| dc.description.abstract | Background: A large and growing body of evidence supports the reconfiguration of trauma services into organised regional systems of care. The London Major Trauma System was the first in the UK and became operational in 2010 comprising of networks of specialised Major Trauma Centres (MTCs) which are equipped to treat the most severely injured patients in a timely manner, and nearby Trauma Units (TUs) which are appropriately set up to manage less severely injured patients. Ambulance crews utilise standardised triage tools to determine the appropriate destination of patients. At present large volumes of trauma present at a limited number of MTCs. This may have an adverse impact on the care provided to trauma and non-trauma patients at MTCs alike. Aims: The overall aim of this study was to optimise the London Trauma Triage Tool to better distinguish between patients requiring MTC-level care and those who could be safely taken to TUs. To achieve this, two studies which utilised trauma registry data and a third simulation modelling study were conducted. Firstly a retrospective cohort study of over 5000 patients with isolated traumatic brain injuries (TBI) was conducted to compare the outcomes of patients who were initially triaged to MTCs against those triaged to TUs both in the cases of patients who required neurocritical intervention and those who only needed conservative treatment. A second cohort study matched over 1200 London Ambulance Service and UK trauma registry records to identify the aspects of the triage tool best suited to identifying patients in need of MTC-level care. Finally, data from the second study was used to build a deterministic algorithm-based simulation model to assess the potential impact of triage tool changes. Results: Findings from the first two studies supported the notion of reducing the number of patients automatically directed to MTCs by the existing triage tool. For TBI patients, overall adjusted mortality was no greater for patients transferred from a TU to an MTC for neurocritical interventions than if they have been admitted to the MTC directly. For patients requiring only conservative management, no mortality difference was seen between MTC and TU patients. In study 2 weaker performing triage criteria such as ‘injury mechanism’ and certain anatomical injury patters were identified and removed from our new modified triage tool. This new tool and other variations were simulated in the model in study 3 demonstrating the potential for up to 3000 avoided MTC admissions with an average year of trauma volume. Conclusion: This thesis has shown the potential to increase trauma system inclusivity without significant detriment to patient safety. Furthermore it has the potential to improve patient experience by keeping more people at their local hospital rather than unnecessarily admitting them to regional MTCs. The newly modified London Trauma Triage Tool came into operation with the London Ambulance Service in March 2020 with plans to formally audit its performance to date. | en_US |
