COVID-19 Pathways

Because of the COVID-19 Pandemic, the normal Patient Pathways of the Trauma Network have been suspended and replaced by specific pathways for the pandemic as follows. This is in line with a national directive that seeks to ensure that Major Trauma Centres remain able to accept major trauma patients, even though they may also have large numbers of COVID-19 patients. To this end, the criteria for taking patients to a Major Trauma Centre (MTC) have been modified so that only patients who really need such care are transferred to the MTC. Prior to this change, several patient who might have needed MTC care, but were subsequently found not to, were transferred.

This is version 9.3 of the COVID-19 Pathways.

There are two main pathways as follows. The algorithms shown below have been modified from the live version, so as not to show sensitive telephone numbers. A single PDF document of this page can be downloaded from the Documents Page. The full version is also available requiring a password.

  • Pre-Hospital - this describes how the two main Pre-Hospital Services, the Ambulance Services and the Helicopter Emergency Medical Service, determine which hospital to take a patient to. This pathway will reduce and better control the number of patients who are taken past a Trauma Unit to a Major Trauma Centre.
  • Secondary Transfers - this describes how staff in Trauma Units determine which patients may be transferred to the Major Trauma Centre, and how to arrange the transfer. This pathway allows the possibility for patients to be kept in the Trauma Unit and, if appropriate, a suitable surgeon would travel to the Trauma Unit to operate on a patient, rather than the patient being transferred to the MTC.

PRE-HOSPITAL PROTOCOLS

SECONDARY TRANSFER PROTOCOLS

Principles

  1. These protocols apply after a patient has been assessed at a Trauma Unit (TU) and the assessing Team determine that the patient may benefit from transfer to a Major Trauma Centre (MTC).
  2. Patients triaged to a TU should be assessed and stabilised within the ED and not ‘turned around at the front door
  3. The Major Trauma Centre at the Royal Sussex County Hospital (RSCH) will have a 24/7 rota of selected consultants to act as “Major Trauma Centre Advice Consultant”. The person on duty at any time can be contacted on a single number. The purpose of this Consultant is to take and screen referrals from Trauma Units to ensure that those patients being transferred to the MTC do so at a time that maximises MTC bed capacity and that patients are not transferred long in advance of any surgical procedure they require. The Advice Consultant will negotiate with the Consultant of relevant specialities within the MTC. They may also negotiate that a surgeon come to a Trauma Unit to perform surgery rather than a patient being transferred to the MTC.
  4. Use of the “Major Trauma Centre Advice Consultant” will not be throughout the whole COVID-19 pandemic. They will be used when either the MTC or Network are at risk of being overloaded.
  5. The decision as to whether the “Major Trauma Centre Advice Consultant” is in use will be decided prospectively. This decision will depend on the OPEL Level of the MTC and the Trauma Network. See Appendix 2 for a description of the OPEL Levels.

    This outcome of this decision will determine whether PATHWAY A or PATHWAY B is in use for non-immediate secondary transfers – see below. Which pathway is in use will be notified to all participating hospitals. It is the responsibility of each hospital to cascade this information to relevant clinicians.

    PATHWAY A – Normal Service – when MTC and the Network are both at OPEL 1 level (see Appendix 2)
    PATHWAY B – Reduced Capacity – when either MTC or Network are at OPEL level 2 or above. This is when the “Major Trauma Centre Advice Consultant” will be in use.

    PATHWAY A is the default pathway for non-immediate secondary transfers.

  6. These protocols comprise two levels of transfers as follows:
    1. Immediate Transfers (<60 minutes) – for patients with life threatening conditions.
      These patients will include those who have been taken to the Traumas Unit for attempted stabilisation due to distance from the MTC (> 60-minute isochrone), as well as patients who either deteriorate at the TU or have been found after initial assessment to have a life-threatening condition.
      1. Patients meeting the exclusion criteria (nursing home patient, active DNACPR decision or relevant advanced directive) will not be suitable for immediate transfer.
      2. Contact SECAmb to arrange an immediate transfer to RSCH
      3. Treating senior clinician in TU to contact the ED Consultant at RSCH (01273 696955)
      4. Examples of pathologies requiring immediate transfer:
        1. Extradural haematoma with altered GCS
        2. Traumatic subdural haematoma in patients <70 years old and requiring airway support
        3. Proven vascular injury with on-going bleeding
        4. Truncal penetrating injury with haemodynamically instability or evidence of pericardial tamponade
        5. Penetrating injury to the neck with expanding haematoma
    2. All other transfers / requests for advice (Non-immediate)
      For all other referrals, there are two separate pathways each with their own algorithm below:

