Eur J Trauma Emerg Surg (2013) 39:3–7 DOI 10.1007/s00068-012-0223-9
REVIEW ARTICLE
History, development and future of trauma care for multiple injured patients in the Netherlands K. W. W. Lansink • L. P. H. Leenen
Received: 3 April 2012 / Accepted: 19 August 2012 / Published online: 13 September 2012 Ó Springer-Verlag 2012
Abstract Introduction The development of trauma systems all over the world resulted in improved outcome for a broad range of trauma victims. In this review, we demonstrate the developments of an inclusive regionalised trauma system in the Netherlands and the subsequent developments in our level one trauma centre and trauma region in comparison. Comparison with other trauma systems With the seasoning of the trauma system, further improvements in outcome could be demonstrated, in the region an OR of 0.84 and in the trauma centre an OR of 0.61, in a later comparison over the years another OR 0.74 was noted. In addition, a further diversification of the trauma populations was seen in the various hospitals with different levels, based on a pre-hospital triage system. Torso and multiple injured patients were more seen in the trauma centre and increased to more than 350 patients with an ISS of [15, whereas monotrauma was almost exclusively seen in the level two and three hospitals. The further development of the trauma system is discussed, in which the minimum requirements of the individual trauma surgeon and institution are taken as a guideline. Future, discussion and conclusion Based on these considerations, a further concentration of the most severely injured patients is proposed in a small country as the Netherlands culminating in one trauma centre for the most severely injured patients, combined with an integrated prehospital helicopter system, on top of the current good functioning inclusive trauma system. These developments
K. W. W. Lansink L. P. H. Leenen (&) Department of Surgery, University Medical Center Utrecht, Suite G04.228, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands e-mail:
[email protected]
could be a template for further developments of trauma systems in Europe. Keywords Trauma systems Polytrauma Quality assessment
Introduction The care for the injured patient in the Netherlands has changed considerably over the years. Since the early 1970s, trauma prevention and trauma care have been a matter of public health. A majority of the improvements and reduction in casualties is due to primary and secondary prevention and, proposedly, only at the most, 25 % of the reduction in casualties can be attributed to improvement in care: tertiary prevention [1]. This paper has a focus on tertiary prevention. After the introduction of a formalised regionalised trauma system in 1999 [2], several changes have taken place. In this review, we report an update of the current situation, on the basis of developments in our own institution over the last 10 years. Furthermore, we compare these results with other results in the world and try to extrapolate these findings into a future policy. As developments in the organisation of trauma systems in other European countries like the UK and Germany are taking place and other countries are on the verge of reorganisation, the lessons learned could be of influence in the further development of trauma systems throughout Europe. In the late 1980s, the Dutch Trauma Society expressed their concerns about the quality of care for trauma patients, in the pre-hospital as well as the in-hospital setting [3]. It became a matter of public and political interest, and measures were taken [2]. During the following years, major transformations were established in trauma care in the
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Netherlands. In 1991, an ‘‘inclusive trauma system’’ was introduced. It was designed to provide care to all injured patients in a given geographical area and, therefore, all acute care hospital facilities were expected to participate in such a trauma system [4]. In 1995, the Advanced Trauma Life Support (ATLS) course was introduced in the Netherlands [5] and implemented in surgical training schedules. Regionalised trauma care became official in 1999 [6]. This incorporated the designation of trauma centres, the regionalisation of individual ambulance care and the introduction of mobile medical teams [2]. Currently, there are 11 trauma regions nationwide, each surrounding a Level I trauma centre. All other hospitals located in the same region are assigned Levels II or III [7]. The Dutch trauma system is based on the American model of trauma regionalisation. Celso et al. [8] performed a meta-analysis on 14 studies concerning trauma centre implementation in the United States. The overall odds ratio for mortality after trauma system implementation was 0.85. In 1999, the University Medical Center Utrecht (UMCU) was designated a Level I trauma centre [6] and in 2000, its trauma care network became official. Twelve regional hospitals are connected to this network. The changes in the trauma system had consequences for the distribution of patients over the various hospitals. The distribution is based on a triage scheme as described by ten Duis and van der Werken [2]. In close