Who needs to take action?
This is a safety critical HSE National Patient Safety Alert (NPSA) to be implemented by all acute hospital sites (including paediatrics) and neuro-surgical centres (NSC).
This alert is for action by those providing acute care to patients with a traumatic brain injury (TBI). A TBI is an alteration in brain function, or other evidence of brain pathology, caused by an external force (e.g. fall, accident, assault, injury). The Senior Accountable Officer supported by the Clinical Director and Leads of Surgery and Emergency Medicine should coordinate implementation of applicable actions.
What is the safety issue?
This HSE NPSA underlines the immediate requirement for all hospitals to have;
- Robust clinical governance arrangements in place for the continuous care and management of patients admitted to hospital with a TBI so that a named responsible Consultant keeps the patient under constant review at the admitting hospital with documented formal handover of care as required.
- Up-to-date and evidence-based policies and procedures for managing a patient with TBI and recognising the deteriorating or unstable patient, including guidance on agreed escalation triggers to help identify the deteriorating patient at ward level and trigger referral to critical care/anaesthetics. This must include agreed local policy for escalation by family/carers.
- Clear and accessible instruction on how and when to refer a patient to a Neuro-Surgical Centre, and how to coordinate management of patients not transferred to a Neuro-Surgical Centre but who require on-going in-patient care.
- Caring for patients with a TBI requires effective and reliable clinical handover processes (including clear, complete and accessible documentation) in place to be used for; shift handover, including for out of hours care, inter-departmental handover and inter-hospital handover.
How to take action?
This alert is accompanied by the ‘Trauma System Implementation Programme-Protocol for the management of acute traumatic brain injury in non-neurosurgical hospitals’ to support local implementation of required actions below.
1.Identify a senior clinician in your hospital to lead the response to this alert.
2.Every patient with TBI must at all times have a named Consultant who has and is aware of clearly defined responsibilities and accountabilities, including for locum cover, out-of-hours care, during handover and transfer.
3.Put in place clear and accessible instructions on how to contact and re-escalate a patient to the NSC, including:
- Referral of all TBI patients to the NSC using the national (recorded) service 1800-TRAUMA / 1800-872-862
- If a patient deteriorates or there are other concerning triggers re-contact with the NSC must be via 1800-TRAUMA / 1800-872-862
- All referrals to a NSC are undertaken by senior clinical staff - Consultant or Registrar only. A Senior House Officer can refer via 1800-TRAUMA only following authorisation by a Consultant or Registrar who cannot undertake the referral due to serious clinical commitments such as surgery / emergency. The responsible Consultant MUST be aware of all such communication and of advice received.
4.Use a structured, standardised communication approach for clinical handover, communication of the acutely unwell or deteriorating patient with a TBI, incorporating specific communication tools such as ISBAR & ISBAR 3 (Introduction, Situation, Background, Assessment and Recommendation). Ensure and document that communication has been received, understood and advice given has been acted upon.
5.Ensure that on-going communication to a NSC is by a senior clinician (Registrar level or above) and that the responsible Consultant at the admitting hospital is aware of all such communication and consequent advice.
6.Develop/update and implement policies, procedures and training to ensure there are robust clinical governance arrangements for the management of patients with TBI from point of entry in the Emergency Department, to admission and to transfer or discharge.
7.Develop/update and implement policies, procedures and training which set out the requirements for monitoring the patient regularly. Clinical examination is key to identification of the deteriorating patient with an acute TBI, see page 4, referenced from the ‘Protocol for the management of acute traumatic brain injury in non-neurosurgical hospitals 2024’ regarding triggers for the escalation of care (when a patient with TBI shows signs of deterioration).
8.Develop clear local pathways for the patient’s family/carer to inform staff of the patient’s baseline/usual condition and to escalate their concerns regarding any deviation or deterioration from this. Incorporate in policies, procedures and training the requirement that such concerns must be acted on and investigated further.
9.Incorporate in policies, procedures and training that expressions of concern from nursing staff, health and social care professionals or staff in training are recognised as triggers for escalation of care. It is important that advice received is understood and acted upon.
10.Neuro-Surgical Centres must include in their processes: mechanisms for monitoring, escalating and managing increasing expressions of concern from acute hospitals regarding a patient including escalation to the relevant Neuro-Surgical Consultant.
11.Ensure that relevant guidance information is available and used by all, including new, locum and trainee staff by revising induction, local training, simulation training and audit.
12.Audit compliance with local policies, procedures and training requirements that have been developed, revised or updated locally on foot of this HSE NPSA and address any findings.
When does action need to be completed?
Please circulate this HSE NPSA to relevant staff by 16 December 2024.
Actions 1- 5 should be implemented immediately
Actions 6-11 should be completed within 6 months (12 June 2025)
Action 12 should be completed within 12 months (12 December 2025) and then repeated annually at a minimum depending on the finding of audits.
Download the HSE NPSA Local Action Plan