Covid-19 and Major Trauma

Reference Number SWTN CG23

Application All Health Board providers

Version 3.0

Replaces N/A

Issue date May 2020

Review date May 2021 (or earlier if required)

Related Guidelines / Policies Multiple

Author(s) Dr D Gill

Internal reviewer(s)

Dr H Hughes (Public Health Wales), Mr I Evans (Critical Care Network), Dr J Birchall (Welsh Blood Service); Dr S Phillips (Co-Chair, Imaging Essential Services Group)

Network Governance Subcommittee review

July 2020

Sign Off

NOTE: This guideline is not intended to be prescriptive and is subject to change as our

understanding of the COVID-19 pandemic evolves. It applies to both periods of surge and control

of the disease. There is separate operational policy in the event of a surge response to COVID-19

and the approach to managing major trauma flow and capacity.

SOUTH WALES TRAUMA NETWORK (SWTN)

CLINICAL GUIDELINE (CG)

2 Covid-19 and Major Trauma – SWTN CG23

Aims & Scope

Given the current COVID-19 pandemic, it is important to establish a set of principles that Health

Boards can apply to the assessment and management of major trauma patients, which can

modified for local use. This is in order to ensure maximum protection of healthcare providers whilst

ensuring an optimal level of care for patients.

This guideline describes these principles under the following headings (some of which may already

have been put in place at the time of writing):

Trauma team activation criteria and reception.

Trauma team roles and responsibilities.

Transfer from Trauma Unit (TU)/Rural Trauma Facility (RTF)/Local Emergency Hospital (LEH) to the Major Trauma Centre (MTC).

Repatriation from the MTC.

Further clinical conditions.

Trauma team activation criteria and reception

The network policy on trauma team activation (SWTN PO4) will be applied, based on the presence

of abnormal physiology, anatomical deficit and mechanism of injury. This will provide a consistent

approach to activating trauma teams across the network.

Whilst taking the pre-alert, the Emergency Department (ED) MUST ask for whether the pre-hospital

team suspect COVID-19 or not or if the patient is confirmed to have COVID-19. This will guide where

in the ED the patient is received to and assessed by the trauma team (i.e. cohorting patients) and

instructions to switchboard at the time of activation. This aligns with the principles framework to

assist the NHS Wales to return urgent and planned services in hospital settings during COVID-19,

June 2020.

3 Covid-19 and Major Trauma – SWTN CG23

The following should be used a guide for both adults and paediatric trauma team activations

(different EDs may use different colour codes for areas – The trauma desk will ensure the crew

know which area of the department they are to go to upon arrival ):

Suspected/confirmed COVID-19 (based on latest case definition) and all patients receiving an

Aerosol Generating Procedures should be treated as high risk until results from coronavirus testing

are known.

Abnormal physiology incl. Traumatic Cardiac

Arrest?

Anatomic deficit?

YES

Activate trauma team

Receive patient in COVID designated

resus area (high risk of Aerosol

Generating Procedures)

NO

Activate trauma team

If suspected/confirmed COVID-19 -

receive in COVID designated resus

area

If not suspected/confirmed COVID-19

– receive in ”unknown status” resus

area

YES

NO

Mechanism of injury triggered?

Activate trauma team

If suspected/confirmed COVID-19 -

receive in COVID designated resus

area

If not suspected/confirmed COVID-19

– receive in “unknown status” resus

area

YES

May not need trauma team activation

Manage as per local ED policy

NO

4 Covid-19 and Major Trauma – SWTN CG23

Trauma team roles and responsibilities

1. In direct patient contact. This will be based on the clinical condition of the patient, seniority of

the trauma team and requirement for time critical interventions.

2. Strategies to minimise direct patient contact where possible should be adopted (e.g. TTL to

undertake primary survey and initial interventions, minimise repeat examination by multiple

trauma team members, reduce direct patient contact during Aerosol Generating Procedures –

AGP (e.g. intubation, finger thoracostomies, CPR).

3. Ensure trauma team members involved in AGP are in full PPE as supported by latest Public

Health Wales guidance.

