Trauma – Who Really Cares?

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What is emergency care if not the rapid assessment and treatment of patients with undifferentiated, and undiagnosed conditions? We claim to be the experts in clinical assessment, resuscitation, establishment of differential diagnoses, and emergency treatment. We are the team players of the health service, working with a multitude of clinical teams and professions to ensure effective and efficient patient care.

It is all the more difficult then to be told that in all our efforts to improve the organisation and delivery of care over the past 10 years, that those patients who are most vulnerable, continue to receive sub-standard care.

The NCEPOD Trauma service review (2007) makes for uncomfortable reading. Mortality and morbidity in the UK continue to be high in contrast to much of the rest of the developed world, and the survey itself identifies significant flaws in both clinical care and the organisation of trauma systems.

The review collated data on patients with severe trauma (ISS⩾16), admitting teams, and organisational structure, from 183 hospitals (83% response rate). The report examines every aspect of emergency trauma care, providing recommendations within each section. A number of key themes emerge, including communication, leadership, and exposure.

Communication is a common criticism in any report, and one that is identified repeatedly in this report – between pre-hospital and hospital teams, between specialties, and during transfer. NCEPOD identify that in only 50% of cases, hospitals were given a pre-alert by the pre-hospital team. This may simply be down to lack of documentation, in the cases examined. From experience, this figure does seem relatively low, especially in relation to trauma, but does not address the quality of that communication, which is often through a third party, is fragmented, or lacking in sufficient detail to make an informed decision about calling the trauma team. Much work has been done across the Ambulance services to improve this process with many pre-hospital staff now able to call directly to receiving centres, speaking to clinical staff.

An efficient trauma team, with clear leadership is the gold standard of trauma care and the study identifies that most units examined have got a formal trauma team (78.1%). However, trauma calls, response times and composition of the teams are variable. Care is led by a consultant in only 40% of cases, and 42% of patients are not seen by any consultant in the emergency department. There is also a clear discrepancy in consultant availability across the 24-hour period, despite the majority of severe trauma patients presenting in the evening or at night. The review identifies a clear relationship between seniority of leadership and quality of care, with those patients managed primarily by junior staff experiencing more ‘inappropriate’ initial responses. It is good to see that almost 80% of units have a formal trauma team, though anecdotally they can bring their own problems. Numbers attending can vary from 3 or 4 at night, to 15 plus during working hours. Co-ordination of the care can be difficult, and potentially very distressing for the patient. In this case less is certainly more, a small team of senior decision-makers being far more effective than whole on-call teams attending to ‘learn’ from the experience.

Severely injured trauma patients continue to account for only a small proportion of overall ED attendance, which is again highlighted in this report. Only 12 ED’s (6.6%) treated more than one severely injured patient per week, with the majority (75%) only treating 1–6 patients over the 12-week period. This underpins concerns with the maintenance of clinical competency in those units with limited exposure to major trauma. NCEPOD (2007) recommend regional review of trauma service delivery to optimise care in major centres, which correlates closely to recommendations coming out of the current review of the NHS.

Those closest to trauma management may criticise this document, simply because it feels like a direct criticism of their specialty, and of the service provided, but, on reflection, they will all be able to identify with the findings, and with the case studies provided, e.g. the 15-year-old boy transferred for neurosurgery who has no brain-stem function, or the patient who goes to CT twice rather than undertake all views at once, etc.

There are issues with the review. It uses retrospective case analysis and as such is dependent on documentation for case evaluation, which may not be a true reflection of events. Using expert clinicians in the evaluation reduces the effect of this limitation. Because the report concentrates on severe trauma only, it excludes many cases that may have been treated as a ‘trauma call’. The distinction between non-severe, and severe, can only be made after initial resuscitation, when Severity Scores can be calculated. This exclusivity may be detrimental when assessing overall clinical care, and organisational structures. Including all trauma patients treated would have provided greater perspective on the total burden of trauma workload and how best it might be organised in the future.

By far my greatest criticism is that there is not one mention of nursing throughout this document. There is no indication of nurse staffing, of seniority, or of specific nursing interventions/roles. As a key team member, patient advocate, and often driving force within the trauma team, it is impossible to understand their exclusion.

Neither is there any examination of the ongoing care of the trauma patient. There is no indication of where patients were managed, time to operation (as appropriate), length of stay, or outcomes. As a review of trauma care, it looks very exclusively at initial care, not marrying this with care outside the pre-hospital or emergency care phases. Surely patient outcome, especially for the severely injured, is not down to these teams alone?

My final question is whether the report goes far enough in its recommendations? It highlights that little real progress has been made in 10 years, after the initial impact of trauma training. There is a sense of complacency, that just because we all have trauma training, and formalised trauma teams, that everything is OK, and that we have reached a plateau of efficacy. The report fails to address the lack of cohesion of trauma care at specialist level, with trauma patients being managed across the spectrum of specialities, dependent on their, or is that our, need.

Trauma patients are a very special cohort. They are generally a young, previously healthy population, who, in seconds, become critically injured, experience severe pain, and need multi-specialty intervention. They are unlike other patients presenting to the health service. The challenge, then, is to build a service that meets their needs, not manage them how best it suits us.

If we say that patients are better managed in emergency departments that regularly see major trauma, how then can we justify their ‘in-patient’ care being managed by teams with little trauma expertise, just because of their specific injury? Can this team effectively address the psychological, or social needs of the individual patient, never mind their specific pain management requirements? Should we then not advocate a move to the establishment of trauma units, where all trauma patients are managed, irrespective of their injuries, with care co-ordinated around the patient rather than the specialty team?

We all love a good trauma case. The chance to make a real difference. To work together with the one patient in mind. To save a life. It is now almost 20 years since trauma care was founded in the US, and ATLS continues to be the ‘gold standard’ of trauma care. The NCEPOD (2007) document gives us all an opportunity to reflect on what we have achieved and what still needs to be done. We must, then, take this opportunity, to dismantle and rebuild the organisation of trauma nationally, using international evidence, and local knowledge to build a service for the future, which sees an ongoing improvement in both mortality and morbidity.

National Confidential Enquiry into Patient Outcome and Death (2007) Trauma: Who Cares? NCEPOD, London