Chapter 16: Guidelines for the Provision of Anaesthesia Services for Trauma and Orthopaedic Surgery 2023

Published: 31/01/2023


Trauma remains the most common cause of loss of life in the under 40s age group in the UK, and as such major trauma centres (MTCs) and trauma units (TUs) have been established to receive patients of all ages and to improve outcomes.1 Early anaesthetic involvement is beneficial at all stages, from the prehospital setting, to emergency departments (ED), operating rooms, interventional radiology suites, postoperative care units and the critical care environment. The need for significant anaesthetic input and support for these complex patients is an integral part of this pathway. Definitive fixation of all indicated fractures should be completed at the earliest possible opportunity.

Hip fracture is the most common condition presenting for emergency orthopaedic surgery in the UK with many patients aged over 65. These patients together with those requiring surgical intervention for fragility fractures present significant challenges and the input from a multidisciplinary team and early surgery is essential to achieve good outcomes in this population.

Primary arthroplasty surgery significantly improves the quality of life and the mobility of those affected. With the advancing age of our population and their increasing expectations, the number of patients requiring primary arthroplasty surgery and subsequent revision arthroplasty surgery continues to rise. This population is frequently older with co-existing medical conditions that need to be optimised prior to surgery, and benefits from a multidisciplinary team (MDT) approach and the use of standardised protocols.

Orthopaedic surgery in children is wide ranging. From closed fracture manipulation and casting, to complex long-bone and soft-tissue surgery or spinal correction of congenital or acquired conditions. These may be associated with neurological conditions, or specific syndromes that could pose challenges to those providing anaesthesia care.  

1. Organisation, staffing and administration

Medical leadership


Every department of anaesthesia should have a designated clinical lead (see Glossary) for anaesthesia services for trauma and a designated lead for anaesthesia services for orthopaedic surgery. This should be recognised in their job plan and they should be involved in multidisciplinary service planning and governance within the unit. They should have access to trust board through a governance structure with explicit pathways of communication.

GPP Strong

Autonomously practising anaesthetists and intensivists should be involved in the planning of local trauma services. Those with defined responsibility for major trauma management should be engaged in the layout and logistics of the resuscitation room, interventional radiology and theatres suites.

GPP Strong

Each department of anaesthesia should have an annual plan in place for the workload to be delivered safely and effectively.2

C Strong

Organisations should explicitly recognise the 24/7 nature of trauma work which requires a specific organisational approach for standards to be achieved throughout the whole of the week.

GPP Strong

The provision of a high-quality trauma and orthopaedic service should be an explicit aim of the hospital executive and senior staff team. This should be reflected in the hospital’s published plans and by the provision of a management structure to support this aim.3,4,5

C Strong

Hospital business plans should address the predicted growth in elective and non-elective demands due to expanding local population and an ageing population.6 Planning should be based on accurate and timely demand and capacity modelling.7

C Strong

Clinical governance

Clinical governance is covered in detail in Chapter 1: Guidelines for the Provision of Anaesthesia Services: The Good Department. The principles of governance described in the chapter are applicable to provision of services for trauma and orthopaedic surgery.


Regular multidisciplinary mortality and morbidity meetings should take place in all trauma centres and follow the guidance of the World Health Organization (WHO).8

C Strong

Anaesthetists should be involved in multidisciplinary governance meetings. Perioperative outcome data should be discussed in these meetings.

GPP Strong

Care pathways and care bundles for common procedures such as hip fracture improve outcomes. Anaesthetists should be involved in developing, delivering and evolving these pathways and bundles.

GPP Strong

Governance meetings should take place across the entire trauma network at defined intervals. Besides individual case discussion, feedback information from the Trauma Audit and Research Network (TARN) should be disseminated, and mechanisms set in place to correct any problems identified.1 

C Strong


General policies detailed in Chapter 2: Guidelines for the Provision of Anaesthesia Services for Perioperative Care of Elective and Urgent Care Patients are relevant to provision of anaesthesia services for trauma and orthopaedic surgery.


Specific local policies pertinent to trauma and orthopaedic surgery should be developed by a multidisciplinary team including an anaesthetist, acute pain nurse, pharmacist, physiotherapist, critical care clinicians, surgeons and other relevant specialties.9

C Strong

Local policies should be in agreement with relevant published national guidelines.

