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Chelsey Smith was 15 when she was left with life-threatening injuries, following a road traffic accident in February last year.
After an initial assessment at the University Hospital in Wishaw, Lanarkshire, Chelsey was rushed to the West of Scotland’s Paediatric Major Trauma Centre in Glasgow for specialist treatment.
Consultant Paediatric Neurosurgeon Roddy O’Kane performed the surgery, to reduce the swelling and pressure on Chelsey’s brain, with part of her skull being removed and stored in her stomach to keep it sterile.
Following intensive rehab with the team at the RHC, Chelsey, who is now 16, has made a remarkable recovery and, less than a year after her final surgery, was a guest of honour at the Major Trauma Centre’s training day this week.
She said: “I just can’t thank all of the team here at the Royal Hospital for Children in Glasgow for everything they have done for me, they have saved my life and given me my life back too.
“I don’t remember much about the day of the accident to be honest, but I’m here now and that’s what matters. I have had so much support from Roddy, my Major Trauma Co-ordinator Lynsay Stewart, all of the staff at the hospital and of course my family.
“Roddy was able to magically take a part of my skull and put it in my stomach to let the swelling reduce in my brain, I don’t really know how it works but it’s amazing. It was a long journey and I would tell anyone who is in a similar situation to keep going, to make this recovery you have to be mentally prepared for it too and thankfully I had so many positive people around me to help with that.”
Chelsey is now back preparing for her exams at Brannock High in Newarthill, has been able to get a part-time job and is hoping to go on to study accountancy.
She said: “Obviously everything that happened was not good, but thanks to the Royal Hospital for Children team in Glasgow I have been able to get back to school and have also started a part-time job.
“I just want to say thank you again to everyone for all they have done for me. Even after my follow-up appointments are finished, I’ll keep coming back to visit, I have missed them all.”
The procedure which involves removing part of the skull is not common, but after other medical interventions were unsuccessful it was the last option to save Chelsey’s life.
Roddy said: “This procedure is not something that we do every day but it gave Chelsey the best chance of surviving the injuries she had sustained during the accident.
“We take part of the skull out and store it in the stomach in order to keep it sterile, this is usually re-attached after a couple of months once swelling has reduced.
“Chelsey’s recovery is absolutely remarkable, based on her condition when she arrived it is incredible to see how well she is doing. There was a real danger to her life and we also anticipated that there would be more of lasting impact on her life.
“We are all so proud of Chelsey and all of the hard work she has put in during her rehab with our specialist teams. We’re delighted for her and her family and were all beaming from ear to ear when we got to see her again today.”
The development of the Major Trauma Service in the West of Scotland came with significant resource to provide rehabilitation in order to achieve the Scottish Trauma Networks stated aim of: Saving Lives. Giving Life Back.
The rehabilitation team within the Major Trauma ward in the Queen Elizabeth University Hospital are delivering early, intensive, multidisciplinary rehabilitation to patients who are multiply injured and have complex rehabilitation needs. The team consists of speech and language therapists, physiotherapists, occupational therapists, clinical psychologists, dietitians, therapy support workers and major trauma co-ordinators.
Initial results are extremely positive and a number of QI projects have also been carried out. An analysis of the data collated since the Major Trauma ward opened in August 2021 shows that the median length of stay in the ward is 10 days. It also showed that 69.4% of patients were discharged straight home from the ward and 20.6% required repatriation to their local hospital. This has contributed to an improved patient journey and in these times of significant pressure on the NHS, is reducing the requirement for ambulance transfers and beds in trauma units.
“a set of measures that assist individuals, who experience or are likely to experience disability, to achieve and maintain optimum functioning in interaction with their environments”
Evidence shows that the earlier rehabilitation is provided and the greater the intensity, the better the outcomes for the patient (Hartley, Keevil, Alushi et al, 2019). It was with this evidence in mind that the ethos of the STN was developed.
The rehabilitation needs of medical inpatients is changing. Development of community based, admission avoidance schemes means that patients admitted to hospital tend to be more unwell and have more complex rehabilitation needs. This has been exacerbated by the COVID-19 pandemic: patients are more frail, deconditioned, present later in disease course and a significant proportion have underlying neurological diagnosis.
