Best Practice in Trauma Care in Australia
Danny Cass
Outline
Best Practice in Trauma Care in Australia
Danny CASS
CEO
Institute Trauma and Injury Management (ITIM)
NSW
Patient Journey Model
Patients (Minor / Major)
Resources
Equipment
Providers
System (Plans)
Hospital
Health Area
Region/State
National
Best Practice in Trauma Care
Public Health Model
Prevention
Avoidance
Injury minimisation
Care
Scene
Transport
Definitive
Rehabilitation
Data
Collect
Analyse
Plan
Implement
Measure
Best Practice in Trauma Care
Australian experience in planning
Each State has made it’s own plan
NSW: Regional plan 1992: under review-stalled
Victoria: Ministerial committee 1999
Queensland: RACS trauma committee 2006
Western Australia: External reviews (x3)
South Australia: Internal review - forgotten
No Federal Government National Plan
Best Practice in Trauma Care in Australia
Simple
The most critical part of optimal trauma practice is rapid transport from scene to definitive care.
Injured patients have possible life saving intervention at the scene, or stop off at suitable hospitals for this.
Best Practice in Trauma Care
Implementation
Starts with Scholarship
Literature
Local data
Lead by Example
Walk the Talk
Understand the different local needs
One size does not fit all
Definitive surgical care is the key component
need a trauma surgical training centre
trauma/acute surgery model
ED lead service
Continual evaluation
dynamic environment
Best Practice in Trauma Care
Trauma optimal care does not result from preparing an evidence based plan and all will understand, money will be provided and a system will be implemented.
Rather
Trauma best practice is a campaign between zealots and cynics, between those happy with the status quo and those who want further improvement
Trauma Care Systems:
where it goes wrong
The unfortunate truth:
Many services focus on their system rather than patient needs
Ambulance “acute transfer”
Emergency Departments “acute resuscitation”
ICU “critical care”
Many clinicians put self interest first
Nurses like to be close to home
Doctors want to feel comprehensive, and keep their skills up
Some surgeons can be part of a arcane culture:
“I learnt by being thrown in, so should you”.
“They are the hospitals patients and if administrators employ untrained people against my advice then it is their problem”
“The data shows volume does not matter so I am happy to deal with the few trauma patients who come into my hospital”
“Trauma fits best with acute surgery”
“I know I was espousing a different plan when I was at the other hospital, but now I have seen the light”
Modern Medicine
Trauma clinicians need to understand decision dynamic
Increasingly more effort for increasingly smaller health gains
How does a Minister of Health decide between:
Cardiac disease (drug eluted stents)
Stroke units
Obesity and diabetes
bird flu
Decisions
Advocacy
“Policy capture”
Big hospitals are under attack “regional hierarchies”
How to build a best trauma system
Trauma Surgeons need to be well informed united and perpetual advocates
Trauma clinicians need to understand each other’s needs for service provision
The solution is that there is enough room for different models: there can be an alignment between patient/local needs and provider needs.
Trauma Systems future - trends
The tyranny of resources is increasingly overwhelming the tyranny of distance
Increase public skills (emergent provider)
Aeromedical trauma specific full skills to scene airway/breathing/circulation
HEMS London/German/USA
Rapid transport to Definitive Care
ED 15 min, Scan on same floor space
Interventional Radiology Special Theatres
Inhouse senior consultants (Surgeons/Radiology)
Outcome studies with comprehensive outpatients and in house research
Trauma Surgical Training Centre
Trauma Laparotomies (Surgical Training must centralise)
NSW 2003 – 178
2004 – 157
2005 – 137
Clinician lead change
Trauma Surgeons have to lead with they themselves initiating amalgamation
Achieve critical mass:
work with like minded clinicians
acceptable “in house” rosters
modern equipment with skilled staff
senior trauma fellows
“Best patient care” and “providers needs” do coincide
Best Practice in Trauma Care in Australia
Institute of Trauma and Injury Management (ITIM):2001
Not associated with any one hospital but clinician focused
Separate from the Department of Health (DOH)
Triple reporting
To the trauma clinicians (Series of clinician lead committees)
To the Department of Health
To the Greater Metropolitan Clinical Taskforce (senior clinicians)
Major and Critical Trauma Database (2000+ per year)
Tackle all levels – bottom to top, top to bottom
Problem solving
Education
Encourage research
Best Practice in Trauma Care in Australia
Victoria:
Minister of Health leadership (Top down)
2 Adult 1 Paediatric Centre for State
One Aeromedical service
Queensland:
Exhaustive consultative process,
potential of 3 Adult and 1 Paediatric centre for the State
NSW:
extensive collegiate system,
good metropolitan data,
but planning paralysis (9 Adult, 3 Paediatric)
Western Australia:
2 good hospital based services but dispute as to which should be State Trauma Centre
South Australia:
Trauma, burns at one hospital and retrieval service based at the other
Northern Territory:
National trauma hospital funding but difficulty in implementation
Canberra:
Good service but struggles to achieve critical mass
Federal Government:
“Trauma is a State responsibility”
SUMMARY
Best Practice depends on:
A whole community approach
Public:
understand and embrace prevention
Learn first responder and first aid skills
Health services:
be trauma patient focused
Resist tendency to be self-serving
Plan for the long term but be flexible
Government:
listen to trauma experts
Follow USA lead – Model Trauma system planning and evaluation (National Trauma Plan)
pick from the best around Australia and the world
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Ministry of Health
