Hub-and-spoke trauma system for Ireland

Two regional hub-and-spoke Trauma Networks, each with a designated Major Trauma Centre for the treatment of major trauma that requires access to specialised trauma care, have been recommended by the Report of the Trauma Steering Group, chaired by Prof. Eilis McGovern. Maureen Browne reports.

It has proposed a central and southern network, with Dublin as the Major Trauma Centre for the central network and Cork for the southern network.

It says locating the two Major Trauma Centres in the most populated areas, namely Dublin city and Cork city, would optimise access and ensure the minimum caseload required for better outcomes.

The Department of Health and the HSE should invite Hospital Groups in the Dublin region to submit proposals nominating hospitals to be considered for designation as the Major Trauma Centre for the

Central Trauma Network. The HSE should designate Cork University Hospital as the Major Trauma Centre for the South Trauma Network, contingent on it meeting the recommended designation criteria.

The HSE should consider University Hospital Galway for designation as a Trauma Unit with Specialist Services within the Central Trauma Network, along with the development of appropriate access and bypass protocols taking into account the role of the hospital in the network.

Trauma care will also be provided in designated Trauma Units –  hospitals which meet specified requirements for the provision of quality trauma care, and there will be clear roles for Injury Units and Local Emergency Hospitals in the Trauma Networks in the treatment of non-trauma related illnesses requiring urgent treatment and less severe traumatic injuries.

The Department of Health and the HSE should continue to explore the potential for all-island collaboration to improve access to trauma services, particularly in border areas.

It should review hospitals outside of the Dublin region with on-site Trauma and Orthopaedic Surgery for potential designation as Trauma Units.

The HSE should also undertake a review of hospitals with Trauma and Orthopaedic Surgery in the Dublin region with a view to a reduction in the number of such units, to a maximum of two Trauma Units in addition to the Major Trauma Centre, in the context of wider service remodelling within and across the Hospital Groups.

The report takes a whole system approach addressing all elements of the trauma care pathway including prevention, pre-hospital care, acute hospital care, rehabilitation and supported discharge.

It only 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.

Health Minister, Simon Harris has  affirmed a commitment to capital investment for the implementation of the new trauma system as part of Project Ireland 2040.  “The specific inclusion of the trauma system in Project Ireland 2040, together with the monies already provided for in the HSE’s 2018 National Service Plan to establish the National Office for Trauma Services, provide a clear signal of this Government’s intent in relation to safer care and better outcomes for trauma patients,” he said.

The report says improvements in outcomes for patients can be achieved by providing patient-focused and planned trauma care. The introduction of a trauma system in England had been associated with a 25% improvement in the risk-adjusted odds of survival for patients sustaining major trauma during 2014/15 compared with 2011/12.

The report said major trauma cases were typically a very small part of the total number of trauma cases, with UK experience indicating that major trauma cases represented of the order of 1% of trauma cases overall and fewer than 1 in 1,000 Emergency Department admissions. However, these major trauma cases had an extremely significant impact not just on the people involved but also on health services overall.

“Trauma services in Ireland have developed in an ad hoc manner and we know that trauma patients do not always receive the right treatment in the right place at the right time,” says the report.

“High numbers of major trauma patients go to hospitals that cannot provide necessary and definitive care; in 2014 and 2015, 30% of major trauma patients had to be transferred to another hospital for urgent or ongoing care as their care needs could not be provided by the initial receiving hospital.

The recommendations in the report include:

• Each of the Major Trauma Centres should treat a minimum number of major trauma patients in order to maintain a critical mass of specialist expertise.
• The central and southern 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.
• Pre-hospital care and transport protocols are required to ensure that individual trauma patients will be brought to the most appropriate facility to receive the right treatment in the right place at the right time.
• A strong focus on comprehensive, patient-centred rehabilitation services is required, with early assessment of rehabilitation needs, as well as enhanced acute, post-acute, regional and community rehabilitation, to enable patients to achieve their maximum functional potential.
• The HSE should ensure that the Trauma System delivers standardised care throughout the country, irrespective of location.
• The HSE should determine the geographical boundaries of the Trauma Networks by proximity and access to designated Trauma Units, and should keep the boundaries under review to take account of any changes over time, including demographic changes or changes to the road network.
• The National Ambulance Service will develop triage and bypass protocols, in line with National Clinical Effectiveness Committee Standards for Clinical Practice Guidance.
• The HSE should ensure that each Major Trauma Centre, Trauma Unit and Trauma Unit with Specialist Services has an orthogeriatric service which takes a leadership role in falls prevention.
• The HSE should develop a comprehensive Fracture Liaison Service to provide high quality, evidence based care to those who suffer a fragility fracture with a focus on achieving the best outcomes for recovery, rehabilitation and secondary prevention of further fracture.
• The National Ambulance Service should develop policies and protocols, in line with the National Clinical Effectiveness Committee’s Standards for Clinical Practice Guidance, to ensure the safe and timely transport and inter-hospital transfer of patients with major trauma.
• The National Ambulance Service should ensure a PHECC registered Advanced Paramedic (AP), with appropriate additional training, is present in the National Emergency Operations Centre (NEOC) 24/7 with support from a consultant level doctor with significant pre-hospital trauma experience, to ensure timely and accurate identification of major trauma in the pre-hospital setting.
• The HSE should examine how existing HEMS resources can be enhanced and further developed, recognising the critical role of aeromedical transport in the timely transfer of high acuity patients and the implementation of a trauma system.
• The HSE National Transport Medicine Programme / service should continue to develop retrieval services in order to ensure capacity and capability to provide a robust and consistent national critical
• care retrieval service.
• The National Ambulance Service should ensure that patients with suspected major trauma are taken directly to a Major Trauma Centre where travel times are within 45 minutes or if travel times exceed this, to the nearest Trauma Unit for rapid stabilisation and subsequent transfer to the Major Trauma Centre if the complexity of their injuries exceeds the capability of the Trauma Unit.
• The National Ambulance Service should enhance pre-hospital care in areas outside of 60 minutes travel time to the nearest Trauma Unit and/or in circumstances where direct transportation to a Major Trauma Centre is required.
• The HSE should ensure that a Family/Patient Liaison Officer is included in the trauma team activation and be in a position to remain with the patient/family at each stage of their hospital journey and particularly on discharge from hospital.
• The HSE should ensure that all patients admitted to a Major Trauma Centre, Trauma Unit and Trauma Unit with Specialist Services, following trauma team activation, are admitted under a named consultant, who is responsible for overseeing their optimal care until or unless agreement is reached with another consultant that the nature of the patient’s injuries makes it appropriate for their admission under a particular specialty.
• The HSE should ensure that a number of key specialists are available in the Major Trauma Centre on a 24/7 basis (as outlined in the Designation Criteria at Appendix 6) and where these are not available (particularly in Trauma Units), protocols are put in place to ensure that they can be accessed as needed.
• The HSE should ensure that Major Trauma Centres have the necessary resources (including theatre and ICU capacity) available for trauma. The National Critical Care Audit should be used to inform planning for critical care beds.
• The HSE should ensure that Major Trauma Centres have access to dedicated, separate, fully resourced daytime operating theatres for trauma and reconstructive surgery, and that Trauma Units have appropriate access to theatres during normal working hours, and after as required.
• The HSE should ensure that Major Trauma Centres, Trauma Units and Trauma Units with Specialist Services develop dedicated trauma wards, to enable co-location of patients with multiple injuries.
• The HSE should ensure that all trauma patients in Major Trauma Centres, Trauma Units and Trauma Units with Specialist Services can access rehabilitation and have their rehabilitation needs assessed within 48 hours of admission, generating a flexible personal prescription for rehabilitation that should accompany all patients as they transition through the pathway.
• The HSE should ensure that rehabilitation services in both acute and community settings adopt a person centred approach, which empowers the patient and the family to participate actively in the process.
• The HSE should ensure coordinated development of regional and community rehabilitation services and long-term support, to meet the needs of all trauma patients within a Trauma Network. This should include appropriately resourced and skilled community rehabilitation teams (CRTs), co-ordination with disability services and the appointment of case managers.
• The HSE National Office for Trauma Services should establish a formal trauma training committee and the HSE should appoint a dedicated lead for trauma education.
• The HSE should appoint a National Clinical Lead for Trauma Services reporting to the proposed new Chief Clinical Officer once appointed, and the National Director of Acute Hospital Services in the meantime, to lead a National Office for Trauma Services and manage the implementation and oversight of the Trauma System.
• The HSE National Office for Trauma Services should establish a Trauma Patient Advisory Committee to provide input into the development of the Trauma System.
• An interim HSE implementation group, to include representation from the Department of Health, should be formed immediately following the adoption of the report to commence the four immediate actions within the first three months of implementation, and to ensure a seamless transfer of responsibility to the National Clinical Lead for Trauma Services, once appointed, and the National Office for Trauma Services.
• The Government should commit to providing annual development funding for this trauma policy across all of its components – prevention, pre-hospital care, hospital care and rehabilitation.