in the University of Manchester, United Kingdom. In 2016, the MTA became the first national clinical audit endorsed by the National Clinical Effectiveness Committee (NCEC) and mandated by the Minister for Health.

Since 2016, all 26 eligible hospitals have been participating in the audit and data have been collected on more than 25,000 major trauma patients. The improved data quality and maturity of the audit has enabled hospital-level reporting since 2017.

The focus of this report is the paediatric major trauma population. This report includes audit data from the years 2014–2019. This report is timely, as a reconfiguration of national trauma services is currently underway, as is the construction of the new children’s hospital. The reconfiguration of these services will result in all the core and specialist trauma services being located on one site in each of the major trauma centres for adults and in the new children’s hospital. Information from this report should be used to inform both key national projects.

Since the publication of A Trauma System for Ireland: Report of the Trauma Steering Group by the Department of Health in 2018, the majority of the focus has been on restructuring the trauma system for adult patients. This report aims to shine a light on the importance of developing the paediatric trauma system within the trauma system’s overall reconfiguration. It is intended that this information will be used by healthcare commissioners, stakeholders and wider society to inform system changes and injury prevention strategies, and to monitor the impact and effects of the reconfiguration of trauma care delivery.

With the construction of the new children’s hospital already underway, it is essential that the correct pathways and resources are put in place to deliver the highest standards of trauma care. This report highlights the lack of rehabilitation services for children, currently CHI at Temple Street and CHI at Crumlin are the only hospitals with dedicated on site access to consultants with experience in rehabilitation, CHI at Temple Street is the only hospital to have a formal rehabilitation service and this is confined to children with neurological injuries (brain and spinal cord). Until such time as the doors to the new hospital open, a clear interim plan should be in place to provide the best trauma care possible within the existing service. The diverse nature of childhood injuries – both in type and in geographical location – will inform modifications to this existing service.

Each hospital, through its MTA governance committee, is encouraged to use MTA reports for continuous quality improvement. Without the constant leadership provided by the hospital clinical leads and the dedication and hard work of the audit coordinators, this audit would not be possible. The NOCA Executive Team and the MTA Governance Committee wish to thank the clinical leads, audit coordinators and staff in the participating hospitals for their continued commitment to, and engagement with, this audit.

EXECUTIVE SUMMARY


Since 2016, all 26 eligible hospitals have been participating in the audit and data have been collected on more than 25,000 major trauma patients. The improved data quality and maturity of the audit has enabled hospital-level reporting since 2017.


KEY FINDINGSKE

Y FI

ND

ING

S > Paediatric major trauma patients made up 5% (n=1382) of the overall major trauma population from 2014 to 2019.

>Paediatric major trauma peaks in the first 2 years of life, with more than one-quarter (26%, n=366) of all serious injuries in children occurring in this age group.

> Males account for a majority (63%, n=874) of paediatric major trauma cases.

> Falls from less than 2 m (termed ‘low falls’), road traffic collisions (RTCs) and burns account for 71% (n=985) of all paediatric major trauma patients.

>Non-accidental injury (NAI) was recorded in 5% (n=64) of all paediatric major trauma patients, and accounted for 34% (n=47) of major trauma in children aged under 1 year.

>Severe injury (Injury Severity Score (ISS) >15) was seen in 35% (n=488) of paediatric major trauma patients, which is comparable to adult major trauma patients.

> Home was recorded as the most common place of injury for paediatric major trauma patients (45%, n=628).

>The limbs and head are the most common body regions injured in all paediatric major trauma patients, at 32% each (n=439 and n=440, respectively).

> Paediatric major trauma presentations were more common in the afternoon and evening between 2.00pm and 9.00pm.

> Paediatric major trauma patients were most commonly admitted during the summer months.

>Although the majority of paediatric major trauma patients were brought to hospital by ambulance (55%, n=578), it is notable that 41% (n=431) were brought in by car.

>Of the patients brought to hospital by ambulance and/or helicopter, a paramedic or advanced paramedic treated 77% (n=482) of paediatric major trauma patients pre-hospital.


> Many injured children were transferred to another hospital for ongoing management (57%, n=994).

> Trauma teams received injured children on arrival to hospital in 20% of cases (n=234).

>Overall, a low percentage of paediatric major trauma patients were documented as having been pre-alerted (13%, n=150); this can be explained in part by a large percentage of patients arriving by car.

>Twenty-seven percent (n=312) of paediatric major trauma patients were documented as having been reviewed by a consultant within 30 minutes of arrival to the emergency department.

> The most common type of surgery performed was limb surgery (54%, n=370).

>Of the 114 paediatric major trauma patients who required a head computed tomography scan (having head injuries and an initial Glasgow Coma Scale score of <13), 52% (n=59) received it within 1 hour.

> The median intensive care unit length of stay (LOS) for paediatric major trauma patients was 1.5 days.

> The median hospital LOS was 5 days for all paediatric major trauma patients, and 6 days for patients with an ISS of >15.

> There were 57 children (4%) who died during hospital admission due to major trauma.

> The most common single mechanism of injury leading to death in paediatric major trauma patients was road trauma (32%, n=18).

> Eighty-three percent (n=1147) of paediatric major trauma patients were discharged directly home from hospital.

> Only 1% (n=19) paediatric major trauma patients were discharged to rehabilitation.

KEY FIND

ING

S


2-9PMPaediatric major

trauma presentations are more common in the afternoon and evening between 2.00pm and

9.00pm.

57%Transfer to another

institution for definitive management

occurred in 57% of paediatric

major trauma cases.

32%The limbs and head

are the most common body regions injured in

all paediatric major trauma patients,

at 32% each.

PAEDIATRIC KEY FINDINGS 2014-2019

35%35% has an Injury Severity

Score (ISS) of >15

ISS >15

26% 71%26% of major trauma

occurs in children aged 0–2 years.

Falls, road traffic collisions and burns account for 71% of

paediatric major trauma.

63%Male

37%Female


83%83% of paediatric

major trauma patients were

discharged directly home from hospital.

1%1% of paediatric

major trauma patients were

discharged to rehabilitation.

5The median hospital

LOS was 5 days for all paediatric major trauma

patients, and 6 days for patients with an

ISS of >15.

PAEDIATRIC KEY FINDINGS 2014-2019

Paediatric major trauma

patients are most commonly admitted during the summer

months.

54%45%The most common type of

surgery performed was limb surgery 54%.

45% of injuries occur in the

home.

52%52% of children who

required a head CT scan received it within 1 hour.


KEY RECOMMENDATIONS

RECOMMENDATIONS FOR THE HEALTH SERVICE EXECUTIVE

The Health Service Executive’s (HSE’s) National Office for Trauma Services and Integrated Care Programme for Children will:

• Use the Major Trauma Audit Paediatric Report 2014–2019 to develop interim paediatric major trauma care pathways until the new trauma system is fully developed and the new children’s hospital in Dublin is built, and to inform the requirements for rehabilitation services for trauma patients regionally and nationally.

• Continue to progress the development of a coordinated trauma system and fully implement the Trauma System for Ireland strategy.

• Define meaningful trauma team and rehabilitation criteria for collection within the Major Trauma Audit (MTA) for adults and paediatric patients.

• The HSE’s National Healthy Childhood Programme will: Use the information about mechanisms and location of injuries from the MTA 2014-2019 Paediatric Major Trauma Audit Report to inform the development and implementation of the Child Safety Programme.

RECOMMENDATIONS FOR THE ROAD SAFETY AUTHORITY

• The Road Safety Authority will: Use information about the mechanisms and location of injuries from the Major Trauma Audit Paediatric Report 2014–2019 to inform injury prevention strategies for children.

RECOMMENDATIONS FOR HOSPITAL MANAGERS, CLINICIANS AND AUDIT COORDINATORS

• Hospital MTA governance committees should complete the National Office of Clinical Audit (NOCA) hospital governance committee survey and continue to meet quarterly to discuss the MTA findings. Actions should be taken to improve services where deficits are identified.

RECOMMENDATIONS FOR NOCA

• NOCA will continue to support hospitals to attain high levels of data coverage and quality until at least 2022, as they recover from COVID-19.

• NOCA will conduct a survey of hospital MTA governance committees to determine what supports are required within the system to support hospitals to utilise the audit data for improvement.

• NOCA will develop meaningful quarterly dashboard reports of key performance indicators for the hospitals and Hospital Groups.

• NOCA will implement processes for the introduction of long-term outcome measures in the MTA.

• NOCA will develop a research group for the MTA, including Public and Patient Interest (PPI) representatives.

• NOCA will increase engagement with PPI representatives to:- develop resources to raise public awareness of preventable causes of major trauma- create information resources for patients - create opportunities for multistakeholder engagement around key issues faced by patients.


In 2019, I became a member of the Major Trauma Audit (MTA) Governance Committee as the Public and Patient Interest (PPI) Representative. In my role at Spinal Injuries Ireland (SII), I act as an advocate to support people in addressing issues encountered across a variety of health and social care settings. As a member of the MTA Governance Committee, I use my experience to contribute to this audit by highlighting aspects of the patient’s experience which are important for the patients and which can get overlooked when the focus is primarily on clinical outcomes.

This important report includes audit data regarding major trauma in children for the years 2014–2019. Monitoring and learning from the data can highlight areas for continuous quality improvement and identify how childhood injuries can be prevented. Although the number of spinal injuries in children is small, these injuries are hugely traumatic and can have a significant impact on the child’s future and on their whole family.

In my role with Spinal Injuries Ireland – which is the only dedicated support service in Ireland for people living with a spinal cord injury (SCI), their family members, carers, and healthcare professionals – we offer a unique national service from the moment the injury occurs, for as long as we are needed. Since the mid-1990s SII has been in the position to fully empathise with and understand the broad range of challenges facing people living with an SCI. We collaborate with allied healthcare professionals to bridge the gaps in the care pathway in order to ensure full inclusion in the local community when a person with a new injury returns home.

SII conducted research with University College Dublin Public and Patient Interest group to explore and identify research priorities utilising a co-design approach with family caregivers of SCI patients. Findings identified how family members have their own specific concerns and information needs which are distinct from those of the patients. This is particularly relevant to parents of a child with an SCI. The parents identified the need for a community support network, professional support, and assistance with navigating the health system for family members and carers.

In order to address these needs, we collaborated with Mater Misericordiae University Hospital to develop a family outreach programme and Peer Support Programme. These programmes have been specifically adapted for parents and carers of children with an SCI and includes trained volunteers who also have children with an SCI. These support services are now available nationwide from the moment a child sustains an injury. This programme complements our Community Outreach Team and the professional counselling that is available to help parents support their children through their injury.

Working with and supporting children with an SCI, we enhance medical and rehabilitation services by helping families to envisage a life with SCI and to come to terms with the reality of injury and disability. It is with this knowledge from SII and the findings from this report that I intend to combine my expertise as the MTA PPI Representative to disseminate the key messages from this report, and to look for opportunities to both prevent paediatric major trauma and to support patients who have suffered from it.

Naomi Fitzgibbon, RGN, MSc, FFRCSINMHead of Services, Spinal Injuries Ireland www.spinalinjuries.ie

CAPTURING PATIENT PERSPECTIVES

NAOMI FITZGIBBON


Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma. These injuries can be caused by blunt or penetrating mechanisms such as falls, motor vehicle collisions, stab wounds, and gunshot wounds (World Health Organization, 2014).

WHAT ARE THE MOST COMMON CAUSES OF MAJOR TRAUMA IN CHILDREN?

The most common causes of major trauma in children in Ireland are falls, road traffic collisions and burns.

HOW CAN WE PREVENT MAJOR TRAUMA IN CHILDREN?

Keep hot things out of the reach of children, especially

hot liquids, cups of tea/coffee, soup, pots on the

stove, kettles and teapots.

Ensure that lids on hot water bottles are fastened

correctly.

Check bath temperatures.

BURNS

FALLS IN CHILDREN AGED 2 YEARS OR UNDER

Take care when carrying small children,

especially on steps/stairs.

Watch out for tripping

hazards.

Fasten straps correctly on

seats.

Always keep bouncers

on a low surface.

Supervise young children sitting on couches or

chairs, in walkers, and on changing tables.

Install safety gates at the top and bottom

of stairs.

Use bicycle helmets for children of all ages.

WHAT IS MAJOR TRAUMA?


Wear seatbelts. Use the correct seat for the child’s age and ensure

that it is fitted properly.

Sit children in the back seats of vehicles.

ROAD TRAFFIC COLLISIONS

FARM ACCIDENTS

Supervise children on farms

at all times.

Know where children are before driving or operating

large machinery.

Lock the doors to sheds and

barns.

Take care when children are around large

animals, such as horses and cows.

Make sure that large objects (i.e. bales of hay,

tanks, bags of fertiliser) are not at risk of toppling.

Ensure that seatbelts

are in place in any farm vehicle.


CHAPTER 1INTRODUCTION


Childhood injury is the leading paediatric public health issue in the world, according to the World Health Organization (WHO, 2008). There are significant economic and societal burdens associated with non-fatal paediatric trauma and its long-term effects. Due to the heterogeneous nature of the paediatric population, treatment varies significantly depending on the age of each patient, and careful consideration is required when planning a responsive and appropriate trauma system. An example of such a system in Australia has shown how an integrated and inclusive regionalised trauma system has been associated with reduced mortality in paediatric major trauma patients (Deasy et al., 2012). The patterns of paediatric trauma are very different from those for adult trauma; and developing a greater understanding of the epidemiology of paediatric major trauma is therefore all the more vital for the new trauma system in Ireland.

Currently, children can present to the emergency department in any of the twenty-six hospitals participating in the MTA. Of those, there are three dedicated paediatric emergency departments. These emergency departments are located in Dublin at Children’s Health Ireland at Tallaght, Children’s Health Ireland at Temple Street and Children’s Health Ireland at Crumlin.

Work is ongoing to build a new children’s hospital, which will have satellite and links to regional paediatric units, in order to support the delivery of comprehensive paediatric care for Ireland’s children and young people. This new hospital will form the central component of a hub-and-spoke system which was described in A National Model of Care for Paediatric Healthcare Services in Ireland (Health Service Executive, 2015). The new hospital will be located on the campus of St James’s Hospital and all emergency care, including trauma care, will be delivered in one place. The main aim of this capital project is to provide Ireland’s children with the best care and treatments and to ensure that the right patient is seen in the right location by the right professionals.

The main emergency department will be supported by two urgent care centres at Tallaght University Hospital and Connolly Hospital, which will provide consultant-led urgent care and better local access to general paediatric and trauma orthopaedics outpatient services, chronic disease multidisciplinary team management, and diagnostics, and will work closely with community and home-based services. These urgent care units will have observation beds, diagnostic imaging and laboratory support. There will also be three regional paediatric units based in Cork, Limerick and Galway.

This is the fifth Major Trauma Audit (MTA) National Report published by the National Office of Clinical Audit (NOCA), and the first focusing on paediatric major trauma patients. The MTA was developed using the Trauma Audit and Research Network (TARN) methodology. TARN has been in operation in the United Kingdom (UK) since the 1980s, and has been at the forefront of quality and research initiatives in trauma care. It is the largest trauma registry in Europe and is clinically led, academic and independent. TARN has been integral to the reconfiguration of trauma care delivery in the UK and monitors the effects of the changes implemented. TARN receives and analyses anonymised MTA submissions from participating Irish hospitals and reports back to these hospitals. This feedback from TARN and NOCA supports hospitals’ and clinicians’ learning and the continuous improvement of care delivered to patients with major trauma. The MTA has gathered data on more than 25,000 major trauma patients in Ireland since 2013.

INTRODUCTION

CHAPTER 1


CHAPTER 1

The main aim of this capital project is to provide Ireland’s children with the best care and treatments and to ensure that the right patient is seen in the right location by the right professionals.

The data from the MTA continue to inform key system changes, such as the reconfiguration of the trauma system and the designation of major trauma centres and trauma units (Department of Health, 2018b). The MTA enables hospitals to measure their care against defined clinical standards in a transparent way, and supports active engagement in quality improvement. It also demonstrates how responsive the trauma system is to the changes that are underway. International evidence has shown us that the synergy between care standards, audit and feedback drive measurable improvements in patient outcomes, including a reduction in mortality (NHFD, 2015).

The MTA Governance Committee welcomes the first paediatric-specific report from the MTA and continues to support the reconfiguration of Ireland’s trauma system for all patients. The current need to focus on the care of the paediatric major trauma population will ensure the development of an informed, prepared and inclusive trauma system for all. Following in the footsteps of other trauma registers, reports focused on paediatrics can bring about significant change and lead to better outcomes for children. Due to the preventable nature of many childhood injuries, the information contained in this report can have far-reaching benefits.


CHAPTER 1

The work reported here is intended for the use of a wide range of individuals and organisations, including:

• patients and carers• patient organisations• healthcare professionals• hospital managers• Hospital Groups• policy-makers.

The report has been designed in three parts:

1. The Major Trauma Audit Paediatric Report 2014–2019 presents our key findings from the audit, including case mix, patient pathway and outcomes for paediatric patients.

2. The Major Trauma Audit Summary Paediatric Report 2014–2019 will be of particular interest to patients, patient organisations and the public.

3. The Major Trauma Audit National Highlights 2019 (Chapter 4) summarises key data fields from the overall major trauma population in 2019.

WHO IS THIS REPORT AIMED AT?


AIM AND OBJECTIVES

OBJECTIVE 3

To provide high-quality data in order to enable research.

OBJECTIVE 2

To promote the use of the data for reflective clinical practice, peer review and quality improvement in order to improve quality of care and reduce death and disability from trauma.

OBJECTIVE 4

To work towards collecting health-related quality-of-life and functional outcome measures which provide greater sensitivity to patient-centred outcomes.

OBJECTIVE 5

To capture the patient voice/experience and disseminate audit findings to patients and the public in an accessible manner.

OBJECTIVE 1

To support the collection of high-quality data in line with Health Information and Quality Authority (HIQA) standards on all major trauma patients in Ireland for local, national and international reporting and comparison.

OUR AIMThe MTA will drive

system-wide quality improvement to achieve the best

outcomes for trauma patients in Ireland.

CHAPTER 1

CHAPTER 2METHODOLOGY


CHAPTER 2

METHODOLOGY

DATA ENTRY

The MTA collects data on all major trauma patients who meet the inclusion criteria specified in Appendix 1. The audit uses the TARN methodology.

