Trauma
April 1st 2012 saw the introduction of Major Trauma Networks in England. Remarkably, this is the first major change in the formal organisation of care for the severely injured in the National Health Service (NHS) since its inception 60 years ago. Why change and why now?
Many countries have centralised management of the most severely injured patients to Major Trauma Centres and there is an international consensus that this allows the development and concentration of expertise in resuscitation, surgery, critical care and rehabilitation. This leads to improvement in survival and reduction in long-term disability, making the system cost-effective. Many trauma systems in the world have evolved from a central Major Trauma Centre in large University Hospitals and very few systems have been designed to provide care for entire countries or regions. However, regional networks that include all hospitals providing trauma care within the region bring more benefit than simply opening a trauma centre. Such systems were developed in Maryland, USA and Victoria State, Australia and provide a public health system for managing severe injuries in the entire population, not just those fortunate enough to live close to the Major Trauma Centre. Outcomes seem to be best in networks that treat more than 500 severely injured patients (Injury Severity Score > 15) per year.
The re-organisation in England is one of the first attempts at developing a national trauma system covering a population of 60 million. The structure of the networks will vary throughout the country depending upon the geography, population size and current infrastructure. The London Trauma System was the first to start, in April 2010, and operates an exclusive system: patients are triaged by the paramedics on scene and are then taken directly to one of four Major Trauma Centres, bypassing all hospitals en route. The small (geographical) size of London allows a median journey time of 14 minutes and 97% of patients reach a Major Trauma Centre in less than 40 minutes. The initial results have been very encouraging with 58 additional survivors in the first year of operation and further benefits are expected as it takes between 3 and 5 years for trauma systems to mature and provide optimal results. The rest of England will use inclusive trauma networks where patients will be taken directly to the nearest Major Trauma Centre if the journey time is less than 45 minutes or will be taken to the nearest Trauma Unit if the journey time is longer or if the patient has an immediate life-threatening injury e.g. airway obstruction. A secondary transfer will then take place, if needed, to the Major Trauma Centre.
Each region in England contains a population of approximately 5 million. Some regions, such as the East Midlands, will have a network with just a single Major Trauma Centre at the hub whilst others will have either 2 or 3 Major Trauma Centres, each with a separate network. Funding for the networks and particularly the infrastructure within each Major Trauma Centres, such as additional critical care, interventional radiology and trauma operating theatres, has been a difficult issue, especially during an economic recession with severe financial constraints. The payment structure for those with multiple injuries has been altered to provide greater funding for patients with severe injuries that require complex treatment and a best practice tariff for major trauma has been introduced to provide additional funding to Major Trauma Centres for patients with severe multiple injuries (ISS > 15) and severe single system injuries (ISS 9-15). This supplementary funding will be based upon care quality standards which will be monitored by the Trauma Audit Research Network.
These changes provide Orthopaedic surgeons with a unique chance to improve patient care by the development of clinical services, audit and research. Working with TARN, we may be able to develop a trauma registry with prospective data on severe musculoskeletal injuries for a population of 60 million. It will take five years for the networks to mature and this is an opportunity we must not miss.
Chris Moran, Professor of Orthopaedic Trauma Surgery, Nottingham University Hospital, UK