GPP Strong

Local policies should be easily accessible to all staff caring for trauma and orthopaedic patients. These include but are not limited to:

  • preoperative screening for complex pain issues and access to acute pain services and advanced pain management methods
  • pain management pathways for patients with chest injuries                                               
  • supervision and monitoring of patients by competent clinical staff during surgery performed under peripheral nerve blocks, including in a block room or similar facility
  • perioperative anticoagulation guidelines for safe placement of epidural and regional nerve block techniques10
  • recognition and management of patients at risk of acute compartment syndrome11
  • ‘Stop Before You Block’12,13,14,15
  • management of complications of regional anaesthesia including high spinal block and accidental dural puncture
  • assessment and management of local anaesthetic systemic toxicity
  • assessment and management of peripheral nerve injury
  • post-procedure monitoring of epidurals, nerve blocks and continuous infusion analgesia on the ward, including follow-up care in hospital and after discharge
  • protocol for whom to call for problems with postoperative pain relief
  • venous thromboembolism prophylaxis after orthopaedic and trauma surgery.16
C Strong

Units should use a delirium assessment tool and a delirium policy describing preventative measures and its management.17

C Strong

There should be specific guidelines for assessing a suspected difficult airway in patients with spine and joint disease and for measuring lung function in patients with kyphoscoliosis.18

C Aspirational

Patients at risk of acute compartment syndrome should be identified on admission to hospital or at the time of surgery, and the condition should be managed within agreed multidisciplinary protocols.11

C Moderate

2. Major trauma



Local policies should ensure that National Institute for Health and Care Excellence (NICE) recommendations and quality standards for major trauma services are met and should be agreed with the regional trauma network.19,20

C Strong

There should be local policies in place to meet the quality standards developed by NICE for:20

  • patients with major trauma who cannot maintain their airway and/or ventilation to have drug‑assisted rapid sequence induction of anaesthesia and intubation within 45 minutes of the initial call to the emergency services
  • patients who have had urgent three-dimensional imaging for major trauma have a provisional written radiology report within 60 minutes of the scan
  • patients with open fractures of long bones, the hindfoot or midfoot have fixation and definitive soft tissue cover within 72 hours of injury if this cannot be performed at the same time as debridement
  • patients with full in-line spinal immobilisation to have their risk of cervical spine injury assessed using the Canadian C-spine rule21
  • MTCs to have a dedicated trauma ward for patients with multisystem injuries and a designated consultant available to contact 24 hours a day, 7 days a week.
  • MTCs to have acute specialist services for rehabilitation after major trauma, and for children and older people.
C Strong

Initial management should follow the adult trauma life support principles with management of airway, breathing and circulation, together with cervical spine stabilisation occurring in parallel rather than in sequence.22 Local guidelines should be followed to ensure that the appropriate tier of trauma call response is made.

C Strong

Pain management pathways should be followed for chest wall injuries including provision for early epidural or nerve blocks in patients with multiple rib fractures.23

C Strong

Assessment and management for a cervical spine injury should follow pre agreed existing NICE and British Orthopaedic Association guidance.24,25 Spinal clearance protocols should be embedded into practice.26

C Strong

There should be a local protocol in place for emergency access to an operating theatre or intervention suite, to provide rapid intervention in life threatening or limb-threatening conditions.27

C Strong

All acute hospitals should have a defined major incident plan. The plan should be built around the regional network of MTCs, TUs and local emergency hospitals (LEHs).19

C Strong



A structured system for recording and receiving information about trauma patients should be developed and implemented. Clear lines of communication to establish this prehospital documentation should be shared with senior nursing staff and trauma teams.19,28

C Strong

Rapid and effective communication is crucial in emergency situations. Communication strategies should consider the use of technologies such as smart phones, and standardised methodology such as situation, background, assessment, recommendation.29

A Strong

Patients who have sustained rib fractures should have an early multidisciplinary assessment involving multidisciplinary teams such as surgeons, pain services, critical care and physiotherapy to determine the optimal analgesia and definitive management options to minimise complications related to altered pulmonary mechanics, lung capacity and ventilation.

GPP Aspirational

There should be a flexible approach to trauma list planning and management to accommodate emergency cases that need priority treatment. There should be a system in place to alert the theatre team of the arrival of an unstable patient with major trauma. Appropriately trained staff and facilities should be available to receive these patients at short notice.18

C Strong

The trauma team should attend to all suspected major trauma, according to the predefined local criteria. The trauma team should also be present for paediatric and older patients (where appropriate), patients with unexpected findings on arrival and to receive patients following interhospital transfer.

GPP Moderate

The time interval between the injury and initiation of management should be considered for patients who have sustained trauma to improve patient outcomes.

GPP Aspirational

The optimal destination for the majority of patients with major trauma is a MTC. A pre-hospital triage tool should be used to differentiate between patients who should be diverted to a MTC and those who could be taken initially to a TU for treatment.19,30 Major trauma patients should only be taken to a TU if the patient needs a life-saving intervention that cannot be delivered by the pre-hospital team.

C Strong

MTCs should have a clear point of contact to provide clinical advice via clearly identified pathways and local tier arrangement to other providers within the network. This includes advice during the pre-hospital stage and while patients are awaiting transfer to MTCs for definitive treatment.

