Trauma Care Systems


Author(s)

Journal

Title

Conclusion

Jurkovich and Mock [3]

J Trauma, 1999

Systematic review of trauma system effectiveness based on registry comparisons

Eight of 11 articles reviewed (period 1987–1997) provided comparable data and consistently demonstrated a 15–20 % reduction in the risk of death comparing trauma system outcomes with major trauma outcome study norms

Sampalis et al. [4]

J Trauma, 1999

Trauma care regionalization: a process-outcome evaluation

This study produced empirical evidence that the integration of trauma care services into a regionalized system reduced mortality

Nast-Kolb et al. [5]

Unfallchirurg, 1999

Quality management in the early clinical treatment of severely injured patients

Since the 1970s, the mortality of severely injured patients could be reduced by approximately 20 % by optimizing the pre-clinical and clinical treatment of severely injured patients

In the United States, the preventable death rate of severely injured patients was reduced to 1–2 % through the implementation of regionalized trauma systems

Celso et al. [6]

J Trauma, 2006

A systematic review and ­meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems

The results of the meta-analysis showed a 15 % reduction in mortality in favor of the presence of a trauma system

Papa et al. [7]

J Trauma, 2006

Assessing effectiveness of a mature trauma system: Association of trauma center presence with lower injury mortality rate

Trauma center counties had significantly lower motor vehicle crash (MVC) death rates than non-trauma center counties. This association was independent of age, alcohol use, speed, rural/urban location, and pre-hospital resources

Lansink and Leenen [8]

Curr Opin Crit Care, 2007

Do designated trauma systems improve outcome?

Designated trauma centers and trauma systems do improve outcome. Inclusive trauma systems outperform exclusive trauma systems in terms of survival of the severely injured

Cameron et al. [9]

Med J Aust, 2008

A statewide system of trauma care in Victoria: effect on patient survival

Introduction of a statewide trauma system was associated with a significant reduction in risk-adjusted mortality. Such inclusive systems of trauma care should be regarded as a minimum standard for health jurisdictions

Haut et al. [10]

Arch Surg, 2009

Surgeon- and system-based influences on trauma mortality

These data support the belief that in a structured trauma program, surgeons with vastly different levels of training can safely provide care and obtain equivalent outcomes

MacKenzie et al. [11]

J Trauma, 2010

The value of trauma center care

Our findings provide evidence that regionalization of trauma care is not only effective but also ­cost-effective

Twijnstra et al. [12]

Ann Surg, 2010

Regional trauma system reduces mortality and changes admission rates

Implementation of an inclusive trauma system in the Netherlands results in more efficient triage of trauma patients among hospitals and is associated with a substantial and statistically significant risk reduction (16 %) of death

Meisler et al. [13]

Acta Anaesthesiol Scand, 2010

Triage and Mortality in 2,875 consecutive trauma patients

Increased survival of severely injured patients can be achieved through early transfer to highly specialized care

Gabbe et al. [14]

Ann Surg, 2011

The effect of an organized trauma system on mortality in major trauma involving serious head injury: a comparison of the United Kingdom and Victoria, Australia

Management of the severely injured patient with an associated head injury in England and Wales, where an organized trauma system is absent, was associated with increased risk-adjusted mortality compared with management of these patients in the inclusive trauma system of Victoria, Australia



More than 50 % of the reduction of mortality is a result of reduction in prehospital time, trauma center designation, better prehospital triage of patients, and shortened time to definitive treatment within the structured organization of a regional trauma care system [4]. Furthermore, within a trauma care system, the mortality of severely injured patients decreases inversely to the level of trauma care provided by facilities where the patient is treated [4].

At the same time, mortality is predicted more accurately by the severity of the injury (age, injury severity score [ISS]  >  15, hypotension, severe head injury, and penetrating injury mechanism) than by the surgeon’s experience or annual surgeon case volume [10]. It is, therefore, important to realize that it takes time to optimize the care provided in all aspects of a trauma care system and to make the system more effective [17]. However, the ultimate goal of each trauma care system should be the improvement of overall functional outcome of severely injured patients [18]. This effect of trauma systems on functional outcome and quality of life is not evidence based and should be subject to further studies [1].

