Section 2. The System

Major Trauma Services in Victoria,
Consideration of Number and Location

The Major Trauma Services (MTS) play a critical role in the trauma system, and decisions on the number and location of MTS was seen by the Taskforce to be a central consideration in design of the Victorian State Trauma System. Victoria currently has one functioning major trauma referral hospital, The Alfred. The Taskforce considered that caution was appropriate in considering argument for expanding the number of adult MTS. In particular, a balance was required between concentrating expertise and patient volumes in a minimum of sites, and a broader range of access and implementation issues which are considered below.

Caseloads and Outcomes

The issues of critical caseload is difficult. A review of the relationship between volume and quality of health care showed that while most of the research reports a positive relationship between volume and outcome of care, the trauma evidence is more uncertain, with the validity of some of the research findings suspect because of problems in adjusting for patient-mix and other confounding factors.

The trauma literature, in general, supports the notion of an inverse relationship between patient outcomes and patient volume, that is, that outcomes (typically measured by mortality) improve as clinician experience and caseload increases.

An analysis of prospectively collected data on 8,872 patients from 1992-1996 from
24 trauma centres in Pennsylvania compared high volume and low volume level I and level II centres. Trauma centres with more than 1,000 cases/year had significantly lower mortality rates for head, neck, brain and lung injuries. (Pasquale et al., 1999).

The American College of Surgeons (ACS) initially recommended that, to maintain proficiency, trauma centres see 600-1,000 'seriously injured' patients per year, (ACS, 1986) and that trauma surgeons operate on 50 'severe and urgent' injury patients per year (ACS, 1990). ACS recommendations have been largely based on results of studies which demonstrated an inverse relationship between high procedure volumes in hospitals and decreased in-house mortality rates for a number of major surgical procedures. (Hannan et al., 1989; Phillips & Luft, 1997). Specific trauma data to support this estimate was lacking and the patient definitions unclear.

More recently, US trauma experts have proposed an annual institutional volume of 400 major trauma cases for trauma centres. There is, however, evidence to suggest that the institutional caseload threshold required to maintain skills is substantially lower than previously recommended. In the Chicago trauma system, trauma centres with the lowest mortality rates were seeing, at minimum 110 patients with serious or life-threatening injuries per year, while those with the highest mortality rates were seeing, at most, 75 such cases (Smith et al., 1990). A Canadian study concluded that small institutional volumes did not preclude high quality trauma care (Waddell et al 1990).

In the Australian context, the evaluations undertaken by the CCRTF have demonstrated fewer preventable and potentially preventable problems contributing to death of trauma patients in hospitals with larger numbers than in hospitals with smaller numbers of patients (Cooper, 1998).

The bulk of the evidence for improved outcomes from the establishment of trauma care systems, comes from the evaluation of the system as a whole. All established trauma systems have a limited number of large volume trauma centres, and so the Taskforce agreed that in the balance of evidence there was support for a limited number of high volume centres in Victoria.

After much deliberation on the available evidence, the Taskforce concluded that there was sufficient evidence for a significant volume-outcome effect in major trauma. There was inconclusive evidence, however for an unequivocal specific minimum caseload volume per institution. The Taskforce therefore, on the basis of the available evidence in the context of the Victorian health system, concluded that a minimum volume of 200 major trauma cases per MTS per year was seen as both supportable and achievable as an appropriate benchmark for optimising clinical outcomes and maintaining clinician skills.

The Taskforce also noted that:

• There was not expected to be an increase in major trauma in the medium and long term.
• The staff and capital infrastructure required to appropriately manage trauma is also required to manage other critical illness. Such capacity is only available, without a substantial injection of capital and recurrent resources, at existing tertiary hospitals.
• The requirement for a MTS to undertake high level system wide functions including education, research and quality improvement, as well as to provide "leadership" requires a high level of institutional commitment at both executive, clinical and services levels (NRTAC, 1993).
• Anecdotal evidence of 'successful' trauma system implementations involves a high degree of commitment and cooperation between the government, major hospitals, emergency and retrieval services and academic institutions. Cooperation is necessary to ensure rapid and appropriate triage, by-pass and transfer of patients. In particular, the Taskforce considered that enhancements to trauma information systems, critical care retrieval system and telemedicine were more likely to be successful if jointly promoted and implemented.
• The Taskforce also recognised that a degree of competitiveness between institutions could be healthy, particularly if directed towards the development of quality services and would be considered as a strong impetus that could lead to accelerated implementation of a more effective system.

MTS Locations

The following major Victorian tertiary hospitals; The Alfred, Austin and Repatriation Medical Centre, Monash Medical Centre, The Royal Melbourne Hospital and the proposed Knox Medical Centre, were considered by the Taskforce as to their suitability as adult MTS sites. The Taskforce was assisted by an in-depth assessment of these services by ACIL based on the criteria for MTS discussed in the section, Role Delineation and Hospital Designation. A report was commissioned as part of this assessment of options for delivering major trauma services in Victoria.

The Alfred, as the current major trauma referral hospital for Victoria, fulfilled all the requirements for a MTS. The Taskforce therefore recommended that it should be designated as one of the two adult MTS for Victoria.

Although the hospitals under consideration, with the exception of Knox Medical Centre (whose service profile was still in development), met the service and service support criteria required of a MTS to greater or lesser degrees, the RMH was found to be most appropriate to take up a MTS role.
There were several reasons for the selection of the RMH as the second adult
MTS location:

• The RMH has demonstrated a level of organisational commitment at both an executive and clinician level that is considered essential for the successful development of a MTS (ACS, 1993; NRTAC, 1993).
• The RMH already has a service and staffing profile that approximates the services required by a Major Trauma Service. The recently renovated Emergency Department provides high quality facilities for the reception of trauma patients.
• The neurosurgery service at the RMH is closely affiliated with the service at the Royal Children's Hospital (now designated as the Paediatric Major Trauma Service).
• The RMH has a large non metropolitan referral base with 12% of the RMH inpatient population from non-metropolitan areas.
• The designation of the RMH as a Major Trauma Service is consistent with the strategic direction of North Western Health in promoting the undertaking of specialised services at the hospital.
• The extensive research and educational infrastructure of the hospital, associated with it's links with the University of Melbourne, will facilitate the undertaking of the higher level of system functions required of a Major Trauma Service.
• Collaboration between the RMH/University of Melbourne and The Alfred/Monash University will create a degree of system robustness that is necessary for the success of the trauma system.

Although helicopter access to RMH at the time of review was sub-optimal, helicopter access to the site could be developed. Road access is good and RMH is the proximate major hospital to Melbourne's airports. Geographical proximity to The Alfred was not considered as a major constraint in developing RMH as the second MTS site, especially when considered in light of these factors favouring RMH as the most suitable location of the hospitals considered. The Taskforce therefore recommended that the RMH be designated as the second adult MTS for Victoria.

As the Royal Children's Hospital already functions as Victoria's major paediatric tertiary referral hospital, the Taskforce recommended that, with some enhancements, it should be confirmed as Victoria's paediatric MTS, and designated as such.