Recommendations

Note: The printed version of this document includes the recommendations relevent to each section at the begining of each section. The electronic version here is different. Each recommendation has links to the section of text that contain background and supporting arguments.

1.0 Trauma System Structure

The Taskforce recommends:

1.1 The key characteristics of the Victorian State Trauma System will be:

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

1.2 The Major Trauma Services function as the hub of the Victorian State Trauma System, providing definitive care to the majority of major trauma patients, either transported directly to Major Trauma Services or referred from regional and metropolitan hospitals.

1.3 Other trauma service levels refer major trauma patients to Major Trauma Services while providing resuscitation, stabilisation or definitive care in a limited number of cases, in consultation with the Major Trauma Services.

1.4 Substantial trauma designation plans for regional hospitals be formulated with the rural trauma system structure and that these be completed on the advice of regional Consultative Committees on Emergency and Critical Care Services and regional hospitals.

1.5 The metropolitan component of the Victorian State Trauma System comprise the Major Trauma Services, a number of Metropolitan Trauma Services, and Primary Injury Services.

1.6 The Alfred and the Royal Melbourne Hospital be designated as the adult Major Trauma Services.

1.7 The Royal Children's Hospital be designated as the paediatric Major Trauma Service.

1.8 The regional component of the Victorian State Trauma System comprise the Major Trauma Services, the regional Consultative Committees on Emergency and Critical Care Services, Regional Trauma Services, Urgent Care Services, and Primary Injury Services.

1.9 Primary Injury Services be hospitals not meeting the resuscitative capacity requirements of a Metropolitan Trauma Service in metropolitan areas and of an Urgent Care Service in regional areas. Primary Injury Services be designated not to receive major trauma in metropolitan and some rural areas.

1.10 Cross-border clinical management strategies be defined by the regional Consultative Committees on Emergency and Critical Care Services in consultation with appropriate interstate bodies.

1.11 Protocols be implemented to support effective functioning of Major Trauma Services, in particular appropriate triage and referral guidelines.

1.12 Infrastructure be implemented to support minimisation of time to definitive care through:

- Provision of prompt management by emergency physicians or intensivists and surgeons in Major Trauma Services and Metropolitan Trauma Services (see 'Role Delineation Guidelines', Appendices 4 and 5). - Timely availability of key consultant surgeons (see 'Role Delineation Guidelines', Appendices 4 and 5).

2.0 System Organisation and Management

The Taskforce recommends:

2.1 The following groups coordinate the Victorian State Trauma System:

- The Ministerial Emergency and Critical Care Committee - A State Trauma Committee - A Major Trauma Service Statewide Coordination Unit - Regional Consultative Committees on Emergency and Critical Care Services.

2.2 A Ministerial Emergency and Critical Care Committee be formed to advise the Minister on the coordination, audit and monitoring, ongoing development and distribution of statewide emergency medical services including, but not limited to, the Victorian State Trauma System.

2.3 The State Trauma Committee be established as the advisory arm of the organisational system providing:

- Policy development - Leadership in statewide system auditing and quality improvement - Purchasing strategies - Best practice advice in a range of areas.

2.4 Priority activities of the State Trauma Committee will be:

- Confirmation of the rural trauma system structure in consultation with regional Consultative Committees on Emergency and Critical Care Services. - Development of a model for referral call reception amongst the Major Trauma Services and subsequent referral distribution. - Advice on a program for collection of extended data items from hospitals providing trauma care, in particular non-Major Trauma Service hospitals, on either an intermittent or case-specific basis. - Establishment of an education subcommittee to initiate education strategies including, but not limited to, integration of currently available training courses and development of an appropriate model for training multidisciplinary prehospital teams in rural areas. - Audit of triage of patients in a 'life-threatening situation' to enable future modification to triage guidelines as appropriate. - Decision on the number and location of Directors of Trauma Services and their role delineation. - Overseeing the function of Major Trauma Services as 'resource centres' providing advice to providers on training and other issues.

2.5 The State Trauma Committee and the Ministerial Emergency and Critical Care Committee incorporate rural representation and liaise with regional Consultative Committees on Emergency and Critical Care Services regarding rural trauma management issues.

2.6 The Major Trauma Service Statewide Coordination Unit be the implementation arm of the organisational structure.

2.7 Regional Consultative Committees on Emergency and Critical Care Services:

- Be integrated into the Victorian State Trauma System to play an important role in rural areas in regard to system promotion, coordination and implementation in a regional context.

