Introduction

While skilled surgical attention is critical in achieving the best possible outcomes for patients with vascular trauma, the clinical effect of surgeons will be diminished if care is not rendered within systemized pathways and established clinical networks that assure the philosophy of “the right care at the right place at the right time.” This chapter will explore the function and characteristics of contemporary trauma systems, using recent military experience as an example, in order to emphasize the necessity of systems-based approaches when seeking to provide optimal care for the patient with vascular injuries.

Trauma Systems Overview

Managing severe injuries requires the timely intervention of multidisciplinary teams across the patient pathway. Fundamentally, trauma systems save lives by rapidly delivering critically injured patients in optimal conditions to specialist surgical teams, with a 10% to 20% reduction in mortality compared to nonspecialist centers.

Patients with vascular injuries are among the prime beneficiaries of the organized delivery of trauma care. The early delivery of patients with active hemorrhage or ischemic limbs to a multidisciplinary vascular-trauma service can save lives and limbs. Because major trauma centers are also likely to be colocated with the regional vascular centers, there is considerable overlap in the personnel, expertise, resources, and infrastructure required to deliver complex trauma care and complex vascular care. These synergies can improve outcomes for trauma patients and nontrauma emergency vascular patients alike.

A regional trauma system is a public health model that manages injury for a defined population. The system manages trauma as a disease entity. The system covers the whole patient pathway, from prehospital care through acute management and into the reconstruction and rehabilitation phases. Included in the public health approach is a responsibility for injury prevention in order to actively reduce the burden of disease to the population. It is crucial that there be a strong commitment to system-wide data collection and analysis, which are used as core enablers for performance improvement.

It is essential to recognize that a trauma system is not the simplistic designation of a “Level I trauma center” conjoined to bypass protocols that send all injured patients to this hospital. While this model improves care for the severely injured patients treated within these centers, it may actually worsen outcomes for less severely injured patients treated within the same center. Patients with mild or moderate injuries—who constitute 85% of all trauma patients—will suffer from deprioritization within an overloaded hospital. Systems that comprehensively address the needs of patients within a given area (so-called “inclusive trauma systems”) incorporate all acute hospitals in a region and have been shown to produce better outcomes for a patient population. Hospitals in an inclusive system are designated according to their capabilities and institutional commitment. In the United Kingdom, centers are designated as major trauma centers (MTCs), which manage severely injured patients, and trauma units (TU) which manage mild and moderately injured patients ( Fig. 3-1 ). In the United States, more levels of capability are designated within a system (Level I to Level IV); and other countries have similarly tiered levels of care.

Regional trauma system overview.

Key Components of a Trauma System

The core purpose of a regional trauma system is to reduce death and disability following injury. However, systems also must make efficient use of resources and must be financially and logistically robust. Not all hospitals can be staffed and equipped to manage all injuries. Major trauma patients must be identified early in their clinical courses and directed to complex multispecialty care in a flexible and “error-tolerant” system that can deliver high quality clinical outputs. Key facets of a trauma system therefore include the following:

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  A regional system integrating hospital and prehospital care to identify and deliver patients to a place of definitive care quickly and safely

  
  
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  A specialized regional trauma center that has responsibility for the management of all injured patients in the region

  
  
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  A prehospital care system closely integrated into the trauma system, with defined triage and bypass protocols

  
  
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  A network of hospitals with defined capability and capacity, and with predetermined transfer agreements for optimizing casualty flow

  
  
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  Acute rehabilitation services to improve outcomes and restore casualties back to productive roles in society

  
  
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  A continuous process of system evaluation, governance, and performance improvement across the network

  
  
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  Ongoing training and education for all health-care professionals involved in the care of injured patients

  
  
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  An active injury prevention program to reduce the burden of injury for the population that the network serves

  
  
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  A responsibility toward research into trauma and its effects, to continuously improve care and outcomes following injury

  
  
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  A system-wide response to disaster and mass casualty incidents

