Trauma care today

Beyond 1993

  • BAH country leader at time of closure in 1993
  • Preserving the principles: the “Acci” principles were used to develop trauma services at the General Hospital, which closed in 1998, Selly Oak Hospital which closed in 2010 and the new Queen Elizabeth Hospital
    • Time honoured system with three receiving teams
    • Well known Major Injuries Unit at front of hospital enabling direct delivery by ambulances to an intensive care unit
    • Need to look after MSK, head, chest and abdominal injuries
  • Need to reintegrate Accident Hospital with other surgical specialities
  • Note – the foundation stone of a new accident hospital was laid at the Queen Elizabeth site 
  • In the 1960s before foundations completed project was abandoned due to the first major post was credit squeeze.  Had the hospital been built the present modern English Major Trauma Centres may have evolved from it
  • Between March and July 1993 parts of the vacant General Hospital were upgraded and the Accident Hospital moved into new premises on 1 August 1993 – the hospital was rechristened the “South Birmingham Trauma Unit”
  • Adaption of 4 team structure permitting a 1 in 4 rota and junior doctors’ hours to be respected
  • Front door run by A&E staff from SOH
  • Major trauma still diverts to MIU
  • Additional capability – SBTU:
    • Each team comprised of two T&O consultants equivalent to one whole time person
    • Two registrars peer team; one SHO per team, one house officer per team
    • One consultant anaesthetist per team supported by two junior anaesthetists
    • Good specialty back up (as before) cardiac, abdominal and vascular surgery
    • Direct link for CT scan transmission to neurosurgery
  • Figures:
    • Admit 12 patients per day (4,500 per annum)
    • Outpatients 32,000 per annum
    • Daily fracture clinic 120 patients per day
    • Admission MIU 300 patients per annum
    • MIU bed days – 25% burns 
  • Residual problem – SBTU
    • Geographical isolation
    • DoH desire to abandon team work and move to shift system 
    • Changes to nursing skills with loss of higher and experienced grades (driven by efficiency targets)
    • Plans to transfer care of injured children to Birmingham Children’s Hospital

Beyond 1995

  • Transfer SBTU A&E, Burns and Plastics Unit to SOH
  • Bespoke new build A&E MIU
  • Direct admission to MIU by ambulance still maintained
  • Selly Oak Hospital embraced the Centre for Defence Medicine in 1999 and became RCDM in 2000
  • Absorbed acute military trauma workload from abroad (Iraq, Afghanistan and elsewhere) with closure of specific military hospitals
  • Became UK receiving hospital for injured soldiers repatriated from Iraq and Afghanistan
  • When Selly Oak Hospital closed services moved to the new Queen Elizabeth Hospital in 2010

Modern Day Trauma Care

  • 2012: Launch of Major Trauma Centres and Networks in England based on old “Acci” principles and military experience gained during theatres of operation
    • Queen Elizabeth Hospital is the Major Trauma Centre for Birmingham, Black Country, Hereford and Worcester trauma network – one of three adult centres in West Midlands (the others being in Stoke and Coventry) and the only paediatric centre being at Birmingham Children’s Hospital
    • New MTC concept embraced:
      • Focus on trauma 
      • Consultant reception in ED
      • Trauma teams
      • Prompt access to imaging and CT
      • Prompt access to theatre
      • Effective critical care
      • Early comprehensive rehabilitation 
      • Early blood, blood product availability 
    • All of the above based on BAH concepts
    • UK system accounts for an additional 850 lives saved per annum in England (Chris Moran 2018)
    • Integrated pre-hospital care, with HEMS and MERIT services, providing 24/7 critical care capability
    • West Midlands CARE Team now operates from QEHB, tasked to Major trauma, medical emergencies – including ROSC and admission avoidance.
    • Fully functional trauma networks with agreed bypass criteria based on a National Triage Tool, which includes physiological, anatomical and special circumstances
    • Regional Trauma Desk identifies cases of severe trauma and ensures appropriate resource tasking e.g. BASICS Dr, HEMS, MERIT, HART.
    • QEHB receives 652 patients with ISS 9-15 (life changing injuries) and 874 patients with an ISS>15 (Major Trauma – Life threatening injuries). These figures were from 01/01/2019 – 31/12/2019 
    • In ED patients received by a trauma team with a consultant team leader 0800-2400 with a consultant call in over-night, which can be initiated through the code red call or by ED staff
    • BHH had an automatic call in for consultants 24/7
    • Effective Code Red capability. Pre-hospital determination of code red, usually peri-arrest hypervolemic patients. Call made by pre-hospital care clinician. Hospital response includes full trauma team, Consultant trauma clinician, consultant anaesthetist, ED consultant and specialty consultants, if area of injury identifiable in the pre-hospital environment. CT scanner and theatres immediately available. Massive transfusion protocol activated, which means immediate availability of blood and blood products.
    • System capable of generating quality survivors without neurological consequences from the most catastrophic injuries.
    • 99.8% chance of survival if you arrive alive in ED with a stab wound. These are amongst the best figures in the UK. Some patients have received 100+ blood products resuscitative surgery and survived with pH of as low as 6.85. 
    • Many of these critically unwell patients will go to CT with a consultant anaesthetist and surgeon, then transferred straight to the operating theatre post scan at the QE
    • CT immediately available for trauma alerts. Interventional radiology and MRI available within 1 hr of request if required in complex trauma.
    • Emergency theatre capability includes immediate access to a trauma theatre.
    • During the daytime trauma and trauma related surgery takes place in
      • The dedicated major trauma service theatre
      • 2 orthopaedic trauma emergency theatres
      • 1 plastic surgery emergency theatre 
      • 2 emergency hand theatres 

    Specialty specific emergency trauma may undergo surgery in a cardiothoracic theatre, neurosurgical theatre, or general surgical theatre.

    • At night there are 2 theatres available for general surgeries – one with resident staff and one with on call staff. In addition, there are 3 other surgical teams that can be called to open a specific cardiothoracic theatre, neuro theatre, a theatre for major hepatobiliary trauma and a transplant theatre team, which in a crisis can be called upon. In the old days the Acci had 2 theatres, both large, which could each take 2 operating tables, if required.
    • BAH (MIU) had 4 critical care beds in the intensive care side and could also uplift to accommodate 2 more beds in the shock room which was adjacent. In a crisis, the combined intensive care and shock room could accommodate 11 patients. The new Queen Elizabeth Hospital has 66 Level 3 ITU beds (1:1 nursing), which are flexible up to 85 beds between level 2 (1 nurse to 2 beds) and level 3 (1:1 nursing).
    • At the QE there is a requirement that specialist consultants be available within 30 mins to attend the hospital. BAH always had access to specialty consultants if required e.g. neurosurgeons.