TRAUMA CARE IN NEW ZEALAND

TRAUMA IN NEW ZEALAND

No overarching national database BUT RTC death rate about 9/100,000/year Major trauma incidence about

40/100,000,year Overall death rate about

25/100,000/year

PREHOSPITAL CARE

PREHOSPITAL CARE

Initial Assessmentof the Trauma Patient

International ATLSInternational ATLS®® Program Program

> 30 Countries> 30 Countries > 1,000,000 doctors > 1,000,000 doctors

trained worldwidetrained worldwide 30 year history30 year history

> 16,000 doctors > 16,000 doctors trained in Australasiatrained in Australasia

1000th EMST course 1000th EMST course in 2011in 2011

Initial Assessment of the Trauma Initial Assessment of the Trauma PatientPatient

Primary SurveyPrimary Survey

ResuscitationResuscitation

Secondary SurveySecondary Survey

Definitive careDefinitive care

Primary Survey

Airway with c-spine control

Breathing

Circulation (stop external haemorrhage)

Disability (AVPU or GCS + pupils)

Exposure and Environmental control

Airway Airway (CAUTION C-SPINE)(CAUTION C-SPINE)

Talk to the patientTalk to the patientLook with suctionLook with suctionChin lift/ jaw thrustChin lift/ jaw thrustOral/nasopharyngeal airwayOral/nasopharyngeal airwayCuffed tube (oral/nasal/surgical)Cuffed tube (oral/nasal/surgical)OXYGENOXYGEN

BreathingBreathing

Ensure airway is adequateEnsure airway is adequateLook (chest wall/RR/cyanosis)Look (chest wall/RR/cyanosis)Feel (chest Feel (chest

wall/trachea/percuss)wall/trachea/percuss)Listen (auscultate)Listen (auscultate)Adjuncts (SaO2)Adjuncts (SaO2)

Tension PneumothoraxTension Pneumothorax

Respiratory distress Respiratory distress (RR>30 or <10)(RR>30 or <10)

Elevated neck veinsElevated neck veins Cyanosis (late)Cyanosis (late) Deviated tracheaDeviated trachea (Hyper)resonant chest (Hyper)resonant chest

on one (both) sideson one (both) sides Unilateral absence of Unilateral absence of

breath soundsbreath sounds

Insertion of chest tubesInsertion of chest tubes

5th ICS in MAL5th ICS in MAL Local anaestheticLocal anaesthetic 3cm incision3cm incision Blunt dissectionBlunt dissection Finger explorationFinger exploration Remove trocarRemove trocar Blunt forceps to Blunt forceps to

insert chest tubeinsert chest tube

Immediately Life-threatening Chest Immediately Life-threatening Chest TraumaTrauma

Airway obstructionAirway obstruction Tension pneumothoraxTension pneumothorax Massive haemothoraxMassive haemothorax Open (sucking) pneumothoraxOpen (sucking) pneumothorax Flail chestFlail chest Cardiac tamponadeCardiac tamponade

CirculationCirculation

Look (stop external Look (stop external bleeding)bleeding)

-- CHECK PERFUSIONCHECK PERFUSION --Feel (pulse/BP)Feel (pulse/BP)Listen (BP)Listen (BP)2 large bore (16Fg) IVs2 large bore (16Fg) IVs2 l balanced salt solution 2 l balanced salt solution

(20ml/kg) in children(20ml/kg) in children

DisabilityDisability

AVPU AVPU AlertAlert responding to Verbal responding to Verbal

stimulistimuli responding to Painful responding to Painful

stimulistimuli UnresponsiveUnresponsive

GCSGCSPupilsPupils

Exposure/Environmental Exposure/Environmental ControlControl

UNDRESS THE PATIENT UNDRESS THE PATIENT COMPLETELY BUT COMPLETELY BUT PROTECT FROM PROTECT FROM HYPOTHERMIAHYPOTHERMIA

ResuscitationResuscitation

Provide airwayProvide airwayOxygenateOxygenateTreat shockTreat shockMonitor vital signsMonitor vital signsECG/ SaO2ECG/ SaO2Urinary catheterUrinary catheter