The first functions of the system are to identify each trauma patient as soon as possible in their clinical course, to render appropriate treatment, and to ensure swift transfer to the most appropriate facility. In the case of major trauma, this will usually involve directing the patient from the point of wounding directly to the nearest MTC. However, the system must ensure that the minority of severely injured patients who are transported to TUs—because they are conveyed by friends or bystanders, or because local prehospital triage protocols are misapplied or function poorly, or because patients are decompensating too rapidly to survive the longer journey—are not disadvantaged. TUs therefore must maintain trauma capacities and skills in early resuscitation and damage control and must offer a clear and rapid pathway for secondary transfer of the patient to the MTC. An important feature of inclusive systems is MTC “ownership” of the severely injured patient. The MTC has responsibility for the transfer of patients from TU to MTC and thus must either accept the patient (usually regardless of MTC bed state) or must arrange transfer to a neighboring MTC (if there are exceptional capacity issues). Patients may be transferred in a very unstable condition, and there must be expertise within the system to provide this assurance of care.

The MTCs must have a demonstrable institutional commitment to the delivery of specialist trauma care. Infrastructure must ensure timely availability of the required specialist services, a consultant-led trauma team, a trauma service that manages the ongoing care of all trauma patients, and a performance improvement structure. The MTC has a clear responsibility to the population of the whole regional system, not just to patients within its physical walls. The MTC assumes a leadership role across the network in trauma training, education, and research and leads injury prevention programs relevant to its patient population.

The system also incorporates acute and chronic rehabilitation services. Patients managed in the MTC are repatriated to their local community as soon as possible following definitive care. This maintains capacity within the MTC while ensuring that patients can access appropriate community teams. Rehabilitation services are integrated across the region so that there is seamless provision of services as the patient moves along the care pathway.

The whole system is monitored by a clinical governance and quality improvement (QI) program. QI can be conceptualized as follows:

A method of evaluating and improving processes of patient care which emphasizes a multidisciplinary approach to problem-solving, and which focuses not on individuals but on systems of patient care that may be the cause of variations. QI consists of periodic scheduled evaluation of organizational activities, policies, procedures, and performance to identify best practices and target areas in need of improvement and includes implementation of corrective actions or policy changes where needed.

Trauma QI is not merely the province of mature systems in well-resourced settings. The principles are equally applicable to trauma care in low- and middle-income countries.

This key element monitors the health of the system against a series of performance indicators. Through proper injury stratification of treated populations, these performance indicators can be compared with regional or national norms. Deficiencies in the system are identified and resources, pathways, training, or other interventions developed and then implemented. This process occurs at a regional level but also within each MTC, TU, and ambulance service. Importantly, a regional system delivers trauma care that achieves these benchmarks with local solutions that reflect its own particular geography, resources, and capabilities. Provision of quality care is linked to both designation status and financial reimbursement. It is possible for MTCs to lose their status, and for TUs to become minor injury units if they cannot demonstrate quality care and a commitment to performance improvement.

There is now a large body of evidence to show that the institution of a regional trauma system can rapidly improve outcomes for trauma patients, reducing mortality by around 40% and reducing preventable deaths to below 1%, while optimizing resource use and reducing costs. Inclusive trauma systems have been implemented in many regions around the world, including parts of the United States, Canada, Australia, Holland, and Germany. Alone, MTCs can reduce mortality from severe injury by around 20%. There is a volume effect in addition to changes in service configuration, and MTCs that see more than 650 major trauma patients a year seem to have an additional outcome benefit. Incorporating MTCs within an inclusive trauma system consistently achieves an additional 20% reduction in mortality. With inclusive systems, the benefit is for an entire region rather than for only those patients managed in the MTC.

The Victoria State Trauma System in Australia recently reported their experience with instituting a regional trauma system for a population of approximately 5 million with around 1400 major trauma patients a year. One pediatric and two adult hospitals were designated as MTCs, 18 hospitals were designated as TU equivalents, and the remaining 117 hospitals were also assigned roles within the system. Within 3 years, the system was able to demonstrate a 38% reduction in the risk of death for patients treated by the trauma system.

