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An appropriately skilled and experienced resident anaesthetist should be available at all times to care for postoperative and emergency patients. The experience and skills necessary to provide this cover are not usually found in training grades below ST3.⁵

Out of hours, consultants should be immediately available by telephone for advice and be able to attend the hospital within 30 minutes. Suitably skilled and experienced theatre staff should also be available.

If the consultant on call is not a neuroanaesthetist, there should be a clearly defined and understood process for the provision of specialist advice from neuroanaesthesia colleagues. Where possible, local arrangements should be considered to facilitate this telephone advice in non-neuroscience centres when required.

Departments that participate in national initiatives, e.g. services for thrombectomy, should review their staffing arrangements to ensure timely emergency cover.^12,13 Thrombectomy should have a protocolised service, ideally staffed by neuroanaesthetists.¹⁴

Educational opportunities for trainees in MTC and TU will undoubtedly occur out of hours due to the nature of trauma. Hospitals in which trainee anaesthetists 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.

Hospitals should consider training of 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. ^{61, 62}

Elective orthopaedic operating lists should be separated from those for trauma orthopaedic surgery, to allow efficient planning, prevent cancellation and enable a flexible response for emergencies.

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.

Hospitals should consider providing specific regional anaesthesia lists, using dedicated areas for performing peripheral nerve blocks. Cohorting cases in this way optimises theatre efficiency, reduces block failure⁷² and creates the environment for developing expertise.

There should be a preoperative assessment clinic for elective orthopaedic surgery. Evidence supports multidisciplinary preassessment and optimisation improves perioperative outcome for joint revision⁷³ and scoliosis surgery.