Executive Summary

Background

Support has grown over recent years for the development of an integrated trauma system in Victoria. There are some indications that major trauma outcomes in Victoria are better than those in North America (Cameron et al., 1995), however research over the last five years has identified a number of system-wide deficiencies adversely impacting on the outcomes for severely injured patients.

A number of studies have drawn attention to this issue. The Consultative Council on Road Traffic Fatalities identified potentially preventable outcomes contributing to death in up to 38 per cent of road traffic fatalities in Victoria (McDermott et al. 1996, McDermott et al., 1998). The Major Trauma Management Study (Danne et al., 1998) identified similar potentially preventable outcomes from all aetiologies of trauma, as well as potentially preventable complications in survivors.

Both of these studies demonstrated recurring deficiencies in trauma management and system response. Problems were identified from the initial response through to definitive treatment, in both metropolitan and rural areas. Examples of these deficiencies were:

• Inadequate availability of prehospital and emergency department advanced life support skills.
• Prolonged times at the scene of accidents.
• Inadequate reception in emergency departments by junior staff and delayed investigation and surgical consultation.
• Triage of patients to hospitals without optimal skills or resources to manage time-critical major trauma patients.

Delays in, and inadequate medical escort for, rural and metropolitan interhospital transfer of major trauma patients.

Recognising the size and complexity of the task of developing an integrated trauma system across Victoria, the Minister for Health, the Hon Robert Knowles MP, established a review of trauma and emergency services in July 1997. The purpose
of the review is to advise Government on an appropriate system-wide structure, arrangements for ongoing monitoring of the accessibility and responsiveness of emergency and trauma services, and education and training issues.

The benefits of creating an integrated trauma and emergency system were foreshadowed in the Metropolitan Health Care Services Plan, released by the Department of Human Services in 1996.

The concept of an integrated trauma system that matches the needs of injured patients to an appropriate level of treatment is formally supported by a number of colleges and organisations, including the Royal Australasian College of Surgeons, the Australasian College for Emergency Medicine, the Consultative Council on Emergency and Critical Care Services, the Australian and New Zealand College
of Anaesthetists, Metropolitan Ambulance Service, and the Neurosurgical Society
of Australasia.

Review Process

A Ministerial Taskforce and a Departmental Working Party were established to assist this review: the Ministerial Taskforce on Trauma and Emergency Services and the Working Party on Emergency and Trauma Services. In forming the membership

of these committees, every effort was made to draw on a cross-section of knowledge and expertise across all relevant organisations and constituencies. Members were appointed as individuals rather than as representatives of any particular constituencies or organisations.

The Ministerial Taskforce on Trauma and Emergency Services and the Working Party on Emergency and Trauma Services worked closely together to develop recommendations for the future restructuring of the trauma system.

Ministerial Taskforce on Trauma and Emergency Services

The Ministerial Taskforce on Trauma and Emergency Services (the Taskforce) was initially established to examine Victoria's emergency and trauma services (see Appendix 1). Although trauma services clearly operate within the wider context of emergency services, the Taskforce considered that supporting local and international evidence was strongest for review and reform of the state's trauma services. The primary focus of the Taskforce was, therefore, to advise on an appropriate trauma system structure and components for cohesive operation of a trauma system. The title was selected to reflect the trauma focus within the wider emergency services context.

The Taskforce was chaired by Mr Robert Doyle MP, Parliamentary Secretary to the Minister for Health. In assessing options for developing major trauma services for Victoria, the Department of Human Services commissioned ACIL Consulting Pty Ltd to advise on selected options and report to the Taskforce.

Working Party on Emergency and Trauma Services

A Working Party on Emergency and Trauma Services (the Working Party) had already been established by the Department prior to setting up the Taskforce. Its role was to develop and prioritise pragmatic emergency and trauma system initiatives identified by the Consultative Committee on Road Traffic Fatalities and other relevant bodies (See Appendix 2). The CCRTF in association with representatives of the learned Colleges and Specialist Societies prepared a report advising on recommendations to reduce the identified problems. The Working Party has subsequently recommended a range of strategies in accordance with a best practice model. It established a close working relationship with the Taskforce through a number of joint memberships.

