Section 2. The System

Structure

Introduction

Current practice in Victoria is for major trauma to be triaged to the closest public hospital emergency department and, therefore, most Victorian public hospitals receive some major trauma patients for definitive management (VIMD, 1998) (Figures 2.1 and 2.2).

Trauma systems internationally have adopted different models for system structure. NRTAC (1993) developed a generic five-level model for Australian trauma systems which the Taskforce used as the basis for creating the most appropriate model for Victoria, in view of population and trauma demographics.

This section describes the trauma system model recommended by the Taskforce, its operating principles and the rationale for adopting this model.

Target Population

Major trauma constitutes the most severely injured subgroup of trauma patients. The definition of major trauma is discussed in detail in Setting the Scene, Chapter 1.

Major trauma patients comprise a small proportion of emergency cases. Trauma constitutes up to 50 per cent of emergency admissions but only 0.5 per cent of these are major trauma. It is estimated that there are currently between 1,000 - 1,200 major trauma cases each year in Victoria and, although the incidence is relatively low, major trauma is associated with high mortality and morbidity.

Major trauma patients are time-critical in that their morbidity and mortality increases with the time delay to reaching definitive treatment for injuries and their sequelae. These patients also have a high incidence of potentially preventable problems (McDermott et al. 1996, Danne et al. 1998). Both these studies found that in 30-40 percent of trauma deaths, there were potentially preventable outcomes.

All trauma patients require efficient, effective treatment; however, the primary purpose of any trauma system is to facilitate coordinated efforts in providing optimal care for severely injured patients. The proposed system is, therefore, targeted at this population that will benefit most from improvements in the organisation of treatment for both clinical and cost-effectiveness reasons
(see Figure 2.3).

Figure 2.1: Metropolitan Melbourne Trauma Separations (ICU Admissions and Deaths),
1997 - 1998 (n=1,218)

Includes public separations identified from the VIMD with discharge ICD9 CM codes 800-959.9 and either an admission to ICU or death.
Excluding: 840-848, 905-925, 930-939, 958-959, and patients 65 years of age or older whose sole trauma code is an isolated hip fracture (820-820.9)
* NB. Western Hospital includes data from Footscray and Sunshine campus'.

Figure 2.2: Rural Trauma Separations (ICU Admissions and Deaths) Victoria 1997 - 1998 (n=386)

Includes public separations identified from the VIMD with discharge ICD9 CM codes 800-959.9 and either an admission to ICU or death.
Excluding: 840-848, 905-925, 930-939, 958-959, and patients 65 years of age or older whose sole trauma code is an isolated hip fracture (820-820.9)
* NB. 30 hospitals are included in the 'other' category. None of these has more than 10 separations.
Separations at Albury Base Hospital include those with Victorian postcodes only.

Figure 2.3 Target Population

Victorian State Trauma System Structure

The Victorian State Trauma System (VSTS) endorsed by the Taskforce involves designating a limited number of hospitals to receive major trauma. These trauma services will fit within a tiered structure. Different complexities of trauma care will be provided at each level of the system (Figure 2.4 Integrated Trauma System).

The Taskforce recommends that there be MTS at The Alfred, Royal Melbourne Hospital (RMH) and Royal Children's Hospital (RCH) which will form the central hub of the integrated system. Available evidence, including international outcome studies, published guidelines and demand projections, while not unequivocal, assisted the Taskforce in the decision that a second adult MTS was both sustainable and would address the current significant system-wide deficiencies in relation to higher level system functions. The VSTS is lead by the MTS.

The metropolitan component of the system comprises (Figure 2.5):

• The MTStwo adult and one paediatric.
• A second level of trauma receiving hospitals called Metropolitan Trauma Services (MeTS). They will receive major trauma unable, for safety or logistic reasons, to be triaged directly to the MTS. They will undertake early transfer of such cases to the MTS and provide definitive treatment to a very limited number of major trauma cases under defined conditions (p.70).
• A number of hospitals designated not to receive major trauma called Primary Injury Services (PIS). Their role is to primarily provide treatment for minor injuries and ailments.

The regional component of the trauma system is also led by the MTSs, however, coordination of trauma system activities at a regional level will be undertaken by the regional CCECCS. The regional component of the system then comprises
(Figure 2.6):

• Regional Trauma Services (RTS) - Regional Trauma Services would be located in major regional centres and would provide a regional focus in trauma management receiving appropriate trauma referral from the surrounding catchment areas (See p.58)
• Urgent Care Services (UCS) - Urgent Care Services would operate in small rural communities where higher levels of trauma care are not accessible and they would provide initial resuscitation and limited stabilisation prior to early transfer.
• Primary Injury Services (PIS) - In regional areas, these include hospitals providing limited stabilisation only, as well as a number of hospitals designated for bypass of all major trauma cases.

Figure 2.4 Integrated Trauma System

The Taskforce considered that the use of descriptors to separate other hospitals treating specialised subgroups of major trauma, such as burns or paediatrics, would unnecessarily complicate the system model.

Key Characteristics and Operating Principles

The Taskforce considered features of international trauma systems associated with improved mortality in severely injured patients (West et al., 1985; Shackford et al., 1987; Smith et al., 1990; Champion et al., 1992; Mullins et al., 1994; Davis et al., 1992).
Interpretation of the available studies highlighted the difficulties entailed in evaluating systems, particularly emergency systems, involving multiple interventions and care providers. In addition, extrapolating results across heterogeneous systems is problematic.



The Taskforce was assisted in its deliberations by guidelines and recommendations developed by key bodies associated with trauma care and its providers. In the US, the ACS (1993) and American College of Emergency Physicians (ACEP, 1993) released guidelines for trauma systems. In Australia, NRTAC (1993) and Australasian College for Emergency Medicine developed guidelines for Australian trauma systems and, in Victoria, the CCRTF (1997) and the Consultative Council on Emergency and Critical Care Services (CCECCS) produced specific recommendations for local conditions. The Taskforce endorses the following key characteristics and operating principles based on these guidelines and recommendations and the latest available evidence.

Although the level of available empirical evidence for specific system design features is not strong enough to be unequivocal, the Taskforce considered that there were sufficient common characteristics and operating principles underpinning the optimal management of patients within trauma systems to develop an enhanced system for Victoria.

• Providers of trauma care be integrated into a coordinated statewide trauma care system with comprehensive and inclusive representation from metropolitan and rural providers.
• Hospitals be designated to levels within a tiered trauma system structure providing different complexities of care.
• Trauma patients be treated by a service that is appropriate to the level of care needed.

• Optimal clinical outcomes for major trauma patients are associated with:
• Minimisation of time to definitive treatment.
• Triage to a specialist trauma hospital that is best able to provide definitive care, rather than to the nearest hospital, within logistic and safety parameters.
• Concentration of expertise.