collaboration with the participating hospitals and the emergency services, an ambulance guideline for adequate triage was developed to get the right patient at the right time to the right hospital [2]. There are currently no data available on the effect of the regionalisation of trauma care for the whole of the Netherlands, but we do have data from the centre region of the Netherlands and from our own institution. The effect of regionalisation on trauma care in the Netherlands for the centre region of the Netherlands was evaluated by our institution and published in 2010 [9]. Moreover, the effect on the results for the trauma centre specifically was evaluated [10]. Recently, we evaluated the sustainability of these results and the maturation of the system in our centre [11]. Comparing the period after and before the regionalisation of trauma care, the odds ratio for in-hospital mortality after trauma corrected for age and injury severity concerning the region as a whole was 0.84 [9], whereas for the trauma centre as such was 0.61 [10]. Comparing the period 2003–2005 with 2007–2009 in our trauma centre, we found a further decrease of mortality with an odds ratio of 0.74 [11]. Because of the new triage guidelines, there was a decrease in the total number of patients delivered to the university hospital from 2,348 in the period before trauma centre designation to 1,721 in the 3 years after trauma centre designation [10].The mean Injury Severity Score (ISS) increased from 9 before to 14 after trauma centre designation, and the annual number of
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patients with an ISS over 15 increased to almost 350 in 2009 [10, 11]. Hence, the triage system did the job it was designed to do. At the Level I trauma centre, this was further illustrated by a decrease in the number of patients who died due to exsanguination, an increase in the number of patients with chest injury and spinal injury, and a decrease in the number of patients with single extremity injury. In 2009, the number of patients aged 65 years or older with a neck of femur fracture treated at the Level I centre was 52; in the nearby Level II inner city hospital, this number totalled 457.
Comparison with other trauma systems Although these developments are encouraging, we are still far away from an ideal trauma system. The Netherlands is a very safe country. Annually, it has less than 700 deaths from traffic accidents, and no more than 2,500 multiple injured patients in the whole country. Most of these patients are treated in one of the 11 designated Level I trauma centres. Many of these centres treat no more than 200 multiple injured patients a year, some even half of this number. Comparing this with the minimum requirements stated in the resources of the American College of Surgeons [12], many of these institutions do not comply with these requirements. Treating these volumes of multiple injured patients makes it very hard, if not impossible, to maintain sufficient expertise in certain rare life-threatening or incapacitating injuries. This low volume of multiple injured patients per Level I trauma centre seems not only a Dutch problem, as this situation is not much different in most European countries. Flohe´ and Nast-Kolb [13] reported on the German situation. In their article on the surgical management of life-threatening injuries, they state that, in a medium-sized trauma hospital in Germany, no more than 100 multiple injured patients each year are treated, leaving the average trauma surgeon with only five emergency procedures each year. On top of the limited number of casualties and death from traffic accidents already achieved in the Netherlands, the Dutch Ministry of Transportation and the Scientific Council for Traffic Safety (SWOV) predict a further decline of about 20 % in casualties from traffic accidents in 2020 [14]. This further stresses the fact that action has to be taken to centralise trauma care for the multiple injured patients in the Netherlands. If we make comparisons with large trauma institutions overseas like Seattle, WA, USA [15] and, Baltimore, MD, USA [16], major differences are apparent. The annual number of trauma patients admitted and treated in these large institutions is about 5,000 to 6,000, which is three to four times the number of trauma patients treated in our Dutch Level I trauma centre in Utrecht. The annual number of multiple injured patients treated at these institutions is
History, development and future of trauma care for multiple injured patients
about 2,000 to 2,500; this is about eight times as many as the annual number treated at the trauma centre in Utrecht, and this is about the same as the annual number of multiple injured patients treated throughout the Netherlands. Because more is not always better, the outcome of trauma patients should be considered. Dutton et al. [16] analysed the results of their institution in Baltimore and found an increase in survival over the years calculated from the Z-score. They managed to increase the Z-score from 2 in 1997 to almost 9 in 2008. These results are far better than the published results from the Netherlands [17, 18] or other European countries [19–21].