Ongoing challenges around bed capacity and ‘front door’ performance forced the opening of additional medical beds in the QEUH in October 2021. The current staffing complement within the medical sector is not able to meet the rehabilitation needs of the patients (Staff to patient ratios: Physiotherapy (PT) = 1:41, Occupational therapy (OT) = 1:56). This means that patients who are assessed as requiring rehabilitation, are seen on average twice a week.
Current staffing resource within the AHP team does not meet the rehabilitation needs of the patients who are located within medical, resulting in longer lengths of stay and reduced independence on discharge requiring significant packages of care and equipment provision. This has financial implications for the NHS in terms of bed days and equipment provision, and for Social Care in terms of ongoing provision of support at home, in addition to the detrimental effects for patients who they are not being facilitated to achieve their maximal functional potential.
Ward 11D was turned fully into a medical ward in October 2021. As no additional AHP staff were provided for these additional bed numbers, and with medical AHP staffing numbers already being low, the AHP Team from the Major Trauma ward were asked to cover these additional medical beds.
This situation was used as an opportunity to collect data on what therapy input and therapy resource was required by the patients within this area to ensure the best quality of care was provided to patient and service and assess the impact of enhanced staffing levels on patient length of stay and outcome.
PT and OT staff from the Major Trauma ward team were assigned to cover the additional medical beds, these staff had experience in neurorehabilitation and were a mix of bands from 6 to 8B.
Increased staff to patient ratio was made available compared to ‘normal’ staffing levels on established general medical wards.
All patients referred to PT/OT over a 6 week period were included.
Patients were provided with daily therapy input as required.
Rehabilitation need and complexity were quantified using the standardised Rehabilitation Complexity Scale (RCS-E)
Data on number of referrals, diagnosis, reason for admission, number of treatment sessions, hours of treatment and number of therapists required for each treatment session was collected in addition to length of stay, and requirement for onward referral to community teams or for packages of care at point of discharge.
Data was collected from both the intervention ward (with enhanced AHP staffing levels) and a comparator ward (with ‘normal’ medical AHP staffing).
The data gathered from both areas is summarised in the following table:
Specific case studies and anecdotal evidence from the Major Trauma team’s time covering 11D showed that it was not only the number of staff available to treat patients that had a positive impact on LOS and patient outcomes. They also found that having staff who were knowledgeable and had experience treating patients with neurological diagnosis with complex rehabilitation needs, was beneficial.
The data highlights that the right number of staff and experience has a significant impact on reducing patients LOS and improving patient outcomes. In this audit LOS was reduced by 6.29days and less patients were referred onto community rehabilitation teams therefore suggesting they achieved their rehabilitation potential in hospital as they received the right amount of specialist treatment. Additionally, significantly fewer packages of care were required for the patients discharged home. This evidence suggests that early and adequate provision of OT/PT intervention is beneficial not only for patients but also for the hospital.
Overall, the data gathered supports the conclusion that improved PT and OT staffing levels can have a positive impact on length of stay and patient outcomes for patients with complex rehabilitation needs, currently managed within medical wards. Ultimately this could result in reduced spend on bed days, equipment provision and care needs for these patients.
The planning and finance department calculated that based on the proposed figure of 416 patients being discharged each year, with an average reduction in length of stay of 6 days per patient, this could potentially save 2496 bed days per year. Based on a cost of £1,200 per day for a general medical bed, this would equate to a saving of £2,995,200 for bed days.
Implementation of the Major Trauma service in the West of Scotland came with significant allocation of resource for rehabilitation. This is to provide early, intensive rehabilitation in line with the British Society for Rehabilitation Guidelines (BSRM, 2015) in order to meet the networks aim of ‘Giving Life Back’.
There is a growing body of evidence which links at least daily multidisciplinary rehabilitation provision with an improvement in long term functional ability (Fan et al, 2020), particularly in patients following acquired brain injury (Konigs et al, 2018).
For patients not on the Major Trauma pathway, this level of daily intervention is not possible due to limited AHP and clinical/neuropsychology rehabilitation resource within the acute neurosurgical service at the Institute of Neurological Sciences (INS). The project compares the rehab provision in INS to major trauma who are staffed at an appropriate level.
