Elsevier

Health & Place

Volume 5, Issue 1, March 1999, Pages 99-110
Health & Place

Trauma systems and major injury centres for the 21st century: an option

https://doi.org/10.1016/S1353-8292(98)00042-2Get rights and content

Abstract

Trauma, especially involving accidents and falls is now the leading cause of death in the UK in the first four decades of life. This paper looks at the existing pattern of Accident and Emergency Units and suggests that because it has grown up in a fragmented and poorly co-ordinated fashion and because it is subjected to demands that it was not designed for, it is inadequate in dealing with the most severe injury cases. Following collaborative work with researchers at the North Staffordshire Hospital, the authors propose a system of thirty major trauma centres to cover the whole of the UK. Each would deal with the most severe accident cases from surrounding hospitals. Using data from the census and from health authorities, analysed within a GIS environment, a locational pattern for these centres is suggested and their catchment areas are outlined.

Introduction

The UK has a relatively low death rate from accidents when compared with other countries (Table 1). Even so, total deaths from accidents exceed 10,000 per annum. Typically this figure divides approximately equally between accidents in the home and those on the roads, with accidents at work accounting for only around 8% (Department of Health, 1991, Department of Health, 1992). Trauma1, especially involving accidents and falls, is now the leading cause of death in the UK in the first four decades of life. As well as the personal tragedy involved, the impact upon population cohorts in their most productive working years of life represents an issue of major national concern in social and economic terms. The Health of the Nation Report published by the Department of Health (1991)established targets for reducing deaths from accidents among both young (15–24 years) and old (over 65 years) people by at least 33% from 1990–2005. Accident prevention is clearly one mechanism by which this can be achieved, but improved treatment of major injury cases can provide a parallel mechanism.

In dealing with major injuries, experience shows that the immediate pre-hospital treatment and rapid transfer to an appropriate treatment centre, especially in the hour or two following an accident, is particularly important. When plotted as a function of time after injury, death from trauma has been shown to have a trimodal distribution (Trunkey, 1983). The first peak represents people who die upon or immediately after an injury, typically from lacerations of the brain, spinal column or major organs. The third peak represents deaths within a few days or weeks, where the cause is often infection or multiple organ failure. In both cases the interval between injury and definitive treatment is arguably less of a factor than the quality of medical care. However, for those deaths occurring around the second peak, i.e. within the first few hours, many could be prevented by rapid transfer to an appropriate treatment centre. This is because such deaths are usually caused by major internal haemorrhages or by multiple lesser injuries resulting in severe blood loss, conditions which respond well to prompt, definitive surgical intervention. It is important that triage and treatment of the highest quality is available in such situations, so, it is argued transfer to a specialised trauma centre, will be the best option even if it involves additional journey times over the nearest and perhaps unsuitable hospital. Recent research in rural Norfolk found no relationship between outcome and time taken to convey road traffic victims to hospital (Jones and Bentham, 1995). This raises issues about the organisation and location of Accident and Emergency (A&E) Units where such cases are treated and the nature of the ambulance (including helicopter) and paramedical services. This paper reviews some of the evidence in favour of major injury centres, briefly examines the nature of A&E services and makes proposals for a significant reorganisation of the system along the lines of major trauma centres.

At present there are 318 A&E units in the UK, handling 12.2 million new admissions per year (Directory of Emergency and Special Care Units, 1996). In fact many of these are peripheral or minor injury units and an alternative figure of 227 major departments is quoted by the Audit Commission (1996). These departments vary greatly in size, case mix and facilities. A significant number, especially in remoter rural areas see fewer than 20,000 new patients a year, whilst there are around ten or a dozen large units that admit over 80,000 new patients annually. Clearly the size has a bearing upon the range of facilities that can be supported and affects the development of skills and experience among staff. Large numbers of admissions are for relatively minor injuries; for example in England and Wales, approximately one third are for cuts, bruises and sprains according to the Audit Commission (1996). Less than half of 1% of patients have life threatening injuries and only 15% require immediate in-patient admission. There is evidence to suggest that seriously ill patients are likely to achieve a less good outcome, including survival, if they are treated in small units where specialist expertise is less available (Audit Commission, 1996, p. 63).

There is also a wide body of evidence to suggest that many problems are occurring with the current organisation of A&E units, both in Britain and elsewhere. In the USA, for example many emergency departments are at crisis level, with a rapid growth of serious injuries, especially related to drugs and violence, from overcrowding and underfunding and from misuse for primary care, often by patients who have inadequate medical insurance. Whilst not all of these conditions are experienced in A&E units in Britain, there are problems over inappropriate attendances, waiting times, staffing levels, delays in reaching a hospital bed and concerns about the quality and appropriateness of treatment. In addition to some of the problems identified in England and Wales by the Audit Commission, the Scottish Trauma Audit Group (1995)concluded that the management of seriously injured patients in Scotland could be improved upon significantly, especially by avoiding delays in transferring patients to appropriate hospitals and by ensuring the provision of experienced staff.