Because from an economic point of view it is not lucrative to provide trauma care for severely injured patients at a high level, over the past decade it was difficult for many trauma systems throughout the world to maintain their standards of care. This problem will become greater in the future because of the growing aging population. The rising costs of regular health care as a result of age-related diseases are also seen in the trauma care system because the elderly (>  65 years old) are at higher risk for injuries requiring expensive care and prolonged hospitalization.



1.1.3 Definitions


A trauma system combines the cooperation of pre-hospital, hospital, and rehabilitation facilities within a defined geographic area integrated with a regional public health system. The goal of the system is to provide the best possible care to traumatically injured patients, according to the severity of their injuries, in the fastest possible way. Such care will be provided by designated trauma centers with different levels of care.

There are two different types of trauma systems. The most common trauma systems are ranged around hospitals with the highest possible level of care (the so-called level I trauma centers). Mainly, these “exclusive” trauma systems prioritize the care of the most severely injured patients needing immediate treatment [8, 12].

The other type of trauma system is the “inclusive” trauma system that aims to provide adjusted care to all injured patients within a certain area, and therefore this system incorporates all acute care facilities at all levels, within that area [8].

The principle target of an inclusive trauma system is to provide the right level of care, conform to the specific requirements of a patient’s injuries, avoid over-referral of patients with minor injuries to level I trauma centers, and thereby making efficient use of available health care resources [12].

There are studies that state that the more inclusive a trauma system is, the better the effectiveness of the system, but there is no clear evidence that one system is superior to the other [2].



1.2 Trauma Care Systems in Different Parts of the World


The main goal of trauma care systems is to optimize the care given to trauma patients in a particular region. By facilitating all phases of trauma care (from patient transport to patient rehabilitation), it provides better adjusted treatment that will benefit patients the most in terms of outcome.

To achieve this goal, it is necessary for all facilitators (political and medical) and trauma care providers to cooperate within the system. The development of a good trauma care system is a difficult process that depends on many factors and many different authorities. The important factors are health care insurance systems, organization of (pre-) hospital care, injury type, and the geographic and demographic situation. Throughout the world, these factors are subject to regional differences and are coordinated by different authorities [19]. Trauma care is more developed in the ‘Western’ countries and therefore the differences in trauma care organization between developed and developing countries are many, but even in countries where trauma care is good, there is still great regional variation in trauma care organization.

A good example of these international differences can be found in the European Union (EU), which includes 27 countries. There are no standard criteria within the EU for how trauma care should be ­organized. Consequently, in practically every country, there is a different approach to the organization of (pre-)hospital care, trauma teams, and rehabilitation. The ­training standards for trauma surgeons are also different in these countries. In some countries, trauma surgery is a separate department (e.g., in Austria) but in other countries is integrated with other ­specialties such as orthopedic surgery (e.g., Belgium, Switzerland) and general surgery (e.g., Italy, The Netherlands). Another variant is that trauma care is covered by different specialties, each with its own area of responsibility (e.g., France, Germany, Portugal, Scandinavia, The United Kingdom) [20, 21]. Overall, in Europe, trauma care appears to be more developed in the central European countries than in the United Kingdom and the Scandinavian and Mediterranean countries [21].

In this chapter we will not focus on a single trauma care system because there is no consensus on which trauma care system is the best and it is probably more important that trauma care has been organized in a certain region rather than how it is organized. In this chapter we provide an overview and comparison of trauma care systems in countries throughout the world where the health care services are of a high standard.


1.2.1 USA


The biggest efforts to initiate standards for trauma care systems in the world were made in the 1970s in the United States of America. At first, the emphasis of trauma care was on high-level trauma centers within exclusive trauma care systems, since the 1990s American trauma systems have become more inclusive as a result of “The Model Trauma Care System Plan” released in 1992 by the Health Resources Services Administration [18].