- Revise roles and functions as indicated by the Taskforce and the State Trauma Committee. - Be appropriately funded to meet their expanded role.

3.0 Triage

The Taskforce recommends:

3.1 Major trauma be identified in the prehospital setting according to specified physiological, anatomical and mechanistic criteria.

3.2 Triage to a Major Trauma Service where a major trauma patient is less than 30 minutes transport time from a Major Trauma Service.

3.3 (p.55) Triage to the highest designated trauma service accessible in 30 minutes where a major trauma patient is more than 30 minutes transport time from a Major Trauma Service.

3.4 Triage to a designated trauma service accessible in the least amount of time in isolated rural areas that are more than 30 minutes from any trauma service.

3.5 Where a patient is triaged initially to a non-Major Trauma Service for initial stabilisation, early liaison with the Major Trauma Service occur and consideration be given to appropriate medical retrieval or interhospital transfer to a Major Trauma Service.

3.6 Where a major trauma patient appears to be in an 'immediately life-threatening situation' during transport, the patient be diverted to the nearest designated trauma service for stabilisation, with subsequent transport to a Major Trauma Service at the earliest appropriate time.

3.7 The triage process for major trauma patients be formally audited with respect to all aspects of its functions and, specifically, with respect to the appropriateness of the prehospital time cut-off for delivery to a Major Trauma Service.

3.8 Timely and proactive transfer of neurotrauma patients to Major Trauma Services to avoid interhospital transfer under conditions of neurological deterioration.

3.9 Neurosurgical triage and transfer guidelines for major trauma still apply in rural areas, even where a neurosurgical specialist practises locally, as the management of these patients requires all the appropriate and agreed service supports of a Major Trauma Service.

3.10 Major trauma (including isolated spinal cord trauma) be triaged to the MTS in the prehospital setting, within the defined safety and logistic constraints (Appendix 7.3).

3.11 Major trauma (as defined in Appendix 7.4) including a spinal cord injury be transferred from the first assessing Emergency Department to the MTS. In the presence of spinal cord deficit, subsequent transfer to the Victorian Spinal Cord Service at Austin and Repatriation Medical Centre will occur at the earliest appropriate time, that is once the patient is medically stable.

3.12 Isolated spinal cord trauma, with a spinal cord deficit, be transferred to the Victorian Spinal Cord Service at Austin and Repatriation Medical Centre at the earliest appropriate time, generally in less than 12 hours, without necessary management at an MTS.

3.13 Spinal cord trauma with other injuries that do not meet the criteria which define Major Trauma (Appendix 7.4), be transferred to the Victorian Spinal Cord Service at Austin and Repatriation Medical Centre at the earliest appropriate time, generally in less than 12 hours.

3.14 Surgical stablisation of the spine, in the presence of spinal neurological deficit, may occur at either the Major Trauma Service or the Austin and Repatriation Medical Centre. This decision will always be made following consultation between the Major Trauma Service and Victorian Spinal Cord Service.

3.15 All spinal trauma in children will be transferred to, and managed at, the Royal Children's Hospital for acute phase care.

3.16 All trauma services receiving spinal trauma patients should consult the Victorian Spinal Cord Service early after patient reception to optimise patient outcomes.

4.0 Trauma Teams

The Taskforce recommends:

4.1 All hospitals designated to receive major trauma patients have a formal trauma team response to the initial reception and management of trauma patients.

4.2 The composition of the trauma team be sourced from clinicians throughout the hospital (such as surgery, intensive care, anaesthetics and emergency department) in order to provide optimal expertise in filling each role in the team.

5.0 Role of Director of Trauma Services

The Taskforce recommends:

5.1 All Major, Metropolitan, Regional Trauma Services and Urgent Care Services have a designated person/s to fulfil the role of Director of Trauma Services.

6.0 Communications

The Taskforce recommends:

6.1 Communication technology and processes be improved to effectively streamline information transfer between care providers, therefore aiding compression of time from injury to definitive care.

6.2 Wider application of mobile systems for prehospital to hospital communication in the immediate future.

6.3 Mobile systems be explored in relation to compatibility and potential for interface with the current Ambulance Service Victoria system, logging reliability and handheld capability.

6.4 Major Trauma Services establish a dedicated phone number for trauma referral and advice, operating with an appropriate default process to ensure immediate clinician contact.

