Section 1. Setting the Scene

Trauma Management

The clinical care of trauma patients presents a challenge to treating clinicians and the organisers of health care systems. The complexity and range of injuries requires an organised approach to the process of care. This organised approach to trauma management requires preset plans and protocols to ensure rapid access to care by dedicated personnel at specialised facilities. The early delivery of severely injured patients to a hospital that can speedily provide the most appropriate care improves the chances of survival. Failure to develop an organised system of care places in jeopardy the achievement of optimal outcomes for those who are injured (NRTAC, 1993).

Preventable outcome analysis has been widely used to monitor the management process. Importantly, preventable outcome analyses have led to major changes in trauma systems and consequent reductions in potentially preventable deaths.

Trauma Management in Victoria

Valuable research undertaken in Victoria on the system of trauma care has focused on an evaluation of both the processes of care and the organisation of system components.

The Consultative Committee on Road Traffic Fatalities (CCRTF) has provided
in-depth clinical and pathological evaluation of the emergency and clinical management of road crash fatalities after the arrival of ambulance services. Established in 1992, the principal objectives of the CCRTF are the identification
of organisational and clinical inadequacies, and assessment of the potential avoidability of individual deaths.

The CCRTF has identified a range of management and system problems
(Figures 1.6 and 1.7) present in all system settings (McDermott et al., 1996, McDermott et al., 1998).

Figure 1.6: Mean Number of Problem Categories per Patient per Area of Care and Their Contribution to Death (CCRTF 1996)

Fig 1.7: Common Management/System Errors (CCRTF 1997)

Setting	Management/SystemErrors
Prehospital	No paramedic/delay in arrival of MICA Prolonged time at scene No 'scoop and run' Inadequate documentation/observations No/delayed intubation or definitive airway management Inadequate ventilatory resuscitation No/delayed/inadequate IV access and fluid resuscitation Failed intubation/IV access No/delayed chest decompression These problems largely related to decreased availability of ATLS officers, most commonly in rural areas
Emergency Department	Inappropriate reception by junior staff Delayed arrival of appropriate consultant No consultant general surgeon No/delayed neurosurgical consultation Inadequate documentation/observations No/delayed chest decompression Delayed/inadequate ventilatory resuscitation Inadequate fluid/blood resuscitation External haemorrhage control problems No/delayed CT investigation Appropriate investigations delayed/unavailable Infrequent ABG/O2 monitoring No CVP/inadequate perfusion monitoring Inadequate management of hypothermia Inappropriate drugs/dosage Delay in despatch to theatre Delay in interhospital transfer
Intensive Care Unit, Ward/High Dependency Unit	Insufficient/delayed fluids Insufficient/delayed blood transfusion Insufficient/delayed coagulation factors No JVP/CVP assessment Inadequate/inappropriate respiratory support Inadequate respiratory assessment Inadequate/inappropriate chest injury assessment Inadequate/inappropriate analgesia Delayed/inadequate chest drain Inadequate/delayed abdominal assessment Delayed/no general surgical consultation Delayed/no repeat CT brain No ICP monitoring Inadequate cerebral perfusion pressure Delayed/no neurosurgical consultation No DVT prophylaxis Fractures not fixed Delayed transfer to operating theatre Delayed transfer to ICU
Transfer	Delayed response of transport No medical escort/inappropriate escort Inappropriate form of transport Inadequate warming

Source: Adapted from Evaluation of the Emergency and Clinical Management of Road Traffic Fatalities in Victoria 1997.
Report of the Consultative Committee on Road Traffic Fatalities in Victoria, 30 September 1998

The complexity of care and range of preventable problems identified in this study, infer that all phases of care, from prehospital to emergency department to ward setting, potentially contribute to suboptimal outcomes.

The Major Trauma Management Study also undertook to provide a preventive outcome analysis of trauma patients. This study identified a range of problems in the management of trauma in Victoria (Danne et al., 1998). This study evaluated
the care of survivors as well as deaths from trauma, and studied trauma of all aetiologies, not just road trauma.

Both the CCRTF study and the Major Trauma Management Study identified potentially preventable outcomes in 30 - 40 per cent of deaths following injury. The Major Trauma Management Study identified potentially preventable outcomes in 40 per cent of survivors suffering significant complications or disability following trauma. The most recent Report of the CCRTF (1998) demonstrated no improvement in trauma system and management problems and identified continuing potentially preventable outcomes in 36 per cent of evaluated road traffic fatalities.

Where similar studies have been conducted overseas, and system changes implemented, the potentially preventable outcome rate has been reduced from similar rates to figures as low as 3 per cent (Cales et al., 1984; Shackford et al., 1986, Davis et al., 1992).

The Major Trauma Management Study identified children, the elderly, the head injured and patients being transferred between facilities as likely to benefit from improvement in the system of care. The ongoing development of an integrated system of trauma care was recommended.

Despite the recognition of these preventable problems in the current management of trauma patients in Victoria, the outcomes from trauma care are generally comparable to international norms. In comparison to similar cohorts in the US and UK, the present system for trauma management is good (Cameron, 1995). This is not to imply that the system cannot be improved, but that changes must focus on strategies to enhance the system as a whole.

Trauma System Development

Internationally, the development of modern trauma care systems has its origins in the techniques used for caring for injured soldiers on the battlefields of Korea and Vietnam. Rapid access to definitive surgical care and refinement of prehospital care techniques significantly reduced US military casualties in both wars. This experience led to the development of similar systems across the US for the treatment of persons injured in motor vehicle collisions, falls and other incidents (Hackey, 1995).