RadiologyRadiology

Chest XRChest XR

AP pelvic XRAP pelvic XR

Lateral cervical spine XRLateral cervical spine XR

Secondary SurveySecondary Survey

Head (remember neurological exam)Head (remember neurological exam) Face (NG tube if not contraindicated)Face (NG tube if not contraindicated) Neck (remember X-rays)Neck (remember X-rays) ChestChest Abdomen (including rectal exam)Abdomen (including rectal exam) Pelvis (urethral catheter if not contraindicated)Pelvis (urethral catheter if not contraindicated) Extremities (splint as necessary)Extremities (splint as necessary) ExternalExternal

HistoryHistory

AllergiesAllergiesMedicationMedicationPast illnesses/injuriesPast illnesses/injuriesLast MealLast MealEvents/Environment Events/Environment

DETAILS OF MECHANISM OF INJURY DETAILS OF MECHANISM OF INJURY ARE VITALARE VITAL

Neurological ExaminationNeurological Examination

GCS (best GCS (best response)response)

PupilsPupils Worst Worst

neurological neurological responseresponse

Localising Localising signssigns

ReflexesReflexes

DocumentationDocumentation

LegibleLegibleChronologicalChronologicalConciseConciseDetail consentDetail consent

MUST BEMUST BE

REMEMBER, YOUR NOTES MAY BEREMEMBER, YOUR NOTES MAY BEREQUIRED FOR EVIDENCE IN COURTREQUIRED FOR EVIDENCE IN COURT

Initial Assessment of the Trauma Initial Assessment of the Trauma PatientPatient

Primary SurveyPrimary Survey

ResuscitationResuscitation

Secondary SurveySecondary Survey

Definitive careDefinitive care

Problems in organising a trauma Problems in organising a trauma centrecentre

ACSCOT Criteria for Trauma ACSCOT Criteria for Trauma System DevelopmentSystem Development

AdministrationAdministration AccessAccess Trauma centresTrauma centres RehabilitationRehabilitation AuditAudit ResearchResearch PreventionPrevention

Key concepts in a trauma Key concepts in a trauma systemsystem

Trauma system co-Trauma system co-ordinationordination

Data collectionData collection Retrieval services/pre-Retrieval services/pre-

hospital carehospital care Emergency DepartmentsEmergency Departments Specialised hospital Specialised hospital

servicesservices RehabilitationRehabilitation

A functioning trauma system gets the right patientA functioning trauma system gets the right patient to the right place at the right timeto the right place at the right time

In some nations, specialisedIn some nations, specialisedhospitals or trauma receptionhospitals or trauma receptionfacilities concentrating on thefacilities concentrating on thetreatment of injuries have treatment of injuries have developed. These are known asdeveloped. These are known astrauma centres. The emphasis intrauma centres. The emphasis inAustralia is now, and is likely toAustralia is now, and is likely toremain, on trauma remain, on trauma systems systems rather than trauma centresrather than trauma centres

Each health care area, district orEach health care area, district orregion should establish an region should establish an organised approach to manage-organised approach to manage-ment of injury victims fromment of injury victims frominjury scene to definitive care.injury scene to definitive care.This approach should beThis approach should beintegrated with the area, districtintegrated with the area, districtor region’s disaster response.or region’s disaster response.

Trauma centre vs Trauma Trauma centre vs Trauma serviceservice

VSVS

What is a trauma centre?What is a trauma centre?

An hospital which, regardless of size,An hospital which, regardless of size,is organised for, and committed to,is organised for, and committed to,the delivery of quality care for the the delivery of quality care for the trauma patienttrauma patient

BUTBUT

There are different levels at whichThere are different levels at whichhospitals can provide quality carehospitals can provide quality carefor the injuresfor the injures