4. All emergency admissions are tested on admission and further testing undertaken if COVID-19

symptoms develop during admission.

5. Ensure that there is forward planning and communication with receiving areas, in particular

where full PPE is being worn by the trauma team (e.g. CT, theatre, ITU), in order for these areas

to prepare.

Pre Hospital

Pre hospital services (including WAST, EMRTS and SAR) will continue to use the appropriate level of PPE

as guided by the latest public health guidance.

At the time the ATMIST is communicated to the receiving hospital, via the regional trauma desk/ Air

support Desk (as appropriate) it is important that the following information is also conveyed;

Whether the patient is being treated as either suspected or confirmed COVID-19 case

Whether the patient has had an AGP.

Whether the pre hospital team will be arriving in red or amber PPE

On receiving the ATMIST, the receiving hospital must advice the pre hospital team (via the regional

trauma desk/air support desk) which area in the department the patient will be received into.

Transfer from TU/RTF/LEH to the MTC

This section should be read in conjunction with the MTC acceptance policy (P01).

Hyperacute and emergency transfers – Pathways 1 and 2

The hyperacute or emergency transfer of a major trauma presents some unique challenges

in the presence of suspected or confirmed COVID-19 and requires careful planning. The

following strategies should be adopted:

5 Covid-19 and Major Trauma – SWTN CG23

As part of the handover between the local TTL and MTC TTL (via the regional trauma desk),

there should be a declaration as to whether the patient is being treated as a

suspected/confirmed COVID-19 case. All patients receiving AGPs should be treated as high

risk until results from coronavirus testing are known.

The handover should include how the patient will be transferred to the MTC and what level

of PPE will be worn by the transfer team (guided by the latest Public Health Wales

guidance).

The above will allow the MTC TTL to coordinate the trauma team response on arrival of the

patient (i.e. where in the ED the patient will be received and by whom, which should be

conveyed to the local TTL).

The transfer should be coordinated with the appropriate level of PPE (guided by the latest

Public Health Wales guidance).

For patients where AGPs have been performed, in particular intubation suitable precautions

are undertaken (incl. use of viral filters, in line suction, careful management of change of

ventilators/clamping endotracheal tubes).

It will be the MTCs responsibility to ensure an appropriate bed is located for the patient,

based on this information and guided by local cohorting policy.

Isolated injuries requiring non-time critical specialist care – Pathway 3

Patients who have confirmed isolated trauma that may require care at a specialised centre

can be referred via direct discussion between the referring hospital and speciality at the

MTC

The discussion should include declaration as to whether the patient whether the patient is

being treated as a suspected/confirmed COVID-19 case, to allow appropriate planning for

reception (i.e. which ward) and operative intervention.

It will be the MTCs responsibility to ensure an appropriate bed is located for the patient,

based on this information, within the agreed 48hrs from acceptance and guided by local

cohorting policy.

Repatriation from the MTC

This section should be read in conjunction with the automatic repatriation policy (P02) – the

principles set out in the policy will apply, in addition to the following considerations:

- At the point the patient is declared medically fit for discharge and the repatriation

database is updated, the MTC Major Trauma Practitioner will contact the TU Major

Trauma Practitioner.

6 Covid-19 and Major Trauma – SWTN CG23

- Information sharing will include whether the patient is a suspected/confirmed COVID-19

case, results of any coronavirus tests and the clinical condition of the patient.

- This information will be passed on to the TU patient access team to make an

appropriate bed allocation, guided by a local cohorting policy.

- The clinical handover should also include in the above declaration.

- The identical conditions of automatic repatriation within 24hrs of the patient being

medically fit for discharge from the MTC will apply.

- Suspected/confirmed COVID-19 should not be a reason for delaying repatriation,

providing that the patient is medically fit for discharge from the MTC and safe to

transfer.

Further clinical considerations

Blood management As a broad principle, the process of Damage Control Resuscitation (outlined in CG07), should be followed to minimise blood products requirements during the acute management of major trauma patients. Guidance has been issued by the Welsh Blood Service (May 2020), in relation to the implementation of best practice conservation measures and match supply with demand: Reduce the need for blood: 1. Think carefully about the indications and appropriateness for initiated a massive transfusion.