The trauma care facilities within a trauma care system in the United States are classified and designated, by the American College of Surgery (ACS), Committee on Trauma into different levels of care (levels I–V) according to the updated criteria for trauma center verification listed in the Resources for Optimal Care of the Injured Patient: 2006. In some states, the process of evaluating trauma care facilities is performed by the state government or local emergency medical services, and in those cases, verification by the ACS is not necessary. Furthermore, some states still provide trauma care through a limited number of designated level I and level II trauma centers, whereas other states have classified every acute trauma hospital according to the levels of care they can provide.

In 2010, a total of over 1,600 trauma centers in 40 states were classified and certified. They included 203 level I, 271 level II, 393 level III, 765 level IV or V, and 43 pediatric trauma centers.


1.2.2 Canada [4, 22]


The trauma care in Canada is organized around the 17 medical universities across the country, and the designation of trauma centers is organized by every province. There is currently no nationwide designation and verification process.

The geographical situation of Canada resembles that of the United States, with major metropolitan areas sometimes having more than one trauma center, and large rural areas with no (pre-)hospital trauma care at all. The central areas and the districts in the Rocky Mountains particularly have problems with pre-­hospital transportation times.

Since 1999, several trauma managers and coordinators in Canada have been organizing meetings and programs to improve the trauma care organization in Canada. In 2008 they founded the Interdisciplinary Trauma Network of Canada.

The designation of trauma care facilities by the Trauma Association of Canada (TAC) started in 2005 and their guidelines were last updated in June 2011. Since 2005, 25 trauma centers have been accredited, of which 13 are level I, one is level II, five are level III, and four are level IV or V. Only four of the 10 provinces took part in the designation process and of the 13 level I centers, nine are situated in the province of Ontario, illustrating the geographical problems mentioned above. The trauma centers are all funded by the provinces and are responsible for leading the trauma care in their regions and act as referral facilities.

Even with the widespread education of ATLS®, the high quality of in-hospital trauma care, and the efforts of the TAC, there is still no countrywide trauma care system in place.


1.2.3 Australia [23]


The Australian mainland consists of five states and three territories, with two of the territories being very small (i.e., Australian Capital Territory and Jervis Bay Territory). The mainland has a nationwide trauma care system as all states have a trauma care system with designated trauma centers. The Northern Territory has only one major trauma center, located in Darwin; the Australian Capital Territory has one major trauma center located in Canberra, but only covers ca. 2,350 km2 of the mainland and is fully enclosed within the state of New South Wales. The Jervis Bay Territory covers only 73 km2 of land and has therefore no trauma care system.

The implementation of trauma care systems in Australia began in the early 1990s in New South Wales and is currently still developing. One of the biggest problems for trauma care systems in Australia is (as in Canada) the particular geography and demography of the nation. It is the sixth largest country in the world with just a little less surface area than the USA, but has only just over 21 million residents, who are concentrated in the urban and metropolitan areas in the coastal regions. In consequence, the ‘outback’ of Australia is large and not provided with health care. This causes a high mortality rate among traumatically injured patients, although the unique organization of the Royal Flying Doctor Service of Australia (RFDS) can reach every resident in the ‘outback’ within a 2 h flight, which puts the “golden hour” of trauma care in another perspective.

The trauma care systems in Australia are initiated and developed by individual states and the acute care facilities are designated by either the regional health service or the state Department of Health. Currently there are ca. 16 level I trauma centers for adult care and ca. seven level I trauma centers for pediatric care assigned throughout the five states and two territories. The Royal Darwin Hospital has also been designated as the National Critical Care and Trauma Response Centre because of the fact that it is the first Australian hospital accessible from South East Asia in the event of a mass casualty or disasterous event. This seems to be in keeping with the concept of many trauma care systems to designate one reference center per one million inhabitants, but when we look at the geographical location of these so-called major trauma services, we find the centers are concentrated in only one city or metropolis in almost every state or territory. Therefore, the organization of trauma care in rural areas is very important. There are six levels of acute trauma care in Australia, divided over two types of trauma networks (i.e., the metropolitan and the rural). In the metropolitan trauma network, the following levels of care are designated: Major Trauma Service (level I), which provides the full spectrum of care and function as a tertiary referral center; Metropolitan Trauma Service (level II), which provides initial assessment and stabilization, and when warranted, initiates transfer to a Major Trauma Service; and Urban Trauma Service (level III), which provides care to patients with minor-to-moderate injuries at local communities in urban areas. The rural trauma network is established on three other levels of care: the Regional Trauma Services provide definitive care of non-major trauma according to the availability of local expertise; the Rural Trauma Services, which have 24 h availability of an on-duty medical practitioner; and the Remote Trauma Services, serving people in remote areas from small hospitals with no immediately available general practitioners.