A critical element in matching healthcare resources to severityA critical element in matching healthcare resources to severityof injury is the ability to categorise hospitals and otherof injury is the ability to categorise hospitals and otherlocation-based providers of injury care according to theirlocation-based providers of injury care according to theircapabilities. This process has been undertaken in othercapabilities. This process has been undertaken in othercountries and resulted in a description of “levels of care”.countries and resulted in a description of “levels of care”.A principle underlying such categorisation is that any givenA principle underlying such categorisation is that any givenfacility should receive enough trauma patients to be able tofacility should receive enough trauma patients to be able tomaintain the skills, experience and expertise of both the staffmaintain the skills, experience and expertise of both the staffand systemand system

Levels of careLevels of care

Advanced Trauma ServiceAdvanced Trauma Service

An An advanced trauma serviceadvanced trauma service is the hub of the trauma system. The care is is the hub of the trauma system. The care isbased around a comprehensive ICU committed to providing treatment tobased around a comprehensive ICU committed to providing treatment tothe injured. The hospital also has many 24hr/7day resources and is completethe injured. The hospital also has many 24hr/7day resources and is completewith regard to contemporary diagnostic services.with regard to contemporary diagnostic services.

These facilities carry the major responsibility to coordinate trauma servicesThese facilities carry the major responsibility to coordinate trauma servicesin urban and rural areas for given regions. Patients are uncommonly in urban and rural areas for given regions. Patients are uncommonly referred on but may be transferred to a tertiary referral service for thereferred on but may be transferred to a tertiary referral service for themanagement of specific injuries. management of specific injuries. Advanced trauma servicesAdvanced trauma services should provide should providea rapid retrieval and primary response service within their geographic area.a rapid retrieval and primary response service within their geographic area.Access for both road ambulance and helicopter should be readily availableAccess for both road ambulance and helicopter should be readily availablewith direct access to the Emergency Departmentwith direct access to the Emergency Department

What are the problems in What are the problems in organising a trauma centre?organising a trauma centre?

Trauma Service OrganisationTrauma Service Organisation

Problems:Problems: Availability of qualified medical directorsAvailability of qualified medical directors Lack of enthusiasm for committee/guidelinesLack of enthusiasm for committee/guidelines Lack of finance for data system/registryLack of finance for data system/registry

ATS DTS BTS

Medical director of the trauma service E D -A trauma committee E D -Organisation chart E D -Written procedural guidelines E E -Written patient management guidelines E E -Surveillance data systems E D -Injury management data systems E D -

Data collectionData collection

Problems:Problems: Different data setsDifferent data sets Every hospital/region Every hospital/region

wants its own softwarewants its own software No overall directionNo overall direction No national registryNo national registry

END RESULT:END RESULT: The trauma system is The trauma system is

flying blind.flying blind.

StaffingStaffing

Problems:Problems: Ensuring ATLS/EMST training available Ensuring ATLS/EMST training available

programme available and all appropriate programme available and all appropriate staff are given access to attend itstaff are given access to attend it

ATS DTS BTS

Doctors present in the hospital 24 hours E E -Doctors on call 24 hours E E EDoctors with EMST training9 E D DNursing staff with trauma training E E D

(e.g. the Trauma Nursing Core Course, TNCC)

Specialists available for resuscitation and early managementemergency medicine E D -surgery E E -anaesthetics E E -intensive care E D -

StaffingStaffing

Problems:Problems: Ensuring nurses Ensuring nurses

have access to have access to trauma training trauma training

Having all relevant Having all relevant specialties either specialties either available ($) or on available ($) or on callcall

Emergency DepartmentEmergency Department

Problems:Problems: No communications with ambulanceNo communications with ambulance Lack of proximate ambulance accessLack of proximate ambulance access

ATS DTS BTS

ED open 24 hours E E -Radio communication with ambulance E E DAmbulance access (same level) E E EOn site aircraft access E D DTriage on arrival E E EDocumented policies and protocols E E -Research and education programs E D -Designated medical director E E -Specialist doctor (FACEM)

in house or on call 24 hours E D -Trained trauma nurse in charge of nursing

resources for trauma E D -Trained nurses and aides E E DRadiology in proximity E E D

Emergency DepartmentsEmergency Departments

Problems:Problems: No designated medical directorNo designated medical director Lack of specialist staffLack of specialist staff Limited availability of trained nursesLimited availability of trained nurses Poor design of departmentPoor design of department Radiology access not proximateRadiology access not proximate