Inclusive System of Care

A trauma system consists of hospitals, ambulance personnel and other service agencies that have a pre-planned response to caring for the injured patient. The development of an inclusive system of trauma care is a recognition that all trauma patients require optimal care (Figure 1.8). An inclusive system integrates all care providers and serves to meet the needs of all injured patients regardless of severity of injury.

Figure 1.8: Scope of a Trauma Care System

The goal of a trauma system is to match a facility's resources with a patient's medical needs so that optimal and cost-effective care is achieved.

Formal trauma systems have three components: a lead public agency with legal authority to establish and enforce trauma system policy; designation of trauma hospitals to provide 24-hour medical services; and prehospital field protocols for identifying critically injured patients who require direct transfer to a designated trauma hospital. Levels of trauma hospitals can be designated within a trauma system.

System Development in the United States

In the US, there are generally two levels of trauma services in urban areas. Level I trauma centres provide comprehensive trauma services and frequently provide training, research, prevention, coordination of field providers, and leadership in implementing and evaluating the system. Level II trauma centres typically provide a full range of trauma care, but do not usually have teaching, research and leadership functions.

Formal trauma systems typically designate only a small number of hospitals as trauma centres. Hospitals without trauma centres still treat large numbers of trauma patients, since most injuries are minor in nature and require only the routine care provided in most emergency departments. Only a small proportion of trauma patients have injuries severe enough to require specialised resuscitation, diagnostic and treatment services of a trauma centre (Goldfarb, 1996).

The establishment of trauma systems in the US has progressed significantly since the initial system development and research undertaken in California in the 1970s and 1980s (West & Trunkey, 1979; West et al., 1983).

The implementation of a trauma system in Orange County, California, had a significant impact on the quality of trauma care. The proportion of deaths judged to be potentially preventable dropped significantly and was associated with significant increases in patient age and severity of injury for those patients dying of vehicular trauma (Cales, 1984).

The development of a trauma system in Oregon had a significant impact on the survival from trauma in that state. Implementation of the system resulted in an increase in the amount of severely injured patients hospitalised in Level I trauma centres and an increase in the likelihood that they will survive their injuries. The adjusted mortality rate at designated trauma centres was reduced by one-third as compared to the pre-trauma system rate (Mullins et al., 1994).

Other trauma system evaluations from San Diego present similar positive results (Shackford, 1986; Davis et al., 1992).

System Development in Australia

National Road Trauma Advisory Council

Trauma system development in Australia has included guidelines for the development of trauma systems by the National Road Trauma Advisory Council (NRTAC) Working Party on Trauma Systems. The Report of the NRTAC Working Party describes standards defining the organisational arrangements and resources required for optimal care of the injured patient from time of injury through all phases of care, in urban and rural Australia. In addition, the NRTAC Working Party developed guidelines for assessing hospital facilities, and assessment of outcome of trauma systems. Considerable work in several states preceeded this report.

New South Wales

NSW Health released a state trauma plan in 1991. This plan was established to address an identified potentially preventable death rate among trauma patients (Deane, 1988). This plan established Area Trauma Services in each of the NSW Health regions. Regional Trauma Services were established in each of the rural regions.

A system for prehospital triage and local hospital bypass was introduced in metropolitan Sydney in 1992, and a system of early notification was introduced in rural NSW in 1993 to speed and streamline delivery of major trauma patients to definitive care locations from isolated regions.

Currently there are eight adult and three paediatric MTSs in Sydney, however, not all of these trauma services provide a full range of surgical services.

South Australia

In South Australia, a review of trauma services was commissioned by the South Australia Health Commission. This reported in 1988 and concluded that the development of a trauma system for Adelaide should be based on the principle that there should be a coordinated and integrated clinical service across hospitals. This report led to the designation of two MTS in Adelaide.

Trauma Services Not Trauma Centres

Critical to the development of a trauma system is the process of designation of trauma hospitals. The designation of trauma services is simply a way of coordinating the care of trauma patients within a geographical region, with all levels of hospitals playing a role.

As demonstrated by the CCRTF and the Major Trauma Management Study, trauma care within hospitals requires the dedicated skills of staff across departments and ongoing expertise beyond the emergency reception phase. The concept of the 'trauma centre' as being the location for all trauma care fails to recognise the importance of other phases of management, specifically the prehospital and rehabilitation phases. Additionally, hospitals providing trauma services are not independent units; they have a role within the system that extends beyond clinical management. Education, research, quality management and injury prevention are important roles that must be filled by a trauma system and trauma care providers.

The concept of Major Trauma Services has been promulgated in Australia by the NRTAC Report of the Working Party on Trauma Systems (1993). MTS form the hub of regional networks and carry a major responsibility in regard to the coordination of other trauma services. These services provide total care for every aspect of injury, from prevention through to rehabilitation. They provide 24-hour availability of resources for resuscitation, initial assessment and definitive care of injuries within the expertise of all major surgical disciplines. They are a core function in an integrated trauma system.

Conclusion

There have been significant advances in the prevention of mortality and morbidity from trauma in Victoria. Ongoing reductions in trauma mortality across all age groups combined with a sophisticated prehospital and hospital system, establish Victoria at the forefront of trauma care.

Despite the overall high standards, local studies of trauma care indicate several areas for ongoing improvement in the process of trauma care. The literature and local experience strongly support the development of an integrated trauma system for Victoria. Integral to this is the establishment of an appropriate organisational structure to lead system development, designation of an appropriate number of trauma services, and establishing clear protocols for the prehospital triage and transfer of trauma patients.