From considerations such as these there have come a number of recommendations concerning the size, location and organisation of A&E units, extending in some cases to the establishment of major injury or Trauma Centres.

The Audit Commission, for example, recommended that 50,000 new cases per year would be the minimum to justify the cost-effective provision of a full range of 24-h support services, but pointed out that only one third of units are currently of this size. Over half of all A&E units in England and Wales are within 16 km (10 miles) of another A&E unit and the spatial pattern owes as much to historic patterns of population and hospital organisation as it does to current need. There are marked variations across the country in the distribution of A&E departments and in the size of area and the population which they serve. A major issue within the argument for consolidating on larger centres is to ensure that a full range of both services and specialities are available to treat the most serious injuries. Even in large hospitals the full range of facilities may not be available, or there may be a dislocation with key facilities located in different hospitals in the same town. Only 25 acute hospitals have Neurosurgery departments on site as well as A&E departments and only six of these have the full range of surgical services. It is also important to achieve a sufficient throughput of cases to ensure effective use of facilities and the enhancement of skills and experience amongst the clinical staff.

However, concentrating solely upon what happens when the patient reaches hospital is not adequate. The question of getting the patient from the scene of the accident to the most appropriate centre as quickly as possible must also be considered. This includes better communication with ambulance and para-medical staff, quick and accurate diagnosis of need, good communications between hospitals and, where appropriate, speedy referral from feeder hospitals to larger and better equipped A&E units.

In North America similar issues have been addressed over a number of years. In Calgary, for example, a major trauma centre has been established at the Sunnybrook Medical Centre since 1976. Considerable success has been claimed for this programme, based largely upon early stabilisation of patients followed by speedy transfer from the referring hospitals (McMurtry et al., 1989). Also in the 1970s a study of motor vehicle accidents in California suggested that survival rates were improved by an organised system of major trauma centres (West and Trunkey, 1979). Further impetus was provided by a series of studies by Cales and colleagues in Orange County California (Cales, 1984).

Section snippets

The Trauma Centre debate

The acceptance of the concept of trauma centres in the USA came with the Trauma Care Systems Planning and Development Act of 1990, following which state wide systems of major trauma centres were commenced. To an important extent these were based upon purely medical elements, such as adherence to the American College of Surgeon's standards and the adoption of written triage criteria, but it was necessary to go outside of clinical expertise to establish an authority responsible for trauma centre

Proposals for a new system of Trauma Centres

The present study, undertaken jointly with colleagues at the School of Postgraduate Medicine at Keele and at the Institute of Health Services Management, aims to move this debate forward by proposing an option for the provision of trauma systems and major injury centres across the UK. The importance of a comprehensive strategy for all patients who suffer injuries should be stressed. These will range from very severe life threatening injuries, through the large range of musculoskeletal injuries

A first approximation

In seeking a set of locations to serve as system hubs we have favoured those hospitals already supporting a set of emergency facilities most closely resembling the desired core set. Likewise, hospitals associated with university teaching have been advantaged in order to build upon multi-disciplinary research in injury treatment and to fulfil responsibility for undergraduate and postgraduate teaching of trauma management. Finally, the choice of system hubs has been governed by those locations

The revised systems

In the light of these findings the initial set of 28 systems was extended to 30 by the inclusion of an additional acute tertiary hospital in north London to better cover the area to the north west of the capital, and in Norwich to provide better service in East Anglia. The system covering South Wales was also modified by moving the hub from Cardiff to Swansea. The revised list of systems, together with the cities where trauma centres would be located is given in Table 2.

As well as seeking out

Characteristics of the trauma systems

The 30 trauma systems proposed from this exercise range in (1991) population size from North East Scotland (737,492) and Coventry (778,634) at the lower end of the scale to Birmingham (3,120,877) and North Central Thames (2,862,509) at the other. The median system population is very close to the figure of two million originally envisaged. In terms of physical size individual systems range from the smallest, North West Thames, at approximately 750 km2, to the largest, North East Scotland

Conclusions

In proposing this system of 30 major trauma centres to cover the whole country we are aware that some problems have not yet been addressed and several loose ends remain. Some of these problems are organisational ones. For example in some of the systems that we have proposed there are historical patterns of referral that result in different problems being sent to different major hospitals; for example from the Inverness area neurosurgery cases are commonly referred to Aberdeen, but

Acknowledgements

This work was carried out in conjunction with Professor John Templeton and Sylvia Bickley from the Postgraduate Medical School at Keele University and Guy Howland, then with the Institute of Health Services Management, but the contents of this paper are the responsibility of the named authors.

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