Research, Service and Technology Developments

Introduction

In an environment of ever-increasing expensive technologies, limited health care funding and lack of available evidence about the effectiveness of many current technologies, health technology evaluation has become a major priority for the Australian health care system. Lack of support for evaluation leaves consumers exposed to unnecessary risks and continues the pattern of wastage of valuable resources.

Similarly, evaluation of clinical practices that may not necessarily involve new technology continues to provide the foundation for rational and justifiable changes to clinical practice. This chapter discusses the areas for ongoing research relevant to trauma care, the technologies likely to impact on trauma care in the future and recommendations for priorities in their introduction.

Research

Injury Prevention Research and Funding

The World Health Organisation (WHO, 1996) advises that research in injury prevention is best directed to those areas of high burden of disease and, if evidence is equivocal or lacking, a strategy of applied research and evaluation is advisable. The National Health Priorities Areas report (NHPA, 1998) indicates that there is a clear need to improve the availability of sound evidence for injury prevention interventions (AIHW, 1988).

The low levels of public research funding for injury research are currently the subject of investigation by the Strategic Research Development Committee of the NHMRC. Most research expenditure occurs in the well-organised and administratively distinct areas of road and occupational safety, and there are low levels of funding for the remaining 40 per cent of injuries causing death and disability (AIHW, 1988).

Clinical Practice

The Taskforce has proposed the introduction of an integrated trauma system for Victoria with the aim of addressing identified system and management deficiencies (McDermott, 1997; Danne, 1998). This will entail significant changes to how and where major trauma patients are managed. Clearly improved outcomes in this patient group are anticipated and need to be rigorously evaluated through well-constructed clinical trials and quality assessment measures.

The STC will set priorities and plans for such research and all levels of the trauma system will participate. The Taskforce has flagged the triage of major trauma patients in a 'life-threatening situation' as a priority research area.

Service and Technology Developments

Appropriate use of health technologies depends on providers adopting an evidence-basis for practice. An enormous amount of work is currently being conducted by bodies such as the Cochrane Collaboration to assemble evidence about all categories of clinical practice, including appropriate use of technologies. New service and technology developments introduced to support Victoria's trauma system should be evaluated through research, where feasible.

Service and Technology Developments

Health technologies are defined as 'any method used by health professionals to promote health, prevent and treat disease, and improve rehabilitation and long term care' (Standing Group on Health Technology, 1994). This definition includes drugs and devices, medical and surgical procedures, plus the organisational systems in which these technologies are provided.

Development of clinical procedures and diffusion of health technologies has usually taken place in the setting of providers' clinical autonomy, with evaluation relying on professional self-regulation. As a consequence, the potential for safety, efficacy and effectiveness of many procedures has not been evaluated (Gelijns, 1990).

There has been major support at many levels of the health care system for devising and disseminating clinical practice guidelines and coordinated care pathways related to common illnesses or symptom complexes. The uptake of evidence and guidelines by providers continues to be patchy as many fear a loss of their clinical autonomy. Ongoing efforts in this area need to be supported and new initiatives devised to improve the uptake of evidence-based practice.

Consideration of the funding implications of new health technologies involves the interplay between a number of complex issues:

• Technologies are usually additive to current practices.
• Technology establishment costs may be high, but recurrent funding is usually more significant.
• IT costs of telemedicine will be high if properly implemented.
• There are potential savings from successful preventive and screening technologies.
• Private versus public involvement in research, development and implementation of new technologies.

Treatment Modalities

The following service or technology developments have been identified by the Taskforce as relevant and potentially beneficial in trauma care:

• Development of the trauma team approach to trauma resuscitation.
• 'Point of care' recording of patient treatments.
• Electronic and bioengineered artificial aids.
• Lighter, more durable prostheses.

Diagnostics

In trauma care, technology developments that speed diagnosis of critical injuries are likely to be of greatest importance. Examples of this might include bedside and near-patient diagnostics and continued expansion of CT, MRI, SPECT imaging.

Ultrasound in Trauma and Emergency Care

Studies by European, US and Japanese facilities have demonstrated that brief, highly focused ultrasound examination can provide a valuable bedside clinical tool for rapid assessment of emergency patients and can be performed to a high standard by non-radiologists with frequent and extensive experience (Tiling, 1990).

A rational approach to imaging of emergency patients which aims to maximise efficiency of resource use and diagnostic accuracy would be to provide imaging that is timely, appropriate for the patient's clinical condition, and performed by the most highly trained staff available.

Transoesophageal Echocardiography

This specialised ultrasound technique, generally performed by cardiologists, has recently been undergoing evaluation as a modality to complement and possibly replace the gold standard of aortography for diagnosis of traumatic aortic dissection (Chan, 1998). Study results have varied widely, perhaps related to the experience of operators. In the largest study to date, a prospective study from 50 US trauma centres, the technique was found to have an unacceptably high false negative rate of 20 per cent, suggesting that at this time aortography should remain the diagnostic procedure of choice (Fabian et al., 1997).

Information Systems

Information Systems

The maturation of clinical information systems is likely to significantly impact on trauma care, as it will in most other aspects of health care delivery. The implementation of decision support systems, clinical pathways, electronic medical records, real-time data collection and physiologic monitoring data integration are likely to be of most relevance to acute trauma care delivery.

Telemedicine

While many definitions of telemedicine exist, the essence of telemedicine is the use of telecommunications technology for medical diagnosis and patient care for sites that are at a distance from the provider. The information exchanged may be a voice, an image, medical records or commands to a surgical robot. The technology encompasses everything from a standard telephone service through transmission of digitised signals in conjunction with computers, fibre optics, satellites and other sophisticated peripheral equipment and software (Currell et al., 1997; Coiera, 1995).

Telemedicine services are expanding around Australia and, through a number of State Government initiatives, have largely focused on providing communication links between tertiary level hospitals/specialists and rural locations for services including psychiatry, general practice, renal dialysis and intensive care (Yellowlees & Kennedy, 1997). A number of telemedicine pilot projects have already been undertaken in Victoria.

While there is a paucity of evidence on the efficacy of telemedicine in improving systems of trauma care, telemedicine has significant potential to impact on the delivery of trauma and emergency services by augmenting the delivery of timely, appropriate care, including appropriate patient transfer, especially for remote and rural services.

Expert advice on current and future management of trauma and emergency patients can be provided through links between tertiary level hospitals and other metropolitan or remote hospital sites for patient interview, clinical examination and transmission of data including radiology/pathology tests and ECGs. Specific teleradiology links are proving particularly useful for discussions of management of neurotrauma and orthopaedic trauma patients. Expert evaluation of patient X-rays and computed tomography images may save unnecessary patient transfer where local services are adequate. The success of teleorthopaedic links such as the Flinders Medical Centre's links to both metropolitan and remote sites has led to plans for a national orthopaedic online register for treatment of trauma patients (Yates, 1998).

As telemedicine technology improves and costs fall, it is expected that there will be increased demand for expansion of telemedicine links. Sustained support by clinicians is likely to depend on the presence of clinical leaders in telemedicine, adequate training in telemedicine interview techniques, and incentives for telemedicine use backed by funding which covers not only the technology but also staff, training, line charges and maintenance (Yellowlees & Kennedy, 1997).

The potential for widespread use of telemedicine means that further discussion and evaluation will be required on a range of issues including:

• Medico-legal issues.
• Reliability and validity of technologies.
• Effectiveness, efficiency and safety of technologies.
• Eligibility of consultations for Medicare Benefit payments.
• Patient confidentiality.
• Quality control and standards of care.
• Rights of access (Currell et al., 1997; Hailey and Jacobs, 1997).