GPP Moderate

The anaesthetist plays a key role in the multidisciplinary team who apart from being involved in airway management in major trauma patients, should provide input into the recognition and management of acute physiological derangement, haemorrhage, and shock.

GPP Strong

Handovers for patients requiring emergency trauma surgery should be structured to ensure continuity of care. Handover protocols should include clear documentation of care delivered and the future treatment plan for the patient.18,31

C Strong



Anaesthesia for the emergency control of major traumatic haemorrhage, and other damage limiting interventions in the operating theatre or radiology intervention suite, should be consultant anaesthetist led. Where consultants are not resident, clear lines of communication and notification should be in place to allow early attendance to trauma calls.

GPP Strong

A major trauma coordinator (or someone in a similar role) should be responsible for overseeing scheduled admissions, preparation and planning for surgery, and for coordination of care of trauma patients with other specialties including critical care and postoperative care.

GPP Strong

Equipment, services and facilities


Immobilisation equipment including a range of appropriately sized semi rigid collars, head blocks, tape, a vacuum mattress and a scoop board should be available. Spinal clearance should be achieved as soon as clinically possible, to minimise discomfort and complications from prolonged immobilisation in patients who do not have spinal injuries.

GPP Strong

In suspected spinal injury, hard spinal boards should only be used as a prehospital extrication device and not be used for transport.32 A scoop stretcher or full-length vacuum mattress should be used for transfer.

C Strong

Equipment for portable monitoring to level 3 standards and ventilation should be available in the ED resuscitation room.33,34

C Strong

Point of care ultrasound (POCUS) should be available as it is a useful adjunct to the primary survey in acute trauma. Operators need to ensure that this procedure does not delay time to definitive imaging or intervention.2,27,35

C Strong

Patients who have acute nerve or spinal cord compression should be referred immediately to a neurosurgeon or specialist spinal unit (where required).36

C Strong

In MTCs with a high volume of patients, prethawed plasma should be immediately available.

GPP Strong

For patients with complex trauma, including spinal cord injuries and traumatic brain injury, there should be rapid access to key professionals and regional specialists. Patients, relatives and carers should be directed to appropriate support groups where relevant e.g. the Spinal Injuries Association.37

C Strong

An emergency operating theatre should be rapidly available at all times for major trauma patients. The available equipment should be suitable for a full range of emergency trauma procedures. Use of this theatre for non-urgent procedures should be tightly controlled. If the designated emergency theatre is occupied, there should be a robust, flexible and agreed backup plan to obtain an appropriate alternative theatre for the next emergency case.

GPP Strong

The emergency operating theatre should be equipped with a radiolucent operating table that allows fluoroscopic imaging of all body parts without repositioning the patient.

GPP Strong

In MTCs and TUs there should be a rapidly accessible imaging suite for patients with major trauma, with immediate access to specialised equipment for the management of difficult airways including physiological and gas monitoring. In addition, the room design should allow visual and technical monitoring of the patient by the anaesthetic staff.38

C Strong

In MTCs and TUs, the resuscitation room receiving bays should be large enough to allow simultaneous emergency procedures to be performed by trauma team members.

GPP Strong

Hospitals admitting patients with major trauma should have critical care to both Level 2 and 3 standards on site.39 Portable invasive haemodynamic monitoring should be available to facilitate transfer to and from the critical care areas.

C Strong

Transportation of the trauma patient


When transporting a trauma patient, the following should be available:

  • appropriately trained and competent staff
  • insurance (personal and medical indemnity)
  • crash test compliant equipment
  • ambulance booking procedures
  • procedures for receiving patients
  • communication between medical teams and families
  • documentation and procedures for repatriation of staff and equipment once the transfer and handover are completed.9,40,41
C Strong

Transport of patients within the hospital and between hospitals (e.g. transfers to major trauma, neurosurgical or paediatric centres) should be undertaken in a timely manner, without unnecessary delays, and in accordance with established guidelines and standards.9,40,41,42,43 Hospital transfers may involve a retrieval service.

C Strong

Local guidelines for patient transfers between referring hospitals, neurosurgical units and local ambulance services should be consistent with national guidelines for the safe transfer of the brain-injured patient.44

C Strong

3. Emergency orthopaedics

Fragility hip fracture


For patients who have sustained hip fractures, femoral or fascia iliaca nerve blocks should be provided in the emergency department (ED) and at the time of surgery (provided that six hours has passed between blocks).45

C Strong

Hospitals providing surgical treatment for hip fractures should have a formal pathway including prompt provision of analgesia (including nerve blocks) and hydration, preoperative assessment of high-risk patients by the anaesthetic team. In addition, orthogeriatrician input should be prioritised on orthopaedic trauma lists.46,47,48,49

C Strong

Risk assessment should be performed in all patients with hip fracture. The Nottingham Hip Fracture score and National Hip Fracture Database Tool could be used to assess risk.50 Frailty scores, the four ‘A’s test score for delirium and the Nottingham Hip Fracture Risk Score for Kidney Injury are useful organ-specific assessment tools.

