National Institute for Health and Clinical Excellence (NICE)
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NICE publishes five new guidelines to standardise trauma care in England

NICE – the National Institute for Health and Care Excellence – has published five new guidelines covering key areas of trauma care; fractures, complex fractures, spinal injury assessment, major trauma and major trauma services.

  • An estimated 1.8 million fractures occur in England every year1
  • Major trauma is the most common cause of death in under 40 year olds2
  • Massive bleeding accounts for over 1,500 trauma deaths each year in England and Wales3
  • Each trauma death costs the nation in excess of £0.75 million4

In 2010 a report by the National Audit Office found the management of major trauma patients was inadequate in England5. They called for a service overhaul. This led to the development and implementation of countrywide major trauma networks (MTN) – groups of hospitals centred around 27 major trauma centres that are equipped to provide the specialist care a trauma patient requires.

Professor Mark Baker, Director for the Centre of Clinical Practice at NICE, said:“2,000 trauma patients are alive today because of the steps taken to ensure that the right patient gets to the right hospital in the quickest time possible. This is fantastic news and something we should all be proud of.

“However, major trauma remains the most common cause of death in patients under 40 years of age in the UK, and despite seeing an 85% reduction in variation of trauma care, we still have work to do to ensure that the care we provide is the best it can be for everyone, no matter where you live.”

Over 1,500 trauma patients die every year from severe bleeding. Recent research has shown that, in England and Wales, some patients who suffer life-threatening bleeding after serious injury do not receive optimal blood transfusion treatment.3,6

This new suite of trauma guidance includes recommendations on the best method to stop bleeding in different injuries and which are most effective for the situation (e.g. at the scene of an accident). They also give recommendations about how best to locate the site(s) of bleed so that surgeons can operate quickly to stop it.

Professor Karim Brohi, Chair of Trauma Sciences at Queen Mary University of London and Deputy Chair of the NICE guideline project executive team said: “Stopping a patient from bleeding is vital for their survival, yet the techniques we adopt across England are inconsistent. They must be improved.

“The new NICE trauma guidelines are based upon the latest scientific evidence. They will bring clarity to this challenging area of trauma care and undoubtedly save lives.”

Every year in Britain, 3 in 100 people will suffer a fracture.7 Some of these may require urgent treatment to save the limb.

The two fracture guidelines aim to clarify when minimal medical intervention is the best option. They also include specific recommendations that will help clinicians effectively manage open fractures (fractures where the bone tears through the skin), which can be serious.

Mr Iain McFadyen, Consultant Trauma and Orthopaedic Surgeon, Royal Stoke University Hospital and member of the NICE guideline project executive team said: “If not managed appropriately and efficiently, non-complex fractures place an unnecessary burden on patients, healthcare services, employers and communities.

“These new guidelines will support medical teams in their assessments about how best to treat and manage these common injuries.”

Mr Bob Handley, Consultant Trauma and Orthopaedic Surgeon, John Radcliffe Hospital and member of the NICE guideline project executive team said:“Complex fractures require well-organised, expert attention to detail in order to avoid devastating complications such as chronic pain, permanent disability or amputation.”

“The two new NICE fracture guidelines contain recommendations based upon latest evidence, which has shown the impact of early diagnosis and effective treatment in avoiding these complications.”

All five trauma guidelines feature recommendations to promote better communication. They suggest a designated point of contact within the trauma team for the patient, their family members and carers. And an aim for the trauma team to give the patient’s GP a written summary including diagnosis, management plan and expected outcome, within 24 hours of admission.

Professor Chris Moran, National Clinical Director for Trauma and a front-line trauma surgeon in Nottingham said: “Every shred of information is precious in trauma cases. It is crucial that we talk not only to each other in the trauma team, but that we also speak to those involved in and those who witnessed the accident.

“I am very happy to see patient information feature so prominently in NICE’s trauma guidelines. We know that a good experience in hospital and an understanding of their targets for recovery can help patients get better more quickly.”

Together these new NICE trauma guidelines give a wide-range of recommendations based upon the latest evidence. They will support trauma teams across the country, promoting high quality, patient-focused care as standard.

Mr David Skinner, Emeritus Consultant in Emergency Medicine, Oxford, and Chair of the NICE guideline project executive team said: “’Thirty years ago UK trauma care was poor and patients suffered. A number of subsequent initiatives have progressively improved this.

“The recommendations in these new NICE guidelines will introduce the latest in evidence-based care across the entirety of our national trauma network.

“This will not only ensure a patient is taken to and treated in the best environment for them; it will ensure that this happens all the time, for every patient in England.”

