Implement national trauma system for Ireland

The prioritised implementation of a national co-ordinated trauma system for Ireland has been urged by the Major Trauma Audit Governance Committee, writes Maureen Browne.

This national trauma system was proposed in February 2018 in a report to government by the Trauma Steering Group.

Key recommendations of that report were pre hospital care and transport protocols to ensure individual trauma patients would be brought to the most appropriate facility, two regional hub-and-spoke Trauma Networks, each with a designated Major Trauma Centre, designated trauma units and a strong focus on comprehensive patient centred rehabilitation services.

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When compared to international standards, there were deficits in clinical care identified, including low levels of consultant-led trauma teams receiving severely injured patients.

The prioritised implementation of this new system has now been called for in the NOCA Major Trauma Audit National Report 2017.

The report launched by RCSI President, Mr Kenneth Mealy in February, presented data from 5,061 patients across 26 trauma receiving hospitals in Ireland. This represented 86% of all major trauma patients in 2017.

The Major Trauma Audit (MTA) National Report focused on the most severely injured patients in the Irish healthcare system.

It revealed:
When compared to international standards, there were deficits in clinical care identified, including low levels of consultant-led trauma teams receiving severely injured patients, poor adherence with National Institute for Health and Care Excellence (NICE) head injury guidelines for time to computed tomography (CT) imaging and low levels of direct admission to neurosurgical care in moderate and severe traumatic brain injury
cases.

Many patients in the Irish setting continued to be brought to hospitals that did not have the services on site to manage their injuries.

Twenty one per cent of patients required transfer to another hospital for ongoing care.

Only 11% of patients were received in hospital by a trauma team.

Only 9% of major trauma patients were documented as having been reviewed by a consultant within thirty minutes of arrival to ED.

Fifty eight per cent of patients arrived to the Emergency Department between 4pm and 8am outside of ‘normal working hours’.

Patients brought to Model 4 hospitals were more likely to receive the definitive care they required.

Major trauma patients in the younger age groups were more likely to be pre-alerted, received by a trauma team, seen by a consultant in the emergency department and transferred to another hospital for further specialist care.

Road trauma accounted for 17% of all trauma in the report. Car occupants accounted for 49% of road trauma, of whom 69% were in the driver’s seat. Twenty per cent of road trauma patients were cyclists, 17% were pedestrians and 12% were motorcyclists.

Among patients aged 15–44 years, the most common mechanism of injury was road trauma

Pedestrians continued to have the highest percentage of severe injuries caused by road trauma (52%).

The leading causes of mortality in major trauma patients in the younger age groups were ‘other’ (which may refer to asphyxiation, drowning, or amputation) and road trauma.

In 2017, there were 269 patients who died from their injuries after arrival at hospital.

One in two patients sustained their injury in their own home.
Ninety five per cent of major trauma patients survived.

Fifty seven per cent of patients who had surgery, had surgery on a limb/s.

The highest proportion of deaths occurred in patients who were aged 75 years and over.

There was a further increase in the mean and median age of major trauma patients to 58 and 61 years, respectively. The age profile of major trauma patients has important implications for healthcare planning.

We need to address the epidemic of low falls in the home through engineering, medical and societal approaches.

The majority of major trauma in Ireland was caused by a low fall of less than 2 metres (57%). Low falls were the most common mechanism of injury for patients aged 45 years and older and for children.

Forty four per cent of major trauma was sustained in patients over the age of 65 years. Older major trauma patients had more complex medical needs. The report showed that they did not receive the same level of response as younger patients with the same severity of injury and had considerably worse outcomes.

Only 60% of major trauma patients were discharged directly home following their hospital admission.

Dr Conor Deasy, Clinical Lead for Major Trauma Audit said: “This report tells us that our homes are dangerous places, especially for older people. We need to address the epidemic of low falls in the home through engineering, medical and societal approaches. We have NCTs to ensure car and road user safety; should we have something similar for our homes, given the burden of injury associated?”

NOCA was established in 2012 to create sustainable clinical audit programmes at national level. NOCA is funded by the Health Service Executive Quality Improvement Division, governed by an independent voluntary board and operationally supported by the Royal College of Surgeons in Ireland.