1.2.4 Germany [24]


The statewide trauma system in Germany is one of the best organized trauma systems in Europe and includes all aspects of trauma care: prevention, (pre-)hospital care system, trauma center designation, rehabilitation units, and a quality control system. According to the current information of the German Society for Trauma Surgery (DGU), there are over 850 acute care facilities registered, forming 57 regionalized trauma networks, of which 17 are already officially certified. Although the overall improvement of trauma patients after the establishment of the trauma system in 1970 is remarkable, the trauma register shows great differences between different trauma care systems throughout Germany due to geographic, demographic, and organizational infrastructure differences. This is why in 2004, the DGU laid the foundation for an improved structure of the statewide trauma systems, the TraumaNetworkD. The main aims were to increase the quality of trauma care, improve cooperation among acute care facilities, and shorten the pre-hospital time to less than 30 min. This was enforced in 2006 by the ‘White Paper on Trauma care’, in which recommendations and strict guidelines for all aspects of acute trauma care are listed.


1.2.5 United Kingdom [21]


After the establishment of the Birmingham Accident Hospital as the first trauma center, which functioned from 1941 until the 1990s, the first pilot trauma care system was launched at the North Staffordshire Hospital in Stoke-on-Trent. This study was initiated by the Royal College of Surgeons in England, and showed bad outcomes in major trauma care in acute care hospitals [25]. The results of the study were not convincing [26], although it showed a decreasing trend in mortality, and in consequence there was much criticism. The development of trauma care was postponed until after the Military Medical Services returned from their missions in Afghanistan and Iraq with proof of excellent results of the trauma care they provided to severely injured soldiers [27]. This led to the establishment of the London trauma system in 2010. This system encompasses four inclusive trauma care systems with approximately four level I trauma centers and facilities with a lower care level. Initiatives to develop a trauma care system at the Birmingham Accident Hospital have also been taken.


1.2.6 The Netherlands [28]


Since the first impetus given by the Dutch Trauma Society in the early 1990s, The Netherlands have developed an excellent, functioning, nationwide, inclusive trauma care system. In 1997, the Ministry of Health, Welfare and Sport established 11 level I trauma centers that are the reference centers in 10 inclusive trauma care systems that cover The Netherlands. The reference centers play a key role in the development of guidelines for trauma care and quality control within each region. Every reference center has a specialized Medical Mobile Team that provides pre-hospital care for polytraumatized patients in addition to the normal paramedic-based ambulance system.

Although this has resulted in enhanced quality of care in all aspects, from pre-hospital care to improvement of facility coordination to the foundation of a national trauma registration, the system also has its imperfections. The biggest concerns in The Netherlands are the shortage of intensive care beds and the organizational shortcomings of pre-­hospital care.