For example, a massive transfusion is unlikely to be of benefit in major trauma with significant or non-survivable brain injury, although it is recognised acutely and in the absence of imaging, the aetiology of shock can be difficult to delineate.

2. Give Tranexamic acid when indicated. 3. Monitor clotting state (where available) using Point of Care coagulation management (e.g.

ROTEM/TEG). Correct coagulopathy early. 4. Use interventions, such as permissive hypotension, determined by patient and procedure. 5. Make all efforts not to revert to crystalloid or colloid resuscitation as this will increase bleeding

and require more blood products. 6. Measure blood loss and use alternatives wherever possible for replacement. 7. Consider cell salvage intra-operatively.

Give blood only when needed:

- Use the NBTC Blood Component Indication App (available on IOS & Android free of charge): https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/14619/blood-components-appppt.pdf

7 Covid-19 and Major Trauma – SWTN CG23

- Use the British Society of Haematology (BSH) Platelet Summary Guidance:

https://b-s-h.org.uk/media/17121/summary-bcsh-platelet-guideline-appendix-1-final- reviewed-may-2019.pdf

- Comply with the All Wales use of O D Negative Red Cells Summary Guidance: https://wbs-intranet.cymru.nhs.uk/bht/wp-content/bht-uploads/sites/4/2020/05/O-D-Neg-Guidance-Summary-final.pdf

- Review requirements for transfusion dependant patients.

Matching demand and supply: - Clinical areas must work in close collaboration with their Senior Management Teams,

Hospital Transfusion Teams (HTT) and the WBS to ensure continuity of supply. - Clinical teams must consider the potential for blood loss, before embarking on any

procedure and plan management. Where blood will be required despite the prudent measures outlined above, do not proceed without confirmation that transfusion services can meet requirements.

- It is recommended this is specifically addressed in all WHO checklist, pre-operative briefings.

- Further details on the management and use of O D Negative red blood cells are included in a document by the blood Health National Oversight Group, appendix 1.

Critical care resources At all times there needs to be an understanding of current and near-future local and regional critical care bed capacity and capability. During the first surge of COVID-19, Welsh Government provided a daily SITREP in relation to critical care capacity and there was close communication between the Critical Care, Trauma, Renal and other clinical networks. Presently, there are no blanket ceilings of treatment/ triage decisions due to lack of capacity, so each decision is made on the likely benefit for the individual patient including for major trauma patients (as above – There is a NICE guideline to help decision making). There are also WG ethical principles to be followed – see link https://gov.wales/coronavirus-ethical-values-and-principles-healthcare-delivery-framework-html.

Urgent and emergency surgery Capability for performing acute trauma resuscitation and resuscitative procedures should be maintained at all receiving TUs and the MTC. Capability for performing emergency life and limb-threatening surgery should be maintained at the MTC. Consideration should be given to delayed, non-operative treatment (e.g. interventional radiology) or conservative approaches for the management of injuries (e.g. immobilisation instead of fixation for fracture management; delayed management of maxillofacial injuries).

8 Covid-19 and Major Trauma – SWTN CG23

Radiology resources Where possible, strategies should be deployed to optimise the use of CT scanning for trauma patients during the coronavirus event, to maximise capacity and avoid delays for deep cleaning. Emergency department: Whole-body CT remains useful as a tool to rapidly identify all injuries and avoid multiple trips around the hospital for patients during their inpatient stay. Mechanism of injury alone should not be used as an indication for CT. Emergency department: If CT availability is restricted or limited, alternative utilisation of plain film and ultrasound evaluation of trauma patients, augmented by serial clinical examination could be considered. Transport of patients around the hospital should be minimised by tailoring use of imaging for inpatients. There should be increased reliance on serial clinical examination. All requests for follow-up/repeat CT need to be organised in collaboration with Radiology consultants and the clinical specialist.

