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Major Trauma Audit (TARN) Context Page

This document provides guidance to assist the interpretation of the key metrics from the Major Trauma Audit as selected by the Trauma Audit & Research Network. Full audits can be reviewed on the audit website (website link). A total of 154 NHS Trusts in England and Wales participated.

Metrics:

1. Case ascertainment

  • Rationale: This metric shows the proportion of eligible cases within the hospital that were submitted to the audit. The comparison is made against Hospital Episode Statistics data. The case ascertainment describes the proportion of patients on whom data were received, compared to the total number of major trauma patients treated by the unit.
  • Guideline/mapping: There is no national guideline related to case ascertainment; the audit does not currently specify an aspirational threshold.
  • Graph/relative performance: There is no graphical display for this metric; the hospital’s performance should be compared against the TARN aggregate.
  • Quality improvement prompt question: consider the other metrics in the context of case ascertainment – particularly where ascertainment is low – and should prompt questions about the quality of audit participation.

2. Crude median time to CT from arrival to CT scan of the head for patients with traumatic brain injury

  • Rationale: Only applies to patients with Glasgow Coma Score < 13 and is from arrival in the care facility. Prompt diagnosis of the severity of traumatic brain injury from a CT scan is critical to allowing appropriate treatment (optimising blood flow and oxygen delivery to the brain) which minimises further brain injury.
  • Guideline/mapping: This metric maps exactly to NICE guideline 176[1]; accordingly, the audit specifies an aspirational standard of < 1 hour.
  • Graph/relative performance: Compared against the NICE guideline which suggests a CT head scan is performed within an hour of the risk factor being identified.
  • Quality improvement prompt question: Where the median time from arrival to CT is longer than the aspirational standard this should prompt questions about the robustness of clinical protocols for investigation of head-injured patients (including the availability of and access to emergency CT scan) and what actions the hospital is taking to reduce the delay until CT.

[1] NICE guideline 176, section 1.4.7

3. Crude proportion of eligible patients receiving tranexamic acid within 3 hours of injury

  • Rationale: a proxy for the true indication uses eligible patients with ‘significant bleeding’ which is defined as those who received any blood products within 6 hours of the injury. Prompt administration of tranexamic acid has been shown to significantly reduce the risk of death when given to trauma patients who are bleeding. There is some evidence that it may cause more harm than good if it is given more than 3 hours after injury.
  • Guideline/mapping: This metric maps approximately to NICE guideline 39, section 1.5.4[1]; mapping is approximate because the guidelines specify that tranexamic acid should be given to patients with major trauma and active or suspected active bleeding as soon as possible after injury. The audit does not currently specify an aspirational standard.
  • Graph/relative performance: Performance is compared against the TARN aggregate.
  • Quality improvement prompt question: Where the trust’s proportion of patients receiving tranexamic acid within 3 hours is less than the national aggregate this should prompt questions about the robustness of clinical protocols for managing bleeding in trauma patients and what actions the hospital is taking to improve the proportion of eligible trauma patients receiving tranexamic acid

[1] NICE guideline 39, section 1.5.4

4. Crude proportion of patients with severe lower limb fractures receiving appropriately timed surgery

  • Rationale: severe lower limb fractures are defined as Gustilo grade 3b or 3c; appropriately timed surgery refers to BOAST 4 standards as below. Outcomes for this serious type of injury are optimised when surgery is carried out in a timely fashion by appropriately trained specialists.
  • Guideline/mapping: This metric maps approximately to the British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons Standard for Trauma (BOAST) 4 standard[1] which recommends initial wound debridement by combined specialist orthopaedic and plastic surgical teams within 24 hours of injury and subsequent skeletal stabilisation and definitive soft tissue coverage within 72 hours of injury; mapping is approximate because the standard incorporates numerous other processes of care in addition to timeliness of surgery (such as antibiotic administration); the audit does not currently specify an aspirational standard.
  • Graph/relative performance: Performance is compared against the TARN aggregate.
  • Quality improvement prompt question: Where the trust’s proportion of patients with severe lower limb fractures receiving appropriately timed surgery is lower than the TARN aggregate this should prompt questions about the effectiveness of clinical care pathways for patients with severe lower limb injury (including adequacy of operating theatre capacity, appropriateness of prioritisation of cases for surgery and effective liaison between orthopaedic and plastic surgery specialists) and what actions the hospital is taking to reduce delays in providing appropriately timed surgery.

[1] British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons Standard for Trauma (BOAST) 4 standard

5. Risk-adjusted in-hospital survival rate following injury

  • Rationale: Defined as ‘additional deaths/survivors per 100 cases’. Death is the most serious outcome after trauma and is known to vary across regions. This metric uses case-mix adjustment to ensure that hospitals dealing with sicker patients are compared fairly against those with a less complex case mix.
  • Guideline/mapping: There is no national guideline related to survival rates after trauma.
  • Graph/relative performance: This is presented as a case mix adjusted figure that takes into account the severity of the injury. Shows the number of additional deaths or survivors per 100 cases. This is based on two years’ worth of data.
  • Quality improvement prompt question: TARN reports outliers at the alert (2 standard deviations) level to providers and publishes alarm (3 standard deviations) level outliers. Negative outliers should investigate what steps the Trust can take to improve their in-hospital survival rate following injury.
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