C Strong

Anaesthetists should facilitate surgery within 36 hours of a hip fracture.51 Surgery should be delayed only if the benefits of additional medical treatment outweigh the risks of delaying surgery. The risks of delay associated with pain and immobility contribute to poor outcomes to a far greater extent than correction of an abnormality to a particular numerical value.45

C Strong

Dedicated trauma operating lists should be scheduled daily, including weekends to meet local demands, and to ensure 36-hour targets for hip fracture are met. Extra provision during the day and in the evenings may be necessary to meet local demands and limit overnight operating.52

C Strong

Unoperated hip fractures in older patients have a high mortality rate. Evidence shows that ASA4 patients assessed as American Society of Anaesthesiologists class 4 have a higher survival rate when managed surgically.53 Hip fracture surgery should be considered for patients even in the presence of significant comorbidities. Provision for safe anaesthesia and recovery of these patients, including handover to ward teams, should be available to facilitate this.

C Moderate

Perioperative anaesthetic care for a patient who is older with a hip fracture should be standardised with the overarching goals of management being patient remobilisation, re-enablement and rehabilitation.

GPP Strong

Anaesthesia (and surgery) for hip fractures should be undertaken by an appropriately experienced anaesthetist (and surgeon).

GPP Strong

An anaesthetic job planned representative should attend regular multidisciplinary hip fracture management meetings and feedback any relevant learning points to departments of anaesthesia and individual anaesthetists, as appropriate. 

GPP Strong

Facilities to provide total hip replacement to hip fracture patients with limited comorbidities should be available seven days a week.  

GPP Strong

Standard protocols for unilateral fascia iliacus compartment blocks should be readily available and training, awareness and management of local anaesthetic toxicity should be ensured to allow timely delivery in the ED.54

B Strong

There should be a formalised integrated pathway for high-risk trauma patients, such as hip fractures, which includes:4,32,55,56

  • a clear diagnostic and management plan made on admission53
  • a clear identification and documentation of comorbidities
  • a clear preoperative assessment and optimisation plan by an anaesthetist and/or an orthogeriatrician57
  • documentation of preoperative investigations and testing
  • a reconciled list of medicines to assess the risk of existing medications (including anticoagulation) and the risk associated with stopping long-term medication53,54,58
  • documentation of risk assessment, mortality risk, discussions with family and any other important decisions24,32,59
  • informed consent for surgery including identification of decision-making proxies (i.e. a lasting power of attorney)4,60
  • a plan for postoperative care4,60
C Strong

Agreed local guidelines should be in place and implemented on the following:

  • compliance with best practice anaesthetic management protocols for hip fracture as recommended by the Association of Anaesthetists.46,61
  • tailored World Health Organization (WHO) safety checklists to discuss the requirement for use of bone cement  
  • preoperative assessment for treatment escalation and cardiopulmonary resuscitation
  • older people (>65 years) and/or frail people with long-bone and periprosthetic fractures should receive similar treatment as those with hip fracture.
C Strong

Departments should develop protocols for reviewing patients with hip fracture postoperatively, to support continuing orthogeriatric care, and to learn from successes and problems as part of continuous quality improvement.45

C Strong

4. Elective orthopaedics

Detailed recommendations for organisation and administration of anaesthesia services for elective surgery are detailed in Chapter 2: Guidelines for the provision of Anaesthesia Services for Perioperative Care of Elective and Urgent Care Patients.


There should be a preoperative assessment clinic for elective orthopaedic surgery.

GPP Strong

The anaesthetist should contribute in the multidisciplinary perioperative care process which focuses on preoptimisation, patient education, standardised enhanced recovery pathways of care aimed at delivering early mobility, discharge, and early return to normal life.46,62 The option of doing nothing should be considered where relevant.63,64

C Moderate

There should be multidisciplinary input for the preoperative assessment of high risk patients such as patients with cognitive disorders, chronic kidney disease, diabetes mellitus and ischaemic heart disease.50,65 The anaesthetist should be involved in preoperative optimisation and prehabilitation plans.60,62

C Strong

In patients aged over 65, frailty screening using an appropriate validated screening tool should be performed and documented early in the preassessment pathway. A screening tool used in combination with direct questioning should also be adopted to help identify patients with cognitive impairment and therefore increased risk of delirium.66

C Moderate

Patients should be screened for chronic pain and opioid use in the preoperative period. Preoptimisation should ensure optimal management of preoperative pain, psychological preparation, education, and expectation management.49,67

C Moderate

A perioperative management plan should be formulated for all patients and should include multimodal analgesia and intrathecal opioid sparing analgesic techniques.68 Multimodal analgesic techniques should aim to provide optimal pain relief whilst minimising side effects such as sedation, postoperative nausea, and vomiting, and hypotension which might compromise early rehabilitation and recovery.47,48,67

C Strong

There should be an enhanced recovery after surgery programme for suitable patients undergoing elective orthopaedic surgery as it improves early mobilisation, reduces length of stay, postoperative complications and mortality.69

C Strong

Elective patients with major comorbidities or those undergoing complex or prolonged surgery should be scheduled earlier in the day, to allow time for postoperative stabilisation.

