Trauma care services in the United Kingdom: past, present and future.
Current provision of trauma services in the United Kingdom is
insufficient, resulting in a high mortality of trauma patients. Multiple
studies proved that regionalisation of the trauma care can significantly
reduce mortality and morbidity by avoiding unnecessary transfer and
reducing delay in delivering definitive surgery. This evidence led to
changes in delivering trauma care in London which showed a significant
reduction in mortality from severe injuries.
KEYWORDS Trauma / Regionalisation / Trauma surgeon
|Article Type:||Clinical report|
|Publication:||Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589|
|Issue:||Date: August, 2012 Source Volume: 22 Source Issue: 8|
Globally, trauma is the leading cause of death and disability in the first four decades of life (Mann et al 1999). It causes more 'life-years' lost than cardiovascular disease and cancer combined, resulting in significant social and economic costs (Mann et al 1999, Soreide 2009). The ultimate goal of the trauma care is to return the patient to an independent and productive life as soon as possible. However, the recovery following injury is a complex problem, and there are many factors leading to the successful outcomes of trauma patients.
The concept of the trauma system care has been practised in many countries, and results show that it significantly improves patient outcome (ACS 1990, Regel et al 1995, Sampalis et al 1997, Soreide 2012, Saltzherr et al 2012). Trauma system care is a comprehensive approach to trauma as a 'disease', utilising the 'trauma chain of survival', which represents a logical sequence in the management of the trauma victim (Soredie 2012). It incorporates early measures in the form of first aid at the scene, basic/advanced life support, followed by prompt advanced therapy in the trauma centre culminating in trauma orientated rehabilitation (Davenport et al 2010, Soreide 2012). Such an approach not only ensures that the trauma victim receives the best possible care at each of these steps, but also emphasises that trauma care starts immediately following the injury. Trauma system care is not only confined to the clinical management of the trauma patient. It also involves trauma related research, public education, performance monitoring and training opportunities.
For many years, the UK has been perceived to provide the best surgical patient care in Europe, but the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) revealed that 60% of trauma patients in England and Wales have received suboptimal perioperative trauma care (Jansen 2010a). So why can't we offer the best care to our 'trauma victims' in the 21st century? The aim of this article is to look at the trauma service experiences from other countries, as well as the past and existing practice of the trauma care services in the UK.
History of the trauma system
To understand current needs and identify areas for further development in trauma care it is essential to look back into the history of trauma service provision.
The need for specialist care for the injured, in order to reduce mortality and disability, was recognised by the UK government as early as 1936. In 1942, the Birmingham Accident Hospital was opened where 'accident surgeons' delivered high quality trauma care. Unfortunately, political pressures and financial cuts led to the closure of the hospital in 1991. Another significant step was the introduction of the Advanced Trauma Life Support (ATLS) in 1989, which became a 'uniform language' for trauma teams all over the world (ACS 2009). However, there has not been any significant improvement since ATLS provision, because ATLS alone cannot guarantee the best outcome for trauma patients. In order to provide the best care a whole new trauma system is required.
The development of trauma systems in the UK lost its momentum when the trauma centre experiment at the North Staffordshire Hospital failed to replicate the findings from the United States trauma centres and concluded that there was no evidence for decreased mortality after the introduction of this 'trauma centre' (Nichol & Turner 1997). However, there were several controversies surrounding this pilot and one could argue that it was almost designed to fail. Firstly, the data were collected retrospectively, and the duration of three years was not long enough to achieve a reduction in mortality in trauma patients (Oakley et al 2004). The 24 hours consultant cover was limited to accident and emergency (A/E) and lacked the critical consultant involvement in the whole pathway of the trauma patient.
Present perspectives in the trauma care provision
Trauma care is becoming one of the front line health issues in the UK. After decades of debate clinicians and politicians are in agreement regarding the implementation of the trauma systems. Establishment of the London Trauma System located at four major trauma hospitals has already shown a significant reduction in mortality from severe injuries (Davenport et al 2010). Similar systems are being established in the East of England and West Sussex (Jansen 2010a). Ongoing reorganisation and centralisation of the services in Wales will likely lead to the development of two trauma centres. However, this is not the case for Scotland. The Scottish Government opted against the major trauma care reorganisation (Jansen 2010a).
Over the past few years significant improvements have been made in the management of the injured patients, mainly due to advances in the various imaging modalities. Focused assessment with sonography for trauma (FAST) scan is routinely performed in the A/E and even in pre hospital phase. The introduction of the multidetecor computed tomography (MDCT) has brought up the next level in the trauma injuries recognition. MDCT allows the whole body to be scanned within five seconds (Chan 2009). Furthermore, some European trauma centres have taken even another step forward, where MDCT is a part of the primary survey. In this new approach, the 'C' within the ATLS 'ABCDE' sequence, stands for circulation and computed tomography (Chan 2009, Saltzherr et al 2012). Subsequently 'E' represents clinical and radiological evaluation of the patient (Chan 2009).
