Section 2. The System

Role Delineation and Hospital Designation

Role Delineation

The development of a systems approach to trauma care entails a delineation of the varying functional roles that hospitals within each region will play, whether in metropolitan or rural areas. Delineation is required because it is neither appropriate nor feasible for every hospital receiving major trauma to be resourced to the level of a MTS. Hospitals providing appropriate trauma care to the appropriate trauma patients will not do so in isolation, but rather work together through clearly recognised linkages.

Broadly, the success of functional and communication links between the services will be manifested by the speed with which a patient arrives at the level of service most appropriate to the injuries present, and the physiological status of the patient when definitive care of injury commences (NRTAC, 1993).

The Taskforce gave particular attention to clarifying definitions regarding 'access' to specialties, in terms of staff availability and level of expertise. Although these recommendations will have resource implications in some designated hospitals, the Taskforce view was that these criteria were necessary to ensure that care of the most severely injured patients would not be compromised. Although the Metropolitan Trauma Services are likely to see the bulk of less severely injured patients in metropolitan areas, they will also stabilise some of the most severely injured in immediately life-threatening situations, currently deemed inappropriate to bypass hospitals. Staffing and equipment recommendations are made with this in mind (Appendices 4 and 5).

Hospital Designation

Over time, the proposed hospital designations (Appendix 6) may need to change if hospitals demonstrate a need to provide greater or lesser complexity of trauma care than is implicit in the recommended system structure.

Any changes in designation status will evolve in consultation with the Ministerial Emergency and Critical Care Committee (MECCC) and the relevant hospital or Network, as trauma system designation has resource implications beyond the delivery of trauma care alone. In addition, system audit trends will provide necessary support for evolution of trauma system designation.

New hospitals, such as Berwick, Knox and Sunshine, will be reviewed as to their appropriate role within the VSTS once they are operational. Such review would be undertaken by the STC in conjunction with the MECCC. A similar process could provide for enabling a hospital to opt-out of participating in the system.

Proposed designation of hospitals to various categories of trauma services (that is, the delineation of their roles) has been done with reference to the current availability of clinical services and geographical considerations. A self-reporting survey of Victorian hospitals was undertaken by the Department in 1997 evaluating current compliance to ACHS (1997) criteria for trauma services. This was one reference point for designating trauma services (Appendix 6). The following factors were other important considerations in the designation of hospitals to various levels of the trauma system.

Geographical Considerations

A number of health care facilities have been designated as Primary Injury Services (PIS). This relates either to significant resource limitations for trauma resuscitation on a 24-hour basis or their close proximity to other higher designated trauma services.

These hospitals will often be bypassed by ambulance services in major trauma cases in preference to other higher designated hospitals. Hospitals designated as PIS may still receive trauma patients who present on foot or by private car. These patients should be rapidly transferred to an appropriate trauma service.

Some hospitals that are designated as PIS may be bypassed, even when their level of service provision is high, because their catchment areas overlap those of MTS. This is most likely to occur in inner Melbourne where Major Trauma Services can be reached within 30 minutes (Appendix 7.3).

In some regional and rural areas, long distances and travelling times between sites with the ability to resuscitate patients preclude bypassing some small isolated hospitals with major trauma. These facilities would be expected to provide only initial resuscitation prior to early transfer. Support for such hospitals will include development of local, multidisciplinary, prehospital teams to pool local expertise and the timely mobilisation of regional and/or state medical retrieval services.

Resource ConsiderationsStaffing/Equipment

Consistent standards of services and service supports are necessary to ensure that hospitals meet their functional role within the trauma system. The NRTAC report (1993) provides role delineation and baseline service requirements for trauma services. The Taskforce perceived the need to develop more specificity for some of the service and service support criteria. The Taskforce identified the following focus areas in designating hospitals to levels of trauma care delivery.

• Emergency department capabilities, in particular seniority, experience and availability of medical and nursing staff providing initial resuscitation and stabilisation.
• Access to surgical and other specialties, in particular speed of access.
• Access to diagnostic services, including speed of access.
• Availability of equipment to manage major trauma in the emergency department and hospital.
• Active interest in and dedication to trauma management.