GPP Strong

Elective orthopaedic operating lists should be separated from trauma lists, to allow efficiency, ensure safety, prevent cancellations and enable a flexible response for emergencies.

GPP Strong

Hospitals should consider providing specific regional anaesthesia lists and using dedicated areas for performing peripheral nerve blocks.70

C Moderate

Elective orthopaedic units performing major inpatient surgery should have 24/7 access to all support services including acute pain services and critical care.

GPP Strong

Major surgery performed in satellite sites should routinely use formal risk assessment tools both before and after the procedure to ensure patients receive the appropriate level of postoperative care. The level of intraoperative and postoperative monitoring should match patients risk. A lower threshold for continuous invasive arterial blood pressure monitoring should be considered in high risk patients.71,72

C Strong

Patients with >1% mortality risk should only be considered for surgical hubs if enhanced care facilities and access to critical care and/ or perioperative medicine services are available on site.71,72

C Strong

5. Equipment, facilities and services

Detailed recommendations for equipment, facilities and services of anaesthesia services for elective surgery are detailed in Chapter 2: Guidelines for the Provision of Anaesthesia Services for Perioperative Care of Elective and Urgent Care Patients.



Patients for elective orthopaedic and planned trauma surgery should have their temperature checked preoperatively on the ward. Warming devices for patients should be available for use in the anaesthetic room, operating theatre, recovery unit and ED.3

C Strong

A range of operating tables with attachments for spinal, thoracic, pelvic and limb trauma procedures should be available as appropriate.73

C Strong

Tourniquets and inflation devices of suitable sizes should be available for upper and lower limb surgery requiring a bloodless field.

GPP Strong

Cell salvage equipment should be available for cases where significant blood loss is anticipated.74,75 Staff who operate this equipment should receive training in how to operate it, and should use it with sufficient frequency to maintain their skills.

C Strong

A rapid infuser allowing the infusion of warmed intravenous fluids and blood products should be available in the anaesthetic room, operating theatre, recovery unit and ED.76

C Strong

Equipment to facilitate haemodynamic and cardiac output monitoring should be available.

GPP Strong

A standardised ‘difficult airway trolley’ should be immediately available in all areas where major trauma patients are received or managed to level 2 (or greater) standards of care. These should be equipped as defined in the Difficult Airway Society (DAS) guidelines.5,77,78

C Strong

Patient positioning for elective and trauma orthopaedic surgery involves a variety of specialist equipment, tables and attachments. These should be suitable to care for patients across a wide weight range, with theatre personnel aware of the upper weight limits.54,79

C Strong



Primary and revision arthroplasty surgery, together with trauma surgery involving bone implants or internal fixation should be carried out in an operating theatre with multiple air changes per hour (e.g., laminar flow).

GPP Strong

Where appropriate, point of care testing for haemoglobin, blood gases, lactate, ketones, coagulation and blood sugar should be available for patients with major trauma throughout the patient journey and those undergoing orthopaedic procedures associated with a risk of haemorrhage.7 If near-patient testing is not available, laboratory testing should be readily and promptly available.80

C Strong

Transport and distribution of blood and blood components at all stages of the transfusion chain must be maintained under appropriate conditions to ensure the integrity of the product.56

M Mandatory

Appropriate blood storage facilities should be clearly identified and provided in close proximity to the emergency operating theatre.52

C Strong

Tranexamic acid should be available for administration if major haemorrhage is suspected in a trauma patient within three hours of injury.81,82,83

C Strong

Newer hemostatic agents and antidotes should be readily available to clinical teams for emergency and trauma surgery.84

C Strong

There should be adequate provision of postoperative beds for orthopaedic and trauma patients to allow timely discharge of patients from theatre recovery areas.

GPP Strong

A fully equipped high dependency unit of level 2 standards should be available on site for high-risk patients undergoing major orthopaedic surgery, including revision joint replacement and surgery involving instrumentation of the spine. If the hospital does not have a Level 3 facility, protocols should be in place to determine when and how to transfer to a hospital with a Level 3 facility. Alternatively, other models of enhanced postoperative care such as a post-anaesthesia care unit should be considered.