DATA COLLECTIONThe data are collected in the local hospitals by audit coordinators who enter the data retrospectively from patient medical records or information technology systems. Each hospital has an audit coordinator and a clinical lead and should have an MTA governance committee. A list of cases eligible for inclusion is identified by running a Hospital In-Patient Enquiry (HIPE) Report by the local HIPE manager. The data are then entered through the TARN website. The audit coordinator and clinical lead can generate local reports. TARN issues clinical reports three times a year and dashboard reports twice a year. In addition, NOCA sends quarterly reports to the Hospital Groups. Most data are entered retrospectively and in accordance with the data collection targets (Table 2.1). TARN’s coders and analytical team provide data analysis in order to create key variables in advance of sharing the data with NOCA. Examples of these key variables are the Injury Severity Score (ISS) (Table 2.2) and the Abbreviated Injury Scale (AIS) (Appendix 2).

Data collection period Data entry target Data reporting date

01/01/2019–31/03/2019 30/09/2019 18/10/2019

01/04/2019–30/06/2019 31/12/2019 30/01/2020

01/07/2019–30/09/2019 31/03/2020 18/04/2020

01/10/2019–31/12/2019 31/07/2020* 23/08/2020*

TABLE 2.1: DATA COLLECTION CALENDAR 2019

*The target date was extended by 4 weeks due to the COVID-19 pandemic.


CHAPTER 2

ISS

DATA ANALYSISNOCA received the data extract from TARN on 2 September 2020. This was later than anticipated due to the COVID-19 pandemic. Analysis for the MTA National Report was completed by the NOCA data analytics team following data checks with TARN. The analysis was conducted using Statistical Package for the Social Sciences V25.

INJURY SCORINGWhen auditing the management of major trauma, it is important to have a method for grading the severity of trauma sustained by a patient. Each injury is scored between 1 and 6 based on its severity using the AIS (Appendix 2). This contributes to the overall ISS for that patient, which is rated on a scale from 1 to 75 (Baker et al., 1974).

ISS CLASSIFICATION ISS EXAMPLES OF INJURIES

Low-severity injury 1–8 Fractured wrist or ankleSimple skull fractureSmall bleed in liver

Moderate-severity injury

9–15 Fractured femurSmall brain contusion (bruising)

Severe injury >15 Large subdural haematoma (bleed between skull and brain)Fracture of the pelvis with significant blood lossSevere injuries to multiple body regions

TABLE 2.2: INJURY SEVERITY SCORE CLASSIFICATION


NOTE: Dublin Hospitals have been displayed collectively by hospital group

SAOLTA UNIVERSITY HEALTH CARE GROUPLetterkenny University HospitalMayo University HospitalSligo University HospitalUniversity Hospital Galway

RCSI HOSPITALSBeaumont HospitalCavan General HospitalConnolly HospitalOur Lady of Lourdes Hospital, Drogheda

DUBLIN MIDLANDS HOSPITAL GROUPMidland Regional Hospital, TullamoreMidland Regional Hospital, PortlaoiseNaas General HospitalSt James’s HospitalTallaght University Hospital

IRELAND EAST HOSPITAL GROUPMater Misericordiae University HospitalRegional Hospital MullingarSt Luke’s General Hospital, KilkennySt Vincent’s University HospitalWexford General Hospital

CHILDREN’S HEALTH IRELANDChildren’s Health Ireland at CrumlinChildren’s Health Ireland at Temple Street

UL HOSPITAL GROUPUniversity Hospital Limerick

SOUTH/SOUTH WEST HOSPITAL GROUPCork University HospitalMercy University HospitalSouth Tipperary General HospitalUniversity Hospital KerryUniversity Hospital Waterford

HOSPITALS AND PEOPLE WE WORK WITH

LETTERKENNY UNIVERSITY HOSPITAL

CLINICAL LEAD: Dr Sinead O’Gorman

AUDIT COORDINATOR: Patrick McGonagle

AUDIT COORDINATOR: Sarah Meagher

MAYO UNIVERSITY HOSPITAL

CLINICAL LEAD: Dr Ciara Canavan

CLINICAL LEAD: Dr Ann Shortt

AUDIT COORDINATOR: Paul Crisham

SLIGO UNIVERSITY HOSPITAL

CLINICAL LEAD: Dr Kieran Cunningham

AUDIT COORDINATOR: Erin Lyons

GALWAY UNIVERSITY HOSPITALS

CLINICAL LEAD: Mr Alan Hussey

AUDIT COORDINATOR: Paul Crisham

UNIVERSITY HOSPITAL LIMERICK

CLINICAL LEAD: Dr Cormac Meighan

AUDIT COORDINATOR: Michael Fitzpatrick

MIDLANDS REGIONAL HOSPITAL, PORTLAOISE

CLINICAL LEAD: Dr Suvarna Maharaj

AUDIT COORDINATOR: Louise Cooke

CORK UNIVERSITY HOSPITAL

CLINICAL LEAD: Mr James Clover

AUDIT COORDINATOR: Ann Deasy

AUDIT COORDINATOR: Karina Caine

UNIVERSITY HOSPITAL KERRY

CLINICAL LEAD: Dr Niamh Feely

AUDIT COORDINATOR: Esther O’Mahony

UNIVERSITY HOSPITAL WATERFORD

CLINICAL LEAD: Mr Morgan McMonagle

AUDIT COORDINATOR: Margaret Mulcahy

SOUTH TIPPERARY GENERAL HOSPITAL

CLINICAL LEAD: Dr Cyrus Mobed

AUDIT COORDINATOR: Susan Ryan

MERCY UNIVERSITY HOSPITAL

CLINICAL LEAD: Dr Adrian Murphy

CLINICAL LEAD: Dr Darren McLoughlin

AUDIT COORDINATOR: Ann Deasy

CHAPTER 2


BEAUMONT HOSPITAL

CLINICAL LEAD: Dr Patricia Houlihan

AUDIT COORDINATOR: Anna Duffy

AUDIT COORDINATOR: Andrea Ormond

AUDIT COORDINATOR: Anthony O’Loughlin

CAVAN GENERAL HOSPITAL

CLINICAL LEAD: Dr Ashraf Butt

AUDIT COORDINATOR: Eilish Sweeney

CONNOLLY HOSPITAL

CLINICAL LEAD: Dr Emily O’Connor

CLINICAL LEAD: Dr Matthew Davies

AUDIT COORDINATOR: Therese Yore

CLINICAL LEAD: Dr Niall O’Connor

AUDIT COORDINATOR: Deborah McDaniel

OUR LADY OF LOURDES HOSPITAL, DROGHEDA

ST VINCENT’S UNIVERSITY HOSPITAL

CLINICAL LEAD: Dr John Cronin

AUDIT COORDINATOR: Brenda Cormican

AUDIT COORDINATOR: Keith O’Brien

WEXFORD GENERAL HOSPITAL

CLINICAL LEAD: Dr Paul Kelly

CLINICAL LEAD: Dr Michael Molloy

AUDIT COORDINATOR: Roisin O’Neill

CLINICAL LEAD: Dr Tomás Breslin

CLINICAL LEAD: Mr Seamus Morris

AUDIT COORDINATOR: Marion Lynders

MATER MISERICORDIAE UNIVERSITY HOSPITAL

CLINICAL LEAD: Dr Carol Blackburn

CLINICAL LEAD: Mr Brian Sweeney

AUDIT COORDINATOR: Trisha Hynds

CHILDREN’S HEALTH IRELAND AT CRUMLIN

CLINICAL LEAD: Prof Alf Nicholson

CLINICAL LEAD: Dr Nuala Quinn

AUDIT COORDINATOR: Jennifer Doyle

CHILDREN’S HEALTH IRELAND AT TEMPLE STREET

REGIONAL HOSPITAL MULLINGAR

CLINICAL LEAD: Dr Sam Kuan

AUDIT COORDINATOR: Helen Evans

ST LUKE’S GENERAL HOSPITAL

CLINICAL LEAD: Dr David Maritz

AUDIT COORDINATOR: Frances Walsh

CLINICAL LEAD: Dr Anna Moore

AUDIT COORDINATOR: Anita Sawyer

MIDLANDS REGIONAL HOSPITAL, TULLAMORE

TALLAGHT UNIVERSITY HOSPITAL

CLINICAL LEAD: Dr Jean O’Sullivan

CLINICAL LEAD: Dr Ciara Martin

AUDIT COORDINATOR: Noel Redmond

CHAPTER 2

ST JAMES’S HOSPITAL

CLINICAL LEAD: Mr Niall Hogan

CLINICAL LEAD: Dr Geraldine McMahon

AUDIT COORDINATOR: Ricardo Paco

NAAS GENERAL HOSPITAL

CLINICAL LEAD: Mr George Little


CHAPTER 3DATA

QUALITYRelevance

Accessibility and clarity

Timeliness and punctuality

Coherence and comparability

Accuracy and reliability


CHAPTER 3

DATA QUALITY STATEMENT

The purpose of the data quality statement (Table 3.3) is to highlight the assessment of the quality of the MTA data using internationally agreed dimensions of data quality as laid out in Guidance on a data quality framework for health and social care (HIQA, 2018). An overview of the aim and objectives of the MTA data collection is included in Chapter 1, and the MTA data source description is detailed in Chapter 2. This report focuses on two cohorts of MTA patients: 1) the Major Trauma Audit Report 2019 cohort, and 2) the Major Trauma Audit Paediatric Report 2014–2019 cohort. The data quality statement identifies strengths in the data quality (such as details which allow for subgroup analysis) and areas for further improvement (such as matching of cases). An overview of the assessment of the MTA against the dimensions of data quality is presented in Table 3.3.

DATA FOR THIS MTA REPORT

This report includes two patient cohorts:1. all patients who arrived for trauma care between 1 January 2019 and 31 December

2019, and who fulfilled the TARN eligibility criteria for inclusion (see Appendix 1)2. all paediatric patients who arrived for trauma care between 1 January 2014 and

31 December 2019, and who fulfilled the TARN eligibility criteria for inclusion (see Appendix 1).

DATA QUALITY

TABLE 3.1: DATA ANALYSIS FOR MAJOR TRAUMA AUDIT REPORT 2019

2019

Number of participating hospitals 26

All TARN submissions 4978

Individual patients 4431

Not transferred (into or out of first hospital) 3491

Direct admissions 4040

TABLE 3.2: DATA ANALYSIS FOR MAJOR TRAUMA AUDIT PAEDIATRIC REPORT 2014–2019

2014-2019

Number of participating hospitals 26

All TARN submissions 1737

Individual patients 1382

Not transferred (into or out of first hospital) 743

Direct admissions 1174


CHAPTER 3

TABLE 3.3: OVERVIEW OF DATA QUALITY FOR MAJOR TRAUMA AUDIT 2019

Dimensions of data quality

Definition (HIQA, 2018)

Assessment of dimension (MTA)

Relevance Data meet the current and potential future needs of users.

The MTA dataset is reviewed continuously as part of the TARN and MTA governance structures in order to ensure that all data fields are relevant. All core data fields are reported on in the MTA National Report and in local hospital reports. Monthly teleconferences with the audit coordinators enable any new data fields or definitions to be discussed and feedback given to TARN.

In 2019, the MTA Governance Committee identified a need to highlight the information about paediatric major trauma, as the trauma system reconfiguration is predominantly focusing on adult trauma.

Feedback on the relevance of the data is sought through interactions with other organisations – such as the Healthcare Pricing Office (HPO), the Trauma Review Implementation Group (TRIG), the National Office for Trauma Services and the Health Service Executive (HSE) – and researchers. Regular meetings took place in 2019 in fulfillment of this.

The NOCA quarterly reports are being developed to provide more real-time feedback and a better understanding of the data using Statistical Process Control (SPC) charts to show variations in data and improvements.


CHAPTER 3

TABLE 3.3: OVERVIEW OF DATA QUALITY FOR MAJOR TRAUMA AUDIT 2019 (CONTINUED)




Accuracy and reliability

Data correctly and consistently describe what they were designed to measure.

The MTA collects data on trauma patients through a secure portal on the TARN website. The reference population for the MTA National Report for 2019 includes two cohorts:

1) all patients admitted in 2019 with major trauma2) all paediatric patients admitted between 2014 and 2019 with

major trauma.

Full inclusion details are described in Chapter 2 and Appendix 1.

The coverage for the reference population of this report is detailed in Figures 3.1 and 3.2. Coverage has been reported at hospital level in the annual national report, and quarterly to the Hospital Groups, since 2017. The expected standard is a minimum of 80% coverage. In 2019, 14 hospitals achieved above the 80% coverage target, with the final national coverage being 76%. For the Major Trauma Audit Paediatric Report 2014–2019, the coverage is estimated to be 81% at a minimum. Since 2018, hospitals could exclude ineligible cases; therefore, the coverage for the paediatric report may be an underestimation – it may be better than we have reported. However, because the coverage is over the minimum target of 80%, we can state that the data are representative.

NOCA collaborates with hospitals and TARN to improve data entry, identify duplicates and clarify missing or incorrect data. TARN provides an accreditation report which calculates the completion of key data fields (detailed in Figures 3.3 and 3.4). The accreditation for 2019 was 95% and the accreditation for the 2014–2019 paediatric report was 94%.

In 2019, two workshops were held for audit coordinators and clinical leads. The workshops were provided by TARN and consisted of a morning session focused on data entry and an afternoon session focused on interpretation of TARN reports. Both workshops were well attended. TARN provides biannual dashboard validation reports to hospitals; these are used by the hospitals in order to review data quality. Other validation reports are also available by logging on to the TARN website (www.tarn.ac.uk).

Although most MTA submissions (i.e. patient journeys) are matched when patients move from one hospital to another, there are a small number of cases that are not, and therefore this will be a key area of focus for improvement within the audit. Further improvement work is ongoing between the NOCA data analytics team and TARN to validate a number of variables. The hospitals participating in the audit will be invited to test these additional validations.


CHAPTER 3





Timeliness and punctuality

Data are collected within a reasonable agreed time period and are delivered on the dates promised.

NOCA issues data collection targets for each hospital to collect a minimum of 80% of data per reporting quarter. The timeliness of submissions per quarter for 2019 was as follows:

Quarter 1: 30 September 2019 Quarter 2: 31 December 2019 Quarter 3: 31 March 2020 Quarter 4: 31 July 2020 (this was 4 weeks later than usual due to the disruption from the COVID-19 pandemic).

These data are processed and reported (released) by NOCA to Hospital Groups within 3 weeks of the end of the reporting quarter, one quarter in arrears. The MTA NOCA reporting calendar is provided in Chapter 2 (Table 2.1).

These reports highlight the national coverage versus the individual hospital coverage in relation to the data collection target and compliance with a number of clinical standards.

These reports are specific to the Hospital Groups and are in addition to the TARN clinical working reports, dashboard reports and local reports generated by TARN for the hospitals.

Data entry targets are reviewed quarterly at each MTA Governance Committee meeting. The closing date for data entry for 2019 was 31 July 2020. The NOCA Monitoring and Escalation Policy details the process of escalation. In 2019, 14 hospitals met the annual target of 80% data coverage and 12 did not. Many of the hospitals had been adversely affected due to the COVID-19 pandemic, with the majority of audit coordinator staff being redeployed for prolonged periods. Hospitals which were not meeting the targets were contacted and supported by the Major Trauma Audit Manager in achieving their targets.


CHAPTER 3





Coherence and comparability

Data are consistent over time and across providers and can be easily combined with other sources.

The MTA uses validated and comparable metrics to allow benchmarking, including the International Classification of Diseases, Tenth Revision (ICD 10) codes used in the HIPE system, the Charlson Comorbidity Index (CCI), the Glasgow Outcome Scale Extended (GOSE), the British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs), the ISS and the AIS.

TARN has a data entry guide and procedure manual for the Republic of Ireland (updated July 2020) available from the TARN website, and NOCA provides a handbook for data collection which is available on the NOCA website (www.noca.ie).

In 2018, a more detailed data dictionary for MTA was commenced, in line with HIQA’s Guidance on a data quality framework for health and social care (HIQA, 2018). This was completed by Q3 2019.

MTA data can be compared directly with data in the UK through the TARN audit. Some definitions vary slightly, but overall, the TARN audit acts as an appropriate international comparator.

Any changes to the dataset, definitions and methodology are documented on the TARN website (www.tarn.ac.uk), and any relevant changes would be noted in the MTA National Report. Changes in data collection are highlighted in the MTA National Report and on the TARN website. There have been no changes documented to date.


CHAPTER 3





Accessibility and clarity

Data are easily obtainable and clearly presented in a way that can be understood.

A list of publications for the years 2014–2019 is available on the NOCA website under Publications (www.noca.ie).

Hospitals and Hospital Groups (if requested) can access their TARN data via a secure portal on the TARN website. This includes three clinical working reports, two dashboard reports and a number of local reports. Access to TARN data for Ireland is managed and governed by NOCA. Policies relating to this were reviewed in 2019 in order to align with evolving data protection legislation (Data Protection Act 2018 (Section 36(2)) (Health Research) Regulations 2018).

The data access request policy is available by contacting NOCA ([email protected]).

Ad hoc requests for data or audit reports must receive approval from the MTA Governance Committee.


CHAPTER 3

DATA COVERAGEThe data coverage refers to the measure of major trauma cases entered against the overall expected number of cases (this is also referred to as case ascertainment). The expected number of cases is estimated based on the HIPE codes for the reporting year. The TARN eligibility criteria for inclusion (Appendix 1) are applied to the national HIPE codes in order to estimate how many patients in each hospital potentially meet the inclusion criteria for the audit. The limitations to this process were identified in the Major Trauma Audit National Report 2016, and during 2017 and 2018, NOCA worked with the HPO and TARN to enable the audit coordinators from the hospitals to identify cases that did not meet the inclusion criteria for the audit and exclude these from the hospital denominators. A report was built on the HIPE system during 2020 that allowed the data for 2019 to be retrospectively entered and an accurate coverage report provided to NOCA.

The national coverage for this report is described in two cohorts: 1) The Major Trauma Audit 2019 total coverage is 76% (Figure 3.1). This includes

patients of all ages who met the inclusion criteria and had data entered on TARN. 2) The Major Trauma Audit Paediatric Report 2014–2019 coverage is 81% (Figure 3.2).

Since 2017, hospitals have been able to exclude ineligible cases; however, in the earlier years of the audit, this mechanism was not in place. Therefore, the coverage for the paediatric report may be an underestimation. However, because the coverage is over the minimum target of 80%, this is not an issue.

