New Trauma System for Ireland will lead to better outcomes for patients by making sure they get to the right place, for the right care, first time – Minister Harris

The Minister for Health today published the report of the Trauma Steering Group, A Trauma System for Ireland.

The Minister for Health, Simon Harris TD, has said that the new Trauma System for Ireland will lead to better outcomes for patients by making sure they get to the right place, for the right care, first time. The Minister today published the report of the Trauma Steering Group, A Trauma System for Ireland, following Government approval.

Minister Harris said:

The report recommends the establishment of an inclusive trauma system which will include two regional trauma networks, one Central and one South. There will be one designated Major Trauma Centre in each of these networks, which should treat a minimum number of major trauma patients in order to maintain a critical mass of specialist expertise. The networks will also include a number of other Trauma Units and, in addition, a Trauma Unit with Specialist Services, which will also deal with trauma cases. This approach of an inclusive trauma system with two networks recognises both the geographical spread of our population and current hospital configuration.

Major trauma involves complex injuries that have the potential to cause prolonged disability or death – estimates are that around 1,600 patients a year in Ireland suffer major trauma. While this is a small number within more than 1.1 million Emergency Department attendances, it is essential that these patients receive the right care in the right place, first time.

At the moment we do not have a trauma system in Ireland. We have Emergency Departments that are equipped to a greater or lesser extent to deal with trauma, and we have pre-hospital emergency care services that bring people to those hospitals without having adequate clear protocols around trauma. This means that currently, patients may present to any acute hospital, regardless of how much expertise and experience in trauma exists there. We know that patients often need to be transferred to a second hospital to receive definitive care for their injuries. This can mean delays in decision-making and treatment that can result in poorer outcomes and preventable disability or death. Internationally, the evidence is clear – the introduction of a trauma system is associated with a reduction in death and disability.

Minister Harris said:

The Minister also noted the important role of the Major Trauma Audit:

Patients who have used trauma services and clinicians were at the heart of the development of the report.

The Chair of the Trauma Steering Group, Professor Eilis McGovern said:

Colm Whooley, former CEO of Spinal Injuries Ireland, a former patient involved in the development of the Report, said:

The Director General of the Health Service, Mr Tony O’Brien, welcomed the publication of the report and said:

ENDS

On 20 July 2017, the Trauma Steering Group established by the Minister in 2015 completed its final report, which was submitted for the Minister’s consideration and approval.

Background

The Trauma Steering Group, established in 2015 and chaired by Professor Eilis McGovern, was tasked with examining the international evidence base with regard to the most efficient and effective organisation of trauma services, in order to reduce preventable death and disability, and to improve patient outcomes.

Summary of the report

Major trauma involves serious and often multiple injuries which have the potential to cause prolonged disability or death. Major trauma cases are typically a very small part of the total number of trauma cases (estimated to be fewer than 1 in 1,000 ED admissions). Estimates suggest Ireland is likely to have 1,600 major trauma cases per year. Currently, significant numbers of major trauma patients go to hospitals that cannot provide necessary and definitive care.

Trauma systems may be exclusive or inclusive. In exclusive Trauma Systems, the focus is predominantly on Major Trauma Centres. An inclusive Trauma System is a network of facilities co-operating in the care of injured patients.

Inclusive trauma systems have been demonstrated to provide better patient outcomes than exclusive systems. In addition, geographically dispersed and less densely populated regions, such as Ireland, are likely better served within an inclusive trauma system. There is a large body of evidence on the benefits of providing trauma care as part of an integrated and inclusive trauma system. The report of the Trauma Steering Group recommends an inclusive hub-and-spoke trauma system for Ireland.

Key Recommendations

The Steering Group recommends the establishment of an inclusive trauma system, and sets out key recommendations for the organisation of trauma care and the provision of patient-centred trauma services. It takes a whole system approach addressing the five phases of the trauma care pathway including prevention, pre-hospital care, acute hospital care, rehabilitation and supported discharge, as follows:

• Prevention: Much can be done to reduce the incidence of trauma and this should be a priority. Trauma prevention includes cross-sectoral initiatives and strategies such as road safety, workplace safety, tackling violence, reducing self-harm and preventing falls.
• Pre-hospital care and retrieval: The report sets out the requirement for pre-hospital transport protocols, to ensure that individual trauma patients are brought to the most appropriate facility and receive the right treatment in the right place at the right time, and makes recommendations on the development of retrieval services. It also recommends the need to examine how existing Helicopter Emergency Medicine Service (HEMS) resources can be developed.
• Reception and intervention: Reception and intervention involves all the immediate urgent surgical interventions provided within the hospital setting. A lack of staff with sufficient experience in the initial receiving trauma team can lead to delayed and/or incorrect decisions, delays in treatment and for the patient, disability or death which could have been avoided. Given that a patient that has suffered major trauma is likely to have multiple injuries, it is critically important that a number of specialists are available on a 24/7 basis. The immediate availability of diagnostics, theatre and ICU capacity is also required.
• Reconstruction and ongoing care: The reconstruction and ongoing care phase of the trauma care pathway commences immediately after resuscitation and urgent surgery following admission, and continues until the patient is discharged from the acute setting. The co-ordination of care provided by a number of specialties is critical to the provision of person-centred care. Trauma & orthopaedic surgery and plastic surgery are particularly relevant.
• Rehabilitation: Trauma patients with early access to rehabilitation will have better outcomes. All trauma patients will need to be able to access specialist senior opinion and have their needs assessed within 48 hours of admission to the acute setting, generating a flexible personal prescription for rehabilitation to accompany them as they transition through the trauma care pathway. Following discharge, major trauma patients may need coordinated regional and community rehabilitation services and long-term supports to meet their needs.

It should be noted that the report addresses the provision of trauma care for adults. The provision of trauma care for children has been considered separately by the relevant National Clinical Programmes, and in the context of the development of the new children’s hospital which will be the paediatric Major Trauma Centre.

Organisation of acute hospital services for trauma patients

By international standards, Ireland could have one trauma network with one Major Trauma Centre linked to a number of Trauma Units. However, given the geographical spread of the population, and current hospital configuration, the report recommends the establishment of a trauma system consisting of two regional trauma networks (Central and South). Each will have a designated Major Trauma Centre, which should treat a minimum number of major trauma patients in order to maintain a critical mass of specialist expertise. Networks should also include a number of Trauma Units. The report recommends that:

• Cork University Hospital be the Major Trauma Centre for the South trauma network, subject to meeting proposed designation criteria
• A hospital in Dublin be selected as the Major Trauma Centre for the Central trauma network
• University Hospital Galway be considered for designation as a Trauma Unit with Specialised Services within the Central Trauma Network
• Hospitals outside of Dublin with 24/7 emergency departments and with trauma and orthopaedic surgery onsite be considered by the HSE for designation as Trauma Units
• A maximum of two hospitals be selected as Trauma Units in Dublin, in addition to the Major Trauma Centre

Other hospitals with 24/7 Emergency Departments (Local Emergency Hospitals), which do not have the required range of services or expertise to safely manage major trauma patients, should continue to treat injuries of lesser severity within the Trauma Networks, as well as non-trauma related illnesses requiring urgent treatment. Injury Units should continue to treat injuries of lesser severity that are unlikely to need admission to hospital.

Immediate next steps

The report sets out immediate actions to be commenced within the first three months of implementation:

• The recruitment and appointment of the National Clinical Lead for Trauma Services, and establishment of the National Office for Trauma Services within the HSE will allow for detailed implementation planning. This is provided for in the National Service Plan 2018.
• For patients with orthopaedic trauma injuries, bypass protocols should be put in place immediately. It is of note that by-pass protocols for fractured neck of femur have already been put in place by the HSE and the National Ambulance Service (NAS).
• Hospital Groups in the Dublin region will be invited by the Department of Health and the HSE to submit proposals for nominated hospitals to be considered for designation as the Major Trauma Centre. It is anticipated that international expertise will be required in the evaluation of proposals and recommendation of a hospital for designation as a Major Trauma Centre.

Major Trauma Audit

• The Minister for Health approved the endorsement of the National Office for Clinical Audit’s Major Trauma Audit in December 2016 as the first national clinical audit to be published as an NCEC National Clinical Audit. The 2016 report of the Major Trauma Audit was published on 31 January last.
• The conduct of good quality clinical audit can improve health for patients by measuring their health outcomes and the processes they undergo within the health system, against a standard that has been informed by best available evidence, often in the form of a guideline. From audit, variations in practice can be identified and the audit data used to inform quality improvement before re-measurement occurs.
• It is intended that implementation of NCEC National Clinical Audit informs local improvement, allows comparisons, and provides valuable information for strategic planning of services at national level. Endorsed and published NCEC National Clinical Audit will also inform and reassure patients that the care they are receiving is being monitored and evaluated in a systematic, robust manner.