Six patients with a diagnosis of brain injury who did not follow the MT pathway were identified and compared with six patients with similar demographics and initial presentation who followed the MT pathway.
Patients were highlighted for the comparison project by the Head Injury Advanced Practitioners at the QEUH.
Outcome measures used: Rehabilitation Complexity Scale (RCS) and the Functional Independence Measure + Functional Assessment Measure (FIM+FAM).
Data was collected on length of stay, disciplines involved, therapy attendances/hours and discharge destination.
Although a small sample size it highlights the variation for patients with similar presentations.
Outcome measures: Improvement in both outcome measures with average FIM+FAM score increasing (by 94 compared to 49) and RCS score decreasing (-9 compared to -5) for MT patients.
In addition to the significantly better patient outcomes on the major trauma pathway it also highlights:
The results of preliminary examination appear to support the hypothesis that patients following the MT pathway, who receive early, intensive, daily input from a multidisciplinary team, have a reduced length of stay and improved functional outcomes compared with those who are not on the MT pathway.
Ongoing research in conjunction with INS colleagues is indicated to yield a larger sample size and determine the reliability of these results and the associated cost savings in relation to bed days in an inpatient bed and long term care needs.
In addition to the findings from the two pilot projects completed, an analysis of the data collated since the Major Trauma ward opened in August 2021 shows that the median length of stay in the ward is 10 days.
It also showed that 69.4% of patients were discharged straight home from the ward and 20.6% required repatriation to their local hospital. This has contributed to an improved patient journey and in these times of significant pressure on the NHS, is reducing the requirement for ambulance transfers and beds in trauma units.
Of the patients that were discharged home, only 24% of them required onward referral for community follow up (Community Rehab Teams, MSK services, Brain injury Teams). Additionally only 6% of patients required a Package of Care at point of discharge.
These results are further evidence that having adequate rehabilitation resource which allows early, specialist multi-disciplinary rehabilitation to be carried out result in shorter length of stay, improved patient flow, improved patient outcomes and a reduction in the requirement for packages of care and community rehabilitation on discharge. The provision of this resource is therefore a benefit to both major trauma patients and the service.
The Scottish Trauma Network (STN) are pleased to announce the publication of the Nursing, Midwifery and Allied Health Professions (NMAHP) NMAHP Development Framework for Major Trauma.
This is hosted within the Education and Training section of the STN website;
The NMAHP Development Framework for Major Trauma will be used by NMAHP practitioners caring for major trauma patients in any in-hospital setting at local, regional and national levels for identifying, planning and supporting learning needs, identifying career pathways and enhancing workforce planning.
This framework is the result of collaborative working between NHS Education for Scotland (NES) and the STN, working closely with NMAHP practitioners and consulting with the STN Education and Workforce group. It is aligned to the already published NES NMAHP Development Framework.
It is currently for registered practitioners at education levels 5-8 with the Healthcare Support Worker element following later in the year, in conjunction with the national HCSW commission.
Introduction by National Clinical Lead
Annual report time arrives once again, and in this new style of presentation my superlatives for the work of all who support the continued work, development and improvements of the Scottish Trauma Network will be brief. This is just as well, as the resources of my thesaurus begin to abate.
It is now 5 years since we convened and commenced our program of work to build and implement an entirely new clinical network of acute care and long-term rehabilitation for Scotland’s most seriously injured. August 30th 2021 witnessed the completion of Phase I with delivery of the fully operational end product. At time of writing, we run smoothly and successfully in the best traditions of “National Collaborative Pragmatism”.
All of this achieved of course, against the backdrop of complications presented to us by the pandemic. A remarkable achievement now recognised and acclaimed at the highest levels of the NHS, the Scottish Government, and national and international media.
This hard-earned and well-deserved reputation requires stiffening of the sinews and strengthening of resolve to be maintained, for us to progress further as we contribute well beyond our remit to the Remobilisation of the NHS in Scotland.
Thus, now begins Phase II, where we plan to tell the story using data, to raise standards for the future, and to demonstrate the sustained improved outcomes for patients, their families, their communities and the nation as a return on the visionary investment of these past 5 years.