The coverage is the direct result of the hard work and commitment of our audit coordinators and clinical leads. Fourteen hospitals achieved the TARN coverage (case ascertainment) target of 80%, and 12 hospitals did not. The data collection in the majority of hospitals was severely impacted from March 2020 due to the COVID-19 pandemic as a result of many of our audit coordinators being redeployed to support frontline services. In an effort to make the data for 2019 as complete as possible, the deadline for data entry was extended by 1 month until 31 July 2020.


CHAPTER 3

FIGURE 3.1: DATA COVERAGE PERCENTAGES BY HOSPITAL, 20191

FIGURE 3.2: DATA COVERAGE FOR MAJOR TRAUMA AUDIT PAEDIATRIC REPORT 2014–2019

FIGURE 3.2: DATA COVERAGE FOR MAJOR TRAUMA AUDIT PAEDIATRIC REPORT 2014–2019

70%75%

99%

82% 81% 79% 81%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2014 2015 2016 2017 2018 2019 Total

PERC

ENTA

GE

YEAR

1 NAAS excluded due to no data entry

FIGURE 3.1 DATA COVERAGE PERCENTAGES BY HOSPITAL, 2019

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Mat

er

Bea

umon

t

Wex

ford

Sou

th T

ippe

rary

Drog

heda

Cork

May

o

Kilk

enny

Galw

ay

Conn

olly

Kerry

Cava

n

Wat

erfo

rd

Tem

ple

Stre

et

Talla

ght

Crum

lin

Tulla

mor

e

Limer

ick

Lette

rken

ny

St Ja

mes

's

Mul

linga

r

Mer

cy

Slig

o

St. V

ince

nt's

Portl

aoise

Nat

iona

l

PERC

ENTA

GE

HOSPITALSCompleteness

80% Coverage completeness


CHAPTER 3

DATA ACCREDITATIONThe completion of key data fields for each recorded episode of care is used as the second measure of data quality (Figure 3.3). This is called data accreditation. TARN applies a standard of 95% for this measure.

The national data accreditation for this report is described in two cohorts:

1) Each hospital’s total accreditation for the Major Trauma Audit 2019 is shown in Figure 3.3, and the total accreditation for 2019 is 95%. Figure 3.4 shows the individual accreditation scores for each of the key data fields that make up the overall accreditation score.

2) Each hospital’s accreditation for the Major Trauma Audit Paediatric Report 2014–2019 is shown in Figure 3.5. The overall accreditation for the paediatric report is 94%.

FIGURE 3.3: DATA ACCREDITATION PERCENTAGES BY HOSPITAL, 2019

FIGURE 3.3: DATA ACCREDITATION PERCENTAGES BY HOSPITAL, 2019

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Tem

ple

Stre

et

Drog

heda

Slig

o

Mat

er

Tulla

mor

e

Cava

n

Mer

cy

May

o

Cork

Conn

olly

Kilk

enny

Wat

erfo

rd

Kerry

Wex

ford

Galw

ay

Beau

mon

t

Sout

h Ti

pper

ary

Talla

ght

Lette

rken

ny

Limer

ick

Mul

linga

r

St Ja

mes

's

Crum

lin

St. V

ince

nt's

Portl

aoise

Nat

iona

l

PERC

ENTA

GE

HOSPITALS

Completeness

95% Target completeness


CHAPTER 3

FIGURE 3.4: DATA ACCREDITATION BY KEY DATA FIELDS FOR MAJOR TRAUMA AUDIT 2019

FIGURE 3.5: DATA ACCREDITATION FOR MAJOR TRAUMA AUDIT PAEDIATRIC REPORT 2014–2019

FIGURE 3.4: DATA ACCREDITATION BY KEY DATA FIELDS FOR MAJOR TRAUMA AUDIT 2019

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Firs

t com

pute

d to

mog

raph

y de

tails

Tran

exam

ic ac

id

Arriv

al ti

me

Ope

ratio

n de

tails

Intu

batio

n

Pre-

exist

ing

cond

ition

s

Tran

sfer

det

ails

Com

pute

d to

mog

raph

y re

port

time

Com

pute

d to

mog

raph

y re

view

time

Pupi

l rea

ctivi

ty

Doct

ors i

n th

e em

erge

ncy

depa

rtmen

t

Inju

ry d

etai

ls

Glas

gow

Com

a Sc

ale

999

call

deta

ils

Incid

ent t

ime

PERC

ENTA

GE

KEY DATA FIELDS National mean accreditation

95%

FIGURE 3.5: DATA ACCREDITATION FOR MAJOR TRAUMA AUDIT PAEDIATRIC REPORT 2014-2019

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Mer

cy

Drog

heda

Galw

ay

Cava

n

Cork

Tem

ple

Stre

et

Mat

er

Sout

h Ti

pper

ary

Wat

erfo

rd

Limer

ick

May

o

Mul

linga

r

Beau

mon

t

Lette

rken

ny

Talla

ght

Wex

ford

Kilk

enny

Slig

o

St. V

ince

nt's

Tulla

mor

e

Portl

aoise

Crum

lin

Kerry

St Ja

mes

's

Naa

s

Nat

iona

l

PERC

ENTA

GE

Completeness

95% Target completeness

CHAPTER 4KEY HIGHLIGHTS

2019

ISS


KEY HIGHLIGHTS 2019

MECHANISM OF INJURY

INJURIES SUSTAINED BY BODY REGION

58%

42%

4431 2019 PATIENTS RECORDED

ABDOMEN3%

LIMBS27%

SPINE16%

MULTIPLE8%

OTHER2%

CHEST15%

HEAD23%FACE5%

65.852.3FEMALE

MEAN AGEMALE

MEAN AGE

FROM A BLOW

FALL LESS THAN 2M

FALL MORE THAN 2M

ROAD TRAUMA

FROM OTHER

10% 58% 10% 17% 5%

This chapter shows the key highlights for 2019 for all ages to allow for comparisons with the previous reports.


PLACE OF INJURY

HOME PUBLIC AREA OR ROAD

INSTITUTION

48% 39% 5%

FARM INDUSTRIAL OTHER

3% 2% 4%

TOTAL NUMBER OF BED DAYS

OCCUPIED

72,737

DISCHARGED DIRECTLY

HOME

60%

MEDIAN LENGTH OF STAY IN ACUTE HOSPITAL (DAYS)

TRANSFERS TO ANOTHER

HOSPITAL

9 DAYS 21%

Percentage of patients with a Glasgow Coma Scale score <13 to receive a computed tomography scan within 1 hour

61%AFTER 1 HOUR39%WITHIN

1 HOUR


CHAPTER 5WHO WAS INJURED

AND HOW WERE THEY INJURED


FIGURE 5.1: PERCENTAGE OF MAJOR TRAUMA AUDIT PAEDIATRIC PATIENTS BY AGE GROUP (N=1382)

10%

16% 17%

25%

16% 16%

0%

5%

10%

15%

20%

25%

<1 1-2 3-5 6-10 11-13 14-15

PERC

ENTA

GE

AGE GROUP

CHAPTER 5

WHO WAS INJURED AND HOW WERE THEY INJURED?Trauma is a leading cause of morbidity and mortality in children (Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2016a). The children and adolescents included in this report ranged in age from newborns to 15-year-olds up until the eve of their 16th birthday. Studying major injury in this group gives us important information that contributes to creating a responsive healthcare system and contributes to public policy and preventive measures. These data have been collected over 6 years (2014–2019) and show the patterns of serious injury sustained by children in Ireland. There were 1,737 submissions, representing 6% of all MTA-recorded trauma submissions (N=30891) during 2014–2019.

AGE

More than one-quarter of all serious childhood injuries occurred in the first 2 years of life (26%, n=366); a proportion of this is unintentional injury, although the exact proportion of unintentional injury is difficult to quantify (Figure 5.1). This is consistent with the data reported in the UK via TARN reports, and with the data reported in the United States of America via the American College of Surgeons’ National Trauma Data Bank reports.



29% 25%13%

19% 21% 26% 22%

25%

48%

54% 48% 41% 33% 43%

46%

27%33% 33% 38% 41% 35%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP

Low severity injury Moderate severity injury Severe injury


CHAPTER 5

FIGURE 5.2: PERCENTAGE OF MAJOR TRAUMA AUDIT PAEDIATRIC PATIENTS BY GENDER AND AGE GROUP (N=1382)

FEMALE (n) 62

<1

76MALE (n)

73

11-13

146

77

3-5

155

80

1-2

148

146

6-10

195

70

14-15

154

Male children are more commonly represented in major trauma cases (63%, n=874) across all paediatric age groups (Figure 5.2). FIGURE 5.2 PERCENTAGE OF PAEDIATRIC MTA PATIENTS BY GENDER AND AGE GROUP (N=1382)

45%

35% 33%

43%33% 31%

37%

55%

65% 67%

57%67% 69%

63%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1–2 3–5 6–10 11–13 14–15 Total

PERC

ENTA

GE

AGE GROUP


CHAPTER 5

MECHANISM OF INJURY

Falls from less than 2 m (termed ‘low falls’), road traffic collisions (RTCs; also known as road trauma) and burns account for 71% (n=985) of all paediatric major trauma patients (Figure 5.3). The most common mechanism of injury is low falls (37%, n=509). Care must be taken in the interpretation of the mechanism ‘low falls’, as a fall from 2 m in a child aged under 1 year (which accounts for 64% of injuries in that age group; n=88) is proportionately higher than a similar fall for an older child. Blows (e.g. assault) were the cause of 12% (n=163) of paediatric major trauma injuries. The majority of these mechanisms of injury are preventable in nature, and these data should be used to inform an injury prevention strategy for children. Burns account for 9% (n=128) of all paediatric major trauma cases, with a notable peak in children aged 1–2 years (27%, n=62). ‘Other’ in terms of mechanism of injury is used when the mechanism cannot be categorised under any of the other options.

FIGURE 5.3: MECHANISM OF INJURY OF MAJOR TRAUMA AUDIT PAEDIATRIC PATIENTS BY AGE GROUP (N=1382)


13%5%

10% 8%16%

22%12%

64%

39%

44%

36%26%

23%37%

5%

10%

10%

11% 8%12%

10%

6%

13%

19% 33% 37%32% 25%

6%

27%

10%6% 5% 2% 9%

7% 6% 7% 7% 8% 10% 7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP

Blow Fall less than 2 m Fall more than 2 m Road trauma Burn Other


13%5%

10% 8%16%

22%12%

64%

39%

44%

36%26%

23%37%

5%

10%

10%

11% 8%12%

10%

6%

13%

19% 33% 37%32% 25%

6%

27%

10%6% 5% 2% 9%

7% 6% 7% 7% 8% 10% 7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



13%5%

10% 8%16%

22%12%

64%

39%

44%

36%26%

23%37%

5%

10%

10%

11% 8%12%

10%

6%

13%

19% 33% 37%32% 25%

6%

27%

10%6% 5% 2% 9%

7% 6% 7% 7% 8% 10% 7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



13%5%

10% 8%16%

22%12%

64%

39%

44%

36%26%

23%37%

5%

10%

10%

11% 8%12%

10%

6%

13%

19% 33% 37%32% 25%

6%

27%

10%6% 5% 2% 9%

7% 6% 7% 7% 8% 10% 7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



13%5%

10% 8%16%

22%12%

64%

39%

44%

36%26%

23%37%

5%

10%

10%

11% 8%12%

10%

6%

13%

19% 33% 37%32% 25%

6%

27%

10%6% 5% 2% 9%

7% 6% 7% 7% 8% 10% 7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP


?


13%5%

10% 8%16%

22%12%

64%

39%

44%

36%26%

23%37%

5%

10%

10%

11% 8%12%

10%

6%

13%

19% 33% 37%32% 25%

6%

27%

10%6% 5% 2% 9%

7% 6% 7% 7% 8% 10% 7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



13%5%

10% 8%16%

22%12%

64%

39%

44%

36%26%

23%37%

5%

10%

10%

11% 8%12%

10%

6%

13%

19% 33% 37%32% 25%

6%

27%

10%6% 5% 2% 9%

7% 6% 7% 7% 8% 10% 7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



13%5%

10% 8%16%

22%12%

64%

39%

44%

36%26%

23%37%

5%

10%

10%

11% 8%12%

10%

6%

13%

19% 33% 37%32% 25%

6%

27%

10%6% 5% 2% 9%

7% 6% 7% 7% 8% 10% 7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



13%5%

10% 8%16%

22%12%

64%

39%

44%

36%26%

23%37%

5%

10%

10%

11% 8%12%

10%

6%

13%

19% 33% 37%32% 25%

6%

27%

10%6% 5% 2% 9%

7% 6% 7% 7% 8% 10% 7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



CHAPTER 5

FIGURE 5.4: INTENT/ACTIVITY AT TIME OF INJURY OF MAJOR TRAUMA AUDIT PAEDIATRIC PATIENTS BY AGE GROUP (N=1382)

By way of further breakdown, Figure 5.4 describes the intent/activity at the time of the injury. Unintentional injury accounts for 78% (n=1073) of major trauma injury types in paediatric major trauma patients. Eleven percent (n=150) of injuries are attributable to sports and typically occur in older children and teens. Non-accidental injury (NAI) was recorded in 5% (n=64) of all paediatric major trauma patients, and accounted for 34% (n=47) of major trauma in children aged under 1 year (Figure 5.4).


1% 2% 6% 1%4%

2% 1% 1%1% 1%

61%

91% 92%84%

69% 58%78%

1% 5%11%

20%24%

11%34%

5%1%

1% 5%

1% 1% 3%

5% 4%2%4% 6%2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP

Alleged assault Intent inconclusive

Non intentional Sport

Suspected child abuse Suspected high-risk behaviour

Suspected self-harm

Non-accidental injury


CHAPTER 5

INJURY SEVERITY SCORE

A breakdown of the Injury Severity Score (ISS) by age group across all paediatric major trauma patients is presented in Figure 5.5. This shows that 35% (n=488) of paediatric major trauma patients suffered severe injuries and 43% (n=596) suffered moderate-severity injuries (this figure represents patients whose data were captured at either their admitting hospital or the receiving hospital). There is fluctuation across the age cohorts. Similar proportions for the ISS were shown in adult major trauma patients from 2014 to 2019, with low-severity injuries recorded in 25% (n=6382) of cases, moderate-severity injuries recorded in 42% (n=10847) of cases and severe injuries recorded in 33% (n=8366) of cases. When compared with the TARN report, Severe Injury in Children: January 2017 – December 2018: England & Wales, similar proportions of paediatric major trauma patients (33%) were shown to have an ISS of >15 (TARN, 2019).

FIGURE 5.5: INJURY SEVERITY SCORE OF MAJOR TRAUMA AUDIT PAEDIATRIC PATIENTS BY AGE GROUP (N=1382)


29% 25%13%

19% 21% 26% 22%

25%

48%

54% 48% 41% 33% 43%

46%

27%33% 33% 38% 41% 35%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP

Low-severity injury Moderate-severity injury Severe injury


CHAPTER 5

PLACE OF INJURY

Home was recorded as the most common place of injury for paediatric major trauma patients (45%, n=628) Figure 5.6. Forty-two percent (n=579) of injuries occurred in public areas or roads, with this proportion increasing across age bands; it ranged from 9% in children aged under 1 year to 66% in patients aged 14–15 years. It is worth noting that 4% (n=58) of injuries occurred on farms, with all ages affected, highlighting how dangerous farms can be for children. ‘Institution’ includes hospitals, prisons, care homes, and educational institutions such as schools.

FIGURE 5.6: PLACE OF INJURY FOR MAJOR TRAUMA AUDIT PAEDIATRIC PATIENTS BY AGE GROUP (N=1382)


86%80%

60%

33%

19%14%

45%

9%13%

28%

53%

65%66%

42%

1%1%

2% 5% 5%4%

3%1%

2%5% 4% 5%

6%

4%

3% 3%4% 4% 5%

10%5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP

Home Public area or road Institution Farm Industrial Other


86%80%

60%

33%

19%14%

45%

9%13%

28%

53%

65%66%

42%

1%1%

2% 5% 5%4%

3%1%

2%5% 4% 5%

6%

4%

3% 3%4% 4% 5%

10%5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



86%80%

60%

33%

19%14%

45%

9%13%

28%

53%

65%66%

42%

1%1%

2% 5% 5%4%

3%1%

2%5% 4% 5%

6%

4%

3% 3%4% 4% 5%

10%5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



86%80%

60%

33%

19%14%

45%

9%13%

28%

53%

65%66%

42%

1%1%

2% 5% 5%4%

3%1%

2%5% 4% 5%

6%

4%

3% 3%4% 4% 5%

10%5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



86%80%

60%

33%

19%14%

45%

9%13%

28%

53%

65%66%

42%

1%1%

2% 5% 5%4%

3%1%

2%5% 4% 5%

6%

4%

3% 3%4% 4% 5%

10%5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



86%80%

60%

33%

19%14%

45%

9%13%

28%

53%

65%66%

42%

1%1%

2% 5% 5%4%

3%1%

2%5% 4% 5%

6%

4%

3% 3%4% 4% 5%

10%5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



86%80%

60%

33%

19%14%

45%

9%13%

28%

53%

65%66%

42%

1%1%

2% 5% 5%4%

3%1%

2%5% 4% 5%

6%

4%

3% 3%4% 4% 5%

10%5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



86%80%

60%

33%

19%14%

45%

9%13%

28%

53%

65%66%

42%

1%1%

2% 5% 5%4%

3%1%

2%5% 4% 5%

6%

4%

3% 3%4% 4% 5%

10%5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



86%80%

60%

33%

19%14%

45%

9%13%

28%

53%

65%66%

42%

1%1%

2% 5% 5%4%

3%1%

2%5% 4% 5%

6%

4%

3% 3%4% 4% 5%

10%5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP



CHAPTER 5

Figure 5.6A shows a further breakdown of the type of road trauma that occurred in paediatric major trauma patients. The majority of road trauma involved pedestrians (19%, n=108) followed by cyclists (16%, n=92). ‘Other’ represents a broad array of trauma that cannot be grouped into one of the other categories. FIGURE 5.6A: TYPE OF ROAD TRAUMA FOR MAJOR TRAUMA AUDIT PAEDIATRIC

PATIENTS (n=579)

47%

19%

16%15%

4%0%

10%

20%

30%

40%

50%

Other Pedestrian Cyclist Car occupant Motorcyclist

PERC

ENTA

GE

TYPE OF ROAD TRAUMA

FIGURE 5.6A: TYPE OF ROAD TRAUMA FOR MAJOR TRAUMA AUDIT PAEDIATRIC PATIENTS (N=579)2

CAR OCCUPANT

15%

PEDESTRIAN

19%

CYCLIST

16%

MOTORCYCLIST

4%

OTHER

47%

2 The category ‘Other’ includes information that was not recorded.


CHAPTER 5

Vehicular trauma is further broken down in Figure 5.6B to examine the patient’s position in a vehicle involved in an accident. The majority of paediatric major trauma patients were back-seat passengers (79%, n=67).