Victorian State Trauma System

Target Population

Major trauma comprises a small proportion of overall emergency cases with an estimated current incidence of 1,000 - 1,200 cases annually in Victoria, if defined simply as those cases with Injury Severity Score (ISS) > 15 (Cameron et al., 1995). The Major Trauma Management Study identified an additional 30 per cent of major trauma cases using a broader definition, but with an ISS < 15 (Danne et al., 1998). This means that there may be considered to be up to 1,800 major trauma cases per year in Victoria. The principal component of major trauma is road trauma, which has been declining over time (see Appendix 3).

The incidence of major trauma may be relatively low, however this group of patients has high morbidity and mortality and, currently, a high level of preventable problems. These patients constitute the most severely injured subgroup of trauma patients and are 'time-critical', in that their morbidity and mortality increases with the time taken to reach definitive treatment.
Although all trauma patients require efficient, effective treatment, the proposed Victorian State Trauma System is targeted at major trauma patients (Figure 2.3). The Taskforce considered that this is the patient population that will benefit most from better organised and coordinated treatment.

The Taskforce considered that an appropriate definition of major trauma for defining the target population and for application in system evaluation and quality assurance involves the presence of at least one of the following:

• Death after injury.
• Admission to an Intensive Care Unit for more than 24 hours, requiring mechanical ventilation.
• Serious injury to two or more body systems (excluding integumentary).
• Injury Severity Score (ISS)> 15.

Urgent surgery for intracranial, intrathoracic, or intraabdominal injury, or for fixation of pelvic or spinal fractures.

The Taskforce recognised that such a definition requires retrospective assessment after diagnosis is complete. Clearly, full diagnosis is not always possible during resuscitation and early management. The patient's diagnostic status necessarily evolves over time with each phase of care, as diagnosis in the prehospital is largely limited to physical assessment, and because many serious occult injuries are only revealed with time as clinical features emerge or diagnostic interventions are undertaken.

Undertriage, or failing to identify major trauma cases and activate a system response, potentially results in suboptimal clinical outcomes. Criteria are therefore required which are predictive of major trauma as defined above but which are also clinically applicable prospectively during early phases of care and which recognise the evolutionary nature of the diagnostic status in major trauma patients. The Taskforce has identified such criteria, in order to give optimal inclusion of major trauma patients into the Victorian State Trauma System. These are contained in the Prehospital Major Trauma Criteria (Appendix 7.2) and the Major Trauma Interhospital Transfer Guidelines (Appendix 7.4).

Benefits of a Trauma System Approach

There is now substantial evidence that early, appropriate, definitive management in major trauma results in optimal outcomes. Trauma management systems provide a coordinated and systematic means for delivering trauma patients rapidly to definitive care. Much of this evidence is from the United States where a number of statewide regionalised trauma systems have been in operation for more than 20 years (Cameron et al., 1995).

The key features of established international trauma systems associated with improved major trauma mortality were considered by the Taskforce. The collective published research and authoritative guidelines from professional bodies, both local and international, identify key features associated with optimal clinical outcomes. Generally, these centre around strategies for delivering the right patient to the right hospital by the fastest and safest means, and include:

• Integration, coordination and inclusiveness of providers.
• Designation of hospitals to receive major trauma.
• Concentration of expertise in trauma management.

Agreed triage and transport protocols.

System Features and Optimal Outcomes

Within a trauma system, providers of trauma care are integrated and do not operate in isolation. Such integration includes prehospital and hospital providers as well as within and between trauma hospitals, particularly rural and metropolitan hospitals. Integration requires system providers to operate with the same terminology and approaches, such as standardised triage and clinical protocols, and to have a clear understanding of their role and areas of expertise within the system.

The system should have coordination mechanisms in place that allow rapid delivery of the trauma patient to 'definitive care' to reduce time from injury to definitive treatment. Coordination is, therefore, essential from time of notification of ambulance services through every phase of care.