The full report can be seen here
National Clinical Lead
Scottish Trauma Network
In April 2022 the ScotSTAR Emergency Medical Retrieval Service (EMRS) North team marked 3 years of operations. EMRS North is part of the Scottish Ambulance Service (SAS) and is funded through the Scottish Trauma Network (STN). Operating from the Aberdeen Airport ScotSTAR North base the duty team comprises of a retrieval consultant and a retrieval practitioner / clinical fellow.
EMRS North consultants come from an anaesthetic, emergency medicine or intensive care medicine background. Consultants spend time working for EMRS and time working in their base hospitals. At present we have consultants from NHS Grampian, NHS Tayside and NHS Highland. The retrieval practitioners all come from a paramedic or nursing background and work full-time for EMRS. The clinical fellow posts have proved extremely popular and allow anaesthetic, emergency medicine or intensive care medicine specialty trainees to join the team for 6 months and develop skills in pre-hospital and retrieval medicine.
The EMRS North has 3 main roles-
EMRS North predominantly cover the North of Scotland but all procedures, equipment and tasking are the same as EMRS West which has two duty teams available 24/7. Practically this means at any one time there are 3 EMRS teams providing national cover spilt between the bases in Glasgow and Aberdeen. This cross cover has seen EMRS North attend taskings across Scotland from Shetland to the Scottish Borders and provides resilience.
The workload is not exclusively trauma and is a good example of how the STN has wide reaching benefits especially in the care of critically ill patients.
In April 2020 Scotland’s Charity Air Ambulance launched their Aberdeen based aircraft Helimed 79. The Helimed 79 base is adjacent to the ScotSTAR North base and the teams work closely together. EMRS North and Helimed 79 brief and train together daily; when requested by the Trauma Desk EMRS North will accompany the Helimed 79 team allowing “red” interventions to be delivered faster and across a greater area.
The first 3 years of EMRS North operations have seen-
Primary taskings typically take around 2.5 hours from a
ctivation to being back on base while secondary transfers take a bit longer with an average duration of 7.5 hours. EMRS North have responded to one major incident and assisted with cross-cover while other major incidents ongoing.
2021 saw the teamwork with Firecrest Films as part of the filming for the Channel 4 series “Rescue: Extreme Medics”. Episode 2 features the EMRS North duty team who attended a plane crash – check it out on All 4 (Channel 4 on demand).
Looking forward the team are expecting a busy summer with international tourists returning and rural populations increasing over the holiday periods. The team are also looking forward to getting out on more liaison visits to referring sites and local ambulance stations.
Issue 11 – Summer 2021
The North of Scotland have released Issue 11 of their newsletter. The newsletter features updates from the STN, MTC and the trauma documentary. There is a focus on Psychology services within the network and information on upcoming education sessions.
To download the newsletter, please click HERE
The eighth report by the Scottish Trauma Audit Group (STAG) since 2011 can be found on the Public Health Scotland website. Compliance with a subset of the Scottish Trauma Network Key Performance Indicators, case-mix adjusted mortality and Patient Reported Outcome Measures (PROMs) are within part one of the report. Part two and three provide a comprehensive summary of injuries and the patient journey for both adults and paediatrics respectively.
Introduction from National Clinical Lead
2020 – 21 has been variously difficult, challenging, interesting and rewarding across the many spheres of activity, development and progress for the Scottish Trauma Network (STN). This Annual Report sits alongside and complements the imminent publication of the Scottish Trauma Audit Group’s (STAG) Annual Report for the same period. They both reveal and explore much of the data, operational and patient-centred clinical stories around this past year’s extraordinary activity within the Network. Set against the pandemic backdrop, the strong message coming from these reports is one of resilience, maintained high-quality patient care and an above-and-beyond spirit of collaboration and pragmatism on a national scale. That key performance and outcome measures have been delivered, yet alone maintained and improved in several areas, is worthy of acknowledgment and appreciation. The reports further explore much of our presentation and discussion at the Scottish Parliament Health and Sport Select Committee in January 2021.