FIGURE 5.6B: POSITION IN VECHICLE FOR ROAD TRAFFIC COLLISIONS (n=85)

DRIVER BACK SEAT PASSENGER

FRONT SEAT PASSENGER

2% 19% 79%


CHAPTER 5

BODY REGIONS INJURED

The limbs and head are the most common body regions injured in all paediatric major trauma patients, at 32% each (n=439 and n=440, respectively) (Figure 5.7). For patients who have an ISS >15, head injuries are the main body region injured, representing 67% (n=327) of cases, whereas limb injuries account for only 1% (n=6) of cases (Figure 5.7A). There is substantial contrast in body regions injured when comparing the youngest and oldest children within the paediatric age range, i.e. children aged under 1 year and those aged 15 years. Figure 5.7B shows the body regions injured in patients aged under 1 year, and Figure 5.7C shows the body regions injured in patients aged 15 years. Head is the main body region injured in children aged under 1 year, representing 70% (n=97) of patients, compared with 18% (n=20) of patients aged 15 years (Figure 5.7C). ‘Other’ in terms of body region includes injuries such as skin and neck injuries, as well as burns and hypothermia. When compared with the TARN report, Severe Injury in Children: January 2017 – December 2018: England & Wales, the various body regions were injured in similar proportions among paediatric major trauma patients with ISS of >15, with the highest proportion also having suffered head injuries (TARN, 2019).

ABDOMEN8%

LIMBS1%

SPINE1%

MULTIPLE7%

OTHER10%

CHEST6%

HEAD67%

ABDOMEN8%

LIMBS32%

SPINE5%

MULTIPLE4%

OTHER13%

CHEST4%

HEAD32%FACE2%

FIGURE 5.7: BODY REGION INJURIES ALL PAEDIATRIC PATIENTS (N=1382)

FIGURE 5.7A: BODY REGION INJURIES ALL PAEDIATRIC PATIENTS WITH AN INJURY SEVERITY SCORE OF >15 (n=488)


CHAPTER 5

FIGURE 5.7B: BODY REGION INJURIES ALL PAEDIATRIC PAEDIATRIC PATIENTS AGED < 1 YEAR (n=138)

FIGURE 5.7C: BODY REGION INJURIES PAEDIATRIC PATIENTS AGED 15 YEARS (n=109)

ABDOMEN1%

LIMBS17%

SPINE1%

MULTIPLE2%

OTHER6%

CHEST3%

HEAD70%FACE0%

ABDOMEN13%

LIMBS20%

SPINE17%

MULTIPLE6%

OTHER12%

CHEST5%

HEAD18%FACE9%


KEY FINDINGS FROM CHAPTER 5• Paediatric major trauma patients made up 5% (n=1382) of the overall major trauma

population from 2014 to 2019.

• More than one-quarter of all serious childhood injuries occurred in the first 2 years of life (26%, n=366).

• Males accounted for 63% (n=874) of paediatric major trauma patients.

• Falls from less than 2 m (termed ‘low falls’), RTCs and burns account for 71% (n=985) of all paediatric major trauma patients. There is a shift from injuries occurring in the home to occurring in public areas or roads as children age.

• Non-accidental injury (NAI) was recorded in 5% (n=64) of all paediatric major trauma patients, and accounted for 34% (n=47) of major trauma in children aged under 1 year.

• Severe injury (ISS >15) was seen in 35% (n=488) of paediatric major trauma cases.

• Home was recorded as the most common place of injury for paediatric major trauma patients (45%, n=628).

• The limbs and head are the most common body regions injured in all paediatric major trauma patients, at 32% each (n=439 and n=440, respectively).


CHAPTER 6THE PATIENT

JOURNEY


CHAPTER 6

THE PATIENT JOURNEY

Currently, there is a health service transformation underway to develop a new children’s hospital in Dublin. This will be the largest, most complex and significant capital investment project ever undertaken in healthcare in Ireland. This new hospital will enhance how acute healthcare services are delivered and will result in better clinical outcomes for children and young people. In 2019, Children’s Health Ireland commenced as a new entity that governs and delivers acute paediatric services in Ireland and currently operates at Crumlin, Temple Street and Tallaght hospitals. This chapter includes data from all 26 hospitals that participate in the MTA. Currently, no hospital in Ireland meets major trauma centre (MTC) status. The criteria for MTCs and trauma units can be found in Appendix 6 of A Trauma System for Ireland: Report of the Trauma Steering Group (Department of Health, 2018b).

Paediatric major trauma care is currently being delivered across 26 hospitals in Ireland. Depending on where in the country a child is injured, the National Ambulance Service (NAS), Dublin Fire Brigade (DFB) or a family member could bring them to any of the 26 hospitals included in this audit. The provision of a seamless, safe, optimal care pathway for patients with multiple injuries is very challenging in the current configuration of trauma care delivery, and even more so for paediatric patients. This chapter will show the journey of paediatric major trauma patients from 2014 to 2019.


CHAPTER 6

PRESENTATION BY TIME OF DAY

Paediatric major trauma presentations are more common during the afternoon and evening between 2.00pm and 9.00pm (63%, n=851) (Figure 6.1). A smaller proportion of children (7%, n=100) presented between the hours of 12.00am and 7.59am from 2014 to 2019 than the proportion of adults in 2019 (17%, n=697).

FIGURE 6.1: PRESENTATION BY TIME OF DAY FOR MAJOR TRAUMA AUDIT PAEDIATRIC PATIENTS (n=1360)

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%00

.00

01.0

0

02.0

0

03.0

0

04.0

0

05.0

0

06.0

0

07.0

0

08.0

0

09.0

0

10.0

0

11.0

0

12.0

0

13.0

0

14.0

0

15.0

0

16.0

0

17.0

0

18.0

0

19.0

0

20.0

0

21.0

0

22.0

0

23.0

0

PERC

ENTA

GE

HOUR

00.00 01.00 02.00 03.00 04.00 05.00 06.00 07.00

08.00 09.00 10.00 11.00 12.00 13.00 14.00 15.00

16.00 17.00 18.00 19.00 20.00 21.00 22.00 23.00

00.00–07.59 08.00–15.59 16.00 –23.59

7% 35% 58%

FIGURE 6.1: PRESENTATION BY TIME OF DAY FOR MAJOR TRAUMA AUDIT PAEDIATRIC PATIENTS (N=1360)3

3 Patients with missing information on time of admission (n=22) are excluded.


CHAPTER 6

PRESENTATION BY MONTH AND SEASON

Paediatric major trauma is more common during the summer months (33%, n=451) (Figure 6.2). There are also increases in admissions noted during the months of March and October; these coincide with school holidays. FIGURE 6.2: PRESENTATION BY MONTH AND SEASON (N=1382)

6% 6%

10%

9%8%

12%

11%10%

8%

9%

5% 5%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

Janu

ary

Febr

uary

Mar

ch

April

May

June July

Augu

st

Sept

embe

r

Oct

ober

Nov

embe

r

Dece

mbe

r

PERC

ENTA

GE

MONTH

FIGURE 6.2: PRESENTATION BY MONTH AND SEASON (N=1382)


CHAPTER 6

MODE OF ARRIVAL

Ambulance was the most common mode of transportation to hospital for paediatric major trauma patients (55%, n=578) Figure 6.3 compared with 79% (n=17534) for adult major trauma patients. Children are often brought to the emergency department (ED) following major trauma by family/carers in a private car (41%, n=431) compared with only 16% (n=3480) of adult major trauma patients; this means that trauma teams must be agile and able to respond to arrivals quickly without pre-notification or time to ready themselves. This differs from adult major trauma patients, who are largely transported by ambulance with a pre-alert to the receiving ED. The Helicopter Emergency Medical Service (HEMS) is delivered through a service level agreement between the Irish Air Corps, the Department of Defence and the HSE, and is based out of Athlone, offering daytime services. Irish Coast Guard helicopters may, in certain circumstances, be tasked with transporting major trauma patients.

4 Patients who were transferred to another hospital have been excluded. Data on patients whose mode of transport to hospital was ‘Other’ or ‘Unknown’ have also been excluded.

FIGURE 6.3: MODE OF ARRIVAL AT HOSPITAL (n=1059) 4

2%HELICOPTER

55%AMBULANCE

<1%WALKING

41%BY CAR

2%HELICOPTER & AMBULANCE


MOST SENIOR HEALTHCARE PROFESSIONAL

Data capture relating to the pre-hospital part of the paediatric major trauma patient’s journey has been challenging for the MTA. The NAS has recently moved to an electronic patient care report (ePCR), which is expected to facilitate better data collection for the audit.

Fifty-nine percent (n=624) of paediatric major trauma patients arrived to hospital by ambulance and/or helicopter. Of these cases, 43% (n=270) were attended to pre-hospital by a paramedic and 34% (n=212) were attended to by an advanced paramedic (Figure 6.4). A small number of medical doctors volunteer critical care support to the NAS, and can be tasked to respond by the National Emergency Operations Centre; as a result, 3% (n=17) of paediatric major trauma patients were seen pre-hospital by a doctor.

CHAPTER 6

FIGURE 6.4: MOST SENIOR PRE-HOSPITAL HEALTHCARE PROFESSIONAL (n=624)5

FIGURE 6.4 MOST SENIOR PRE-HOSPITAL HEALTHCARE PROFESSIONAL (n=624)

43%

34%

20%

3%

0%

10%

20%

30%

40%

50%

Paramedic Advanced paramedic Not known Doctor

PERC

ENTA

GE

HEALTHCARE PROFESSIONAL

5 Only direct admissions by ambulance and/or helicopter are included in Figure 6.4.


CHAPTER 6

ADMISSIONS BY HOSPITAL

Cork University Hospital was the busiest single receiving centre for paediatric major trauma patients in Ireland (17%, n=195). Combined, the three Children’s Health Ireland EDs accounted for 34% (n=404) of major trauma presentations. Cork University Hospital (Figure 6.5) will be one of two designated adult MTCs in the new trauma system described in A Trauma System for Ireland: Report of the Trauma Steering Group (Department of Health, 2018b) and a regional paediatric unit. Of note, both Mercy University Hospital and Midland Regional Hospital Portlaoise are largely bypassed (receiving 1% of all paediatric major trauma cases each) for all ambulance-borne paediatric major trauma patients, and do not have on-call arrangements with emergency medicine consultants for reception of seriously injured children who are brought by private car to these hospitals.

FIGURE 6.5: NUMBER OF PAEDIATRIC MAJOR TRAUMA PATIENT ADMISSIONS BY HOSPITAL (N=1174)6

6 Patients who were transferred to another hospital have been excluded. Hospitals with fewer than five admissions have not been presented in Figure 6.5. Connolly had no paediatric patients.

Figure 6.5 excludes individual data for Beaumont Hospital, Mater Misericordiae University Hospital, Naas General Hospital, St James’s Hospital and St Vincent’s University Hospital; however, data from these hospitals were included in the overall calculations. Connolly Hospital did not record any individual data for paediatrics during 2014-2019.

FIGURE 6.5: NUMBER OF PAEDIATRIC MAJOR TRAUMA PATIENT ADMISSIONS BY HOSPITAL (N=1174)

17%

13%12%

9% 9%

8%

5%

3% 3% 3% 3%2% 2% 2% 2% 2% 2% 2%

1% 1%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Cork

Tem

ple

Stre

et

Crum

lin

Talla

ght

Limer

ick

Drog

heda

Galw

ay

Cava

n

Kilk

enny

Kerry

Wat

erfo

rd

Mul

linga

r

Wex

ford

Lette

rken

ny

Slig

o

Tulla

mor

e

May

o

Sout

h Ti

pper

ary

Mer

cy

Portl

aoise

PERCEN

TAGE

HOSPITALS


CHAPTER 6

TRANSFERS

This section focuses on patients who were transferred for care of their injuries. The decision to transfer a patient for management of their injuries and the timeliness of the transfer should be based on medical need and best practice; however, it may also relate to the availability of a bed and other resources at the receiving hospital. The transfer process is cumbersome, requiring multiple phone calls, a transfer team and an ambulance, and often denudes smaller hospitals of staff for the duration of the transfer. There are contesting, and sometimes conflicting, priorities at play in the transfer of patients.

Interfacility transfer was performed for 57% (n=994) of paediatric major trauma patients (Figure 6.6); this compares with 31% (n=9106) of adult major trauma patients from 2014-2019 who required interfacility transfer during the same time. All of the hospitals included in the MTA are either Model 3 or 4 facilities, as defined by the HSE (see Table 6.1). Figure 6.6 shows the percentage of interfacility transfers between the Model 3 and 4 hospitals, as well as those from the Children’s Health Ireland (CHI) sites. Currently, no one location has all of the specialties on site that are required in order to definitively manage paediatric major trauma patients. When Ireland has one children’s hospital, this will reduce the number of transfers and improve care for paediatric major trauma patients.

The majority of transfers out were from Model 3 hospitals (57%, n=220). This indicates the need for a more coordinated trauma system that can facilitate the direct transport of seriously injured children to the ‘right place’, either by land or air, in a greater proportion of cases. This also highlights the need for integrated secondary transport systems, activated from the scene of the incident, to intersect the case at the regional unit for earlier onward transport to a paediatric trauma centre that can deliver definitive trauma care.


CHAPTER 6

TABLE 6.1: HOSPITAL MODELS

Model 3 hospitals provide:• acute surgery• acute medicine • critical care.

• Cavan General Hospital• Connolly Hospital• University Hospital Kerry • Letterkenny University Hospital• Mayo University Hospital • Mercy University Hospital • Regional Hospital Mullingar• Midland Regional Hospital Portlaoise • Midland Regional Hospital Tullamore• Naas General Hospital• Our Lady of Lourdes Hospital Drogheda• Sligo University Hospital• South Tipperary General Hospital• St Luke’s General Hospital, Carlow/Kilkenny• Wexford General Hospital.

Model 4 hospitals provide:• acute surgery• acute medicine • critical care• tertiary care • supra-regional care (in certain locations).

• Beaumont Hospital – neurosurgery and renal transplant

• Cork University Hospital – plastic and reconstructive surgery, neurosurgery, cardiothoracic surgery, and oral and maxillofacial surgery

• Mater Misericordiae University Hospital – cardiothoracic surgery, heart and lung transplant, spinal surgery, and extracorporeal membrane oxygenation (ECMO)

• St James’s Hospital – cardiothoracic surgery, burns surgery, plastic and reconstructive surgery, and oral and maxillofacial surgery

• St Vincent’s University Hospital – liver transplant and pancreatic surgery

• Tallaght University Hospital – pelvic and acetabulum reconstruction

• Galway University Hospitals• University Hospital Limerick• University Hospital Waterford.

Paediatric-only EDs • CHI at Temple Street• CHI at Crumlin• CHI at Tallaght.


CHAPTER 6

FIGURE 6.6: NUMBER OF PATIENTS WHO WERE TRANSFERRED, BY HOSPITAL MODEL AND CHILDREN’S HOSPITAL (N=1737)

36% 39%

55%

44%

4%

26%

4%

1%

3%

15%

57%

17%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Children's hospitals Model 3 Model 4

PERC

ENTA

GE

HOSPITAL MODEL

No transfer Transfer in Transfer in and out Transfer out



CHAPTER 6

TRANSFERS BY MECHANISM OF INJURY

The highest shares of paediatric major trauma patients who were transferred occurred among those who received burns (55%, n=71), followed by patients who had a fall of more than 2 m (53%, n=70) (Figure 6.7).

FIGURE 6.7: PERCENTAGE OF PAEDIATRIC MAJOR TRAUMA PATIENTS WHO WERE TRANSFERRED VERSUS NOT TRANSFERRED BY MECHANISM OF INJURY (N=1382)

51% 55%43%

53%46%

39%

49% 45%57%

47%54%

61%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Blow Burn Fall less than 2 m Fall more than 2 m Road trauma Other

PERC

ENTA

GE

MECHANISM OF INJURY

Transferred Not transferred



CHAPTER 6

TRANSFERS BY LOCATION OF INJURY

Paediatric major trauma patients who were injured in an institution (57%, n=27), at a farm (48%, n=28) or at home (48%, n=299) were those most commonly transferred from one hospital to another to receive definitive care (Figure 6.8). ‘Institution’ includes hospitals, prisons, care homes, and educational institutions such as schools.

FIGURE 6.8: PERCENTAGE OF PAEDIATRIC MAJOR TRAUMA PATIENTS WHO WERE TRANSFERRED VERSUS NOT TRANSFERRED BY LOCATION OF INJURY (N=1382)


48% 45%57%

48%

33% 36%

52% 55%43%

52%

67% 64%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Home Public area orroad

Institution Farm Industrial Other

PERC

ENTA

GE

LOCATION OF INJURY

Transferred Not transferred


CHAPTER 6

TRANSFERS BY BODY REGION INJURED

Paediatric major trauma patients who had a head injury were more likely to be transferred (61%, n=270) than patients who had other body regions injured (Figure 6.9).

FIGURE 6.9: PERCENTAGE OF PAEDIATRIC MAJOR TRAUMA PATIENTS WHO WERE TRANSFERRED VERSUS NOT TRANSFERRED BY BODY REGION INJURED (N=1382)


61%51% 50% 47% 42% 40% 36% 33%

39%49% 50% 53% 58% 60% 64% 67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Head Spine Other Face Multiple Abdomen Chest Limbs

PERC

ENTA

GE

BODY REGION INJUREDTransferred Not transferred


CHAPTER 6

KEY FINDINGS FROM CHAPTER 6• Paediatric major trauma presentations are more common during the afternoon and

evening between 2.00pm and 9.00pm.

• Paediatric major trauma patients are most commonly admitted during the summer months.

• Although the majority of paediatric major trauma patients are brought to hospital by ambulance (55%, n=578), it is notable that 41% (n=431) are brought in by car.

• Of the patients brought to hospital by ambulance and/or helicopter, a paramedic or advanced paramedic treated 77% (n=482) of paediatric major trauma patients pre-hospital.

