The Irish Association for Emergency Medicine warmly welcomes today’s publication of the Report of the Trauma Steering Group ‘A Trauma System for Ireland’. As experts in Emergency Medical Care, the Association has, for many years, highlighted the urgent need to reform how trauma care is delivered to this small but very important subset of patients who sustain major life-threatening or life-changing injury. The ultimate beneficiary of this change will be the patient, their family and society; getting the right patient to the right people with the right skill set as early as possible means that patient has the best chance of survival, a shorter recovery time and a better chance of getting back to life as they knew it before their injury. Good early care saves both lives and ultimately saves money.
The National Office of Clinical Audit NOCA’s most recent Major Trauma Report notes that 28% of major trauma victims needed to be transferred from the hospital they were initially brought to, because that hospital did not have the services required to deal with the multiply injured trauma patient. This is a subgroup of about 1,600 of the 1.3 million patients brought each year to Emergency Departments across Ireland who will benefit from the development of an Inclusive Trauma System.
The current unsatisfactory situation for this group of patients should be understood in order to properly appreciate what is involved in the proposed Inclusive Trauma System. Today, if you crash your car on Dublin’s M50 and sustain head, spinal, abdominal and bony injuries, you will be brought from the crash site to the nearest hospital. No one hospital in Dublin has all the trauma specialties on site – you will need to be transferred from the first hospital to the neurosurgical centre at Beaumont Hospital to have your brain bleed operated on; be moved from there to the Mater Misericordiae University Hospital to have your unstable spinal injury operated on and from there to Tallaght Hospital to have your fractured pelvis operated on and ultimately be moved from there to the National Rehabilitation Hospital in Dun Laoghaire for rehabilitation. The situation in rural Ireland is similarly inadequate. If you sustain the same constellation of injuries in Claremorris, for example, you will be brought to the Emergency Department in Mayo University Hospital. While you will be able to undergo emergency surgery there to stop bleeding from your abdominal organs, many vital hours will typically be lost before a bed is available at the neurosurgical or spinal centre and a team is available to transfer you. These hours make a difference to the likelihood of a good recovery. Already, a number of smaller hospitals have trauma by-pass protocols in place whereby ambulances will avoid bringing patients with obvious significant fractures to that hospital – this report supports further work towards ensuring that patients are triaged to the right hospital that has the right expertise available to manage that patient’s injuries.
A fundamental philosophy of the Inclusive Trauma System model with the Major Trauma Centre having all trauma specialities on site at the hub is that if the patient’s needs exceed that which can be delivered at the Trauma Unit, Local Emergency Hospital or Injury Unit that patient can be retrieved or transferred out without delay, seamlessly. There is a shared responsibility between the smaller hospital and the Trauma Service at the Major Trauma Centre to ensure a ‘push and pull’ approach exists to get the patient to the right care quickly.
It is vital for patients that the ‘A Trauma System for Ireland’ report is implemented in its entirety and as soon as possible. The international experience from England & Wales and Australia tells us that we will see 30% more survivors as a result. Implementation involves appropriate resourcing of pre-hospital and retrieval services so they can get seriously injured patients to the right expertise safely; it involves ensuring trauma teams with senior leadership are available to ensure the reception at Emergency Departments and early intervention is both safe and effective; it involves ensuring that Radiology, Surgical, Critical Care and Rehabilitation capacity is available and it involves measuring the effects of these changes by robust real time trauma audit. Cherry picking just elements of the implementation of the trauma system could result in outcomes that are worse for patients, for example if patients bypass smaller hospitals to be brought to centres that do not have capacity to deal with them. A Trauma System relies on every link in the chain of survival working so that patients reap the rewards we anticipate and they deserve.