The provision of regional trauma systems is inexpensive compared to other interventions in modern health care. The cost per disability-adjusted life year (DALY) saved by a trauma system is estimated at around $2500 compared to, for example, preventive cardiovascular interventions such as aspirin ($22,000) or statins ($245,000) for patients over 50 years of age; dialysis ($50,000) or transplant ($10,000) for end-stage kidney disease; and tamoxifen ($124,000) or Herceptin ($210,000) for breast cancer. Additionally, it has been demonstrated that instituting a system to optimize trauma care has significant beneficial effects on the management of all emergency patients by reducing wait times in the emergency department, improving access to operating rooms, reducing bed stays, and improving outcomes.

Trauma Center Function

When a hospital is designated as a regional trauma center, it accepts responsibility for the delivery of injury care to all people living and working within its catchment area. The trauma center has a duty to ensure that injured patients will receive high-quality trauma care at the most appropriate hospital and in a timely manner. Further, it is responsible for the continuum of care, from the first prehospital response through completion of rehabilitation, including the quality of care received at other trauma-receiving hospitals within its region. The center also has a public health duty to reduce the injury burden through injury prevention activities for its population.

The volume and type of work that a trauma center receives is important and must be carefully planned and monitored. There is a strong relationship between outcome and the volume of major trauma patients seen, with up to 50% improvements in mortality observed in the highest-volume trauma centers. Thus the population base that a regional center serves must be large enough. It is recommended that, at a minimum, trauma centers should admit a minimum of 250 severely injured trauma patients per year (and ideally 400-600). This equates to one trauma center for each 3-4 million people depending on regional differences in injury load and specific geographic concerns. Having too many centers that see too few patients is detrimental to a trauma system and patient outcomes—as experienced by several cities in the United States and Australia.

Conversely, a trauma center cannot manage all injured patients within its region. Most patients do not have major trauma or multisystem injuries and will overload a single unit, reducing overall outcomes. These patients are managed more efficiently in secondary trauma receiving units (TRUs). These are part of the regional trauma system and are held to the same standards of care, but will not have all specialties and may not have dedicated trauma services. The links between a regional specialist center and the secondary trauma centers within a region must be robust and assure patient care, education, and clinical governance across the locality. Transferring patients to a higher level of care is based on clinical imperative, not on the current availability of resources (e.g., intensive-care beds) at the TU. At all times, the responsibility for delivery of trauma care rests with the regional unit.

Trauma specialist centers have all surgical specialties (including interventional radiology) required for the care of multisystem trauma patients on-site and in-house, 24 hours a day. There is capacity and expert support from diagnostic radiology, transfusion, critical care, rehabilitation, and other allied services. However the mere presence of these services will not be sufficient for designation as a regional specialist unit, because improvements in outcomes and the process of care are only seen when the overall responsibility of the care of trauma patients is managed by a specialist trauma service.

The function of the trauma service is to provide expert care for trauma patients, integrating the care of multiple teams and advocating for patients, both within the hospital system and during ongoing community care. The service is responsible for trauma education to all staff involved in trauma care, ensuring appropriate certification and ensuring that best-practice guidelines are understood and implemented. Typically the service will review all trauma patients following admission and will perform a tertiary survey and radiology review. Patients with a single system injury (e.g., isolated brain injury, femur fracture), may be signed off on by the service to the care of a specialty team, but patients with combined injuries (brain injury and femur fracture) remain under the care of the trauma service with appropriate specialty input. The final responsibility to ensure delivery of quality trauma care remains with the trauma service for all admitted patients.

The trauma service is a multidisciplinary team made up of surgeons, specialist nurses, occupational therapists, physiotherapists, data collection staff, and administrative staff. Internationally most systems are headed by trauma-trained general surgeons, but there are regional variations. More importantly, there are dedicated trauma specialists within all surgical specialties (anesthesia, critical care, radiology, transfusion) who interface with the trauma service and their departments. Trauma program managers, trauma-nurse coordinators, and nurse case managers are central to the daily activities of the service, while the data collection and analyses staff monitor the health of the system.

