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Opportunities for associate principal investigator roles should be encouraged.¹⁰⁵

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.

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

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.

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

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.

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.

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.

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

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