The management of specialised major trauma is discussed later in the section on triage and transfer, however, transfer guidelines take into consideration the differing service capacities and specialties of designated trauma hospitals.

Private hospitals with emergency departments are designated as PIS. This is consistent with the existing Department of Human Services Circular 4/1998, 14/4/98 regarding the role of private hospitals in the management of time-critical patients.

Major Trauma Services (Appendix 4)

The MTS will provide definitive care to most of the State's major trauma caseload, either through primary triage or secondary transfer, and will deliver leadership and support to the system as a whole. Leadership will be demonstrated by active involvement in education and performance feedback, implementation of triage policies and clinical protocols, and system monitoring and research (Figure 2.4).

In this way, the MTS will function, not as trauma 'centres', confined to the physical walls of their hospitals, but as 'services' driving an integrated system.

A hospital designated as a MTS would provide:

• A centre of excellence in trauma management.
• The central hub of an integrated system with responsibility for advising trauma services in both metropolitan and regional areas and developing the trauma system.
• Expert care to major trauma patients from resuscitation through acute and post acute phases:
• - from within its catchment area, that is within 30 minutes travelling time, or
• - referred from other trauma services in Victoria, or
• - transported or retrieved by air.
• Clinical advice on stabilisation and other interventions when liaising with
• non-MTS hospitals.
• Back-up to other MTS for patient reception as required.
• Leadership in education, research, quality improvement and performance monitoring.
• 24-hour trauma reception team, with a 24-hour consultant level trauma team leader and be integrated with equivalent level emergency department services.
• Surgical services functioning with consultant level participation in trauma reception. Surgical consultants should be available within 15 - 30 minutes maximum and 24 hour on-site registrar cover should be present.
• Support by equivalent level intensive care services (equivalent to ACHS level III) with 24-hour on-site registrar, and operating suites with 24-hour on-site staff.
• Access to neurosurgery and cardiothoracic surgery 24-hour on-site.
• Undergraduate and postgraduate teaching.
• Research in trauma care.

Metropolitan Trauma Service Structure

The Taskforce has initially designated nine MeTS, recognising that it may be appropriate to modify this over time, in consultation with the STC, MECCC and networks, and dependant on the audit of performance of the trauma system.

Figure 2.5: Metropolitan System Structure

Metropolitan Trauma Services (Appendix 4)

The MeTS provide a second level of trauma service delivery to the MTS. A MeTS would:

• Stabilise major trauma patients who cannot be transported directly to MTS within the required time limits, prior to their transfer to MTS after early communication.
• Provide definitive care to a very limited number of major trauma patients where a patient's injuries are assessed as not severe enough to warrant transfer, and the referring hospital has the capacity to provide appropriate definitive care, and the MTS is in agreement with non-transfer for that particular patient.
• Be staffed by a 24-hour trauma reception team, with access to a surgical consultant experienced in trauma management on a 24-hour basis.
• Be integrated with an equivalent level emergency service.
• Be supported by equivalent level intensive care services (equivalent to ACHS level II or greater) with 24-hour on-site registrar, and operating suites with
• 24-hour availability.
• Provide a support role to the MTS in times of high demand.
• Participate in system-wide education, quality and performance monitoring and undertake research.
• Non-clinical functions (data collection and quality management) would be steered by the proposed STC, MTS and the respective Metropolitan Health Care Network.

Primary Injury Services (Appendix 5)

Consistent with the development of an inclusive trauma system, some hospitals are delineated as a PIS. This relates either to significant resource limitations for trauma resuscitation or their close proximity to a higher designated trauma service. These hospitals are appropriate for the treatment of ambulatory patients with minor injuries and ailments. Some hospitals are designated as PIS even when their level of service provision is high. This is because their catchment areas significantly overlap those of MTS or MeTS.

Major trauma patients when transported by ambulance will bypass these services in preference for other higher designated hospitals. Hospitals designated
as a PIS may still occasionally receive major trauma patients who self-present. These patients should be rapidly transferred to an appropriate trauma service.