• Many injured children were transferred for ongoing management (57%, n=994).


CHAPTER 7CARE OF PAEDIATRIC

MAJOR TRAUMA PATIENTS IN THE ACUTE HOSPITAL

SERVICE


CHAPTER 7

CARE OF PAEDIATRIC MAJOR TRAUMA PATIENTS IN THE ACUTE HOSPITAL SERVICEPRE-ALERT

Pre-alert is a system whereby the ambulance service communicates to the receiving hospital that it is bringing a patient to the ED, the nature of the patient’s injuries, the patient’s physiology, their expected requirements on arrival and the expected time of arrival.

Figure 7.1 includes analysis of pre-alert to the initial hospital patients were brought to after sustaining a traumatic injury. A low percentage of paediatric major trauma patients were documented as having been pre-alerted (13%, n=150), which is comparable to the adult major trauma population (10%, n=2403). One of the reasons for such low levels of paediatric major trauma patients being pre-alerted is in part due to so many patients being brought to hospital by car. Other reasons include issues with the pre-hospital documentation not being accessible by the audit coordinators. In recent years, progress has been made with the NAS and the development of an ePCR, which continues to be rolled out across the health service. Out of the paediatric major trauma cases who were pre-alerted, the majority arrived at hospital by ambulance or helicopter (98%, n=147), compared with 99% (n=2383) for adults.FIGURE 7.1 PRE-ALERTED BY AGE GROUP (n=1174)

5%11% 10% 15% 15% 18% 13%

84% 72% 76%72% 68% 66% 72%

11%17% 15% 14% 17% 17% 15%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP

Pre-alerted Not pre-alerted Not recorded

FIGURE 7.1: PRE-ALERTED BY AGE GROUP (n=1174)7

7 Figure 7.1 refers to direct admissions only


CHAPTER 7


RECEPTION BY TRAUMA TEAM

Time to critical interventions and outcomes is improved when a trained trauma team is present on the arrival of a severely injured patient (Driscoll and Vincent, 1992). The UK’s National Health Service (NHS) Clinical Advisory Group on Trauma (2010) recommended that trauma teams in MTCs should be led by a consultant or by a registrar with the necessary seniority, experience and training in trauma units. In Ireland, the lack of clear national standards on what should constitute a trauma team or when such a team should be activated makes measuring reception by a trauma team challenging. Currently, it is up to participating hospitals to define their trauma team and report whether this definition of a trauma team was activated.

The overall percentage of paediatric major trauma patients received by a trauma team at the first receiving hospital is low, with only one in five (20%, n=234) patients being met by a trauma team on arrival (Figure 7.2), compared with only 9% of adults (n=2232). This may largely be due to many children being brought to the hospital by car.FIGURE 7.2 RECEPTION BY A TRAUMA TEAM BY AGE GROUP (n=1174)

10%19% 18% 21% 23% 24% 20%

90%81% 82% 79% 77% 76% 80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP

Received by a trauma team Not received by a trauma team

FIGURE 7.2: RECEPTION BY A TRAUMA TEAM BY AGE GROUP (n=1174)8


CHAPTER 7

FIGURE 7.2A RECEPTION BY A TRAUMA TEAM WITH ISS>15 BY AGE GROUP (n=391)

17%

38%29%

38% 40% 41%35%

83%

62%71%

62% 60% 59%65%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP

Received by a trauma team Not received by a trauma team

FIGURE 7.2A: RECEPTION BY A TRAUMA TEAM FOR PAEDIATRIC PATIENTS WITH AN INJURY SEVERITY SCORE >15 BY AGE GROUP (n=391)9

9 Figure 7.2A refers to direct admissions only

Figure 7.2A describes paediatric major trauma patients with an ISS of >15 who were received by a trauma team. Similar to Figure 7.2, a high percentage of paediatric patients were not received by a trauma team (65%, n=255), compared with 84% (n=6460) of adults.


CHAPTER 7

GRADE OF MOST SENIOR DOCTOR TREATING PATIENT ON ARRIVAL

Figure 7.3 shows that 41% (n=479) of paediatric major trauma patients were seen by a consultant on arrival. A further 21% (n=251) were seen by a specialist registrar and 28% (n=323) were seen by a registrar, meaning that 90% (n=1053) of all paediatric major trauma patients were treated by a senior decision-maker on arrival to hospital, compared with 82% of adults (n=19550).


FIGURE 7.3: GRADE OF MOST SENIOR DOCTOR TREATING PAEDIATRIC PATIENTS ON ARRIVAL BY AGE GROUP (n=1174)10

FIGURE 7.3 GRADE OF MOST SENIOR DOCTOR TREATING PAEDIATRIC PATIENT ON ARRIVAL BY AGE GROUP (n=1174)

34%42% 38%

45% 41% 41% 41%

28%18% 23%

19% 25%19% 21%

26% 27% 27% 29% 25%30% 28%

9% 9% 7% 5% 6% 7% 7%3% 5% 5% 3% 3% 3% 3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP

Consultant Specialist Registrar Registrar SHO Other


CHAPTER 7

11 Table 7.1 refers to direct admissions only

TIME TO SEE PATIENTS ON ARRIVAL AT HOSPITALS

Patients should be triaged and reviewed in a timely manner by the relevant grade doctor according to their injuries. A review by a senior doctor involves a primary survey, a decision regarding trauma team activation, analgesia, appropriate imaging, and management, and can lead to better outcomes (NHS, 2018). A consultant saw 27% (n=312) of paediatric major trauma patients within 30 minutes of arrival to the ED Table 7.1.

Consultant 312 (27%) 479 (41%) 176 (45%) 241 (62%)

Specialist Registrar 0 (-) 251 (21%) 0 (-) 48 (12%)

Registrar 148 (13%) 323 (28%) 34 (9%) 84 (21%)

Senior House Officer 217 (18%) 80 (7%) 69 (18%) 11 (3%)

Other (not recorded) 497 (42%) 41 (3%) 112 (29%) 7 (2%)

*Refers to direct admissions onlyPlease note: Percentages may not sum to 100% due to rounding.

Most senior Most senior Most senior Most senior doctor seeing doctor seeing doctor seeing doctor seeing patient on patient in patient with patient with arrival in the ED ED after arrival an ISS>15 on an ISS>15 <30mins arrival in the ED in ED after <30mins arrival (n=1174)* (n=1174)* (n=391)* (n=391)*

TABLE 7.1: MOST SENIOR DOCTOR SEEING A PATIENT ON ARRIVAL IN THE EMERGENCY DEPARTMENT, AND SEEING THOSE WITH AN INJURY SEVERITY SCORE >1511


CHAPTER 7

SURGERY

Figure 7.4 shows a breakdown of paediatric major trauma surgical interventions by age group (n=689). Some patients had multiple surgeries while other patients had surgery at more than one hospital and therefore generated more than one submission. The most common type of surgery performed was limb surgery (54%, n=370).

12 Of the 1,382 total patients (which represents 1,737 admissions to hospitals), 689 had major surgery. Figure 7.4 refers to the main surgery performed in the hospital to which the patient was admitted; subsequent surgeries in the same hospital are not included here. A patient may have also had two or more surgeries performed in two or more hospitals and therefore be counted more than once in Figure 7.4

FIGURE 7.4: SURGICAL INTERVENTION BY BODY REGION INJURED AND AGE GROUP (n=689)12

FIGURE 7.4 SURGICAL INTERVENTION BY BODY REGION AND AGE GROUP (n=689)

3% 6% 6% 7% 5%4% 1%2%

3% 7%12%

5%

24%

12%12%

15%19% 11%

15%

48%

52%

61%

58%50%

46% 54%

24%

34%18%

14% 13%

10%17%

2% 1% 3%12%

3%1% 2% 1%

1%2% 1%

1%2%

1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP

Abdomen Face Head and brain Limb(s) Skin/soft tissue Spine Thoracic General


FIGURE 7.5 AIRWAY MANAGEMENT OF PAEDIATRIC MAJOR TRAUMA PATIENTS WITH A GCS <9 (n=98)

81%

1%

12%

6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Intubated – ED Intubated -pre – hospital Intubated – both ED and pre – hospital

Not known

PERC

ENTA

GE

AIRWAY MANAGEMENT

CHAPTER 7

HOSPITAL SYSTEMS PERFORMANCE

The Trauma Audit & Research Network (TARN) audit is underpinned by clinical standards and systems indicators, which are intended to provide opportunities for learning and quality improvement.

1. AIRWAY MANAGEMENT IN PATIENTS WITH A GLASGOW COMA SCALE <9

International guidelines use a Glasgow Coma Scale (GCS) score of <9 as a criterion for the requirement of definitive airway management, i.e. endotracheal or tracheal intubation, on arrival at an ED (Royal College of Surgeons of England, 1999).

Figure 7.5 shows that there were 98 paediatric major trauma patients with a recorded GCS of <9, and 81% (n=79) were documented as being intubated in the ED.

FIGURE 7.5: AIRWAY MANAGEMENT OF PAEDIATRIC MAJOR TRAUMA PATIENTS WITH A GLASGOW COMA SCALE <9 (n=98)


CHAPTER 7

2. TIME TO COMPUTED TOMOGRAPHY FOR HEAD INJURY PATIENTS AT INITIAL TREATING HOSPITAL

Head injury patients with an initial GCS of <13 should have a computed tomography (CT) head scan within 1 hour of arrival to hospital (National Institute for Health and Care Excellence, 2014). Of the 114 paediatric major trauma patients who required a head CT (having head injuries and an initial GCS of <13), 52% (n=59) received it within 1 hour of arrival to hospital Figure 7.6. This is based on the patients’ presentation to the initial treating hospital. The median time to CT scan was 1.0 hours (interquartile range (IQR) 0.4–1.5 hours).

FIGURE 7.6: PERCENTAGE OF PAEDIATRIC MAJOR TRAUMA PATIENTS TO RECEIVE A COMPUTED TOMOGRAPHY SCAN WITHIN 1 HOUR (n=114)

FIGURE 7.6 PERCENTAGE OF PAEDIATRIC MAJOR TRAUMA PATIENTS TO RECEIVE A CT SCAN WITHIN 1 HOUR (n=114)

52%48%

1 hour or less

More than one hour


CHAPTER 7

3. INTENSIVE CARE UNIT ADMISSION

Patients sustaining major trauma are admitted to a critical care service for many reasons, including ongoing resuscitation, organ support and/or closer monitoring. Critical care encompasses both intensive care and high-dependency care. In practice, level 2 is the high-dependency care and level 3 is the intensive care level of critical care (National Standards for Adult Critical Care Services, 2011). The length of stay (LOS) in an intensive care unit (ICU) can be influenced by the availability of ICU beds, the needs of the patient and/or the availability of step-down beds. CHI at Temple Street and CHI at Crumlin are the only hospitals with paediataric ICU’s. This highlights the need to develop pathways to hospitals that are equipped to manage paediatric patients.

Table 7.2 shows that the median ICU LOS for paediatric major trauma patients was 1.5 days, compared with 3 days for adult major trauma patients. For patients with an ISS of >15, the median LOS was 2 days, which is comparable with that reported in the TARN report, Severe Injury in Children: January 2017 – December 2018: England & Wales (TARN, 2019); for MTA paediatric patients with severe traumatic brain injury (TBI), the median LOS was 3 days. This compares with the median LOS of 4 days for adult major trauma patients with ISS of >15, and of 5 days for adult major trauma patients with severe TBI.

TABLE 7.2: INTENSIVE CARE UNIT LENGTH OF STAY FOR PAEDIATRIC MAJOR TRAUMA PATIENTS

ICU LOS FOR ALL MTA PAEDIATRIC PATIENTS

ICU LOS FOR MTA PAEDIATRIC PATIENTS WITH AN ISS OF >15

ICU LOS FOR TARN PATIENTS UK (2017-2018) WITH AN ISS OF >15

ICU LOS FOR MTA PAEDIATRIC PATIENTS WITH SEVERE TBI

Number of patients

306 230 - 62

Median LOS, in days (IQR

1.5 (1–4) 2.0 (1–5) 2.0 (1–5) 3.0 (1–9.25)

ICU bed days 1182 984 4203 370


CHAPTER 7

4. HOSPITAL LOS

Hospital LOS for trauma patients is dependent on the nature and severity of the injuries sustained, the baseline health of the patient, the efficiency of the hospital in delivering care and the ability of the hospital to discharge the patient to an appropriate setting when they are medically well enough to leave the acute hospital. Many patients’ recovery will extend well beyond hospital discharge. Access to rehabilitation, step-down facilities, and home and community supports influence the LOS at the acute hospital for severely injured patients. The median hospital LOS for all paediatric major trauma patients was 5 days, and the median LOS for paediatric major trauma patients with an ISS of >15 was 6 days, which was the same as that reported in the TARN report, Severe Injury in Children: January 2017 – December 2018: England & Wales (TARN, 2019). The comparable figures in adult major trauma patients were 9 and 11 days, respectively (Table 7.3).

TABLE 7.3: HOSPITAL LENGTH OF STAY FOR PAEDIATRIC MAJOR TRAUMA PATIENTS

HOSPITAL LOS FOR ALL MTA PAEDIATRIC PATIENTS

HOSPITAL LOS FOR MTA PAEDIATRIC PATIENTS WITH AN ISS OF >15

HOSPITAL LOS FOR TARN PATIENTS UK (2017-2018)WITH AN ISS OF >15

Number of patients 1382 488 -

Median LOS, in days (IQR) 5 (3-9) 6 (4-11) 6 (4-13)


KEY FINDINGS FROM CHAPTER 7• Overall, a low percentage of paediatric major trauma patients were documented as

having been pre-alerted (13%, n=150).

• Only one in five (20%, n=234) paediatric major trauma patients were met by a trauma team on arrival at hospital.

• Forty-one percent (n=479) of paediatric major trauma patients were seen by a consultant on arrival.

• Twenty-seven percent (n=312) of paediatric major trauma patients were documented as having been reviewed by a consultant within 30 minutes of arrival to the ED.

• The most common type of surgery performed in paediatric major trauma patients was limb surgery (54%, n=370).

• Of the 114 paediatric major trauma patients who required a head CT (having head injuries and an initial GCS of <13), (52%, n=59) received it within 1 hour.

• The median ICU LOS for paediatric major trauma patients was 1.5 days.

• The median hospital LOS for all paediatric major trauma patients was 5 days; this was 6 days for patients with an ISS of >15.

CHAPTER 7


CHAPTER 8OUTCOMES


This chapter will describe the outcomes of paediatric major trauma patients in terms of mortality and discharge destination. Mortality is reported at 30 days post-discharge.

MORTALITY AT 30 DAYS POST-DISCHARGE

Mortality is a crude measure of the quality of care in major trauma patients; quality of life and return to independent living are far more patient-centred measures. The NOCA MTA is working towards developing these outcome measures. There were 57 (4%) paediatric major trauma patients recorded as having died during their hospital admission between 2014-2019. All patients who died had an ISS of >15 (n=57). This compares favourably to the TARN report, Severe Injury in Children: January 2017 – December 2018: England & Wales, which reported 7.7% mortality in patients with an ISS of >15 (TARN, 2019).

MORTALITY AND AGE

Figure 8.1 shows the percentage of patients within each age group who died from their injuries as a proportion of the total number of patients who died (n=57). The highest percentage of deaths was recorded in patients aged 14–15 years (30%, n=17).

CHAPTER 8

OUTCOMES

FIGURE 8.1: MORTALITY IN PAEDIATRIC MAJOR TRAUMA PATIENTS BY AGE GROUP (n=57)


4%

18%

16%

18%

16%

30%

0%

5%

10%

15%

20%

25%

30%

<1 1-2 3-5 6-10 11-13 14-15

PERC

ENTA

GE

AGE GROUP


FIGURE 8.2: MORTALITY IN PAEDIATRIC MAJOR TRAUMA PATIENTS BY MECHANISM OF INJURY (n=57)

11%

5%2%

32%

51%

0%

10%

20%

30%

40%

50%

60%

Blow Fall less than 2m Fall more than 2m Road trauma Other

PERC

ENTA

GE

MECHANISM OF INJURY

MORTALITY BY MECHANISM OF INJURY

The most common single mechanism of injury leading to death in paediatric major trauma patients was road trauma (32%, n=18) (Figure 8.2). ‘Other’ – which includes asphyxiation, drowning and amputation – accounts for 51% of deaths (n=29).

CHAPTER 8



CHAPTER 8

FIGURE 8.3: MORTALITY IN PAEDIATRIC MAJOR TRAUMA PATIENTS BY BODY REGION MOST SEVERELY INJURED, BY AGE GROUP (n=57)


100%

60%

44%50%

22%12%

37%

10%

2%

20%

4%

10%

2%

10%

11%

6%

5%

20%

44%

20%

78% 82%

51%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 1-2 3-5 6-10 11-13 14-15 Total

PERC

ENTA

GE

AGE GROUP

Head Abdomen Chest Spine Multiple Other

MORTALITY BY BODY REGION INJURED

Figure 8.3 shows that 37% (n=21) of deaths were attributable to head injuries; this was also found to be the most common body region injured leading to mortality in the TARN report, Severe Injury in Children: January 2017 – December 2018: England & Wales (TARN, 2019). Deaths due to head injuries were more common in younger children and babies, whereas deaths due to injuries to ‘other’ body regions – which includes skin and neck injuries, burns, and hypothermia – were more common in older children (Figure 8.3).


CHAPTER 8

DISCHARGE DESTINATION

Figure 8.4 shows that 83% (n=1147) of paediatric major trauma patients were discharged directly home from hospital. It is of concern that so few paediatric patients appear to be receiving rehabilitation in an inpatient facility 1% (n=19). This may be due in part to a lack of robust data on rehabilitation within the MTA, or a consequence of low levels of formal provision of dedicated paediatric rehabilitation services in the acute hospital setting in Ireland. A number of recommendations have been made as part of the Trauma System for Ireland: Report of the Trauma Steering Group by the Department of Health in 2018. These recommendations relate to acute rehabilitation in an MTC which should be reflected in the new childrens hospital.

13 The category ‘Other’ includes information that was not recorded.14 Mortuary figures do not equate to mortality figures, as mortality is reported at 30 days post-discharge.