References

Public Health Wales (accessed 19/05/2020): https://phw.nhs.wales/topics/latest-information-on-novel-coronavirus-covid-19/ Clinical guide for the management of major trauma patients during coronavirus pandemic (accessed 3/06/2020) https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0070-specialty-guide-major-trauma-clinical-guide-27-march-2020.pdf Principles framework to assist the NHS Wales to return urgent and planned services in hospital settings during COVID-19, June 2020. COVID-19 – Guidance for bed spacing (Aerosol Generating Procedures), June 2020.

9 Covid-19 and Major Trauma – SWTN CG23

Appendix 1

Management & Use of O D Neg Red Cells

Produced on behalf of the Blood Health National Oversight Group (BHNOG):

O D Neg Work stream

Summary

Although issues of red cells has reduced in Wales by 6.6% in the last 3 years the demand for group

O D Negative (O D Neg) red cells as a percentage of total red cells issues continues to rise.

This guidance has been developed to provide hospitals in Wales and the Welsh Blood Service (WBS)

with information and assistance to help them proactively manage supplies of O D Neg red cells

within a clear and consistent framework. The management of these units should be seen as a

collaborative venture with both the hospitals and WBS undertaking specific responsibilities to

optimise supply.

By applying and working to these principles it will ensure that there is sufficient supply of O D Neg

within the blood supply chain and help prevent significant shortages from occurring.

The Guidance has been developed in collaboration with Transfusion Laboratory Managers (TLMs)

across Wales and considers all factors in the effective management of blood stocks within the

hospital transfusion laboratory, clinical area and blood establishment setting. The Guidance is

consistent with BCSH Guidelines for Pre-Transfusion compatibility procedures (2013)1 and a

practical guideline for haematological management of major haemorrhage (2015)2.

Repeated survey of the fate of O D Neg highlighted three specific areas of practice that could be

influenced to optimise management of O D Negs:

Wastage due to time expiry (TIMEX)

Transfusion to non-O D Neg patients to avoid TIMEX

Emergency use of O D Neg

The guidance will focus on these three areas.

Effective and active stock management is essential to minimise wastage and inappropriate

usage of O D Neg red cells.

Hospital Transfusion Laboratories should:

Aim for O D Neg issues to be <12% of total red cells issued*

Aim for O D Neg wastage of <6% of total O D Neg issued*

Stock Management

10 Covid-19 and Major Trauma – SWTN CG23

If these measures are not considered achievable, a realistic target should be identified,

documented and reviewed annually.

Undertake a formal review of stock levels of O D Neg on a six monthly basis.

NB: it would be good practice to review the stock levels of all other groups at the same

time to ensure local demand is being appropriately accounted for.

Engage transfusion laboratory staff with the outcomes of these reviews to develop a clear

understanding of stock management principles at all levels.

Define the optimum, the minimum and the maximum stock levels of O D Neg (in units),

monitoring deviations below/above these min/max stock holding thresholds

Inform WBS Hospital Services of any changes to stock levels post review

Enter stock level and wastage data into Blood Stocks Management Scheme (BSMS) Vanesa

database in a timely manner

To help achieve these measures, stock level reviews should consider:

Distance from supplying WBS site

Storage locations of O D Neg across the health board/hospital, which may include the

number of satellites storage facilities

Patient demographic and clinical specialities on hospital site

Onward supply to third party services e.g. EMRTS, private hospitals and hospices

Use of data supplied by WBS dashboard and/or BSMS to actively monitor issues and

wastage figures

Liaising with WBS Hospital Services/ Blood Health Team

Additionally, Hospital Transfusion Laboratories should consider the following:

Ensure stock is stored in expiry date order and rotated to prompt selection of shortest

dated unit first

o To assist staff in this process consider the development of a list of short dated stock, which

is updated regularly

Repatriate O D Neg to routine issue stock with a minimum of 7 days to expiry to reduce

wastage; this may be where remote issue is in use or stock is identified for emergency use

Monitor the number of units of O D Neg issued to non O D Neg patients to prevent time

expiry

Regularly review the number of satellite O D Neg storage locations: the number of units

held in each, and the number of units annually used from each location

Stock share within Health Boards to avoid wastage

Regularly audit issues, wastage and returns supplied to third party services e.g. EMRTS,

private hospitals and hospices

Participate in peer review of performance using dashboard data

Note: there is no requirement to order cde/Kell Neg units for O D Neg stocks. BSH guidelines state

that women of childbearing potential (<50 years of age) should receive O D Neg, Kell Neg units.

