Elsevier

Injury

Volume 34, Issue 9, September 2003, Pages 728-734
Injury

Trauma care systems in the United Kingdom

https://doi.org/10.1016/S0020-1383(03)00151-7Get rights and content

Introduction

It has long been established that death after major injury and long term morbidity depends not only on the severity of the injury sustained but also on the standards of treatment [1]. Throughout both the developed and the developing worlds, death and disability after severe injury, increasingly the consequence of road accidents [17], place an increasing and unacceptable burden on society, particularly as most of the victims are under 40 years of age [8].

More than 30 years ago studies in the United States, and subsequently in Europe, showed unequivocally that early and effective resuscitation and rapid transport from the scene of an accident to an appropriate hospital which can provide effective, definitive care, reduces mortality and morbidity [4], [5], [18]. In the late 1970s, West and Trunkey published the classic study from Orange County in California, which demonstrated that patients taken to a centre with special expertise in the management of major injuries had a much lower risk of preventable death than those taken to the nearest local hospital [19], [20]. Within a few years regional trauma systems were developed and centres were categorised according to the facilities and resources available. At the same time the organisation of Emergency Services was centralised so that victims of injury could be triaged at the site of an accident and taken to the most appropriate facility.

In 1988, a report from the Royal College of Surgeons of England (RCSEng), on the management of patients with major injuries, demonstrated many of the deficiencies in the system of trauma care in the United Kingdom [7]. The report was based on a retrospective study of 1000 trauma deaths and it showed that of those patients who reached hospital alive and who later succumbed, 1/3 of their deaths were preventable. The report concluded that patients with major injuries should be managed in large acute hospitals with a wide range of facilities and access to experienced senior staff; that there should be improved training for all staff dealing with major trauma and that much investment into trauma research was necessary. It also recommended that pre-hospital care should be improved, with enhanced training for ambulance staff and better methods of transport to major centres [2].

At about the same time, a prospective study was carried out by the Royal College of Surgeons of England on 150 patients with major injuries admitted to four hospitals. Only 11% of the patients were seen initially by a senior registrar, or a consultant. Seventy-one of the 150 patients required surgery; a consultant was present at only four of these interventions. The overall mortality in this group of patients was 21% and in a third of those who died the recovery probability had been greater than 50% using TRISS methodology [21].

In 1989, the British Orthopaedic Association produced a report: ‘The Management of Trauma in Great Britain’ [15]. It was recognised that too many patients with severe injuries were being admitted to relatively small units with neither adequate facilities nor significant consultant input and that there were too few consultants with a special interest in trauma care. The recommendations of the RCSEng report (1988) were endorsed and it was also recognised that better definitive care should be provided for patients with severe but, non-life-threatening skeletal injuries.

Further reports on the management of skeletal trauma and severely injured patients were published by the British Orthopaedic Association in 1992 and 1997 [16], [12]. Both these reports reiterated the same themes: there was no unified system for trauma care in the United Kingdom; many patients were still being taken to hospitals with inadequate staffing, experience and resources; many hospitals were unable to maintain an adequate standard of care, partly due to lack of facilities and partly due to lack of experience and frequent exposure to major trauma.

The advantages of the American and European systems of Regional Trauma Centres, which were ranked by the facilities and expertise they could offer, were discussed. By definition a ‘Level I Trauma Centre’ in the United States would have all surgical specialities represented on site with senior medical staff available in all those specialities 24 hours a day, to provide optimal care for the most severely injured.

The cost implications of the development of Regional Trauma Centres, with the re-organisation of specialities and specialist hospitals that have grown up across the United Kingdom in an adhoc manner, were recognised. In the United Kingdom in the mid 1990s there were only six hospitals where all specialities were represented on one site (see Table 1). For geographical, historical, but largely short-sighted financial reasons, the American model was not recommended. It was agreed that the bulk of major trauma should still be treated in District General Hospitals (DGHs). The concept of hub and spoke trauma systems was introduced, in which DGHs, the spokes of the wheel, would work together and in collaboration with a large acute hospital at the hub.

In this model, some 30 large acute hospitals around the UK would provide regional specialist expertise in most aspects of trauma and would provide an integrated system of care, together with smaller hospitals in their region. A national strategic plan was advocated to provide the quality of care seen in other developed nations [12].

Unfortunately, despite the profusion of reports all advocating the development of systems of trauma care and collaboration between hospitals, there has been little support from the Department of Health, or other Government agencies, for an integrated national trauma care framework, largely because of the financial investment now necessary for such a programme [13]. The political consequences of the reconfiguration of emergency services required may have also proved a disincentive for action, politicians fearing the alienation of their potential voters by closing down cosy, but ineffective, local Accident and Emergency departments in small neighbourhood hospitals.

The most recent review of trauma care in the United Kingdom is a joint report from the Royal College of Surgeons of England and the British Orthopaedic Association (2000), entitled ‘Better Care for the Severely Injured’ [3]. This comprehensive review identifies the persistent lack of adequate trauma care systems in Britain and strongly advocates the development of a national trauma service, which would raise the standards of provision of care within an acceptable cost framework. Unlike previous reports it also establishes acceptable standards of care for patients with major injuries. All body systems are covered and, in addition, recommendations are made for initial assessment and resuscitation, anaesthesia, intensive care and rehabilitation. These standards are designed to provide hospital Trusts with attainable goals against which to audit current activity.

Section snippets

The incidence of severe injury

One of the reasons that there has been little enthusiasm for the development of American style Regional Trauma Centres is that the pattern and incidence of severe injury is quite different in the United Kingdom from both the United States and the rest of Europe. Whilst it is accepted that the majority of traumatic injuries are musculo-skeletal and the incidence of new fractures in UK hospitals is over 900,000 per year, significant musculo-skeletal injury occurs in only in one in sixty-four

The future of trauma systems in the United Kingdom

The major prerequisite for the development of an effective system for the management of trauma is a National Trauma Service, developed from defined trauma systems, using a network arrangement between adjacent hospitals with different levels of provision for the more severely injured. These systems would be based on geographical distribution and would integrate pre-hospital care, initial transfer and subsequent inter-hospital transfer where necessary, sophisticated assessment and resuscitation

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