national average. In the review of an inclusive Canadian
trauma system (Quebec), a statistically significant mortality reduction for critically injured patients could only be demonstrated between 1999 and 2006, ten years after the completion of the system implementation. When reviewed this mortality reduction was a massive 24% suggesting that regionalised inclusive trauma systems may provide better care for trauma victims. It should be noted, however, that in lower-income countries this reduction in mortality may be identified even earlier with the utilisation of ongoing audits. The two recent studies from Durban both demonstrated a low missed injury rate and a mortality reduction with the establishment of a dedicated trauma service with trauma-surgeon led teams providing initial and definitive care. Prevention is also an essential
«The treating healthcare workers need to understand that trauma patients have more than anatomical injury only»
of Surgeons Committee on Trauma, the Royal Australasian College of Surgeons and the Trauma Society of South Africa have recently compiled such criteria for their regions, while the WHO Essential Trauma Care programs (EsTC-Guidelines and Prehospital Trauma Care) are relevant to lower income countries. The fourth step in this process is
continuous data collection and the establishment of registries to enable the audit of outcome and resource utilisation. To this end there are a number of commercially available systems such as NTRACS (American College of Surgeons), TraumaBank (Trauma Society of SA) and others, which allow for accurate data collection and review. Early appropriate care comes to naught when the rehabilitation programs and even residential rehabilitation facilities are not a part of the inclusive trauma system. The role of the physical or occupational therapist, dietician, speech and swallowing therapist among other team members
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cannot be understated, both in the acute care hospital and in the rehabilitation centres outside the hospital environment. This remains the greatest challenge in lower-and middle-income countries. When all these steps have taken place
the bodies that fund healthcare must realise that the establishment of systems per se is not a ‘quick-fix’. It takes around 10 years for the long-term results of the system to show improved survival and cost-efficiency. This was elegantly demonstrated in two recently published studies. In the first study it was demonstrated that Delaware’s inclusive trauma system, in which all hospitals providing acute care participate, was associated with an incremental, significant decrease in mortality of the most critically injured patients, which was more substantial than the American
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component of the system, which implies that not only healthcare providers, but also law enforcement, social services, fire services and non-governmental organisations must be involved in the design and implementation of a trauma system. The use of the Haddon Matrix approach will identify both upstream and downstream interventions to reduce the incidence of trauma and guide interventions to reduce the impact of injury.
CONCLUSION Across the world trauma systems are in different stages of development, with the low-middle income countries at the infant stage and parts of the developed higher income countries at either the implementation or audit stages. Different systems work for different countries (e.g. from the American ‘paramedic to hospital system’ with limitation of scene time, to the French ‘stay and play’ doctor-based pre-hospital care). Each world region must decide what is most appropriate to their income range and ability to provide care, however it is well demonstrated that good systems reduce mortality and morbidity. Most importantly a commitment is required to ongoing development of prevention programs to curb a disease process that is mostly preventable. ■
AH
REFERENCES References available on request (
magazine@iirme.com)
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