Regional Trauma Service Structure

Preliminary consultation with the regional CCECCS has occurred regarding the proposed regional structure of the VSTS. There was a broad consensus that the Taskforce should offer substantive plans for the regional CCECCS to comment on and implement in a regional context. Each region will need to apply the structure and principles of the VSTS with local geography, resources and population while developing a regional plan and contingencies for managing major trauma or other time-critical cases. It is clear from these consultations that the system must be applicable in rural areas and offer improved major trauma management for rural patients if it is to gain rural support and succeed at all.

In addition, there was a clear desire for a process to be formulated for more detailed ongoing consultation with regions, such as through CCECCS representation in any future advisory framework on trauma and emergency services. The Taskforce recommendations support this. All regions supported an expanded role for the regional CCECCS as appropriate and necessary and the Taskforce considered that the Government should make available additional funding support.

There was a range of opinions about the appropriateness of the concept of hospital 'designation', especially 'non-designation', in rural areas and the feasibility of regional hospital bypass plans. This largely related to long distances between facilities in many areas.

It is the Taskforce's view that regions, especially in isolated areas, should develop local networks or teams for resuscitating time-critical patients, including major trauma. These teams would pool the resources and provide clear roles for local, skilled individuals of varying disciplines in both the prehospital setting and in isolated hospitals with limited resources.

Figure 2.6: Regional System Structure

Regional Consultative Committees on Emergency and Critical Care Services

The Taskforce considers that the regional CCECCS are the most appropriate mechanism for the coordination of trauma care in regional areas. The regional CCECCS will oversee the clinical functioning of the Regional Trauma Services located at the base hospitals and work with these and other trauma services in the region in coordinating system activities, such as education, research or quality improvement.

Regional Trauma Services (Appendix 5)

A hospital designated as a Regional Trauma Service (RTS) would be located in a major regional centre and would provide a regional focus for the management of trauma patients. While the responsibility for regional system development largely sits with the regional CCECCS, the RTS would have a role in receiving appropriate trauma referrals from the surrounding catchment areas. The non-clinical and higher

level functions of the RTS would be steered by the respective regional CCECCS working in collaboration with the MTS.

RTS would:

• Provide resuscitation and stabilisation of major trauma patients prior to their transfer to a MTS, after early communication with the MTS.
• Provide definitive care for a very limited number of major trauma patients where a patient's injuries are assessed as not severe enough to warrant transfer, and the referring hospital has the capacity to provide appropriate definitive care, and the MTS is in agreement with non-transfer for that particular patient.
• Provide definitive care for non-major trauma patients according to availability of local expertise.
• Provide a regional retrieval service where appropriate.
• Be integrated with an emergency service.
• Be supported by an equivalent level intensive care service and operating suites on a 24-hour basis.
• Undertake undergraduate and postgraduate education, research, quality monitoring and performance activities.

Urgent Care Services (Appendix 5)

Urgent Care Services (UCS) will operate in small rural communities where higher levels of trauma care are not accessible.

UCS would:

• Provide an initial resuscitation and a limited stabilisation capacity prior to early transfer of major trauma patients who are outside the catchment area of RTS.
• Provide definitive care to non-major trauma patients according to patient need and available local resources.
• Participate, through its formal links with the RTS/MTS, in some aspects of undergraduate education, research, quality improvement and performance monitoring activities.

Primary Injury Services (Appendix 5)

In regional areas, these include some isolated hospitals that will need to provide limited emergency care on occasions. A number of other PIS would be designated for bypass of all major trauma cases. Whether PIS in each region will stabilise major trauma cases will be decided by the regional CCECCS.

See discussion of Primary Injury Services on page 55.

Cross-Border Clinical Management

The management of trauma patients across state boundaries requires further consideration. In areas close to the Victorian border, the Taskforce considered that it may be more appropriate to transfer a patient interstate rather than to a Victorian hospital. Likewise, it might be more appropriate for patients in some interstate regions to be treated by Victorian hospitals. For example, Albury Hospital provides a retrieval service that covers some of north-east Victoria, patients from Mildura are often transferred to Adelaide for ongoing care, and Echuca treats patients from southern NSW.

Regional CCECCS should develop defined strategies for major trauma referral and transport in border regions in consultation with relevant interstate bodies.