      Either

      1. for patients with a head injury contact the duty Neurosurgical Consultant or Registrar at RSCH (01273 696955) AND complete on-line referral on www.referapatient.org/refer-a-patient

      OR

      1. for all other cases – first identify which PATHWAY is in use at the time. If you are not sure, use PATHWAY A – but you may then be asked to make a second telephone call as per PATHWAY B:
        1. PATHWAY A - contact duty Consultant for the relevant speciality at the MTC.
        2. PATHWAY B - contact the ‘Major Trauma Centre Advice Consultant’ at RSCH on 07741 234469.

      In either case this should ideally be from a consultant but must occur after discussion with the consultant leading the patient’s care at the TU.

      DO NOT make adult trauma referrals by any other route.

      Paediatric major trauma referrals should be made to your normal receiving Paediatric MTC.

  7. All secondary transfers should only occur after a doctor at the receiving hospital has been informed of and agreed to the transfer.
  8. The MTC will provide 24/7 access to a major trauma consultant and consultants in neurosurgery, cardiothoracic surgery, general surgery, paediatric surgery, liver surgery and intensive care to discuss the appropriateness and feasibility of transfer.
  9. Wherever possible in the appropriate timeframe, discussion between sending and receiving hospital should be between Consultant and Consultant. If a Consultant cannot assess the patient sufficiently quickly (e.g. in the Immediate Transfer group), then the Consultant may delegate this role to a doctor who is able and authorised to:
    1. perform and accurate assessment of the patient’s condition and needs
    2. agree to and arrange admission at the “sending hospital” if the outcome of the consultation is not to transfer the patient
    3. act as host and arrange theatres etc. if the outcome of the consultation is for a specialist surgeon to attend perform the surgery at the “sending hospital”.
  10. The separate Transfer Protocols for Spinal Injury is suspended.
  11. Exclusion Criteria for transfer of patients from TU to MTC:
    1. nursing home patient
    2. patient with a relevant advanced directive
    3. patient refused by the consultant at the MTC
    4. patient over the age of 75 with fixed, dilated pupils
  12. When arranging Emergency or Urgent secondary transfer to the MTC always contact the Ambulance service. They will assess and decide whether transfer by HEMS might be more appropriate. Patients considered to have risk of COVID-19 should NOT be transferred by helicopter – because time to clean the helicopter is prohibitive.
  13. The two algorithms below are for adults and children from their 16th For children under 16, referrals should be direct to relevant Paediatric MTC - Kings College Hospital or Southampton General Hospital. When transferring children to the Paediatric MTC, the telephone numbers to contact the ED Consultants are as follows:
    1. Kings College Hospital: 0203 299 9000 ext. 5447
    2. Southampton General Hospital: 023812 206 666 (Direct dial Resus Priority Phone).

SITREP REPORTS

Each Trauma Unit will complete SITREP entries for each Major Trauma patient who is still an inpatient in the TU and who has been referred to, or whose case has been discussed with, the MTC on a SITREP spreadsheet and e-mail it each day by 09:00 to bsuh.sussextrauma@nhs.net.

This will allow the MTC and the Network managers to track all patients that are still in the Trauma Units that might still require specialist advice or treatment.

For each patient, the following details will be required:

  • NAME
  • DOB
  • COVID STATUS IF KNOWN: - positive/unknown/negative
  • CONTACT NUMBER FOR TREATING CONSULTANT
  • BRIEF RESUME OF INJURY
  • ONGOING CLINICAL ADVICE REQUIRED?: - yes/no
  • MANAGED LOCALLY?: - yes/no
  • ONGOING NURSING OF REHAB ADVICE REQUIRED?: - yes/no
  • PATIENT DISCHARGED?: - yes/no

An MTC Consultant will only telephone the named TU Consultant if the ADVICE REQUIRED section is marked as YES

APPENDIX 1 - ABBREVIATIONS

CCD Ambulance Service Critical Care Desk
DNACPR Do Not Attempt Cardiopulmonary Resuscitation
HEMS Helicopter Emergency Medical Service
MTC Major Trauma Centre
RSCH Royal Sussex County Hospital
TU Trauma Unit