GPP Strong

Clinical deterioration can be identified using early warning scores and mitigated by proactively reviewing patients at risk. Arrangements to seek critical care input in deteriorating patients in a timely manner should be in place.

GPP Strong

6. Areas of special requirements


Anaesthetists will often be part of the MDT responsible for the initial resuscitation and stabilisation of the critically ill or injured child, prior to transfer to a specialist centre. All hospitals with an ED will be exposed to high volumes of paediatric patients with low-energy transfer injuries. Detailed recommendations for paediatric services are described in GPAS Chapter 10: Guidelines for the Provision of Paediatric Anaesthesia Services 2022.


Staff should be vigilant for non-accidental injury in children with trauma injuries and should make enquiries of the circumstances around major trauma and ask if there are safeguarding concerns.

GPP Strong

Healthcare workers, including the anaesthetist, must be aware of the local policy for child protection, and that they have an obligation to document and report any concerns to a responsible individual.85

M Mandatory

Hospitals must have guidelines in place to ensure the safety of children admitted to hospital, to monitor injured children known to be at risk, and identify concerns arising from any injury or pattern of injuries.86 They must provide the appropriate training related to these guidelines.

M Mandatory

Pregnant patients

Trauma is a leading cause of non-obstetric mortality in pregnant patients.4 Although the primary duty of care is to the mother, fetal and maternal wellbeing are inextricably linked. Standards for non-obstetric emergency procedures in pregnant patients are described in GPAS Chapter 5: Guidelines for the Provision of Emergency Anaesthesia Services.


A standardised approach should be taken when completing a trauma survey in pregnancy and a maternal-foetal trauma checklist should be considered as this lays the foundation for interdisciplinary collaboration in a stressful environment.87

C Strong

Provision for fetal monitoring and emergency lower (uterine) segment caesarean section should be available if indicated in the ED.88,89,90

C Strong

In pregnant orthopaedic trauma patients, diversion to a centre with obstetric and trauma expertise directly from the scene of an injury should be considered, to avoid delay of appropriate specialist care.91

C Strong

Older patients


A patient-centred approach is preferred for documenting advanced care plans, which include overall treatment goals including resuscitation status. It should include discussing and planning treatments that should be considered, not just those that should be withheld.18

C Strong

A fall of less than two metres is the most common mechanism of injury in older patients. Prehospital triage to aid early identification of severe injuries in older patients should be available to allow quick transfer from TU to a MTC for specialist investigation and intervention.92

C Strong

Older patients who are admitted following trauma should have a comprehensive geriatric assessment. The use of frailty screening tools may facilitate more informed early decision making in older trauma patients.93

C Strong

Protocols for end of life care should be in place to manage older patients with frailty who are unlikely to survive. The multidisciplinary team and patient’s family or next of kin should be involved in these decisions.94

C Strong

7. Training and education


All patients undergoing anaesthesia should be under the care of an autonomously practising anaesthetist whose name is recorded as part of the anaesthetic record.4,95

C Strong

All anaesthetists providing anaesthesia for trauma and orthopaedics should have appropriate knowledge, skills, attitudes and behaviour in accordance with the RCoA training standards.96

C Strong

Anaesthetists with a specific interest in orthopaedics and trauma should deliver regular theatre sessions to ensure the maintenance of their skills and experience.

GPP Strong

Anaesthetists with responsibility for the intraoperative care of trauma patients should ensure that their skills and knowledge of current recommendations are up to date, particularly in the management of major haemorrhage.

GPP Strong

MTC and TU anaesthetic departments should consider appointing anaesthetists with an interest in prehospital care (see Glossary). Anaesthetists who provide prehospital care outside the hospital setting should be qualified to do so.97

C Strong

Anaesthetists who manage patients with major trauma should consider undertaking Advanced Trauma Life Support (ATLS), European Trauma Course or equivalent training, and should update their training at regular intervals.

GPP Strong

Anaesthetists providing anaesthesia for trauma and orthopaedic surgery should learn and maintain expertise in a wide range of regional anaesthetic techniques, including central and peripheral neural blockade.96

C Strong

All anaesthetists involved in the management of major trauma should understand the principles and techniques of haemorrhage control resuscitation to prevent the lethal diamond of hypothermia, acidosis, coagulopathy and hypocalcemia using low-volume fluid resuscitation, blood products and damage control surgery.94,98,99

C Strong

Appropriately trained theatre staff should be available when treating patients with multiple injuries. They should be skilled and experienced in all surgical specialties that may present in the treatment of patients with multiple injuries.

GPP Strong

Anaesthetic trauma theatre teams should be trained in the correct use of all essential anaesthetic theatre equipment used for trauma surgery.