FIGURE 8.4: DISCHARGE DESTINATION FOR PAEDIATRIC MAJOR TRAUMA PATIENTS (N=1382)13,14

FIGURE 8.4: DISCHARGE DESTINATION FOR PAEDIATRIC MAJOR TRAUMA PATIENTS (N=1382)

83%

11%

4%1% 1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Home Other acute hospital Mortuary Rehabilitation Other

PERC

ENTA

GE

DISCHARGE DESTINATION


CHAPTER 8

KEY FINDINGS FROM CHAPTER 8• There were 57 children who died during hospital admission due to major trauma.

• The highest percentage of deaths was recorded in patients aged 14–15 years (30%, n=17).

• The most common single mechanism of injury leading to death in paediatric major trauma patients was road trauma (32%, n=18)

• All paediatric major trauma patients who died had an ISS of >15 (n=57).

• The head was the most common single body region injured in paediatric major trauma patients who died (37%, n=21).

• Eighty-three percent (n=1147) of paediatric major trauma patients were discharged directly home from hospital.

• Only 1% (n=19) paediatric major trauma patients were discharged to rehabilitation.


CHAPTER 9AUDIT UPDATE


UPDATE ON AUDIT RECOMMENDATIONS FROM 2018

Strategic Recommendations Update

The MTA continues to highlight the need for a coordinated trauma system that can deliver direct and timely access to established and properly resourced trauma teams; key investigations and interventions, including early CT scans; and well-coordinated multidisciplinary rehabilitation, as well as the need to promote injury prevention.

The MTA has built a rapport with the National Clinical Lead for Trauma Services and the National Office for Trauma Services

The MTA advocates for the implementation of the Trauma System for Ireland strategy as a matter of urgency and will provide data monitoring capacity in order to ensure that the National Clinical Lead for Trauma Services, the Trauma Review Implementation Group (TRIG) and the Trauma Networks can monitor the system’s performance and react and prioritise resources appropriately.

The data from the MTA continue to inform the design of a coordinated trauma system attuned to the societal needs that are identified through the MTA in Ireland. The MTA was also integral in informing A Trauma System for Ireland: Report of the Trauma Steering Group. A request for data from 2016–2018 was granted and issued to the National Office for Trauma Services to assist in the decision-making and planning for the national trauma system.

The MTA continues to highlight the need for a multi-agency, multidisciplinary and coordinated strategy to address prevention and management of the most common mechanism of injury in Ireland: low falls.

NOCA has continued to disseminate falls prevention information in the form of home safety advice since the publication of the Major Trauma Audit National Report 2018. This was done at a number of national conferences and shared with key falls groups, such as the Health Service Executive (HSE) AFFINITY National Falls and Bone Health Project (2018–2023) and the HSE National Quality Improvement Team.

Governance Update

Each hospital should have an active MTA hospital governance committee engaged in using the reports from this audit to actively engage in quality improvement and reduce the variation in performance across all hospital sites.

Throughout 2019, the MTA Governance Committee developed a hospital MTA governance committee survey.

NOCA will conduct a survey of MTA hospital governance committees and will provide guidance and tools to support this.

The distribution of this survey was delayed due to the COVID-19 pandemic and the redeployment of staff from the MTA. The survey will now be distributed in Q4 of 2020.

CHAPTER 9

AUDIT UPDATE


CHAPTER 9

Data quality Update

NOCA will continue to work with hospitals to improve data quality, e.g. matching patient cases that have been transferred from one hospital to another.

In 2019, the availability of reports to highlight unmatched cases was covered in detail during the TARN workshops for audit coordinators. The Major Trauma Audit Manager also reiterated the importance of matching cases at the monthly teleconferences throughout the year.

In 2020, a portal on the HIPE system has been developed that enables the audit coordinators to run their own reports to identify cases for inclusion in the audit and to mark cases that are ineligible. This has enabled the data for 2019 to be retrospectively updated in order to provide more complete coverage for this report. This will also facilitate coverage reports throughout the year in a more timely fashion. These regular reports can be shared with TARN and allow more accurate reporting in the TARN clinical reports and dashboard reports.

Outcomes Update

The MTA will progress the development of key data fields in order to capture meaningful data for rehabilitation in Ireland through the rehabilitation subcommittee and the MTA Governance Committee.

The MTA Governance Committee has liaised with the National Office for Trauma Services regarding the need for a clear definition of rehabilitation. Work is continuing on this.

The MTA will continue to progress the development of longer-term outcome measures for the audit.

A request for funding for the development of longer-term outcome measures was submitted to the Department of Health.


AUDIT DEVELOPMENTS

The Major Trauma Audit National Report 2018 was published in early 2020 and, due to the impact of COVID-19, many of the national conferences the data are normally presented at were cancelled. Two TARN workshops took place during 2020: the first was in person in the Royal College of Surgeons in Ireland on 26 February 2020, and the second was a virtual workshop which took place on 30 September 2020. Throughout the year, monthly teleconferences were held and, due to the pandemic, became videoconferences to bridge the gap where in-person networking was no longer possible. Due to the current restrictions on holding face-to-face meetings, NOCA has had to find new ways of working and supporting the hospitals. The virtual nature of the most recent TARN workshop meant that the session could be recorded and shared with anyone who could not attend at that time, and this will now form part of a repository of materials to support hospital audit coordinators.

In 2019–2020 , several key developments took place, including:• completion of the MTA data dictionary• updated quarterly hospital and Hospital Group reports• implementation of the new data analytical portal by TARN• development of the HIPE MTA portal for ineligible cases.

CHAPTER 9


CHAPTER 9

PUBLICATIONS

In late 2019, an article entitled “Cycling related major trauma in Ireland” which used MTA data from 2014 to 2016 was published by Dr James Foley, Marina Cronin, Louise Brent, Tom Lawrence, Dr Ciaran Simms, Dr Kevin Gildea, Dr John Ryan, Prof. Conor Deasy and Dr John Cronin in the journal Injury (https://www.injuryjournal.com/article/S0020-1383(19)30746-6/fulltext). The study found that:

• Cycling injuries occur in a predominantly young male population and are associated with more severe injuries than other mechanisms of injury.

• A common mechanism for cycling injuries is a collision with a motor vehicle, but the exact nature of the incident is unknown for the majority of collisions.

• Using hospital data provides valuable information on the injuries sustained by cyclists, and could be used to guide injury prevention strategies.

In early 2020, an article entitled “Trauma on Farms in the Republic of Ireland” using MTA data from 2014 to 2016 was published by Dr Micheal Sheehan, Louise Brent and Prof. Conor Deasy in the journal Injury (https://doi.org/10.1016/j.injury.2020.05.001). The study found that:

• Injuries on farms are increasing annually.• Males are more likely to suffer injuries.• Farmers work later into life compared with people employed in other industries,

and farmers who suffer injuries are becoming older and more medically complex.• The median age of patients in the study was 54.5 years.• Six percent of farm accidents occurred in children.• Twenty-seven percent of farm accidents occurred in people aged 65 years or over.• Summer was the most common season for injuries on farms.• Limbs were the most common body region injured (32%), followed by the chest

(21%), spine (16%) and head (15%).• Almost one in five patients required surgery.• Eighteen percent of patients required admission to an ICU.• Ninety-six percent of patients presented to hospital between 8.00am and 12.00pm.• The most common mechanism of injury was a blow from an animal (29%), followed

by falls (27%).• The majority of patients were discharged back to their own home; however, many

needed further care in a subsequent hospital or ongoing rehabilitation. Inpatient mortality was 2.6%, most commonly due to head injury.

• Most accidents happened on a Monday.

The findings from this study were widely shared on social media and radio during Farm Safety Week.


CHAPTER 9

FUTURE DEVELOPMENTS

The robust nature and advancing maturity of the MTA means that the data can be used to provide a detailed subgroup analysis, such as the analysis provided in this report for paediatric major trauma patients. The MTA continues to encourage researchers and healthcare workers to apply for access to the audit data for research and quality improvement.


CHAPTER 10RECOMMENDATIONS


RECOMMENDATIONS

CHAPTER 10

RECOMMENDATIONS FOR THE HEALTH SERVICE EXECUTIVERECOMMENDATION 1The Health Service Executive’s (HSE’s) National Office for Trauma Services and Integrated Care Programme for Children will: • Use the Major Trauma Audit Paediatric Report 2014–2019 to develop interim paediatric

major trauma care pathways until the new trauma system is fully developed and the new children’s hospital is built, and to inform the requirements for rehabilitation services for trauma patients regionally and nationally.

• Continue to progress the development of a coordinated trauma system and fully implement the Trauma System for Ireland strategy.

• Define meaningful trauma team and rehabilitation criteria for collection within the Major Trauma Audit (MTA) for adults and paediatric patients.

Rationale

• The publication of A Trauma System for Ireland: Report of the Trauma Steering Group (Department of Health, 2018b) sets out clear guidance for the development of an evolved and efficient trauma system.

• In A Trauma System for Ireland: Report of the Trauma Steering Group, specific reference is made to the need for national bypass and standardised pathways of care for specific groups of trauma patients. This strategy does not put any focus on paediatric major trauma patients. The MTA has highlighted the diverse nature of major trauma in the paediatric population, in terms of both the variety of injuries and of the geographic location where injuries occur. An integrated system must be able to respond to these challenges.

What action should be taken?

• The HSE’s National Office for Trauma Services should use the data from this report to develop an interim plan and pathways of care for paediatric major trauma patients. The National Office for Trauma Services should continue to use the data from the MTA to evaluate the implementation of the national trauma system and to collect valuable information on trauma team configuration and rehabilitation.

Who will benefit from this action/recommendation?

• Patients will benefit from a more streamlined, efficient and appropriate pathway of care, resulting in more timely interventions and better outcomes.

• The HSE will benefit from a more efficient use of resources bringing the right patient to the right hospital for the right care at the right time, in line with the Sláintecare Implementation Strategy (Department of Health, 2018a).

Who is responsible for implementing this action/recommendation?

• The HSE’s National Office for Trauma Services is responsible for using the findings from this report to inform the development of the trauma system.

When will this be implemented?

The development of the trauma system is ongoing and may take many years; however, changes to paediatric pathways could be operationalised nationally during 2021 and 2022.


CHAPTER 10

RECOMMENDATION 2The HSE’s National Healthy Childhood Programme will:

• Use the information about mechanisms and location of injuries from the MTA 2014-2019 Paediatric Major Trauma Audit Report to inform injury prevention strategies for children.

Rationale

• The information contained within this report indicates that many paediatric major trauma injuries are preventable in nature.


• The information about type of mechanism and location of injury can be shared parents/guardians.

• The relevant findings from the audit will be included in training programmes for healthcare professionals delivering the Child Safety Programme.

• Materials provided to parents/guardians, as part of the Child Safety Programme, will reflect key messages, based on the findings of the audit.


• Babies and children in the 0 to 5 years age group and their parents will benefit from less accidents and injuries.

• Hospitals will have a reduced demand for services.


• The National Healthy Childhood Programme can use the Child Safety Programme to disseminate these important safety messages.


The National Healthy Childhood Programme is delivered to all children, free of charge, from birth to age 13 years. The Child Safety Programme is delivered by public health nurses, during child health assessment visits, to babies and children from birth to 5 years.

The National Healthy Childhood Programme is delivered to all children, free of charge, from birth to age 13 years. The Child Safety Programme is delivered by public health nurses, during child health assessment visits, to babies and children from birth to 5 years.


CHAPTER 10

RECOMMENDATION FOR THE ROAD SAFETY AUTHORITYRECOMMENDATION 3The Road Safety Authority will:

• Use information about the mechanisms and location of injuries from the Major Trauma Audit Paediatric Report 2014–2019 to inform injury prevention strategies for children.

Rationale

• The information contained within this report indicates that many paediatric major trauma injuries are preventable in nature.


• The information about the mechanisms and geographic location of injuries can be used to inform public safety messages for the home, public places and roads. Information campaigns can be supplemented with this additional information in order to help prevent further childhood injuries.


• Children and parents will benefit from fewer accidents and injuries.

• Hospitals will benefit from a reduced demand for services.


• The Road Safety Authority can use their existing safety advice campaigns to disseminate these important safety messages.


This is an ongoing process.


RECOMMENDATIONS FOR HOSPITAL MANAGERS, CLINICIANS AND AUDIT COORDINATORSRECOMMENDATION 4Hospital MTA governance committees should complete the National Office of Clinical Audit (NOCA) hospital governance committee survey and continue to meet quarterly to discuss the MTA findings. Actions should be taken to improve services where deficits are identified.

Rationale

• Since 2016, the MTA has been accredited by the National Clinical Effectiveness Committee, thus mandating that the relevant hospitals participate fully in the audit. This includes data collection and validation, and use of the data for quality improvement.

• In 2018, a key recommendation from the MTA was that each hospital should have an active hospital MTA governance committee.


• Clinical leads and audit coordinators should complete the hospital MTA governance committee survey in Q4 of 2020.

• Clinicians and healthcare workers involved in the care of major trauma patients should meet regularly to evaluate care and processes.


• Hospitals will strengthen their governance for major trauma care and quality improvement.

• NOCA will benefit from further compliance with the audit’s standards for data quality, care and governance.


• Hospital managers and MTA clinical leads should ensure that their hospital is engaging fully with the MTA and the output from the data.


This is an ongoing process for the improvement of governance at hospital level.

CHAPTER 10


CHAPTER 10

RECOMMENDATIONS FOR NOCARECOMMENDATION 5Support hospitals to attain high levels of data coverage and quality until at least 2022, as they recover from COVID-19.

Rationale

• The data collection for one calendar year does not usually finish until the end of Q2 (30 June) of the following year. In 2020, the impact of the global COVID-19 pandemic caused significant disruption to the healthcare system, particularly from March to June. During this period, most of the MTA audit coordinators were redeployed to frontline services and away from audit work, thus impacting their ability to input and validate data. The care of major trauma patients is a protected service, and need is unpredictable. As such, its support and provision must remain protected even during a pandemic.

• As a result, TARN allowed an additional month for data collection until the end of July.


• NOCA will continue to evaluate the impact of the COVID-19 pandemic and develop new ways of working to best support the 26 participating hospitals and ensure that timely data reporting continues. Due to the evolving nature of the COVID-19 pandemic, there have been significant and long-lasting impacts on Ireland’s hospitals and how they contribute to clinical audits such as the MTA.


• NOCA will benefit by developing new ways of working with hospitals virtually.

• Hospitals will benefit from access to supporting materials, augmented data collection calendars, and training materials for audit collection during this time.

• The healthcare system will benefit from updates related to care, data quality, and outcomes due to the pandemic.


• NOCA is responsible for evaluating and developing novel ways to ensure that clinical audit continues during difficult circumstances in order to help the healthcare system understand how care has been impacted by significant events.


This will be continuously implemented and evaluated throughout 2020 and 2021.


RECOMMENDATION 6NOCA will conduct a survey of hospital MTA governance committees to determine what supports are required within the system to support hospitals to utilise the audit data for improvement.

Rationale

• Since 2016, the MTA has been accredited by the National Clinical Effectiveness Committee, thus mandating that the relevant hospitals participate fully in the audit. This includes data collection and validation, and use of the data for quality improvement.

• In 2018, a key recommendation from the MTA was that each hospital should have an active hospital MTA governance committee.


• A survey of each hospital’s compliance with the 2018 recommendation will be undertaken by NOCA.

• NOCA will survey the presence, composition and activities of the hospital MTA governance committees.


• Hospitals will strengthen their processes to use clinical audit data from the MTA to improve care.

• NOCA will benefit from further compliance with the audit’s standards for data quality, care and governance.


• Hospital managers and MTA clinical leads should ensure that their hospital is compliant with the recommendations from the MTA.


The survey will be sent to all hospitals in Q4 of 2020 and published in the 2020 MTA report. Findings from this survey will be used to develop additional supports and resources to help the hospitals improve their engagement with the audit.

CHAPTER 10


CHAPTER 10

RECOMMENDATION 7NOCA will develop meaningful quarterly dashboard reports of key performance indicators for the hospitals and Hospital Groups.

Rationale

• Sharing information is a key objective of any clinical audit, and the usability and clear messages from the data should be apparent and easily understood. NOCA has committed to developing meaningful quarterly reports for all audits. This will inform quality improvement projects (QIPs) and research.


• The NOCA data analytics team will work with the MTA Governance Committee to identify key performance indicators that can be produced quarterly and shown on a Statistical Process Control (SPC) chart.


• Hospitals will benefit from having more real-time quarterly information that can show signs of clear improvement or lack thereof.

• NOCA will be able to use these reports to support the hospitals to improve and develop resources that can assist the hospitals.


• The NOCA data analytics team and the Major Trauma Audit Manager.


This will be implemented in Q4 2020.


CHAPTER 10

RECOMMENDATION 8NOCA will implement processes for the introduction of long-term outcome measures for all ages in the MTA.

Rationale

• The MTA only collects data during patients’ in-hospital acute episode of care.

• Long-term outcome measures can inform how healthcare services and interventions have, over time, affected patients’ quality of life, daily functioning, symptom severity, survival and residence, as well as the patients’ point of view, therefore informing healthcare services whether healthcare interventions actually make a difference to people’s lives (Williams et al., 2016).


• The MTA, in conjunction with TARN, will continue to work towards defining key data for long-term follow-up of major trauma patients.

• Research funding will be sought in order to conduct meaningful research into how best to collect long-term outcome measures for major trauma patients.


• NOCA will be able to provide long-term outcome data for reporting

• Clinicians and healthcare workers will better understand the impact of major trauma care and outcomes in the longer term, and will be able to evaluate care pathways.

• Patients will be able to provide feedback and contribute to the audit.


• NOCA and TARN will be responsible for developing long-term outcome data collection for the MTA.


This will be implemented from 2020 to 2022.


CHAPTER 10

RECOMMENDATION 9NOCA will develop a research group for the MTA, including Public and Patient Interest (PPI) representatives.

Rationale

• The MTA Governance Committee should set up a formal research group for the audit, as the maturity of the audit and data will now allow meaningful research to be conducted.

• The benefits of using this robust MTA dataset in creating new knowledge that prevents injury and improves how we care for those injured is imperative.


• The MTA Governance Committee will agree on a subgroup of the committee and extended membership of a research group for the MTA.

• NOCA will extend invitations and coordinate the establishment of a research group for the MTA.


• NOCA will enhance its audit portfolio with high-quality research outputs.

• The MTA will benefit from the findings of this research, and this may shape and inform future amendments to the data or inform hospitals about changes to processes of care.


• The Major Trauma Audit Manager will coordinate the development of the MTA research group.


This will be discussed at the final MTA Governance Committee meeting for 2020 and will be commenced in Q1 of 2021.