1.2.7 France


In France, the emphasis of the trauma care systems is on pre-hospital care, with well- organized physician-based emergency care. The designation of hospitals in France is different from that in the USA but there is also a difference in the level of care. There are three different types of emergency departments: (1) The Service dAccueil des Urgences (SAU) can provide a high level of care because they can rely on the following 24 h specialties: intensive care, internal medicine, cardiology, anesthesia/intensive care, and visceral-, gynecological-, and orthopedic surgery. These SAU departments are situated in the Hôpital de reference (level I trauma center) or Hôpital de recours (level II trauma center), and the centers are found in university hospitals (32 in France) or bigger general hospitals throughout France. (2) The Pôle Spécialisé dAccueil des Urgences can provide the same high level of care as the SAU departments but are specialized in a certain area of health care, for instance, pediatrics. (3) The Unité de Proximité dAccueil, dOrientation et de Traitement des Urgences are found in smaller district hospitals, the Hôpital de proximité (level III trauma centers) where at least one physician (24 h/day), a state-registered nurse, and technical facilities enabling standard imaging and laboratory tests are available. The facilities have limited resources but can stabilize critically ill patients before transferring them to facilities with higher levels of care. The role of the level IV and level V trauma centers is overtaken by the physician-based Service d’Aide Médicale Urgente (SAMU) Organizations.

There are no specialized hospitals in France for trauma care but the designated trauma centers each other at the regional level throughout France.


1.3 The “Ideal” Trauma Care System [29]


As a result of improving diagnostic and therapeutic options in recent times, the demands and expectations of medical trauma care are becoming increasingly higher. Although there are a few studies showing that inclusive trauma systems perform better than exclusive trauma systems in terms of outcome, the key components of the systems are the same.

To guarantee the best possible care for each trauma patient and to have the right trauma patient at the right time, at the right place, an ‘ideal’ functioning trauma care system is needed. The ‘ideal’ trauma care system includes the following components that will be discussed in the next section: (1) Prevention of trauma. (2) Pre-hospital care. (3) In-hospital care. (4) Rehabilitation facilities. (5) Internal and external quality control. (6) Education and research programs.

There is a seamless transition between each phase of care in an effective trauma care system that results in getting the right patient, at the right time, to the right place. This will eventually result in the reduction of disability, mortality, and costs and thereby an increase in productive working years. However, in every system there is always a small percentage of preventable deaths and inexplicable treatment deviations that lead to complications in the trauma population served, even in the most developed and ‘ideal’ trauma care system [5].


1.3.1 Prevention


Prevention of trauma is the first, and possibly most important, component of trauma care systems. This part of the trauma care system can intervene in the first peak of the trimodal death distribution of trauma, in which one third to one half of all traumatic deaths occur. Although the implementation of trauma care centers can make a big difference in death and disability rates from trauma injuries, trauma prevention has more opportunities for decreasing the impact of trauma on both the personnel and community level [8]. Because the trauma care systems we discuss in this chapter are systems in developed Western countries, the main issues of prevention have already been dealt with. In both Europe and North America, traffic safety is improved by safety measures such as traffic rules, road signs, safer cars, seatbelts, and motor helmets. Such prevention prevents injuries from blunt trauma, which is the main cause of death and disability in European countries.

In North America, and particularly in the United States, penetrating injuries continue to be the greatest cause of death and disability resulting from trauma. Prevention of penetrating injuries is a difficult issue to address in the American community, where the ­possession of weapons is still common. Even after ­several tragedies over the past 20 years (e.g., the mass­acres at Waco, Columbine, and Virginia Tech), it is still not really a point of discussion.

In conclusion, prevention of blunt trauma continues to evolve even though it is highly developed in all the countries discussed here. On the other hand, prevention of penetrating injuries is a difficult issue, particularly in the United States, where it is common.


1.3.2 Pre-hospital Care


The pre-hospital care plays a very important role in the second peak of the trimodal death distribution in trauma. It is being repeatedly proved that reduced pre-hospital time results in favorable outcomes for severely injured patients.

In some remote areas of countries with extended rural regions such as Australia, Canada, and the USA, there is no professional acute care system present. In some of these areas, there are groups of motivated people, sometimes organized in special occupational groups, who are trained to provide first aid in a basic or even advanced form. In some areas, some of these groups can even transport seriously injured patients to an acute care facility in special vehicles; it is the only possible alternative to a professional pre-hospital care system in such areas.

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Apr 6, 2017 | Posted by in CRITICAL CARE | Comments Off on Trauma Care Systems
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