The glue that binds and assures all facets of a trauma center’s activities is its performance improvement program, which includes clinical governance and quality-assurance monitoring. Trauma center standards are set as quality, process, and outcome measures. For example, patients with intraabdominal hemorrhage would have quality targets such as “be met immediately by a consultant-led, fully ATLS–qualified trauma team” and “immediate availability of ultrasound in the resuscitation room.” Process standards would include “time to emergency laparotomy of less than 1 hour,” and outcome standards would include posttrauma laparotomy complication rates and mortality outcomes compared to other national trauma centers. This requires a trauma registry and data collection system to identify variances from these standards, as well as a robust peer-review program to review the deviations and to implement change within relevant departments. How each trauma center actually achieves these targets requires a local solution, which will be different for each institution.

Turning a multispecialty hospital into a specialist trauma center is not a trivial task, and it involves a significant investment in staff and resources, as well as changes in the delivery of health care and clinical governance. The ideology of the specialist center as being responsible for its entire population base is at variance with the ivory-tower mentality of most specialty units in large academic institutions. Managing the interface between other hospitals in the region and prehospital care providers requires commitment, communication, education, and a lot of hard work. Despite this, the cost of implementing trauma specialist centers and regional systems is very cheap, and the potential savings due to minimized disability result in a net gain for society.

Trauma Systems in Combat Casualty Care

United States, United Kingdom, and other NATO military medical forces deployed in support of Operations in Iraq and Afghanistan have provided continuous combat casualty care for more than a decade at the time of publication. Initially, this medical response lacked a cohesive and structured approach. Referencing the positive impact of civilian trauma systems on patient outcomes, a group of military clinicians advocated a theater trauma system based on the civilian model. The United States Central Command (CENTCOM) implemented an inclusive system of trauma care in its theater of combat operations, designated as the Joint Theater Trauma System (JTTS). The United Kingdom’s Defence Medical Services reached a similar conclusion and began an independent yet strikingly similar endeavor to build an ad hoc trauma system for its forces engaged in Iraq and Afghanistan. The stated vision of the JTTS was to ensure that every soldier, marine, sailor, and airman injured on the battlefield had the optimal chance for survival and had maximal potential for functional recovery: the right patient to the right care in the right place at the right time. Although the epidemiology of military trauma differs from civilian experience, the structure, function, and role of the JTTS is largely modeled after the civilian trauma system principles, as outlined in the American College of Surgeons Committee on Trauma (ACS COT) Resources for the Optimal Care of the Injured Patient . This document identifies criteria for civilian trauma care resources and practices for optimization of standards of care, policies, procedures, and protocols for care of the trauma patient. The content of the manual provides guidance for medical care personnel from the prehospital arena, through hospital and subspecialist care. The ACS COT Verification Review Committee (VRC) was initially developed in the early 1970s and functions as the oversight process and verifying entity for the American trauma care system.

Following the example of the ACS COT, the JTTS identifies and integrates processes and procedures to enable recording of trauma patient–related data at all levels of care to promote continual process improvement. This essential data facilitates prediction of needed resources, evaluation of outcomes, education, and training needs in order to improve continuity of care across the combat care continuum and to facilitate real-time changes (based on data) in these conflicts. Oversight and direction for the theater trauma system above Level I is directed by the CENTCOM surgeon. The US-based parent organization, now known as the Joint Trauma System (JTS), embraces the system concept for the entire continuum of care from point of injury to medical facility and onward to rehabilitation in continental U.S. facilities. A philosophy of continuous improvement has driven and matured the system; and it now exceeds the capabilities of the U.S. trauma care system on which it was modeled.

After 8 years of continuous development, the JTTS has arrived at a crucial junction, and it is imperative to codify this experience for all future Department of Defense (DoD) deployed medical operations and to maintain its existence through funding, planning, and staffing. This will ensure that the benefits of the current system will be available to future surgeons working in conflict situations and will ensure that corporate memory is preserved.