A sustainable trauma system requires inclusive representation from rural and metropolitan providers in both system planning and maintenance. Designation of Hospitals To Receive Major Trauma

The stratification of hospitals to designated trauma care roles is important and is based on resource and geographical considerations (Appendix 6). Trauma patients are managed in a service that is appropriate for the level of care indicated by their injuries. Only a very limited number of such services are designated as Major Trauma Services, which provide a 'centre of excellence' in all aspects of trauma management. Concentration of Expertise

The literature in general supports an inverse relationship between mortality rates and caseload volume, that is mortality rates diminish as clinician experience and institutional caseload increases. Designating a limited number of hospitals to receive major trauma, especially the Major Trauma Services where a large caseload of trauma is managed, effectively concentrates trauma expertise in a few institutions. Concentrating trauma expertise in a few specialist institutions then logically requires the majority of major trauma cases to be delivered to these sites, according to agreed triage and transfer protocols, in order to maximise outcome benefits for patients and maintain clinician skills. Concentration of expertise and volume:outcome issues are discussed further in the section, Major Trauma Services in Victoria - Consideration of Number and Location. Triage and Transport Protocols

The prehospital and interhospital triage and transfer guidelines (Appendices 7 and 8) are designed to maximise the number of major trauma patients that will be treated in the Major Trauma Service. These guidelines necessarily involve bypass of non-Major Trauma Service hospitals, within defined logistic and safety constraints. Compliance with such agreed guidelines is integral to the efficacy of a trauma system.

Structure

The Victorian State Trauma System 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 Major Trauma Services at The Alfred, Royal Melbourne Hospital and Royal Children's Hospital 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 Major Trauma Service was both sustainable and would address the current system-wide deficiencies in relation to higher level system functions. The Taskforce intends that the necessary clinical infrastructure is in place at the Major Trauma Service prior to the activation of triage and transfer protocols.

The Taskforce envisages that the Victorian State Trauma System will be led by the Major Trauma Services. The Major Trauma Services will treat most of the State's major trauma caseload, either through primary triage or secondary transfer, and will deliver leadership and support to the trauma system as a whole. This 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).

The metropolitan component of the system should comprise (Figure 2.5):

• The Major Trauma Servicestwo adult and one paediatric.
• A second level of trauma receiving hospitals called Metropolitan Trauma Services. They will receive major trauma unable, for safety or logistic reasons, to be triaged directly to the Major Trauma Services. They will undertake early transfer of such cases to the Major Trauma Services and provide definitive treatment to a very limited number of major trauma cases under defined conditions.

Primary Injury Services that are appropriate for the treatment of patients with minor injuries. Ambulance services, when transporting major trauma patients, will bypass these hospitals for a higher level service.

The regional component of the trauma system is also led by the Major Trauma Services. The regional Consultative Committees on Emergency and Critical Care Services will undertake a coordinating role in regional trauma management and system activities.

The clinical components of the regional system should then comprise (Fig 2.6):

• Regional Trauma Services located in major regional centres providing regional focus for trauma management.
• Urgent Care Services in small rural communities where higher levels of trauma care are not accessible and they provide initial resuscitation and stabilisation prior to early transfer.

Primary Injury Services in regional areas include some isolated hospitals that may need to provide initial resuscitation to major trauma cases on occasion. Other Primary Injury Services in areas less isolated may be designated for bypass of all major trauma cases on the advice of the regional Consultative Committee on Emergency and Critical Care Services.

Regional Issues

In a statewide trauma system, regional and rural trauma care providers share many common needs with their metropolitan counterparts, however some issues they face are different. The Taskforce recognises that:

• Regional designation of hospitals to receive major trauma will require more detailed consideration of regional geographic, resource and demand factors.

• Triage and bypass may be difficult in regions where resources are dispersed.
• Effective and timely referral of major trauma to the Major Trauma Services will depend on a collaborative approach from the Major Trauma Services, a rapid response retrieval system and a reliable and streamlined process for referral.
• Training and skill retention are problematic when exposure to major trauma is sporadic and access to training courses limited by time, distance or money.

These issues are common to a number of other medical and surgical specialties but warrant particular attention in the context of the proposed system and are discussed in the appropriate sections throughout the report.

Infrastructure

System Organisation and Management

The successful development of the Victorian State Trauma System will depend on statewide coordination of a complex integrated service system. An organisational structure has been recommended to provide a central, system-wide, non-institutional focus; coordinate the efforts of all agencies involved in trauma care, and provide means to develop and implement strategies for improving trauma services.