6.5 The Major Trauma Services trauma contact number provide response by a consultant level clinician (defaulting to the duty senior 'trauma' registrar with authority to admit).

6.6 Earlier hospital notification by prehospital providers to receiving hospitals be enhanced through:

- Educational/training strategies to highlight importance of and need for early hospital notification regarding patient condition. - Emphasis on the importance of early hospital notification in the sequencing process via the Communications Centre.

6.7 Standardised, comprehensive transfer documentation capturing data for trauma providers be developed in consultation with the Victorian Ambulance Clinical Information System project and the State Trauma Committee.

7.0 Retrieval and Transfer

The Taskforce recommends the following in relation to retrieval of major trauma patients:

Medical Staffing Model

7.1.1 The proposed medical staffing model for the statewide retrieval service be:

- A centrally-based pool of staff who are trained for and frequently undertake retrievals. - Drawn from a number of hospitals on a roster basis, enabling most stakeholders to participate in the provision of the service. - Available within a notification time of five minutes enabling an immediate response for rotary wing missions when clinically required. - Consultant level medical practitioners or Senior Registrar level medical practitioners. - Sourced from a range of craft groups (for example, emergency physicians, intensivists, anaesthestists, cardiologists) enabling the most appropriate practitioner for the mission. - Located on a shift-to-shift basis with consideration of access to appropriate transport platform.

7.1.2 Provision be made for training of senior registrars in transport medicine through teaching and experience.

Regional Retrieval Services

7.2.1 Funding be enhanced to rural retrieval services to effectively operate as part of a statewide retrieval system.

7.2.2 Regional retrieval services continue to coordinate missions that require treatment at a regional hospital level but, for missions requiring tertiary level care, there be timely liaison with the statewide retrieval system.

7.2.3 Simultaneous dispatch of regional and statewide retrieval services be an option on a case-by-case basis to minimise time to definitive care and enhance support available to regional ambulance services and local hospitals.

Communication and Coordination

7.3.1 A single phone contact number activate retrieval processes.

7.3.2 The referring clinician be able to discuss patient management prior to transfer with a consultant level coordinator, for both regional and central retrieval missions.

7.3.3 The proposed retrieval activation sequence involving a single call to either a regional or central Retrieval Coordinator be trialled and audited, with an option to change to a statewide central single number if appropriate.

7.3.4 A statewide focus for the coordination and operation of medical retrieval in Victoria be provided by a Director of Retrieval Services who would assume overarching responsibility for the state wide adult retrieval service.

Data

7.4.1 A standardised retrieval dataset be developed.

7.4.2 This dataset be linked to the statewide trauma dataset.

Education and Promotion of the Role of Retrieval Services

7.5.1 Education strategies be developed emphasising:

- The role and profile of retrieval services - The need for early activation after patient reception.

7.5.2 Regional base hospitals take a leadership role with regard to the promotion and education issues of medical retrieval.

Transport Platform and Equipment

7.6.1 Access to additional rotary wing aircraft is required to ensure retrieval response capacity in time-critical cases.

7.6.2 Payload capacity and range of any additional rotary wing aircraft be appropriate for the requirements of staewide medical retrieval.

7.6.3 Review of the location and accessibility of helipads when planning new hospitals and for existing hospitals which will play a substantial role in the transfer of major trauma and other time-critical cases.

7.6.4 Air Ambulance Victoria operate pressurised fixed wing aircraft, to decrease travel time, improve patient/staff comfort and enable safer transport of neurotrauma patients.

Process

7.7.1 Wider consultation and development of the proposed model with other system users and stakeholders.

7.7.2 The Department of Human Services prepare a full proposal and costings on this retrieval service model for evaluation by the Ministerial Emergency and Critical Care Committee.

8.0 Quality Management

The Taskforce recommends:

8.1 Trauma quality management be developed and implemented at all levels throughout the Victorian State Trauma System.

8.2 All hospitals treating trauma patients collect Epidemiological Minimum Dataset items, those receiving major trauma collect the additional data items of the Trauma Minimum Dataset and Major Trauma Services collect System Performance Minimum Dataset items. The collection of extra data be implemented as required for specific projects.

8.3 Audit of process and outcomes of trauma care be established and data used in targeting education and quality improvement programs on a system-wide basis and injury prevention and health promotion campaigns.