NICE (2015), ‘Fractures (complex):assessment and management’, draft for consultation. Accessed online.

AL McCullough et al (2014) ‘II. Major trauma networks in England’ Br. J. Anaesth 113(2): 202-206. Accessed online.

Stanworth et al (2016) ‘Mortality from trauma haemorrhage and opportunities for improvement in transfusion practice’ BJS. Accessed online.

TARN ‘The Trauma Audit & Research Network – an overview’. Accessed online.

National Audit Office (2010) ‘Major Trauma in England’. Accessed online.

NHS Blood and Translpant (2016) ‘News Release: Emergency blood transfusions for major trauma need to be more rapid and consistent’. Accessed online.

L J Donaldson (2008) ‘The epidemiology of fractures in England’ J Epidemiol Community Health 62:174-180. Accessed online.

Spinal Research ‘Facts and Figures’. Accessed online.

S Yoong and R Spence (2015) ‘Major Trauma Networks’ Ulster Med J 84(1): 69-70. Accessed online.

10 TARN ‘Press release on major trauma 2015’. Accessed online.

Notes to editors

About the fracture guideline

  1. 3 in 100 people in Britain will suffer a fracture each year and 4 out of 10 people will have at least 1 fracture in their lifetime.7
  2. Many non-complex fractures get better with a cast or simple splint, but others have the potential for complications. We need to achieve a balance to ensure those serious fractures are not missed, but those simpler ones are not over-treated.
  3. The guideline gives recommendations on; initial pain management and immobilisation, acute stage assessment and diagnostic imaging, management in the emergency department, ongoing orthopaedic management, documentation and information / support for people with non-complex fractures and their families and carers.

About the complex fracture guideline

  1. A complex fracture is a severe break of the bone. The bone may break into multiple pieces and cause damage to the surrounding skin and muscle.
  2. Complex fractures make up the minority of the 1.8 million fractures that occur in England each year, but take a long time to heal and can cause disability. They are a large burden on healthcare resources.1 
  3. The guideline gives recommendations on; management in pre-hospital settings, immediate destination for people with suspected complex fractures, initial assessment and management in acute care, imaging and haemorrhage control of pelvic fractures, management of open fractures, management plan and referral for adults with pilon fractures and children with intra-articular distal tibia fractures, documentation and information / support for people with non-complex fractures and their families and carers.

About the spinal injury assessment guideline

  1. Spinal injury usually involves a fracture of the neck or back, which sometimes leads to nerve damage (spinal cord injury) and paralysis.
  2. Approximately 1000 people sustain a new spinal cord injury each year in the UK and there is an estimated 50,000 people living with paralysis in the UK and Ireland.8
  3. This guideline gives recommendations on; assessment and management in pre-hospital settings, pain management in pre-hospital and hospital settings, immediate destination after injury, emergency department assessment and management, diagnostic imaging, communication with tertiary services, early management in the emergency department after traumatic spinal cord injury, information and support for patients, family members and carers, and documentation in pre-hospital and hospital settings.

About the major trauma guideline

  1. Major trauma constitutes injuries which are life-threatening and may result in permanent disability.9
  2. The most common cause of major trauma is road traffic accidents.2
  3. This guideline gives recommendations on; immediate destination after injury, airway management in pre-hospital and hospital settings, management of chest trauma in pre-hospital settings, management of chest trauma in hospital settings, management of haemorrhage in pre-hospital and hospital settings, reducing heat loss in pre-hospital and hospital settings, pain management in pre-hospital and hospital settings, documentation in pre-hospital and hospital settings, information and support for patients, family members and carers, and training and skills.

About the major trauma services guideline

  1. Immediate management of major trauma patients costs the NHS between £0.3-0.4 billion per year.9
  2. The Trauma Audit and Research Network (TARN) 2015 audit has shown that since the introduction of MTNs, the chance of surviving major trauma has improved by 50% in England.10
  3. This guideline gives recommendations on; pre-hospital triage, transferring patients with major trauma, pre-alert procedures, procedures for receiving patients in trauma units and major trauma centres, transfer between emergency departments, organisation of hospital major trauma services, documentation, monitoring and audit, information and support for patients, family members and carers, training and skills, and access to major trauma services.

About NICE

The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.

Our aim is to help practitioners deliver the best possible care and give people the most effective treatments, which are based on the most up-to-date evidence and provide value for money, in order to reduce inequalities and variation.

Our products and resources are produced for the NHS, local authorities, care providers, charities, and anyone who has a responsibility for commissioning or providing healthcare, public health or social care services.

To find out more about what we do, visit our website:www.nice.org.uk and follow us on Twitter: @NICEComms.

 

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