Intensive Care UnitIntensive Care Unit

Problems:Problems: Lack of commitment to trauma careLack of commitment to trauma care Inadequate bed numbers to meet Inadequate bed numbers to meet

demanddemand Lack of quality (open vs closed unit)Lack of quality (open vs closed unit)

Staffed and equipped in accordance withANZCA P10, (Appendix 4)Minimum Standards for Intensive Care Unit L III L II/I -(L III = Level III)

ATS DTS BTS

Radiology and medical Radiology and medical imagingimaging

Problems:Problems: Lack of priority access to Lack of priority access to

imagingimaging Insufficient funds for up-to-date Insufficient funds for up-to-date

equipmentequipment

Equipment including but not limited toangiography E D -sonography E E -nuclear scanning E D -CT scanning E D -

ATS DTS BTS

Operating theatres and Operating theatres and recovery roomrecovery room

Problems:Problems: Lack of 24 hour capabilityLack of 24 hour capability No priority access to OR 24/7No priority access to OR 24/7 Unavailability of specialised servicesUnavailability of specialised services Lack of specialised equipmentLack of specialised equipment

Staff immediately available 24 hours E E -Specialised equipment

cardiopulmonary bypass capability D - -neurosurgical capability E D -operating microscope D - -on-site X-ray E E -

ATS DTS BTS

Laboratory serviceLaboratory service

Problems:Problems: Lack of commitment to provide emergency serviceLack of commitment to provide emergency service Inadequate supplies of bloodInadequate supplies of blood

Available 24 hours a day E E -Services including but not limited to

standard analyses of blood etc E E Dblood typing and cross matching E E -coagulation studies E E -blood bank E E -blood gas and pH E E -serum and urine osmolality E E -microbiology E E -drug and alcohol screening E E -

ATS DTS BTS

Quality assurance, training Quality assurance, training and researchand research

Problems:Problems: No $s for researchNo $s for research No time/planning for No time/planning for

training programmestraining programmes No enthusiasm for No enthusiasm for

clinical indicatorsclinical indicators

QA organisation structure E D -Use of clinical indicators E D -Trauma outcome studies E D -Trauma research programs E D -Trauma training programs

doctors E D Dnurses E D Dallied health personnel E D D

ATS DTS BTS

RehabilitationRehabilitation

Problems:Problems: Number of spinal units Number of spinal units

does no match demanddoes no match demand True rehab facilities for True rehab facilities for

younger patients hard to younger patients hard to accessaccess

Funding streams for Funding streams for rehabilitation byzantinerehabilitation byzantine

Few rehabilitation Few rehabilitation specialistsspecialists

Excessive delays in Excessive delays in beginning rehab process beginning rehab process reinforcing “sick” reinforcing “sick” behaviourbehaviour

Some general trauma centre Some general trauma centre problemsproblems

Difficulties in retaining and attracting Difficulties in retaining and attracting staffstaff

Determining the best training system Determining the best training system for surgeons who manage traumafor surgeons who manage trauma

Most trauma related services Most trauma related services experience significant in-hospital experience significant in-hospital delays in scheduling surgery for all delays in scheduling surgery for all but the most urgent patientsbut the most urgent patients

Intensive care resources often less Intensive care resources often less than demandthan demand

Transfer to rehab. locations almost Transfer to rehab. locations almost always delayedalways delayed

Funding stream uncertainFunding stream uncertain

SummarySummary

A trauma system is effective at reducing A trauma system is effective at reducing preventable death by 15%-50% (Level III)preventable death by 15%-50% (Level III)

Trauma “centres” are a loose definition which Trauma “centres” are a loose definition which applies to hospitals working within a trauma applies to hospitals working within a trauma system.system.

Trauma “centres” should provide an effective Trauma “centres” should provide an effective trauma service, the key to optimal outcome.trauma service, the key to optimal outcome.

Trauma “centres” and services are problematic Trauma “centres” and services are problematic to run and must be matched to level of to run and must be matched to level of demand and mechanism of injury.demand and mechanism of injury.