11 Covid-19 and Major Trauma – SWTN CG23

There should be sufficient to meet the needs of this group of patients in the stock population

without ordering specifically.

Welsh Blood Service (WBS) should:

Maintain a database of hospital stock levels of O D Neg (Hospital Services)

Aim for a stock holding of 8 days for O D Negs (this will include stock available for issue and

stock in process) We never have O neg stock of 8 days?

Using the above data ensure sufficient stock is available at all times and that procedures

are in place to manage blood supply

Monitor WBS wastage of O D Neg

Collaboratively share information with hospitals

O D Neg has historically been viewed as the group for emergency red cells. Hospital

Transfusion Labs should ensure measures are in place to support switching to another group

where appropriate as soon as it is safe to do so:

Hospital clinical areas & Hospital Transfusion Laboratories should:

Use O D Pos for ABO group unknown emergency females not of childbearing potential (i.e.

>50 years of age) or adult males. This is in accordance with BCSH Guidance

o Hospitals should have a policy to determine whether to provide O D Pos units for

these patients immediately or whether to move to O D Pos units following initial

transfusion of 2 O D Neg units

o Hospitals should risk assess use of O D Pos units in emergencies and develop a

structured implementation plan including education of clinical and scientific staff

with realistic timescales for introduction

Have clear guidance in place for MHP management of known O D Neg patients. For this

group, hospitals should consider switching to O D Pos after transfusion of 6 units of O D Neg

to conserve O D Neg stock.

Have technologies and validated laboratory processes to allow urgent issue of group specific

blood within 20 minutes of receipt of sample to minimise inappropriate use of O D Neg.

Ensure that pre-transfusion samples are obtained prior to the administration of the first unit

of emergency red cells

Be educated as to what units they will receive/issue in an emergency, i.e. clinicians should

be aware that they may receive O D Neg, O D Pos or group specific units

Continuously audit all MHPs activated to better understand usage of blood components

including O D Neg

Emergency & Major Haemorrhage

12 Covid-19 and Major Trauma – SWTN CG23

Engage in educational opportunities, including regular MHP drills, to improve patient care

during a major haemorrhage

Incorporate these recommendations into MHP activations and make all staff involved in

MHP aware of them.

Education of the clinical users of O D Neg, especially those in the emergency setting, is

essential to be able to support the recommendations identified in this guidance document.

Hospital Transfusion Committee (HTC) meetings should be used to engage with clinical

colleagues on issues such as blood usage, changes in practice, blood conservation measures

etc.

Clinical teams should be educated to understand the importance of inappropriate use of red

cells generally with particular emphasis on management of O D Neg stocks

Clinical teams should be educated to understand when transfusion of O D Neg blood is

appropriate:

o O D Neg must be given in:

non- emergency transfusion of patients who are O D Neg

emergency transfusion of females of childbearing potential (< 50 years of

age) in accordance with BCSH guidelines who are ABO group unknown or

O D Neg

o O D Neg may be appropriately given in:

Initial (first 6 units) emergency transfusion of females not of childbearing

potential (>50 years of age) and males who are known O D Neg, or are

identified as D Neg on historic grouping.

emergency where no other blood group is available

This information may be disseminated as follows:

o Using networks already developed by Transfusion Practitioner teams to share

this information explaining the rationale to educate clinical colleagues about

provision of emergency blood

o Using these recommendations to empower laboratory staff if they are

challenged about blood supplied in an emergency

Clinical Education

13 Covid-19 and Major Trauma – SWTN CG23

References

1. Milkins, C., Berryman, J., Cantwell, C., Elliott, C., Haggas, R., Jones, J., Rowley, M.,

Williams, M., Win, N. (2013) Guidelines for pre‐transfusion compatibility procedures in

blood transfusion laboratories. Transfusion Medicine, 23, 1-71

2. Hunt, B.J., Allard, S., Keeling, D., Norfolk, D., Stanworth, S.J., Pendry, K. (2015) A practical

guideline for the haematological management of major haemorrhage. Br J Haematol.,