RECOMMENDATION 10NOCA will increase engagement with PPI representatives to:

• develop resources to raise public awareness of preventable causes of major trauma• create information resources for patients • create opportunities for multistakeholder engagement around key issues faced

by patients.

Rationale

• In line with NOCA’s guidance for MTA Governance Committee membership, it is essential that PPI representative involvement is included at every level of the audit. This will bring an enhanced understanding about what is important to patients and the public, and ensure that key findings from the audit are meaningful to patients and the public and are widely disseminated.


• A second PPI representative should be recruited to the MTA Governance Committee.

• Opportunities for PPI representative involvement in the MTA should be actioned throughout the year, including at the MTA workshop, as a research committee member, as a member of the MTA report writing group, and in the development of patient information resources and media campaigns.


• NOCA will benefit from the PPI representative’s perspective regarding how MTA information can be disseminated to the patient and public audience.

• Patients and the public will be provided with information from the audit that is meaningful to them and which could ultimately help prevent major trauma.


• NOCA is responsible for the recruitment of PPI representatives.


NOCA is constantly looking to expand the number of PPI representatives contributing to audits, and this will continue through 2020–2021.

CHAPTER 10

CHAPTER 11CONCLUSION


CHAPTER 11

CONCLUSION

This report provides the first comprehensive analysis of paediatric major trauma in the Irish population. This is timely, given the opportunities for improving care for traumatically injured children throughout Ireland presented by the new children’s hospital, as this will be the single paediatric major trauma centre for the State. The report highlights that paediatric major trauma is of low frequency, at 5% of the overall trauma caseload for the 26 participating Irish hospitals. This represents a challenge in ensuring that healthcare institutions have the required expertise, preparedness and practice for presentations and procedures that happen relatively infrequently. The report also highlights the volume of major trauma patients attending model 3 and level 4 hospitals outside of Dublin and the need for on-site expertise and rapid transport services to get critically injured children to the right place at the right time. The MTA will continue to inform the reconfiguration of the Irish trauma system so that it is continuously modifying and improving, driven by the data and outcomes of MTA reports, in order to ensure equity of access to efficient and high-quality care for the children and adults of Ireland.

A key finding from this report has been the many preventable mechanisms of injury leading to major trauma in children. Disseminating injury prevention messages to key groups and programmes will be a key focus for the audit.

Moving forward, the MTA will work to support hospital MTA governance committees to use the data to identify areas of variation and develop QIPs to improve care.


REFERENCES


REFERENCES

Williams, K., Sansoni, J., Morris, D., Grootemaat, P and Thompson. C (2016) Patient-reported outcomes measures Australian Commission on Safety and Quality in Health Care https://www.safetyandquality.gov.au/sites/default/files/migrated/PROMs-Literature-Review-December-2016.pdf [Accessed 20 November 2020].

Baker, S.P., O’Neill, B., Haddon, W. Jr and Long, W.B. (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. Journal of Trauma and Acute Care Surgery, 14(3), pp. 187-196. [Accessed 20 November 2020].

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (2016)a Fatal Injury and Violence Data [Internet]. Available from: https://www.cdc.gov/injury/wisqars/fatal.html [Accessed 20 November 2020].

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (2016)b Nonfatal Injury Data [Internet]. Available from: https://www.cdc.gov/injury/wisqars/nonfatal.html [Accessed 20 November 2020]. [Accessed 20 November 2020].

Deasy, C., Gabbe, B., Palmer, C., Babl, F.E., Bevan, C., Crameri, J., Butt, W., Fitzgerald, M., Judson, R. and Cameron, P., 2012. Paediatric and adolescent trauma care within an integrated trauma system. Injury, 43(12), pp.2006-2011.

Department of Health (2018)a Sláintecare Implementation Strategy [Internet]. Available from: https://assets.gov.ie/22607/31c6f981a4b847219d3d6615fc3e4163.pdf [Accessed 20 November 2020].

Department of Health (2018)b A Trauma System for Ireland: Report of the Trauma Steering Group [Internet]. Available from: https://health.gov.ie/wp-content/uploads/2018/02/Report-of-the-Trauma-Steering-Group-A-Trauma-System-for-Ireland.pdf [Accessed 20 November 2020].

Department of Health (2019) First 5 Implementation Plan 2019-2021 [Internet]. Available from: https://www.gov.ie/en/publication/26b2ce-first-5-implementation-plan-2019-2021/ [Accessed 20 November 2020].

Driscoll, P.A. and Vincent, C.A. (1992) Variation in trauma resuscitation and its effect on patient outcome. Injury, 23(2), pp. 111-115. [Accessed 20 November 2020].

Foley, J., Cronin, M., Brent, L., Lawrence, T., Simms, C., Gildea, K., Ryan, J., Deasy, C. and Cronin, J., 2020. Cycling related major trauma in Ireland. Injury, 51(5), pp.1158-1163. [Accessed 20 November 2020].

Health Information and Quality Authority (2018) Guidance on a data quality framework for health and social care [Internet]. Available from: https://www.hiqa.ie/sites/default/files/2018-10/Guidance-for-a-data-quality-framework.pdf [Accessed 12 November 2020].

Joint Faculty of Intensive Care Medicine of Ireland (JFICMI) in association with The Intensive Care Society of Ireland (2011) National Standards for Adult Critical Care Services Available from : https://www.anaesthesia.ie/attachments/article/57/JFICMI_Minimum_Standards%20Rev-01.pdf [Accessed 12 November 2020].

National Clinical Programme for Paediatrics and Neonatology (2015) A National Model of Care for Paediatric Healthcare Services in Ireland [Internet]. Dublin: Health Service Executive. Available from: https://www.hse.ie/eng/about/who/cspd/ncps/paediatrics-neonatology/moc/chapters/ [Accessed 20 November 2020].

National Health Service (2018) London Major Trauma System: Management of elderly major trauma patients – Second Edition [Internet]. Available from: https://www.c4ts.qmul.ac.uk/downloads/pan-london-major-trauma-system-elderly-trauma-guidancesecond-editiondecember-2018.pdf [Accessed 16 November 2020].

REFERENCES


REFERENCES

National Institute for Health and Care Excellence (2014) Head injury: assessment and early management: Clinical guideline [CG176] [Internet]. Available from: https://www.nice.org.uk/guidance/cg176 [Accessed 23 October 2019].

NHS Clinical Advisory Group on Trauma (2010) Regional Networks for Major Trauma: NHS Clinical Advisory Groups Report [Internet]. Available from: http://www.uhs.nhs.uk/Media/SUHTInternet/Services/Emergencymedicine/Regionalnetworksformajortrauma.pdf [Accessed 20 November 2020].

Royal College of Surgeons of England (1999) Report of the working party on the management of patients with head injuries. London: Royal College of Surgeons of England. [Accessed 20 November 2020].

Royal College of Physicians (2015) National Hip Fracture Database annual report 2015. London: Royal College of Physicians. Available from: http://www.nhfd.co.uk/nhfd/nhfd2015reportPR1.pdf [Accessed 20 November 2020].

Sheehan, M., Brent, L. and Deasy, C., 2020. Trauma on farms in the Republic of Ireland. Injury. [Accessed 20 November 2020].

The Trauma Audit and Research Network (2019) Severe Injury in Children: January 2017 – December 2018: England & Wales [Internet]. Available from: https://www.tarn.ac.uk/content/downloads/3572/Severe%20Injury%20in%20Children%202017-2018.pdf [Accessed 20 November 2020].

World Health Organization (2008) World report on child injury prevention. World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/43851/9789241563574_eng.pdf;jsessionid =788F451483EE2817F232A49635BA937B?sequence=1 [Accessed 20 November 2020].

World Health Organization (2014) Injuries and violence, the facts. World Health Organization. h t tps : //apps .who. in t/ i r i s /b i t s t ream/hand le/ 10665/ 149798/9789241508018_eng pdf;jsessionid=F983209806005B5AC4ED B8DAC8FB218B?sequence=1 [Accessed 20 November 2020].


APPENDICES


The decision to include a patient should be based on the following 3 points:1. ALL TRAUMA PATIENTS IRRESPECTIVE OF AGE2. WHO FULFIL ONE OF THE FOLLOWING LENGTH OF STAY CRITERIA

DIRECT ADMISSIONS

Trauma admissions whose length of stay is 3 days or more

ORTrauma patients admitted to a High

Dependency Area regardless of length of stayOR

Deaths of trauma patients occurring in the hospital including the Emergency Department

(even if the cause of death is medical)OR

Trauma patients transferred to other hospital for specialist care or for an ICU/HDU bed.

PATIENTS TRANSFERRED IN

Trauma patients transferred into your hospital for specialist care or ICU/HDU bed whose

combined hospital stay at both sites is 3 days or more

ORTrauma admissions to a ICU/HDU area

regardless of length of stayOR

Trauma patients who die from theirinjuries (even if the cause of death is medical)

Patients transferred in for rehabilitation only should not be submitted to TARN.

APPENDIX 1: INCLUSION CRITERIA

3. AND WHOSE ISOLATED INJURIES MEET THE FOLLOWING CRITERIA

BODY REGION OR SPECIFIC INJURY

INCLUDED – IN ISOLATION (EXCEPT WHERE SPECIFIED)

EXCLUDED – IN ISOLATION (EXCEPT WHERE SPECIFIED)

HEAD All brain or skull injuries LOC or injuries to scalp

THORAX All internal injuries

ABDOMEN All internal injuries

SPINE Cord injury, fracture, dislocation Spinal strain or sprain. or nerve root injury.

FACE Fractures documented as: Significantly Fractures documented as Closed and Displaced, open, compound or comminuted. simple or stable. All Lefort fractures All panfacial fractures. All Orbital Blowout fractures

NECK Any Organ or vascular injury or hyoid fracture Nerve Injuries Skin Injuries

FEMORAL All Shaft, Distal, Head or Subtrochanteric Isolated Neck of femur or Inter/Greater FRACTURE fractures, regardless of Age. trochanteric fractures ≥ 65 years. Isolated Neck of Femur or Inter/ Greater trochanteric fractures <65 years old

FOOT OR HAND: Crush or amputation only. Any fractures &/or dislocations, JOINT OR BONE even if Open &/or multiple

FINGER OR TOE None All injuries to digits, even if Open fractures, amputation or crush &/or multiple injuries.


BODY REGION OR SPECIFIC INJURY

INCLUDED – IN ISOLATION (EXCEPT WHERE SPECIFIED)

EXCLUDED – IN ISOLATION (EXCEPT WHERE SPECIFIED)

LIMB – UPPER Any Open injury. Any Closed unilateral injury fractures, (EXCEPT Any 2 limb fractures &/or dislocations. (including multiple closed fractures & or HAND/FINGERS) dislocations or the same limb)

LIMB – BELOW Any Open injury. Any Closed unilateral injury fractures, KNEE (EXCEPT Any 2 limb fractures &/or dislocations. (including multiple closed fractures & or FEET/TOES) dislocations or the same limb)

PELVIS All isolated fractures to Ischium, Sacrum, Single pubic rami fracture >65 years old. Coccyx, Ileum, acetabulum. Multiple pubic rami fractures. Single pubic rami fracture <65 years old. Any fracture involving SIJ or Symphysis pubis.

NERVE Any injury to sciatic, facial, femoral or All other nerve injuries, single or multiple. cranial nerve.

VESSEL All injuries to femoral, neck, facial, cranial, Intimal tear or superficial laceration or thoracic or abdominal vessels. perforation to any limb vessel. Transection or major disruption of any other vessel.

SKIN Laceration or penetrating skin injuries Simple skin lacerations or penetrating injuries with with blood loss >20% (1000mls) blood loss < 20% (1000mls); single or multiple. Major degloving injury. (>50% body region) Contusions or abrasions: single or multiple. Minor degloving injury. (<50% body region)

BURN Any full thickness burn or Partial/superficial Partial or superficial burn <10% body surface area. burn >10% body surface area

INHALATION All included

FROSTBITE Severe frostbite Superficial frostbite

ASPHYXIA All None

DROWNING All None

EXPLOSION All None

HYPOTHERMIA Accompanied by another TARN eligible injury Hypothermia in isolation

ELECTRICAL All None


INJURY DETAIL

Injury detail is of paramount importance to any TARN submission, therefore all injuries sustained by a patient must be recorded on every submission.

Information relating to injuries should be obtained from the following sources: clinician’s notes, nursing notes, radiology reports, operative notes, discharge summaries and post mortem reports.

Guidelines to help with injury documentation, record:• Length, depth or grade of lacerations (especially to internal organs)• Depth, size and location of haemorrhages and contusions (especially in the brain)• Open or closed fractures• Stability & site of fractures (e.g. comminuted/displaced shaft/proximal/distal fracture)• Articular (joint) involvement (e.g. intra-articular, extra-articular)• Blood loss• Vessel damage• Location & number of rib fractures• Compression or effacement of ventricles/brain stem cisterns• Neurology associated with spinal cord injuries• Instability, blood loss, joint involvement or vascular damage associated with pelvic fractures• Cardiac arrest associated with asphyxia or drowning

UNCONFIRMED INJURIES

Injuries should only be recorded when the diagnosis is confirmed.Never record possible, probable or suspected injuries.

RADIOLOGY REPORTS AND POST-MORTEMS

The user should paste a radiology report into the relevant imaging section of any electronic data collection and reporting (EDCR) submission.

When a report is pasted into an EDCR submission, it will automatically appear on the AIS coding section, thus ensuring that the TARN coder has all the information in front of them before assigning AIS codes.

Post mortem results should be used whenever available even if this results in a delay in dispatching your submission.

All injury coding using AIS is done centrally at TARN, but users can see every AIS code issued by TARN by clicking into the AIS coding section once a submission has been approved.

Accurate and detailed injury descriptions will enable a more precise Injury Severity Score and therefore a more accurate Probability of Survival calculation.

ANATOMICAL INJURY DESCRIPTIONS


CODING STRUCTURE EXPLAINED

BODY TYPE OF SPECIFIC SPECIFIC LEVEL LEVEL AIS REGION ANATOMICAL ANATOMICAL ANATOMICAL STRUCTURE STRUCTURE STRUCTURE 4 5 0 2 0 2 2

All existing codes on the TARN database that were coded with AIS98 (previous version of Dictionary) were successfully mapped to corresponding AIS2005 codes, so continuing comparisons can be made.

BACKGROUND INFORMATION

A.I.S. was first published in 1969 by the Association for the Advancement of Automotive Medicine (A.A.A.M.). The latest edition (AIS2005) is now available from the AAAM website: www.AAAM..org at cost of $250 per dictionary.

STRUCTURE

• Based on anatomical injury.• A single AIS score for each injury.• More than 1500 injuries listed.• Scores range from 1 to 6, the higher the score the more severe the injury.• The intervals between the scores are not always consistent e.g. the difference between AIS3 and AIS4 is not

necessarily the same as the difference between AIS1 and AIS2.

EXAMPLE AIS CODES

INJURY NUMERICAL IDENTIFIER AIS SEVERITYFracture 1 rib 450201 1 MinorFractured 2 ribs 450202 2 ModerateHaemopneumothorax 442205 3 SeriousBilateral lung lacerations 441450 4 SevereBilateral flail chest 450214 5 CriticalMassive chest crush 413000 6 Maximum

APPENDIX 2: ABBREVIATED INJURY SCALE (AIS)


ROLE NAME

Prof Conor Deasy, National Board for Ireland of the College of Emergency Medicine Clinical Lead and Chair

Louise Brent NOCA Irish Hip Fracture Database and Major Trauma Audit Manager

Dr Tomás Breslin Irish Association for Emergency Medicine

Ann Calvert Emergency Medicine Nursing Interest Group

Fiona McDaid Emergency Medicine Nursing Interest Group

Mr Darach Crimmins Royal College of Surgeons in Ireland – Neurosurgery Programme

Rachael Doyle HSE National Clinical Programme for Older People

Jacqueline Egan Pre-Hospital Emergency Care Council

Dr Joan Fitzgerald Royal College of Physicians of Ireland – Pathology

Naomi Fitzgibbon PPI Representative, Spinal Injuries Ireland

Dr Jennifer Hastings Joint Faculty of Intensive Care Medicine of Ireland

Nora Hourigan Hospital In-Patient Enquiry Manager

Macartan Hughes National Ambulance Service

Mr Dara Kavanagh Royal College of Surgeons in Ireland – General Surgery

Marion Lynders MTA Audit Coordinator Representative

Dr Ciara Martin Children’s Health Ireland – Paediatric Emergency Medicine

Mr Morgan McMonagle Royal College of Surgeons in Ireland – Irish Association of Vascular Surgeons

Dr Peter MacMahon Royal College of Surgeons in Ireland – Faculty of Radiologists

Dr Caroline Mason Mohan Public Health, Royal College of Physicians of Ireland

Dr Jacinta McElligott Royal College of Physicians of Ireland – Rehabilitation Medicine

Dr Gerry Lane Irish Committee for Emergency Medicine Training Chair/Nominee

Dr George Little National Emergency Medicine Programme Nominee for MTA

Mr Brendan O’Daly Irish Institute of Trauma and Orthopaedic Surgery – Trauma and Orthopaedic Programme

Rosie Quinn Therapy Representative

Geraldine Shaw HSE Office of Nursing and Midwifery Services

Mr Barry O’Sullivan Irish Association of Plastic Surgeons

Olga Brych NOCA Data Analyst (BY INVITATION)

Collette Tully NOCA Executive Director (BY INVITATION)

APPENDIX 3: MTA GOVERNANCE COMMITTEE


APPENDIX 4: FREQUENCY TABLES


N %<1 138 10.0%

1–2 228 16.5%

3–5 232 16.8%

6–10 341 24.7%

11–13 219 15.8%

14–15 224 16.2%

Total 1382 100.0%

FIGURE 5.2: PERCENTAGE OF MAJOR TRAUMA AUDIT PAEDIATRIC PATIENTS BY GENDER AND AGE GROUP (N=1382)

