The Minister for Health, Simon Harris TD, today joined patients, clinicians and other healthcare professionals at the Royal College of Physicians in Ireland to formally launch of the report of the Trauma Steering Group, A Trauma System for Ireland.
Minister Harris said:
“This report aims to reduce the incidence and the burden of trauma and to significantly improve the survival rate of major trauma patients, by ensuring that every patient receives the best possible standard of care in the most appropriate facility. It addresses the entire care pathway from prevention through to rehabilitation, and recommends the establishment of an inclusive trauma system with two hub-and-spoke trauma networks and up to 13 trauma receiving hospitals.”
The Minister paid tribute to the Chair of the Trauma Steering Group, Professor Eilis McGovern, for her leadership and commitment in developing the report, and welcomed the involvement of patients, clinicians and healthcare professionals in the process.
He emphasised the clear evidence underpinning the report’s recommendations:
“The report’s recommendations reflect international evidence and, importantly, translate it to the Irish context to ensure it responds to our population needs, demographics and geography and that it takes account of where we are starting from in our current services. It provides us with a comprehensive and sound foundation on which to move forward for Irish patients.”
The Minister also affirmed a commitment to capital investment for the implementation of the 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.”
Speaking at the launch, Professor McGovern said:
“Our focus throughout this development process has been on patient outcomes. Our report recognises that all stages of the care pathway, from prevention through to rehabilitation, have their own key role in supporting better outcomes. I believe the 45 recommendations included in this report will together help ensure the care provided to Irish patients is on a par with international standards.”
Mr Colm Whooley, who participated in the development of the report, spoke about his perspective as a former patient, saying:
“The most important thing from the patient’s perspective is to receive the best possible care. I welcome the report’s emphasis on better outcomes and on ensuring that those who suffer complex injuries get the right care, at the right place, first time.”
The Director General of the HSE, Mr Tony O’Brien, acknowledged the considerable work undertaken by Professor McGovern, the Steering Group members and all those involved as working group members, or who had participated in the consultation process, saying:
“This report presents an evidence-based vision for the organisation of trauma care supported by consideration of governance, quality assurance and training and education, all of which are core to the successful implementation. I look forward to progressing the implementation of this major report through the establishment of a National Office for Trauma Services, in the interests of patients.”
Notes to the Editor:
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.
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 & 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.
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.
- The Trauma System has been included as a specific project within Project 2040, providing for capital investment for dedicated trauma wards, trauma receiving areas and trauma theatres.
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.