System coordination and development will be assisted by a new committee structure led by an overarching Ministerial Emergency and Critical Care Committee addressing trauma system issues as well as the broader issues affecting emergency services in this State. A State Trauma Committee will act as a subcommittee to the Ministerial Emergency and Critical Care Committee and address trauma system issues exclusively and in detail. These two committees will be assisted in trauma system implementation and planning by a collaborative, cross-campus Major Trauma Service Statewide Coordination Unit with statewide responsibilities, and by enhanced integration of regional Consultative Committees on Emergency and Critical Care Services.

Triage and Transfer Protocols

The Taskforce has endorsed a service model where the application of trauma triage protocols will result in the majority of major trauma patients being managed at Major Trauma Services. Ideally, direct transport to Major Trauma Services would deliver patients from the scene of injury, requiring bypass of other hospitals within defined logistic and safety parameters. Where primary triage to Major Trauma Services will not be possible, patients will be delivered to another level trauma service for resuscitation and stabilisation. Early consultation by receiving trauma services with Major Trauma Services will occur and most patients will undergo timely and appropriate interhospital transfer from both metropolitan and regional trauma services to the Major Trauma Services.

Retrieval and Transfer

The Taskforce has considered the role of Victoria's medical retrieval system. These deliberations are from the perspective of identifying possible mechanisms for delivery of major trauma patients to definitive care in the safest and most expeditious manner. The proposed model focuses on integrating current retrieval services, achieving more timely retrieval and transfer of time-critical patients, and providing high standards of care during transport that match the patient's clinical needs. Recognition has been given to the need to consider fixed wing and rotary wing fleet upgrades.
Specifically, the Taskforce recommends medical staffing and system activation models, data integration between current services, educational strategies regarding the role of retrieval services and an aircraft capacity for the State. The proposed model will undergo wider consultation and development with emergency service system users and stakeholders.

Quality Management

The Taskforce considers that all phases of trauma management require process and outcome evaluation. A quality management structure will incorporate prehospital and hospital components. Opportunities for combined quality improvement processes across facets of the system will also be developed.

Establishment and expansion of specific trauma datasets are endorsed. Data collected will be incorporated in a quality improvement process involving development of quality indicators, processes for monitoring function, peer review, improvement activities and reevaluation. Audit and other quality improvement activities will be undertaken or overseen by the State Trauma Committee and Ministerial Emergency and Critical Care Committee.

Education and Training

The Taskforce considers that efficient and effective trauma management will be dependent on the provision of education and training programs that meet the needs of staff from diverse disciplines. A number of courses in trauma management are already available and the Taskforce considers that these should be integrated wherever possible.

Rural practitioners have particular educational needs. For some rural or regional clinicians, these relate to infrequent exposure to major trauma patients, geographical isolation from high level services and clinical advice, and barriers in accessing continuing and advanced training courses.

The Taskforce recommends strategies to establish a framework for meeting the requirements of trauma care practitioners. The State Trauma Committee, the Major Trauma Service Statewide Coordination Unit and Directors of Trauma Services will be responsible for implementing this framework.

Research, Service and Technology Developments

A number of potentially beneficial developments in diagnostics, treatment modalities and information technology applicable to trauma care have been identified by the Taskforce, though many technologies still require clear evidence for their effectiveness.

Clinical outcomes in major trauma patients will be rigorously evaluated through well-constructed clinical trials. The State Trauma Committee will set priorities for trauma research relevant to, and requiring participation of, all levels and facets of the trauma system.

Funding

Purchasing approaches will incorporate incentives to promote quality outcomes and system efficiency, in line with the Taskforce recommendations. In particular, purchasing approaches will support the agreed triage and transfer protocols delivering the majority of major trauma patients to Major Trauma Services.
The Taskforce recommends developing purchasing options for policy in consultation with other key providers and stakeholders at implementation stage.

The Taskforce notes that the proposed Victorian State Trauma System has some significant resource requirements. These are justifiable when viewed in the context of the high human and financial costs currently associated with potentially preventable outcomes in major trauma patients.

Conclusion

Trauma care and systems have had, and will continue to have, considerable fluidity and scope for debate. The Taskforce recommends system restructuring aimed at integrating trauma care and further improving patient outcomes.

This report sets out the framework for developing the Victorian State Trauma System. It discusses the system and the rationale behind recommended improvements, and identifies priority strategies for implementation.