170, 788-803

14 Covid-19 and Major Trauma – SWTN CG23

Management & Use of O D Neg Red Cells

Summary of Actions/Measures

Stock Management Hospital Transfusion Labs

O D Neg issues <12% of total red cells issues*

Measure: 12 month rolling average, monitored via data dashboard supplied by WBS

O D Neg wastage <6% of total O D Neg issues*

Measure:12 month rolling average, monitored via data dashboard supplied by WBS

*If these measures are not considered achievable, a realistic target should be identified, documented and reviewed annually.

Define the optimum, the minimum and the maximum stock levels of O D Neg (in units)

Actions: Agree at HTT/HTC and share with TLM group/WBS; Ensure all laboratory staff are made aware of these

Monitor deviations below/above the min/max stock holding thresholds

Measure: Monitored via data supplied by WBS

Monitor O D Neg issued to non O D Neg patients to prevent time expiry

Measure: Ongoing audit of issues; report results to WBS on a quarterly basis

Review stock level of O D Neg on a six monthly basis

Action: Using wastage and transfusion to avoid wastage data, and min/max deviation data

Enter stock level and wastage data into BSMS Vanesa database in a timely manner

Action: Ongoing data entry

O D Neg stock is stored in expiry date order and rotated

Action: Implement as local practice and train laboratory staff

Repatriate O D Neg to main issue stock with a minimum of 7 days to expiry

Action: Implement as local practice and train laboratory staff

Review number of satellite O D Neg storage locations

Action & measure: Agree at HTT/HTC, using wastage data and annual audit of issues from satellites

Issues, wastage and returns of O D Neg supplied to third party services

Measure: Annual snapshot audit of 1 month of activity

Stock share within Health Boards to avoid wastage

Action: Implement as local practice where applicable, and ensure good communication between sites

Stock Management WBS

WBS – maintain a database of hospital O D Neg stock levels

Action: Collate information from hospitals (including date of review) and share database regularly at TLMs for benchmarking and scrutiny

WBS – O D Neg aim for stock holding of 8 days

Measure: BSMS Vanesa report – run quarterly

WBS – Using the above data ensure sufficient stock is available at all times and that procedures are in place to manage blood supply

Action: Agreed at demand planning, and shared with TLM group/WBS

WBS – monitor WBS wastage of O D Neg Measure: BSMS Vanesa

15 Covid-19 and Major Trauma – SWTN CG23

Emergency & Major Haemorrhage

Use of O D Pos for ABO group unknown females not of childbearing potential (i.e. >50 years of age) or adult males in emergencies

Action: Review MHP policy and amend as necessary in accordance with clinical practice guidelines i.e. BCSH

Measure: Use of O D Pos for patients listed above, from data captured in MHP audit (see below)

Guidance for MHP management of known O D Neg patients

Action: Review MHP policy and amend as necessary according to clinical consensus

Laboratory processes allow urgent issue of group specific blood within 20 minutes

Action & Measure: Evidence that laboratory procedures are in place to meet this recommendation; if not currently met, consider suitable actions that may be required to rectify.

Pre-transfusion samples prior to administration of the first unit of emergency red cells

Measure: Capture as part of (ongoing) MHP audit; any consistent outliers to be discussed at HTC

All MHPs activated should be audited

Action and Measure: Ensure there is a fit for purpose audit tool capturing relevant data on every MHP

Regular MHP drills

Action: MHP drill to be undertaken every 6 – 12 months with clinical areas where MHP activation is commonly predictable

Clinical education

Hospital Transfusion Committee (HTC) engage with clinical colleagues

Action: Promote attendance at HTC to all clinical groups using blood/blood conservation techniques

Clinical teams should be educated to understand the significance of inappropriate use of O D Neg

Action: Promote educational material and issues and audit data; present at relevant clinical meetings

Clinical teams should be educated to understand when transfusion of O D Neg blood is appropriate

Action: Promote awareness and understanding of these O D Neg recommendations and local MHP policy