Future, discussion and conclusion On top of the current inclusive trauma system in the Netherlands, we propose a further concentration of care for the multiple injured patient to one specialised trauma hospital. The current structure with 11 trauma regions and trauma centres would stay intact, but there would be a reassignment of the current level status of all hospitals in the trauma networks. The current Level I hospitals would work in close co-operation with the new specialised trauma centre and their surrounding Level II and III hospitals within their trauma networks. If events would occur such as disasters or war, were the specialised trauma hospital will not be available or bypassed, the back up will come from the current Level I centres. The Netherlands is a relatively small country with an area of 200 9 300 km, with two-thirds of the 16 million
300 km
200 km
Fig. 1 The Netherlands is a relatively small country with an area of 200 9 300 km. The proposed trauma centre positioning is signified as a red dot in the virtually geometrical centre of the country. Most of the population is located in the western half of the country
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inhabitants living in an even smaller consecutive area of about 8,000 km2, in or around the larger cities of the country (Fig. 1). It therefore, would be possible to concentrate all multiple injured patients in one specialised trauma hospital and still have trauma care available within one hour after injury for all injured patients in the Netherlands. The annual number of multiple injured patients in the Netherlands is about 2,500 with an over-triage of 50 to 60 %; this will lead to approximately 6,000 trauma admission annually. These numbers are comparable with large trauma centres like those in Seattle and Baltimore. Emphasis should be given to the triage criteria on which patients will be triaged primarily to the specialised trauma centre and, in case of under-triage, which patients should be transferred from other trauma facilities to the specialised trauma centre. One of the concerns if we were to concentrate all multiple injured patients to one specialised hospital would be keeping pre-hospital times within acceptable limits. This could be feasible by adjusting the method of transportation of these multiple injured patients. Currently, the average rescue time, from first 112 call to emergency department arrival, for trauma patients in the trauma region centre of the Netherlands is 52 min. Virtually all the trauma patients are brought to the trauma centre by road ambulance, although, in many cases, a trauma team is brought to the accident site by helicopter for assistance. The Netherlands currently has a helicopter service available from four regions. We state that, if in the Netherlands most multiple injured patients would be transported to a specialised trauma centre by helicopter, the pre-hospital times would stay within acceptable limits. For most multiple injured patients, this would probably mean a shorter pre-hospital time than with the current practice of transport by ground ambulance. An expansion in the number of helicopter services in the Netherlands would be necessary. A recent German study demonstrated a time advantage with air transportation. For each patient brought to the trauma centre, a time advantage for a 35-km range amounts to 20 min when the patient is transported via a helicopter instead of via an ambulance [22]. Follow up of these patients would be another challenge. Two-third of the Dutch population will be within an hour’s road distance from the newly proposed specialised trauma hospital. For patients living further away, an outpatients clinic on a regular basis in one of the current Level I centres or rehabilitation facilities, supported by staff from the specialised trauma hospital, can be organised. Several specialty trauma care facilities could be concentrated in this newly proposed Level I trauma centre. In the Netherlands, there are currently three separate burn centres. These all are located in non-academic institutions and all are struggling with sufficient numbers of intensive care unit (ICU) beds, adequate personnel and 24-h care. Another group of patients who would benefit from this
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concentration is the group with spinal injuries and spinal cord injuries. The spinal cord injury patient interest group has pleaded already for some years for the concentration of this specialised care in one centre. It would be a logical and desirable step forward to concentrate these patient groups in the aforementioned Level I specialised trauma centre. Because of the concentration of trauma patients, resources, knowledge and know-how, the specialised trauma centre will function as an accelerant for quality in trauma research and trauma education. Furthermore, it will provide knowledge and background information for further primary and secondary prevention. This will also influence quality in trauma care in the long run. Another option to achieve concentration of care to multiple injured patients in the Netherlands would be reducing the number of Level I trauma centres from 11 to 3 or 4. Concentrating the care to a few of the existing trauma centres will, in our opinion, not solve the problem. The scale advantage of concentration would be largely lost. Furthermore, in the current situation, these centres already have a daily problem of accommodating the patients in their hospitals. There is a daily battle between elective and emergency care competing for the limited resources like intensive care facilities and emergency operating time. So, doubling the number of multiple injured patients in these centres would be a very challenging and precarious enterprise. We propose an inclusive trauma system in which the current Level I centres would work in close co-operation with the new specialty trauma centre and with their current surrounding Level II and III hospitals. A change of level status will be necessary for all current hospitals and will have to be more in line with the international standards and patient numbers. The severely injured patients comprise less than 5 % of all admitted injured patients; therefore, the loss of these patients to the new genuine Level I trauma specialty centre would have only limited impact on the current Level I and II hospitals, as their numbers were not that high. These hospitals can develop niches in certain specialties, such as secondary surgery, sport-related injuries or geriatric fractures, or they can develop curricula like the American emergency surgery programmes. In conclusion, further development and improvement of trauma care in the Netherlands would require concentration of the severely injured in one speciality trauma centre, within the inclusive Dutch trauma system. Conflict of interest
None.
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