8.4 All hospitals treating trauma patients identify a person responsible for collecting and forwarding data items for review.

8.5 The collection process be coordinated through the Major Trauma Service Statewide Coordination Unit and the statewide trauma registry maintained by the Major Trauma Service Statewide Coordination Unit.

8.6 Collection of data items be automated and use existing data sources as much as possible.

8.7 Exploration of ways to enhance the Victorian Emergency Minimum Dataset and Victorian Inpatient Minimum Dataset data items as the main source for Epidemiological Minimum Dataset trauma monitoring.

8.8 A single trauma registry using common software, hardware and data definitions be developed to facilitate the collation of data and system performance monitoring across trauma services.

8.9 Linkage of existing data sources be investigated, including Police Accident database and Ambulance Service Victoria data.

8.10 Immunity from legal discovery be provided for quality improvement discussions and associated documents.

8.11 Auditing of regional trauma management activities be undertaken by the regional Consultative Committees on Emergency and Critical Care Services.

8.12 Preventable outcome studies utilising peer review by a state committee be undertaken for specifically identified tasks, including trauma deaths. System Performance Minimum Dataset data be utilised for this activity.

9.0 Education and Training

The Taskforce recommends:

9.1 Undergraduate, postgraduate and continuing education needs of all staff involved in trauma care be considered and fulfilled though the Victorian State Trauma System.

9.2 Cooperative effort between universities, specialist colleges and hospitals in the implementation of education strategies.

9.3 Major Trauma Services function as 'resource centres' making available consistent, common information about education and training options.

9.4 Better integration of the large number of training courses currently available for the multiple disciplines engaged in trauma care.

9.5 The Director of Trauma Services in each hospital ensure the provision of appropriate strategies to meet the educational needs of hospital staff involved in the care of trauma patients.

9.6 Team leaders and all senior medical staff managing major trauma be at least qualified in Early Management of Severe Trauma.

9.7 The statewide introduction of a single, standard training course that is accessible for Victorian nurses involved in trauma care and integrated with other existing training courses.

9.8 Inexperienced medical and nursing staff participating in trauma resuscitation have senior staff supervision.

9.9 Principles of trauma management be a component of undergraduate medical and nursing education.

9.10 The educational strategies of the Rural Doctors' Association of Victoria Lives @ Risk Committee and the Rural Workforce Agency Victoria be promoted.

9.11 Difficulties in participationof general practitionersespecially from rural areas, in attending training courses, such as Early Management of Severe Trauma and Advanced Paediatric Life Support be further considered.

9.12 Regional Consultative Committees on Emergency and Critical Care Services develop and implement trauma education plans for their local area in consultation with the State Trauma Committee.

9.13 The State Trauma Committee develop an appropriate model for training multidisciplinary prehospital teams in rural areas.

9.14 Ambulance/MICA paramedics be adequately trained to participate in trauma team management in regional/rural emergency departments as appropriate

9.15 Innovative education processes, such as mobile simulators, telemedicine and multidisciplinary training, be developed to maintain the skills for personnel who have rare exposure to trauma and medical emergencies.

9.16 The role of the Victorian State Trauma System, including public education, is important to the success of injury prevention strategies.

9.17 Collaboration of the Victorian State Trauma System with other key stakeholders in injury prevention to:

- Support public education - Strengthen the measures that provide effective injury prevention - Increase the adoption and enforcement of safety legislation or policies - Contribute to injury research.

10.0 Research, Service and Technology Developments

The Taskforce recommends:

10.1 Statewide application of telemedicine in the neurosurgical management of major trauma patients.

10.2 Integration of telemedicine links.

10.3 Maturation of clinical information systems.

10.4 The introduction of digital communication systems.

10.5 Technological developments that speed diagnosis of critical injuries.

10.6 Introduction of service and technology developments that have a proven efficacy and value for the health care system.

11.0 Funding

The Taskforce recommends:

11.1 A tiered strategy for investment prioritising the following key areas:

- System coordination mechanisms, including data collection, analysis and
dissemination
- Targeted trauma education and training
- Enhanced primary transport and secondary retrieval services
- Hospital staffing levels that meet role delineation specifications.

11.2 Purchasing options that support the system improvement strategies recommended by the Taskforce, such as triage and transfer of major trauma patients to Major Trauma Services according to appropriate guidelines.

11.3 Purchasing options to be further developed with key providers and stakeholders during the implementation stage.