GPP Strong

Staff in the recovery area and in the wards who receive patients after surgery with epidural infusions, nerve blocks or intravenous opioid infusions (including patient controlled analgesia) should have received up to date formal training in caring for such patients.

GPP Strong

Staff expected to top up medication for patients with epidurals and continuous nerve blockade should be trained in administration of such medications.

GPP Strong

Anaesthetic practitioners involved in the administration of anticoagulant therapies should have current and up to date knowledge in their use.

GPP Strong

There should be regular multidisciplinary in-situ simulation training for the initial management of major trauma care and resuscitation to standardise clinical practice. Simulation can improve technical and non-technical skills including communication and teamwork.100

C Strong

Appropriate early referral to the acute pain services and use of regional analgesia should be considered in patients with chest trauma.101

C Aspirational

The diagnostic and therapeutic applications of POCUS in trauma are expanding. There should be emphasis on quality training and a robust governance process for operators within the trauma multidisciplinary team.102

C Strong

Major incident training exercises should take place at regular intervals.

GPP Aspirational

Organisations should provide mandatory training relating to advance care planning and resuscitation policies and documents.35,103

C Strong

Educational opportunities for anaesthetists in training in MTC and TU will undoubtedly occur during predictable job planned consultant direct clinical care sessions out of hours as a result of the nature of trauma. Hospitals in which anaesthetists in training work a full or partial shift system should consider providing additional consultant programmed activities to allow training and supervision to take place in the evening.

GPP Aspirational

Hospitals should consider training ED staff in acute pain management of both adult and paediatric patients with trauma, in particular using ultrasound-guided femoral nerve block or fascia iliaca block for hip fractures in elderly patients and femoral fractures in children.41,104

B Strong

The definitive care of complex spinal and pelvic injuries requires early multidisciplinary specialist spinal (orthopaedic or neurosurgical surgery) and pelvic team discussion. The anaesthetist managing such cases should have appropriate training and experience in management of these complex patients including management of associated complications.

GPP Moderate

8. Research, audit and quality improvement


All sites should consider participating in active research studies on the National Institute for Health and Care Clinical Research Network portfolio for Trauma and Emergency Care.105

C Aspirational

All MTCs should have a dedicated research lead with appropriate job planned time and should receive training on ethical and organisational issues.106

C Strong

All clinicians involved in trauma care should be aware of active studies and consider completing good clinical practice training and participating in screening and recruiting of research participants.105,107

C Strong

Opportunities for associate principal investigator roles should be encouraged.105

C Strong

Trauma and orthopaedic surgery should be included in anaesthetic departmental audit programmes, including continuing audit of complications and adverse events. The trauma anaesthetists should have provision in their job plan to attend trauma MDT meetings for discussion regarding high risk patients.

GPP Moderate

All hospitals treating patients with hip fractures should participate in national audits, e.g., National Hip Fracture Database or the National Joint Registry to monitor its performance against national benchmarks, quality standards, and contribute to research. Outcomes from these audits should be discussed at governance meetings and distributed to anaesthetic staff.108,109

C Strong

All hospitals receiving major trauma patients should contribute to the TARN, to monitor their performance against national benchmarks and quality standards and contribute to research.1 Comparative data analysis and display on the national major trauma dashboard (via TARN) is invaluable for quality assurance.

C Strong

MTCs and TUs in England should undergo regular peer reviews within the National Peer Review Programme with their performance being judged according to national major trauma measures.110

C Strong

All new patients with spinal cord injuries should be referred through the NHS Spinal Cord Injury Service (NSCIS) and registered on the National Spinal Cord Injury Database.28 The incidence of complications should be recorded.

C Strong

There should be clear processes and policies for reporting and learning from near misses and critical incidents. National patient safety alerts should be communicated and actions agreed locally to reduce the risk of harm.

GPP Strong

Nationally agreed key performance indicators should be used to monitor the performance of the pathways for hip fractures and major trauma and reviewed by a multidisciplinary committee including a trauma lead anaesthetist. In addition, local quality indicators should be developed proactively, to support continuing improvement of these services within organisations.

GPP Strong

Impact of enhanced recovery pathways for elective surgery should be audited to focus beyond the length of stay to improve patient outcome and satisfaction.

GPP Strong

Evaluation of patient-centred outcomes on pain management and quality of recovery in hospital and after discharge using a validated questionnaire can be a useful tool to guide quality improvement in care pathways.111,112

B Strong

Organisations should have a service improvement team that coordinates national and local projects, and encourages a multidisciplinary approach to trauma and orthopaedic services. Data should be collected to provide high quality information to drive change and support service development. Good data, quality improvement tools and organisational support can create feedback strategies which drive improvement.27

C Strong

9. Patient information

The Royal College of Anaesthetists has developed a range of Trusted Information Creator Kitemark accredited patient information resources that can be accessed from the RCoA website. Our main leaflets are now translated into more than 20 languages, including Welsh.