A randomised controlled trial showed that computed tomography (CT) located in the resuscitation/trauma room reduced the time required to obtain CT imaging when compared with the traditional CT location in the radiology department (Saltzherr et al 2012). Although the study did not prove the differences in the clinical outcomes, this finding is of great importance for a number of reasons. Firstly, clinical examination in the critically ill obtunded traumatised patient is unreliable; therefore prompt CT leads to quicker diagnosis and definitive treatment. Secondly, availability of CT in the resuscitation area avoids the need for patient transfer, which can dislodge the formed clots and lead to the haemorrhage. Thirdly, life saving procedures (interventional radiology) can be performed in the same room without further delays (Gross et al 2010). However, this approach requires a multidisciplinary approach with early senior input, which still remains a major obstacle in the UK.
The consultant factor
Substantial evidence from the military experience proved that trauma patients benefit from early senior input (Rew 2011). Unfortunately, the majority of consultant surgeons do not attend trauma calls in the A/E. It is likely that this is the consequence of the nature of trauma as a specialty; trauma is associated with unpredictable work hours and therefore it carries a significant impact on the work-life balance. Nevertheless, the level one trauma centre needs to fulfil certain criteria, such as 24 hour consultant led trauma team and presence of all major acute specialties on site. One may think that it is challenging to expect a uniform agreement from the senior clinicians, but in many regions in the UK this is already a fact for other specialities. For example vascular and upper gastrointestinal (GI) surgical services have been reorganised and successfully managed within several clinical networks in order to improve specialist patient care and outcomes. So far, vascular surgery is the only surgical specialty with a consultant delivered care, as opposed to a consultant led service - which still applies to the majority of surgical specialties, including trauma.
Unfortunately, the majority of the trauma patients are still managed in local emergency departments by a 'trauma team' consisting of non-surgeons, juniors or less experienced clinicians who often spent too much time relying on Hartmann's solution to manage the massively bleeding trauma victim. They seem to forget the 'time' and the fact that they will not be providing definitive control of haemorrhage in the A/E department. A bleeding patient requires rapid decision making regarding immediate transfer to the operating theatre for surgical control of the haemorrhage. This decision is best made by an experienced consultant surgeon who is the best clinician to monitor vital signs and relate them with the patient's physiological status (Mains et al 2009).
To achieve a high quality service for trauma victims we also urgently need dedicated and enthusiastic trauma surgeons who would be responsible for taking the patient through all phases of the 'trauma disease', from resuscitation, into the reconstruction and rehabilitation phase (Brohi 2009). A trauma surgeon's role is critical in establishing a better quality of care, because he or she has the expertise to recognise all the consequences of trauma disease.
Trauma surgeons play a vital role in the incorporation of all important interventions to optimise the patient outcome, such as damage control resuscitation (DCR) and damage control surgery (DCS). They make the decision whether the transfusion should begin immediately after surgical haemorrhage control has been established or even during the resuscitation phase in the emergency department. They also ensure that the patient is transferred to theatre without delay.
After the traumatic 'first hit', disturbed immune and coagulation systems make trauma patients susceptible to a 'second hit' insult related to surgical procedures. Aggressive and prolonged surgical interventions in such circumstances worsen the hypotension and tissue perfusion, activate primed neutrophils and increase the risk for multi organ dysfunction syndrome (MODS) (Stahel et al 2009). During the operation, the trauma surgeon observes vital signs which, along with the haemodynamic parameters, the number of transfused units, the lactate level and the coagulation profile results, guide the surgeon when selecting patients who would benefit from DCS.
The DCS concept is applicable to any of the major body compartments, including the neck, chest abdomen, pelvis and limbs. Regardless of the involved anatomical area the objectives of DCS are the same and they aim to arrest bleeding and coagulopathy, limit contamination and inflammatory response and enclose the viscera (Moore et al 1998). It is a temporary measure enabling the salvage of critically ill trauma patients with exhausted physiology (Lee & Peitzman 2006). DCS breaks the lethal triad (hypothermia, coagulopathy and acidosis) which facilitates aggressive resuscitation of patients on the ICU with subsequent definitive repairs (Stahel et al 2009). Following the DCS the trauma victim is transferred to the intensive care unit in order to correct the exhausted physiology. On restoration of normal physiology, the patient returns to theatre for a definitive procedure, which usually takes place within 48 hours of injury.