There are many examples to celebrate, but I take this opportunity to highlight and express admiration and gratitude to the Scottish Ambulance Service, the ScotSTAR and EMRS transport and retrieval arms, and the newer Advanced Paramedics in Critical Care red teams therein. Their relentless and complex work in supporting and enabling the pandemic response across trauma and all related critical care services has been inspiring. The STN and patients are thankful to them beyond words. These thanks are expressed in equal measure to all staff and services recruited in good faith and optimism to the STN, yet who found themselves redeployed and reallocated to support the response in other vital areas such as Emergency Departments, Trauma Wards which became Covid High Dependency Units and Critical Care areas, and Theatres.
More interesting still is what much of this tells us about the improved access we now have to data and patient-reported measures. These are the mainstays of why the STN does what it does. With STN Trauma and STAG coordinators now embedded in our hospitals, we are able to reach more broadly across and deeper into the care of trauma patients than ever before. The resulting information and its analysis will further “tell the story” as we move beyond delivery of Phase I later this year, with the opening of the Major Trauma Centres at the Queen Elizabeth University Hospital in Glasgow, and the Royal Infirmary of Edinburgh, and the operational delivery of the Regional Networks in the West and South East of Scotland. These final pieces of the jigsaw will complete the national picture alongside the MTCs at Aberdeen Royal Infirmary and Ninewells Hospital in Dundee opened in 2018, supporting all the component services within our Regional Networks.
It is to be hoped that by the time of next year’s report we will be able to reflect upon a time of challenge and change with a more secure feel for what the immediate and medium-term future holds for our service. This learning allows us to reenergise and reconvene with strength, determination and the confidence that comes from surmounting such a significant hurdle.
Every person and every collaborative and linked service involved, described and embraced within the following pages is deserving of the greatest of gratitude and recognition. We are indebted to you all.
The full report can be seen here.
National Clinical Lead
Scottish Trauma Network
This week is Child Safety Week hosted annually by the Child Accident Prevention Trust (CAPT) to raise awareness of preventable serious injury and death.
In our Paediatric working groups digestion of Button Batteries and Magnets are frequent topics with some parents unaware of the potential dangers. In the United Kingdom, clinicians have seen an increase of nearly double patients attending the Emergency Department with this injury.
Whys is swallowing button batteries and magnets so harmful?
Surprisingly, the harm is not usually caused by the chemicals leaking from the battery but due to the battery itself reacting with bodily fluids, such as mucus or salvia. This creates a circuit to release a substance like caustic soda, which is a strong alkali that can burn through tissue. Alkaline substances are on the opposite end of the pH scale to an acid but is still very dangerous. ‘Dead’ or ‘Flat’ batteries also have the potential to release the alkali so should be treated with the same caution.
BBC have released a video to highlight the risk of button batteries if they are digested:
If magnets are digested, they effectively burn holes in the intestines or bowels. The magnets stick together internally and through organs and tissues, and can cut off blood supply causing the tissue to die. Magnets are much more complex than button batteries to extract. The patient would need emergency surgery, then, depending on the severity of injuries, they may need numerous operations, bowel resection and time in intensive care.
The below picture from CAPT shows an x-ray from the case of a three-year-old swallowing small, round coloured magnets from a magnetic toy.
How to keep your children safe!
The British Association of Paediatric Surgeons have produced a set of questions to consider:
what are the symptoms after swallowing?
IF YOU EXPECT YOUR CHILD HAS SWALLOWED A BUTTON BATTERY OR MAGNET, GO TO YOUR CLOSEST EMERGENCY DEPARTMENT AS SOON AS POSSIBLE.
Many trusts, organisations have campaigned for the trading standards for magnets and button batteries to be changed, recently the standards had changed for button batteries.
The Royal College of Emergency Medicine: website
British Association of Paediatric Surgeons: website
Child Accident Prevention Trust – website
Healthcare Safety Investigation Branch – Final report – Healthcare Safety Investigation Branch (hsib.org.uk)
Building Safer Communities – Building Safer Communities (harmandinjuryhub.scot)
Issue 8 – April 2021
As South East of Scotland Trauma Network approaches it’s launch date along with the MTC opening, the newsletter focuses on Network and Recruitment updates, Training and Education as well as how the region performed in the Scottish Trauma Audit Group annual report.
To download the newsletter, click HERE