Information for patients, relatives and carers


Patients should have easy access to reliable sources of information (web based and written) for joint replacement surgery. Options for anaesthesia and analgesia, and potential benefits and risks of each option should be discussed with patients to support shared decision making.46,113

C Strong

Patient information leaflets on hip fractures should be available for patients, relatives and carers.114,115 The clinicians should collaborate with the patients in selecting the most suitable treatment option based on best available evidence and informed patient preferences.63,116,117,118,119

C Strong

Enhanced recovery programmes for patients undergoing primary arthroplasty surgery should provide comprehensive details of the patient journey including MDT led hip and knee school and expectations in terms of postoperative physiotherapy and early mobilisation where necessary. Information provided should be comprehensive and should include details of regional anaesthesia

GPP Strong

When it is considered appropriate for a do not to attempt cardiopulmonary resuscitation in the event of a cardiopulmonary arrest (DNACPR) order, this should be discussed with capacitous patients, including those who have expressed their own wish not to be resuscitated.120 In patients not without capacity to consent, every attempt should be made to discuss this with next of kin and/or patient advocates holding power of attorney (or an independent mental capacity advocate), according to local trust guidelines.

C Strong


To give valid informed consent, patients need to understand the nature and purpose of the procedure. Detailed recommendations for consent are described in GPAS Chapter 2: Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients.


Informed consent may not be possible for many patients undergoing hip fracture and major trauma surgery because of delirium, dementia, altered conscious level, severe pain or the effects of sedative drugs. Patients should not be asked to sign a consent form if they do not have capacity to do so. Standard operating procedures must be compliant with the Mental Capacity Act 2005. A high level of integrity should be maintained, and good documentation is essential.121,122,123

M Strong

All decisions concerning the consent process and treatment plans, including decisions about whether or not to operate, should be documented clearly, noting the risks, benefits and alternatives that were explained to the patient.86,89

C Strong

10. Financial considerations

Part of the methodology used in this chapter in making recommendations that considers the financial impact for each of the recommendations. Very few of the literature sources from which these recommendations have been drawn have included financial analysis.

The vast majority of the recommendations are not new recommendations, but they are a synthesis of already existing recommendations. The current compliance rates with many of the recommendations are unknown, and so it is not possible to calculate the financial impact of the recommendations in this chapter. It is impossible to make an overall assessment of the financial impact of these recommendations with the currently available information.

11. Implementation support

The Anaesthesia Clinical Services Accreditation (ACSA) scheme, run by the RCoA, provides a set of standards based on the recommendations contained in the GPAS chapters. As part of the scheme, departments of anaesthesia  self-assess against the standards and undertake quality improvement projects to close the gap. Support is provided by the RCoA in the form of the good practice library, which shares documents and ideas from other departments on how to meet the standards. Further advice can be obtained from the ACSA team and department’s assigned College guide.

The ACSA standards are regularly reviewed on at least a three yearly basis to ensure that they reflect current GPAS recommendations and good practice. This feedback process works both ways and the ACSA scheme regularly provides CDGs with comments on the GPAS recommendations, based on departments’ experience of implementing the recommendations.

Further information about the ACSA scheme can be found here:

Areas for future development

Following the systematic review of the evidence, the following areas of research are suggested:

  • advanced pain relief techniques for trauma patients before surgery
  • expanding national joint registry to include data on medical conditions
  • expanding national joint registry to include data throughout patient journey from referral to ‘years after surgery’
  • research into clinical deterioration (both medical and surgical aspects) in patients waiting for elective surgery
  • use of perioperative older persons services to enhance the perioperative assessment with a comprehensive geriatric review
  • local gap analysis against GPAS standards – widened as national survey to identify national gap
  • local audits to assess compliance with specific GPAS standards
  • local compliance with GPAS standards and outcomes
  • identification of high impact GPAS standards specific to trauma and orthopaedics
  • minimum staffing tools for safe and effective staffing in trauma and orthopaedics.


Autonomously practising anaesthetist - a consultant, or an associate specialist, specialist doctor and speciality doctor (SAS) doctor who can function autonomously to a level of defined competencies, as agreed within local clinical governance frameworks. 

Clinical lead - doctors undertaking lead roles should be autonomously practicing doctors who have competence, experience and communication skills in the specialist area equivalent to consultant colleagues. They should usually have experience in teaching and education relevant to the role and they should participate in quality Improvement and continuing professional development activities. Individuals should be fully supported by their clinical director and should be provided with adequate time and resources to allow them to undertake the lead role effectively.

Prehospital care - auditing long term outcomes on fractured neck of femur and revision of major joint surgeries using a validated objective tool.


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