How an inclusive trauma system will work in Ireland

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An inclusive trauma system, in which all healthcare facilities are involved in the care of injured patients at a level commensurate with their capabilities and resources, is planned for Ireland, Mr. Keith Synnott, National Clinical Lead for Trauma Services with responsibility for the implementation of the report, “A Trauma System for Ireland,” told a HMI Webinar.  Maureen Browne reports.

“What we are trying to do is to match the patients’ needs to the most appropriate facility, and it’s the system, rather than the hospital that chooses the level at which a patient is managed.  The aim  is to try and manage a patient at an appropriate facility, as close as is appropriate to where they’re injured.  This is not necessarily the closest hospital or the largest hospital but the most appropriate hospital that is most convenient to them,” he said.

In the UK, within two years of introducing an inclusive trauma system, there was a sustained increase of 20% in the chances of surviving trauma. This would translate in Ireland to approximately 100 people a year alive who would otherwise be dead.

Mr. Synnott is a Consultant Orthopaedic Spine surgeon working in the National Spinal Injuries Unit in the Mater Hospital and the National Rehabilitation Hospital, Dublin. He has a particular interest in the management of spinal and general orthopaedic trauma. He is a previous programme director for the Higher Surgical Training Scheme for Trauma and Orthopaedics and sits on the Council of the RCSI.

This would translate in Ireland to approximately 100 people a year alive who would otherwise be dead

Welcoming him and Mr. Damian McGovern, General Manager of the Trauma Programme  to the Webinar, HMI President, Mr. Tony Canavan said these on-line Webinars were a really good way for the HMI to connect with and support Health Managers to provide a high level of healthcare management. The HMI was driving an accessible Institute where managers in the public and private system would be involved.   The meeting was moderated by the HMI’s Dr Valerie Twomey from the National Rehabilitation Hospital.

Mr. Synnott said  a significant number of hospital admissions were due to major trauma and with about 1,400 deaths a year, it was a significant cause of mortality.   It was the leading cause of death among children and young adults,  it preferentially affected young adults and children, people who were economically productive. However, the demographic was changing slightly due to the amount of major trauma in older adults, because of frailty and falls.

“We often focus on deaths, but we know that for every fatality, there are about two survivors with serious or permanent disability, so the scope for improving trauma care is quite significant . The other thing about trauma is if you get treated, and you are cured ,the recurrence rate is quite low. And like everything else trauma care is advancing over time.”

Mr. Synnott said  that trauma was unexpected, hard to plan for and was often multi system. The single biggest advance in trauma care was in looking at how the system could deliver care for these kinds of patients.

 “What we’re looking to implement in Ireland is a trauma system that comprises  two networks, one for the South, and one for the rest of the country. Each of these networks would have a major trauma centre at the hub, with a variety of spokes reaching out across the whole spectrum of the healthcare system.

The  two Major Trauma Centres, in Dublin and Cork, would  provide the highest level of specialist trauma care to the most severely injured patients in the one hospital. The MTCs would be supported by  Trauma Units which would deliver more general trauma care to the majority of patients who did not need the specialist expertise of a Major Trauma Centre.   The National Ambulance Service was being resourced  for the introduction of the trauma system and the HSE would work with the National Rehabilitation Hospital and other rehabilitation services to progress the rehabilitation-specific recommendations of the National Trauma Strategy.

“The network of the hub and spokes will try and draw patients towards the most appropriate place for their management, where they can be stabilised and then treated.  The network will sit across the entire country, drawing the injured patients into where they will be treated, and then trying to deliver them back home or to the appropriate facilities to continue their rehabilitation.  They may require acute specialist rehabilitation, either in the major trauma centre or in the National Rehabilitation Hospital, post-acute care rehabilitation or they might need rehabilitation in the community to prepare them to get home.

A significant number of hospital admissions were due to major trauma and with about 1,400 deaths a year, it was a significant cause of mortality

“The idea is that regardless of where an injury happens, equity of access is built into the system and hopefully, the system will deliver the same quality of care to every injured patient, no matter where they are.”

The current  report on a new  trauma system for Ireland, which was published in February 2018 had been accepted by the Government which had approved  the implementation of its recommendations.

He said in his experience as a spine surgeon, he had never seen a patient complain about the distance they  had to travel to get the care they needed.  “They have complained about the length of time it had taken them to get there and the system that delivered them there. So, it is important that we try and get a system that can deliver a patient efficiently and safely to the right place at the right time and that’s our overarching ethos and philosophy. This is a system-wide change and it is not just about the Major Trauma Centre. We want to fully integrate the network within the trauma system so that patients can get a better quality of care , have a more consistent quality of care and that everything can be more efficiently utilised in the injury units. It will also allow us to extend the coverage of the trauma system to less well populated areas.

“So trauma units will need to be distributed around the country to try and provide this care. In many instances the trauma unit will be able to provide definitive care, be it orthopaedic or other types of trauma care, but occasionally a patient will require a secondary transfer because of the complexity, or because of the combination of injuries that they have. And again what the system would like to do is to try and streamline that process.”

Under the planned system there would not be  an inappropriate refusal of a patient who needed urgent transfer. 

Mr. Synottt said  under the planned system there would not be  an inappropriate refusal of a patient who needed urgent transfer.  ‘Phone calls would not be to ask permission to transfer a patient, but would inform the unit that the patient was on the way and ‘a no refusal policy’ would be mandated.

The designation of  hospitals as trauma units had been completed in Dublin (St. Vincent’s and Tallaght University Hospitals) and outside Dublin it was unlikely to be a very difficult process because candidate centres were limited to those that already had trauma and orthopaedics. They were currently defining the minimum criteria required for a hospital to function as a Trauma Unit, which would allow them to identify any resource gaps that might be present.

Mr. Synnott said they were all looking at planned trauma care, which recognised that not all trauma patients needed an admission. They were looking at how surgical management could be planned and scheduled, maybe two or three days a week, allowing  hospitals to cohort certain injury types. This would provide scope to save a huge amount of bed days and trolley times and provide better treatment and allow patients to plan when they were having their treatment.

He said  rehabilitation  was vital and it was unfortunately a Cinderella service. There was a lot of work underway to decide how best to develop the rehabilitation service.  We needed to increase capacity and one aim was that a rehabilitation needs assessment would be filled in within 48 hours of  patients arriving in the trauma unit or trauma centre, and this would follow them through the whole system. This would allow early planning for the rehabilitation journey of the patient and would prevent duplication. The trauma networks would dove-tail with the Managed Clinical Rehabilitation Networks to ensure that integration was streamlined.

The first phase of establishing a trauma system for Ireland was to try and put in place the fundamentals of the system, Major Trauma Centres,  transport protocol and different components  required. Phase two was building capacity, which would be done incrementally.

“We  did a lot of work for the Estimates and we have a refined plan which we’re working on implementing, using the money that was allocated last year for the Major Trauma Centre in Dublin. This year we have done a lot of work trying to identify what is required in Cork to develop it as a Major Trauma Centre and we are planning a similar in-depth piece in Galway, which is going to be a Trauma Unit with special services.  This is something that needs definition because it doesn’t really exist anywhere else but recognises the range of services currently available in GUH and their geographic location.  Beyond that we’ve got a sequence of prioritised developments, recognising that we can’t do it all at once. So, next year we will flesh out the work on Galway and  also look at Waterford and Drogheda which are the two centres which will see the biggest increase in volume as trauma patients by-pass some other that currently receive trauma patients.