towards better trauma care
The UK is moving towards higher standards of trauma treatment, but more must be done to create a truly world-class service. Jan Jansen reports on regionalisation and specialisation in trauma care
"The re-organisation of trauma services in the UK should draw on all available experience"
Trauma care remains an important public health issue. The management of patients with major injuries – other than skeletal trauma – is not recognised as a surgical subspecialty in the UK, and there is no infrastructure for their care. This organisational failure is reflected in clinical outcomes: A recent National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report found that 60% of trauma patients in England and Wales had received a standard of care considered less than good practice. Mortality after major trauma is considerably higher in the UK than in the USA.
There is compelling evidence that the regionalisation of trauma care improves outcome. Trauma systems – in essence managed clinical networks – have been in existence in North America and parts of South Africa and Europe for several decades. Trauma centres, stratified according to capability, form the secondary and tertiary care components, as well as the administrative and academic backbone of the service.
My own experiences of working in trauma centres in South Africa and Canada, and observing trauma care in several centres in the USA, confirm that the standard of care is considerably higher than currently offered in the UK’s NHS. The reception phase is invariably protocolised – ATLS-based, but incorporating pre-defined task allocation and horizontal teamworking strategies – and led by experienced clinicians, facilitating a swift and efficient initial assessment. The Johannesburg Hospital trauma unit resuscitation protocol runs to several dozen pages!
Bedside ultrasound is available in all of the North American centres I have visited. At LAC+USC in Los Angeles, there is one machine per resuscitation bay. CT scanners are located in close proximity to resuscitation rooms – avoiding the lengthy and dangerous transfers which unfortunately remain common in many British hospitals.
Recognising the limits of physical examination, patients admitted to the trauma centres I have worked in and visited are much more thoroughly investigated than in the UK. This is facilitated by having radiologists who are resident on call, or technology which allows staff to view the images at home, via the internet. Interventional radiology services are similarly available around the clock, and require little discussion.
Unlike in the UK, where the care of trauma patients is shared between different specialties, often without clear leadership, trauma care in North America and South Africa is co-ordinated, and largely provided by trauma surgeons. These surgeons have a general surgical background, with additional training in trauma and often critical care. They are responsible for the care of patients with torso-, vascular- and polytrauma, with input from other specialties, such as neurosurgery and orthopaedics.
Although trauma centres provide an impressive level of care, they cannot function in isolation: Successful trauma systems are inclusive, integrating pre-hospital care, all levels of trauma centres, non-trauma centres, and even rehabilitation facilities. Such extensive and diverse clinical networks require development and maintenance. The success of the North American model of trauma care is at least in part due to the ownership of the system by trauma surgeons, who form a large, dedicated and influential specialty.
The lack of a similar service delivery framework in the UK is often blamed on the lower incidence of trauma, and particularly penetrating injuries. Although trauma is less common than in North America or South Africa, this should not be used as justification for substandard treatment. Many other rare conditions, for example sarcomas, are expertly cared for through managed clinical networks. The perception of rarity is added to by the decentralised nature of trauma care provision, which dilutes experience.
Many other NHS services – such as paediatric surgery, intensive care, and oncology – have been regionalised, often on the basis of much less evidence than there is for the regionalisation of trauma care. Tertiary trauma care is highly cost-effective: The cost per QALY is around $1,700-3,800, which is considerably less than many other accepted treatments.
The proposed establishment of major trauma centres in England and Wales therefore represents a welcome paradigm shift in health policy. The designation and development of such centres is proceeding apace in London, which is aiming to have two new major trauma centres – at King’s College Hospital and St George’s Hospital – by 2010, in addition to the existing unit at the Royal London Hospital. A fourth unit, at St. Mary’s, is also planned, and will open its doors in 2011.
Many questions remain. How will these new centres will be staffed? Which specialty will provide the necessary leadership? How will the surgeons be trained and accredited? My experiences abroad have convinced me that a dedicated subspecialty is an absolute requirement for the successful development and operation of a trauma service. Most life-threatening injuries affect the torso and vasculature, and – as elsewhere in the world – general surgeons, with appropriate additional training, are therefore probably best placed to provide such a service. However, given the historical development of general surgery along lines of elective interest, there are at present few British general surgeons with a declared interest in trauma.
The re-organisation of trauma services in the UK should draw on all available experience. The exemplary results obtained by the defence medical services in Iraq and Afghanistan demand closer co-operation between the NHS and the military. Such co-operation is common in the USA: All three branches of the military have formal associations with large civilian trauma centres, permitting military surgeons to maintain and develop their skills between deployments, and allowing civilian surgeons to draw on the experience of their military counterparts.
Disappointingly, the Scottish Government has decided not to follow England’s lead. Scotland’s geography and demography poses unique challenges, but the potential benefits of regionalising trauma services are the same as elsewhere in the UK. Hopefully, increasing public awareness of outcomes, together with continued lobbying by the profession, will eventually lead to the establishment of a trauma service in Scotland.