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National Clinical Guideline Centre (UK). Major Trauma: Service Delivery. London: National Institute for Health and Care Excellence (NICE); 2016 Feb. (NICE Guideline, No. 40.)
9.1. Introduction
It is imperative that a person with major trauma is in the right place to receive the best definitive treatment as quickly as possible. In chapter 6 it is recognised that within a trauma network a major trauma centre (MTC) is usually the optimal place for a person with major trauma to be transported to for treatment. However there are circumstances where this is not the case and this chapter focuses on the situation where the critically ill trauma patient has required immediate medical intervention and has been taken to the nearest trauma unit (TU). Once the patient is stabilised at the trauma unit it is important they are transferred to a MTC as soon as possible to receive the specialist care they need.
While in adult trauma care the practice is usually to send a team from the TU but the question of who best should accompany the patient on the transfer is unanswered. Transfers may be undertaken by the local TU clinical team or a specialised retrieval service sent by the receiving specialist unit. The former option would mean that the patient could be sent off immediately without delay but with non-specialist staff that may not be able to provide the urgent specialised treatment needed during transfer. Whilst the specialist retrieval team can provide this urgent care its use is associated with a delay caused by waiting for the team to arrive for pick up at the sending centre. The purpose of this review was to determine if providing a specialist retrieval service is clinically and cost effective.
9.2. Review question: Is it clinically and cost effective to provide a retrieval service?
For full details see review protocol in Appendix C.
Table 20PICO characteristics of review question
| Population | Critically injured trauma patients (that is, those who would trigger an advanced response at a MTC) |
|---|---|
| Objective | To determine whether it is clinically and cost effective to provide a dedicated trauma retrieval service to transfer patients from ED to further care |
| Intervention | Retrieval service for secondary transfer |
| Comparison | Transfer by TU clinical team |
| Outcomes | Critical:
|
| Study design | RCTs or observational |
9.3. Clinical evidence
No clinical evidence was found relevant to this review.
See also the study selection flow chart in Appendix D and excluded studies list in Appendix J.
9.4. Economic evidence
Published literature
No relevant economic evaluations were identified.
See also the economic article selection flow chart in Appendix E.
9.5. Evidence statements
Clinical
No relevant studies were identified.
Economic
No relevant economic evaluations were identified.
9.6. Recommendations and link to evidence
| Recommendations | Recommendations for senior doctors and nurses in trauma units
|
|---|---|
| Description of current UK services | The configuration of trauma services into trauma networks means that specialised services are usually located within a MTC. For this reason a MTC is usually the optimal place for patients with major trauma to be treated. The GDG have noted in chapter 6 that there are circumstances where this is not the case and a patient with major trauma is located in a trauma unit. These reasons include, the patient was under triaged, they self-presented, their clinical condition deteriorated or they were transported to the nearest hospital facility for life-saving treatment or stabilisation. The consequence of this situation is that the specialised services needed are not easily accessible. The question of the location of services, outreach and how to access specialist care is an issue across the patient pathway. The GDG chose to focus on the immediate life threatening situation where patient has been diverted to a TU as this an area that varies across the UK. There are some hospital trusts in the UK that have implemented a dedicated transfer service, where clinicians with the skills required for the transfer of critically injured patients are always available to transfer patients requiring urgent specialised treatment between hospitals. This is not the norm and more typically staff from the sending TU are required to transfer the patient to a MTC. |
| Relative values of different outcomes | The GDG specified mortality (up to 12-months), health-related quality of life, time taken to transfer, delay to admission to MTC, complications arriving during or due to transfer, and length of hospital stay as critical outcomes in the evaluation of a retrieval service compared to transfer by TU clinical team. |
| Trade-off between clinical benefits and harms | No clinical evidence was found for this review. In the absence of any evidence, the GDG were unable to make recommendations on the use of specialist retrieval teams for the transfer of major trauma patients from emergency departments to major trauma centres. While the GDG were unable to make a specific recommendation on the personnel transferring the patient they noted that rapid transfer is critical to avoid delay in diagnosis and treatment and to prevent mortality and reduce morbidity. Taking this into account the GDG recommended that a patient should be transferred within 30 minutes of the decision to transfer. This timing recommendation emphasises the need to avoid any delay in treatment. It is also important that only life-saving interventions are undertaken in the trauma unit, 30 minutes is to remind the team that the MTC is the ultimate destination for the patient to receive definitive treatment. The GDG emphasized the importance of a transfer protocol and that all staff are trained in the protocol. The protocol should include the training and skills escorts should have to manage the patient during the transfer, and detail the equipment and processes surrounding transferring critically ill or injured patients. |
| Trade-off between net health benefits and resource use | No economic evidence was included for this review. The GDG considered the importance of reducing delays to treatment and its consequences in terms of mortality and resource use. A dedicated retrieval service is already in operation in some hospitals in the UK, however, for most hospitals, this will require the implementation of a new service. Ensuring the availability of appropriately skilled staff 24/7 is likely to be costly; however this was thought to be outweighed by a reduction in mortality and further resource use. The GDG decided to recommend that a patient should be transferred within 30 minutes from the decision in order to avoid delay in diagnosis and treatment and to prevent mortality and reduce morbidity. This recommendation may be associated with an increase in cost as health care professionals have to be available for a transfer to a MTC within 30 minutes. Overall the GDG judged this to be a cost effective use of resources as it would improve patient outcomes and reduce harms from delay in treatment. All hospitals in the UK should already have a protocol for the onward transfer of critically ill patients who require specialist treatment. However, the GDG felt that greater awareness of the protocol, through staff training, would be beneficial in ensuring that transfers are carried out in a timely manner. |
| Quality of evidence | There was no clinical evidence identified for this question. The GDG chose to make a research recommendation, while making recommendations for the safe transfer of patients. |
| Barriers to implementation | The implementation of a dedicated transfer/retrieval service will be a new service for most hospitals in the UK, and therefore will require initial reorganisation to ensure that additional staff are available. |
| Other considerations | The GDG felt that it was important for all hospitals to audit and review cases where patients requiring transfer experienced delay, to ensure that any barriers to the timely transfer of critically injured patients are identified and can be resolved. |
- Transfer between emergency departments - Major Trauma: Service DeliveryTransfer between emergency departments - Major Trauma: Service Delivery
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