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Transporting major trauma patients from the margins of a UK trauma system
  1. Tim Nutbeam1,
  2. Alan Leaman2,
  3. Peter Oakley3
  1. 1West Midlands Deanery, Birmingham, UK
  2. 2Princess Royal Hospital, Telford, UK
  3. 3University Hospital of North Staffordshire, Stoke UK
  1. Correspondence to Dr Tim Nutbeam, West Midlands Deanery, 43 Middlepark Drive, Northfield, Birmingham B312FL, UK; timnutbeam{at}hotmail.com

Abstract

Objective For serious motor vehicle crashes (MVC) occurring in a rural area to quantify: how many occur more than 45 min by road to a major trauma centre (MTC); how many occur more than 45 min by helicopter to an MTC; and how many patients might have to be taken to a local trauma unit if their incident occurs more than 45 min by road from an MTC and when the helicopter cannot fly.

Methods MVC occurring in Shropshire, in which patients were killed or seriously injured during 2006–9 (inclusive) were analysed using the following parameters: distance from MTC by road; distance from MTC by air; weather and visibility-related factors that affect the operation of a helicopter emergency medical service.

Results 722 serious MVC occurred, of which 626 (87%) occurred more than 45 min by road from the MTC. Of these 626 incidents, 408 occurred in conditions in which the helicopter could fly. There were 218 incidents (30%), which were more than 45 min by road from the MTC and which occurred when the helicopter could not fly.

Conclusions The transportation of patients from remote and rural areas to MTC remains problematical. Further work is required to develop more efficient systems of retrieval and transfer, and in particular to consider how emergency medical helicopters might operate safely at night.

  • Emergency care systems
  • emergency departments
  • major trauma management
  • nursing
  • paramedics
  • prehospital
  • trauma
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Following a series of reports, the Department of Health has decided that a network of trauma systems should be established in the UK.1–3 Such systems will be based on a small number of major trauma centres (MTC) located in urban areas. In outlying areas there will be other hospitals called trauma units (TU), which will be capable of receiving major trauma but which will not have the specialist services provided by the MTC. A modified version of a triage system developed by the American College of Surgeons will be used to identify major trauma patients.4

Current opinion is that major trauma patients should be taken directly to an MTC providing this is within 45 min travelling time. In the UK this commonly equates to 20–40 miles by road or 60 miles by helicopter. Patients more than 45 min travelling time will be usually be taken to a local TU.

Patients in peripheral areas will usually be transported by helicopter. However, there are limitations to when helicopters can fly, including during the hours of darkness and in adverse weather conditions.5 The purpose of this article is to examine in detail an area at the margins of a UK trauma system, and in particular: (1) to quantify how many serious motor vehicle crashes (MVC) occur more than 45 min by road to an MTC; (2) to quantify how many serious MVC occur more than 45 min by helicopter to an MTC; (3) to quantify how many patients might have to be taken to a local TU if their serious MVC occurs more than 45 min by road from an MTC, and when the helicopter cannot fly.

MVC are an important cause of major trauma in the UK, and almost 60% of true major trauma patients (injury severity score >15) come from such incidents (T. Nutbeam personal communication with Trauma Audit Research Network October 2010). Police crash investigation units collect detailed information about serious MVC, and this provides excellent data about the location, prevailing weather conditions and visibility. For these reasons this study used serious MVC as an indicator of total major trauma workload.

The area studied was the county of Shropshire. This is a predominantly rural county, much of which lies on the margins of a proposed trauma system. There are two district hospitals in Shropshire (in Shrewsbury and in Telford) and at present both are potential TU. Major trauma patients from Shropshire are taken to an MTC in Stoke on Trent, and this centre is serviced by helicopters operated by the Midlands Air Ambulance Service.

Methods

A map was constructed showing the county of Shropshire and indicating those parts more than 45 min by road, and more than 45 min by helicopter, from its MTC in Stoke on Trent (figure 1). Data on serious MVC in Shropshire were obtained for 2006–9 (inclusive) from the West Mercia Police Constabulary. These data included the location, date and time of the incident, weather conditions, and whether the incident occurred in daylight or in darkness.