Female Male TotalN % N % N %

<1 62 44.9% 76 55.1% 138 100.0%

1–2 80 35.1% 148 64.9% 228 100.0%

3–5 77 33.2% 155 66.8% 232 100.0%

6–10 146 42.8% 195 57.2% 341 100.0%

11–13 73 33.3% 146 66.7% 219 100.0%

14–15 70 31.3% 154 68.8% 224 100.0%

Total 508 36.8% 874 63.2% 1382 100.0%


<1 1–2 3–5 6–10N % N % N % N %

Blow 18 13.0% 11 4.8% 24 10.3% 26 7.6%

Fall less than 2 m 88 63.8% 89 39.0% 101 43.5% 122 35.8%

Fall more than 2 m 7 5.1% 22 9.6% 23 9.9% 37 10.9%

Road trauma 8 5.8% 30 13.2% 44 19.0% 114 33.4%

Burn 8 5.8% 62 27.2% 24 10.3% 19 5.6%

Other 9 6.5% 14 6.1% 16 6.9% 23 6.7%

Total 138 100.0% 228 100.0% 232 100.0% 341 100.0%11–13 14–15 TotalN % N % N %

Blow 35 16.0% 49 21.9% 163 11.8%

Fall less than 2 m 58 26.5% 51 22.8% 509 36.8%

Fall more than 2 m 17 7.8% 27 12.1% 133 9.6%

Road trauma 81 37.0% 71 31.7% 348 25.2%

Burn 11 5.0% ~ * * *

Other 17 7.8% 22 9.8% 101 7.3%

Total 219 100.0% 224 100.0% 1382 100.0%

~ Denotes five cases or fewer * Further suppression required to prevent disclosure of five cases or fewer



<1 1–2 3–5 6–10N % N % N % N %

Alleged assault ~ * 0 0.0% ~ * 0 0.0%

Intent inconclusive ~ * ~ * ~ * ~ *

Unintentional 84 60.9% 207 90.8% 214 92.2% 285 83.6%

Sport 0 0.0% ~ * 12 5.2% 38 11.1%

Non-accidental injury 47 34.1% 11 4.8% ~ * ~ *

Suspected high-risk behaviour ~ * ~ * 0 0.0% 9 2.6%

Suspected self-harm 0 0.0% 0 0.0% 0 0.0% ~ *

Total 138 100.0% 228 100.0% 232 100.0% 341 100.0%11–13 14–15 TotalN % N % N %

Alleged assault ~ * 14 6.3% 20 1.4%

Intent inconclusive ~ * ~ * 20 1.4%

Unintentional 152 69.4% 131 58.5% 1073 77.6%

Sport 43 19.6% 54 24.1% 150 10.9%

Non-accidental injury 0 0.0% 0 0.0% 64 4.6%

Suspected high-risk behaviour 10 4.6% 10 4.5% 32 2.3%

Suspected self-harm 8 3.7% 14 6.3% 23 1.7%

Total 219 100.0% 224 100.0% 1382 100.0%



<1 1–2 3–5 6–10N % N % N % N %

Low-severity injury 40 29.0% 57 25.0% 31 13.4% 65 19.1%

Moderate-severity injury 35 25.4% 110 48.2% 125 53.9% 162 47.5%

Severe injury 63 45.7% 61 26.8% 76 32.8% 114 33.4%

Total 138 100.0% 228 100.0% 232 100.0% 341 100.0%11–13 14–15 TotalN % N % N %

Low-severity injury 46 21.0% 59 26.3% 298 21.6%

Moderate-severity injury 90 41.1% 74 33.0% 596 43.1%

Severe injury 83 37.9% 91 40.6% 488 35.3%

Total 219 100.0% 224 100.0% 1382 100.0%



<1 1–2 3–5 6–10N % N % N % N %

Home 118 85.5% 183 80.3% 139 59.9% 114 33.4%

Public area or road 12 8.7% 30 13.2% 66 28.4% 181 53.1%

Institution ~ * ~ * ~ * 18 5.3%

Farm ~ * ~ * 11 4.7% 15 4.4%

Industrial 0 0.0% 0 0.0% ~ * 0 0.0%

Other 4 2.9% 7 3.1% 10 4.3% 13 3.8

Total 138 100.0% 228 100.0% 232 100.0% 341 100.0%11–13 14–15 TotalN % N % N %

Home 42 19.2% 32 14.3% 628 45.4%

Public area or road 143 65.3% 147 65.6% 579 41.9%

Institution 11 5.0% 8 3.6% 47 3.4%

Farm 12 5.5% 13 5.8% 58 4.2%

Industrial 0 0.0% ~ * * *

Other 11 5.0% 22 9.8% 67 4.8%

Total 219 100.0% 224 100.0% 1382 100.0%


FIGURE 5.6A: TYPE OF ROAD TRAUMA FOR MAJOR TRAUMA AUDIT PAEDIATRIC PATIENTS (n=579)

N %Other 271 46.8%

Pedestrian 108 18.7%

Cyclist 92 15.9%

Car occupant 85 14.7%

Motorcyclist 23 4.0%

Total 579 100.0%

FIGURE 5.6B: POSITION IN VEHICLE FOR ROAD TRAFFIC COLLISIONS (n=85)

N %Driver ~ *Front-seat passenger ~ *Back-seat passenger 67 78.8%

Total 85 100.0%



FIGURE 5.7: BODY REGION INJURED IN ALL PAEDIATRIC PATIENTS (N=1382)

N %Abdomen 111 8.0%

Chest 58 4.2%

Face 30 2.2%

Head 440 31.8%

Limbs 439 31.8%

Multiple 55 4.0%

Other 181 13.1%

Spine 68 4.9%

Total 1382 100%

FIGURE 5.7A: BODY REGION INJURED IN PAEDIATRIC PATIENTS WITH AN INJURY SEVERITY SCORE >15 (n=488)

N %Abdomen 38 7.8%

Chest 28 5.7%

Head 327 67.0%

Limbs 6 1.2%

Multiple 33 6.8%

Other 49 10.0%

Spine 7 1.4%

Total 488 100%

FIGURE 5.7B: BODY REGION INJURED IN PAEDIATRIC PATIENTS AGED UNDER 1 YEAR (n=138)

N %Abdomen ~ *

Chest ~ *

Face 0 0.0%

Head 97 70.3%

Limbs 23 16.7%

Multiple ~ *

Other 8 5.8%

Spine ~ *

Total 138 100.0%



FIGURE 6.1: PRESENTATION BY TIME OF DAY FOR MAJOR TRAUMA AUDIT PAEDIATRIC PATIENTS (n=1360)

N %00.00 17 1.3%

01.00 18 1.3%

02.00 17 1.3%

03.00 12 0.9%

04.00 9 0.7%

05.00 5 0.4%

06.00 8 0.6%

07.00 14 1.0%

00.00–07.59 100 7.4%08.00 21 1.5%

09.00 45 3.3%

10.00 43 3.2%

11.00 55 4.0%

12.00 64 4.7%

13.00 72 5.3%

14.00 83 6.1%

15.00 91 6.7%

08.00–15.59 474 34.9%16.00 98 7.2%

17.00 123 9.0%

18.00 122 9.0%

19.00 133 9.8%

20.00 105 7.7%

21.00 96 7.1%

22.00 60 4.4%

23.00 49 3.6%

16.00–23.59 786 57.8%Total 1360 100.0%

FIGURE 5.7C: BODY REGION INJURED IN PAEDIATRIC PATIENTS AGED 15 YEARS (n=109)

N %Abdomen 14 12.8%

Chest ~ *

Face 10 9.2%

Head 20 18.3%

Limbs 22 20.2%

Multiple * *

Other 13 11.9%

Spine 18 16.5%

Total 109 100.0%



FIGURE 6.2: PRESENTATION BY MONTH AND SEASON (N=1382)

N %January 85 6.2%

February 83 6.0%

March 137 9.9%

April 125 9.0%

May 116 8.4%

June 159 11.5%

July 149 10.8%

August 143 10.3%

September 110 8.0%

October 125 9.0%

November 74 5.4%

December 76 5.5%

Total 1382 100.0%

FIGURE 6.3: MODE OF ARRIVAL AT HOSPITAL (n=1059)

N %Ambulance 578 54.6%

Ambulance and helicopter 23 2.2%

Car 431 40.7%

Helicopter * *

Walking ~ *

Total 1059 100.0%


FIGURE 6.4: MOST SENIOR PRE-HOSPITAL HEALTHCARE PROFESSIONAL (n=624)

N %Paramedic 270 43.3%

Advanced paramedic 212 34.0%

Not known 125 20.0%

Doctor 17 2.7%

Total 624 100.0%


FIGURE 6.5: NUMBER OF PAEDIATRIC MAJOR TRAUMA PATIENT ADMISSIONS BY HOSPITAL (n=1174)15

N %Beaumont Hospital ~ *

Cavan General Hospital 39 3.3%

Children’s Health Ireland at Temple Street 154 13.1%

Children’s Health Ireland at Crumlin 144 12.3%

Cork University Hospital 195 16.6%

Letterkenny University Hospital 22 1.9%

Mater Misericordiae University Hospital ~ *

Mayo University Hospital 19 1.6%

Mercy University Hospital 12 1.0%

Midland Regional Hospital Tullamore 20 1.7%

Regional Hospital Mullingar 26 2.2%

Midland Regional Hospital Portlaoise 7 0.6%

Naas General Hospital ~ *

Our Lady of Lourdes Hospital Drogheda 91 7.8%

Sligo University Hospital 21 1.8%

South Tipperary General Hospital 19 1.6%

St James’s Hospital ~ *

St Luke’s General Hospital, Carlow/Kilkenny 38 3.2%

St Vincent’s University Hospital ~ *

Tallaght University Hospital 106 9.0%

Galway University Hospitals 57 4.9%

University Hospital Kerry 31 2.6%

University Hospital Limerick 105 8.9%

University Hospital Waterford 31 2.6%

Wexford General Hospital 23 2.0%

Total 1174 100.0%



Children’s hospitals Model 3 Model 4 TotalN % N % N % N %

No transfer 286 36.2% 150 38.7% 307 54.8% 743 42.8%

Transfer in 351 44.5% 16 4.1% 143 25.5% 510 29.4%

Transfer in and out 33 4.2 ~ * * * 51 2.9

Transfer out 119 15.1% 220 56.7% 94 16.8% 433 24.9%

Total 789 100.0% 388 100.0% 560 100.0% 1737 100.0%


15 Connolly had no paediatric patients



Transferred Not transferred TotalN % N % N %

Blow 83 50.9% 80 49.1% 163 100.0%

Burn 71 55.5% 57 44.5% 128 100.0%

Fall less than 2 m 218 42.8% 291 57.2% 509 100.0%

Fall more than 2 m 70 52.6% 63 47.4% 133 100.0%

Road trauma 160 46.0% 188 54.0% 348 100.0%

Other 39 38.6% 62 61.4% 101 100.0%

Total 641 46.4% 741 53.6% 1382 100.0%


Transferred Not transferred TotalN % N % N %

Home 299 47.6% 329 52.4% 628 100.0%

Public area or road 262 45.3% 317 54.7% 579 100.0%

Institution 27 57.4% 20 42.6% 47 100.0%

Farm 28 48.3% 30 51.7% 58 100.0%

Industrial ~ * ~ * ~ *

Other 24 35.8% 43 64.2% 67 100.0%

Total 641 46.4% 741 53.6% 1382 100.0%



Not transferred Transferred TotalN % N % N %

Abdomen 67 60.4% 44 39.6% 111 100.0%

Chest 37 63.8% 21 36.2% 58 100.0%

Face 16 53.3% 14 46.7% 30 100.0%

Head 170 38.6% 270 61.4% 440 100.0%

Limbs 295 67.2% 144 32.8% 439 100.0%

Multiple 32 58.2% 23 41.8% 55 100.0%

Other 91 50.3% 90 49.7% 181 100.0%

Spine 33 48.5% 35 51.5% 68 100.0%

Total 741 53.6% 641 46.4% 1382 100.0%


FIGURE 7.1: PRE-ALERTED BY AGE GROUP (n=1174)

Pre-alerted Not pre-alerted Not recorded Total

N % N % N % N %<1 6 5.0% 102 84.3% 13 10.7% 121 100.0%

1–2 22 11.1% 144 72.4% 33 16.6% 199 100.0%

3–5 19 9.8% 146 75.6% 28 14.5% 193 100.0%

6–10 42 14.7% 204 71.6% 39 13.7% 285 100.0%

11–13 28 14.8% 128 67.7% 33 17.5% 189 100.0%

14–15 33 17.6% 123 65.8% 31 16.6% 187 100.0%

Total 150 12.8% 847 72.1% 177 15.1% 1174 100.0%

FIGURE 7.2: RECEPTION BY A TRAUMA TEAM BY AGE GROUP (n=1174)

Received by a trauma team

Not received by a trauma team Total

N % N % N %<1 12 9.9% 109 90.1% 121 100.0%

1–2 38 19.1% 161 80.9% 199 100.0%

3–5 35 18.1% 158 81.9% 193 100.0%

6–10 61 21.4% 224 78.6% 285 100.0%

11–13 44 23.3% 145 76.7% 189 100.0%

14–15 44 23.5% 143 76.5% 187 100.0%

Total 234 19.9% 940 80.1% 1174 100.0%

FIGURE 7.2A: RECEPTION BY A TRAUMA TEAM FOR PAEDIATRIC PATIENTS WITH AN INJURY SEVERITY SCORE >15 BY AGE GROUP (n=391)

Received by a trauma team

Not received by a trauma team Total

N % N % N %<1 9 17.3% 43 82.7% 52 100.0%

1–2 20 37.7% 33 62.3% 53 100.0%

3–5 17 28.8% 42 71.2% 59 100.0%

6–10 32 38.1% 52 61.9% 84 100.0%

11–13 27 39.7% 41 60.3% 68 100.0%

14–15 31 41.3% 44 58.7% 75 100.0%

Total 136 34.8% 255 65.2% 391 100.0%


FIGURE 7.3: GRADE OF MOST SENIOR DOCTOR TREATING PAEDIATRIC PATIENTS ON ARRIVAL BY AGE GROUP (n=1174)

Consultant Specialist registrar Registrar Senior House

Officer Other Total

N % N % N % N % N % N %<1 41 33.9% 34 28.1% 31 25.6% 11 9.1% 4 3.3% 121 100.0%

1–2 83 41.7% 36 18.1% 54 27.1% 17 8.5% 9 4.5% 199 100.0%

3–5 74 38.3% 45 23.3% 52 26.9% 13 6.7% 9 4.7% 193 100.0%

6–10 127 44.6% 53 18.6% 83 29.1% 13 4.6% 9 3.2% 285 100.0%

11–13 77 40.7% 48 25.4% 47 24.9% 12 6.3% 5 2.6% 189 100.0%

14–15 77 41.2% 35 18.7% 56 29.9% 14 7.5% 5 2.7% 187 100.0%

Total 479 40.8% 251 21.4% 323 27.5% 80 6.8% 41 3.5% 1174 100.0%

FIGURE 7.4: SURGICAL INTERVENTION BY BODY REGION INJURED AND AGE GROUP (n=689)

Abdomen Face General Head and brain Limb(s)N % N % N % N % N %

<1 0 0.0% ~ * 0 0.0% 6 24.0% 12 48.0%

1-2 0 0.0% ~ * 0 0.0% 12 12.4% 50 51.5%

3-5 ~ * ~ * 0 0.0% 15 12.0% 76 60.8%

6-10 12 6.4% 6 3.2% ~ * 28 15.0% 109 58.3%

11-13 8 6.1% 9 6.8% ~ * 25 18.9% 66 50.0%

14-15 8 6.5% 15 12.2% 0 0.0% 14 11.4% 57 46.3%

Total 32 4.6% 34 4.9% ~ * 100 14.5% 370 53.7%

Skin/soft tissue Spine Thoracic TotalN % N % N % N %

<1 6 24.0% 0 0.0% 0 0.0% 25 100.0%

1-2 33 34.0% 0 0.0% ~ * 97 100.0%

3-5 22 17.6% ~ * ~ * 125 100.0%

6-10 27 14.4% ~ * ~ * 187 100.0%

11-13 17 12.9% ~ * ~ * 132 100.0%

14-15 12 9.8% 15 12.2% ~ * 123 100.0%

Total 117 17.0% 23 3.3% 9 1.3% 689 100.0%



FIGURE 7.5: AIRWAY MANAGEMENT OF PAEDIATRIC MAJOR TRAUMA PATIENTS WITH A GLASGOW COMA SCALE <9 (n=98)

N %No intubation 0 0.0%

Intubated – ED 79 80.6%

Intubated – pre-hospital ~ *

Intubated – both ED and pre-hospital 12 12.2%

Not known 6 6.1%

Total 98 100.0%


FIGURE 7.6: PERCENTAGE OF PAEDIATRIC MAJOR TRAUMA PATIENTS TO RECEIVE A COMPUTED TOMOGRAPHY SCAN WITHIN 1 HOUR (n=114)

N %Within 1 hour 59 51.8%

After 1 hour 55 48.2%

Total 114 100.0%


N %<1 ~ *

1–2 10 17.5%

3–5 ~ *

6–10 10 17.5%

11–13 9 15.8%

14–15 17 29.8%

Total 57 100.0



N %Blow 6 10.5%

Fall less than 2 m ~ *

Fall more than 2 m ~ *

Road trauma 18 31.6%

Burn 0 0.0%

Other 29 50.9%

Total 57 100.0%




<1 1–2 3–5 6–10N % N % N % N %

Abdomen 0 0.0% 0 0.0% 0 0.0% ~ *Chest 0 0.0% 0 0.0% 0 0.0% ~ *Head ~ * 6 60.0% ~ * ~ *Multiple 0 0.0% ~ * ~ * 0 0.0%

Other 0 0.0% ~ * ~ * ~ *Spine 0 0.0% ~ * 0 0.0% 0 0.0%

Total ~ * 10 100.0% 9 100.0% 10 100.0%11–13 14–15 TotalN % N % N %

Abdomen 0 0.0% 0 0.0% ~ *Chest 0 0.0% 0 0.0% ~ *Head ~ * ~ * 21 36.8%

Multiple 0 0.0% ~ * ~ *Other 7 77.8% 14 82.4% 29 50.9%

Spine 0 0.0% 0 0.0% ~ *Total 9 100.0% 17 100.0% 57 100.0%


FIGURE 8.4: DISCHARGE DESTINATION FOR PAEDIATRIC MAJOR TRAUMA PATIENTS (N=1382)

N %Home 1147 83.0%

Other acute hospital 147 10.6%

Mortuary 58 4.2%

Rehabilitation 19 1.4%

Other 11 0.8%

Total 1382 100.0%


NOTES


NOTES


NOTES

Phone: +353 1 4028577Email: [email protected]: @noca_irl

www.noca.ie

MAJOR TRAUMA AUDIT

Documents