The trauma surgeons make the final decisions as to when is the best window of opportunity for the trauma patient to return to theatre for additional emergency or definitive surgery. The surgeon is the only clinician who can make definitive procedure plans along with alternative operative strategies, and therefore makes the decision for all the other specialties. On the other hand, there is a group of critically ill patients who are not fit for any definitive procedures beyond 48 hours. The surgeon appreciates the fact that different surgical procedures have a different impact on the patient and that some injuries can be left without definitive care for longer than others.
At present, only skeletal injuries are recognised as a trauma specialty, and although the trauma and orthopaedic consultant is responsible for management of trauma cases, in practice few such consultants attend trauma calls (Pitts et al 2009). On the other hand, current general surgical training is focused on the elective workload. Even if we had new training in place, it would take at least another six years for surgeons to be prepared to provide the care which we desperately need now. Perhaps we should consider recruiting some vascular surgeons as they have the ability to enter most of the body compartments and have the ability to arrest haemorrhage with open or endovascular techniques (Brightwell 2010). General surgical trainees, after further training in trauma surgery and intensive care, could also fill the current 'gap' in the trauma provision.
Trauma care training in the UK
At present, there are limited formal trauma teaching opportunities. A considerable amount of time is dedicated to teaching a variety of medical and surgical conditions during medical school. Given the complexity of trauma and the rapidly evolving trauma related research it would seem logical to incorporate trauma disease within the undergraduate curriculum. This year Swansea University for the first time incorporated a trauma teaching session for the undergraduates within the curriculum, but this is not the case across the UK. Exposure to basic trauma knowledge and skills could not only educate, but could also help to influence future career choices in the current era of reduced and accelerated training programmes. Medical students can further develop their interests in trauma by taking up elective placements in trauma centres abroad (Fuge 2011).
The growing interest in trauma in the UK led to the establishment of the National Student Trauma Conference, which is aimed at the foundation trainees and takes place yearly in Edinburgh. Subsequently emergency care, core and higher surgical trainees can formalise trauma skills by a variety of the courses delivered by the surgical Royal Colleges. Such courses include: Advanced Trauma Life Support (ATLS), Specialty Skills in Emergency Surgery and Trauma, Pre-Hospital and Emergency Department Resuscitative Thoracotomy, Emergency Abdominal and Thoracic Surgery for the General Surgeon, and Definite Surgical Trauma Skills for the General Surgeon.
The Master's Programme in Trauma Surgery at the Swansea University is the only formal trauma training available in the UK. It is primarily aimed at the higher surgical trainees (trauma and orthopaedics, plastics, maxillo-facial and general surgery) who have strong interests in trauma as evidenced by involvement in audits, research and publications. The MSc Trauma Surgery is a two and a half year part-time study, which takes students through all the phases of the trauma disease from initial resuscitation to final recovery. During the first year the one week blocks provide the essential knowledge and practical skills in trauma. The second year is aimed at the development of an independent research thesis related to trauma surgery and leads to the dissertation.
Future developments in the trauma care provision
Many questions regarding the new training will remain unanswered. But it is important to remember that critically ill polytrauma patients represent a most vulnerable group of patients. These patients require a dedicated trauma surgeon who is responsible for taking them through all the phases of the 'trauma disease' pathway, with all interventions being aimed at the reduction of the tissue hypoperfusion and restoration of the physiological balance to ensure an optimal outcome.
The 21st century trauma systems require not only a resuscitation area which provides computerised tomography (CT)/angiography and theatre suite at the same time, but full integration of rehabilitation services, education, research and performance monitoring (Gross et al 2010). At present, dedicated trauma rehabilitation services do not exist. Trauma patients and their families are somehow neglected, when compared to the support which, for example bowel cancer patients receive, when faced with a permanent stoma.
It is also necessary to raise awareness among the public, because trauma is still not perceived as an important health problem. A vital component of performance monitoring would be the introduction of a mandatory trauma registry. At present there is only one optional database available: the Trauma Audit & Research Network (TARN). The UK is moving towards higher standards of trauma care and the current poor organisation, lack of training and education in definitive trauma care should not justify the provision of the substandard care (Brohi 2009). An extensive clinical network is required to coordinate future trauma systems. It is a dynamic process and there are numerous challenges, but when fully implemented it will provide a continuum to all phases of care, ranging from the prehospital and in patient phases to outpatient rehabilitation and reintegration of the patient into an independent individual.
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by Jakub Kaczynski and Joanna Hilton
Correspondence address: Jakub Kaczynski, ABM University Health Board, General Surgery Department, Morriston Hospital, Swansea, SA6 6NL. Email: firstname.lastname@example.org
About the authors
Jakub Kaczynski MBChB (Hons), MRCSEd
Speciality Registrar in Vascular Surgery, Morriston Hospital, Swansea
Joanna Hilton MBChB, FRCS
Consultant General and Colorectal Surgeon, Morriston Hospital, Swansea
No competing interests declared
Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication April 2012.
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