|Scotland's trauma decision|
|Wednesday, 29 February 2012|
In this opinion piece, Editor John Duncan considers the challenge of delivering world-class major trauma care to patients north of the border
Trauma is a Public Health issue. Surgeons are intimately involved in the treatment of patients with trauma but so are first responders, the ambulance service and rehabilitation specialists.
Surgeons have concentrated on achieving the best outcomes for patients under their care, and doctors in emergency medicine aim to provide the highest quality care for patients with major trauma while coping with the huge workload of less severe injury and emergencies.
Hospitals can produce plans and algorithms to manage the patients who present to them, but is there a plan which ensures that the individual trauma patient is admitted to the most appropriate facility? The point at question is whether, as a healthcare system, we need such a plan in order to achieve the best possible outcomes for patients who present with major trauma.
The first challenge is to define what we mean by major trauma. We know it when we see it but we have to have a definition. It can be defined in terms of a number generated from a scoring system, e.g. an injury severity score greater than 15, but perhaps, more practically, it can be defined as an injury which could result in permanent disability or death. More pragmatically, it is one where the complexity exceeds the capabilities of the unit to which the patient is admitted.
“Hospitals can produce plans and algorithms to manage the patients who present to them, but is there a plan which ensures that the individual trauma patient is admitted to the most appropriate facility?”
About a thousand patients suffer major trauma each year in Scotland. This number of major trauma patients, and the way in which they are presently distributed, means that the institutional experience of even the largest centres is below the recognised threshold for a service capable of improving outcomes.
In England, changes are being introduced which will go some way to having a system of care which would bear comparison with trauma systems in place round the globe. The College is producing a report into the care of major trauma patients in Scotland and this report may stimulate the debate that is necessary to reorganise care to the benefit of our patients.
If we compare UK outcomes for major trauma patients to those cited in the international literature, there is some evidence to suggest that, overall, the UK we does not fare very well. There is, of course, an issue about whether the pattern of major trauma in the UK is comparable to that in North America, with its much higher incidence of penetrating trauma. However, to this non-trauma surgeon, it does seem clear that there are aspects of trauma care in the UK which could be improved if we adopted a system of care which streamlined pre-hospital care towards the definitive care which the patient requires. The emphasis on high- quality care in the hours immediately following injury, and its beneficial effect on outcomes, is recognised by us all. The issue is how best to achieve that.
There is an established literature from major developed economies which have implemented systems to try to provide optimal care for trauma patients. The aim is obviously to reduce death but also to reduce disability. In Scotland, we have a lack of information about the distribution and timing of trauma incidents and little data on outcomes other than mortality. The Scottish Trauma Audit Group (STAG) has produced data but the published data is now 10 years old and it is unfortunate that the data from the later period of the STAG’s work has never been published. STAG’s reinstatement in 2011 is the start of understanding our distribution and case mix as integration of this data with pre-hospital data and outcome data is necessary to plan properly the system which would work best in Scotland.
There are drivers which make re-organisation necessary. The evidence that our outcomes are not what they might be is the most important. Another key driver is the changes we have seen in working times and the impending reduction in trainee numbers, which we are assured is coming.
The evidence from other jurisdictions suggests that co-locating all of the specialties necessary to manage major trauma is important. The establishment of such an institution in Scotland, with the co-location of all the necessary specialties and expertise, would be a world-class training experience for surgeons of the future. Only one hospital in Scotland has all of the specialties necessary located on a single site, and even it does not have the volume of cases which the literature would suggest is optimal – a redistribution of the workload would be necessary to achieve that.
The correct pattern of care for Scotland is not clear. Adopting the standard that if transfer to the point of definitive care can be accomplished in less than 45 minutes then the patient can bypass another closer hospital, then much of Scotland’s Central Belt could be covered by one major trauma unit. The rest of the country would have to be served in another way.
Major trauma patients account for less than 1% of the trauma workload of emergency departments and so any re-organisation which moves the major trauma workload away from local hospitals would still require the remaining 99% to be managed within local regions. Such a re-organisation would not close many emergency departments.
As in other clinical situations, having a well thought through plan which is coherent and widely understood usually improves outcomes when implemented consistently. We hope that a report will stimulate the production of such a plan for the benefit of Scottish patients, as victims of major trauma elsewhere in the UK begin to reap the benefit of centralised, specialist care.
John Duncan, Editor