Figure 1

Map showing the county of Shropshire and those parts within 45 min by road and 45 min by air to the major trauma centre in Stoke on Trent.

For police purposes a serious MVC is one in which there is a death or when someone sustains life-threatening injury. It should be noted that more than one casualty may arise from each serious MVC, but that the analysis below refers to incidents and not to the total number of casualties.

Under current regulations helicopters cannot fly to incident locations at night, or in poor visibility or icy conditions.5 For the purposes of this study, police data indicating that the incident occurred in darkness, or when fog/mist or snow/ice prevailed, were taken as meaning that the helicopter could not fly.

Results

The results are outlined in table 1. During the 4-year period there were 722 serious MVC in Shropshire, of which 626 (87%) occurred more than 45 min by road from the MTC.

Table 1

Serious MVC in Shropshire 2006–9 inclusive

In respect of transportation by helicopter, almost all of Shropshire is within 45 min by air to its MTC (figure 1).

Of the 626 serious MVC that occurred more than 45 min by road, 408 occurred in conditions in which the helicopter could fly. The remaining 218 occurred when the helicopter could not fly (either during the hours of darkness, or during adverse weather conditions, or when both prevailed).

This means that of the 722 serious MVC there were 218 (30%) that occurred at locations more than 45 min by road to the MTC and when the helicopter could not fly.

Discussion

The results indicate that in the area studied approximately 30% of serious MVC occur at locations more than 45 min by road to an MTC and when the helicopter cannot fly. This suggests that at least one major trauma patient each week will be taken to a local TU first rather than directly to an MTC. Such patients will therefore not enjoy the immediate benefits of the specialist services available at an MTC.

Analysis of the data shows that the main reason the helicopter could not fly was because the incident occurred in the hours of darkness (211/218). In these conditions one possible solution is for the helicopter to fly to established and appropriately illuminated landing sites to which patients could be taken by land-based vehicle. Patients could then be transferred and flown on to an MTC.

Alternatively a system of ‘delayed primary retrieval’ might be employed. In such cases patients would be taken to the nearest TU, and a helicopter, with its specialist crew, would be despatched to an illuminated landing site adjacent to this unit. The helicopter specialists would assess the casualty in the TU, administer any urgent interventions, and then transfer the patient to an MTC.

Such systems would overcome the difficulties of flying at night, and ensure that 98% (704/722) of patients from serious MVC could be taken promptly to an MTC either by land, or by helicopter, or by a combination of both.

The data also show that on only 18 occasions (8%) would bad weather have prevented flying. This correlates well with previous information for this area, which indicated that poor weather conditions prevent helicopters flying on 45–50 days each year (12%).5

Previous articles have suggested that extended prehospital times are not associated with increased mortality,6 7 and it could be argued that major trauma patients should be taken directly to an MTC by land-based vehicle, even if this involves a journey in excess of 45 min. However, most emergency physicians would not relish working single-handedly on a major trauma patient in the back of an ambulance for 60–90 min.

One weakness of this study is the use of serious MVC as an indicator of total major trauma workload. However, the quality of the police data used allowed assumptions to be made about conditions affecting helicopter operations, and was justifiable for this reason. Data from trauma audit and research networks indicate that MVC cause approximately 60% of true major cases.6 It is therefore apparent that the 50 cases each year that this study indicates would have to be transported to a local TU are likely to represent a significant underestimate.

In conclusion, it is clear that the transportation of major trauma patients from remote and rural areas to MTC remains problematical. Further work is required to develop more efficient systems of retrieval and transfer, and in particular to consider how emergency medical helicopters might operate safely at night.

Acknowledgments

The authors would like to thank the West Mercia Police Crash Investigation Unit for its invaluable help.

References

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Footnotes

  • Competing interests None to declare.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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