Trauma Systems, Triage and Transport
A trauma system is an organized approach to handling injured patients that involve’s principles of triage and transport, and works with local Emergency Medical Services to bring about the highest quality of care for the injured client. A trauma system must not be costly and must involve the best in care from the pre-hospital care on through rehabilitation of the client.
Trauma systems depend on the region the care is being given to the patient. Trauma care involves many disciplines of medicine, from the prehospital phase through to the rehabilitation phase. All phases of care are represented in trauma systems. The goal of trauma care is to enhance overall community health. You can do this by identifying who is at risk for trauma and by creating preventative solutions that can decrease the injuries and death from traumatic situations. A secondary goal is to provide the best care to have the best possible treatment from the prehospital phase through to rehab so that there can be lesser morbidity (injury) and mortality (death) from traumatic injuries.
Another important aspect of trauma systems is disaster care and disaster preparedness. This will help people at risk for natural disasters and terrorist attacks. The US Department of Health and Human Services has recently developed the Model Trauma System Planning and Evaluation Standard, which is designed to help victims of mass tragedy as well as victims of more minor disaster situations.
Trauma is not just “an accident”. It is an epidemic of situations that affects people of all ages with often devastating results. The estimated cost of trauma per year is about $260 billion USD. Because we know a lot about human behavior and injury, we know that most injuries are preventable and predictable. The way we approach trauma is currently based on what we have learned from past war conflicts. All aspects of trauma care from rapid assessment, triage, surgical care, and nutritional care have been derived from military experience.
The American College of Surgeons Committee on Trauma was established in 1949 and came out of the Committee on the Treatment of Fractures, created in 1922. The first specific trauma unit was established at the University of Maryland in 1961. In 1966, a white paper was established that was entitled “Accidental Death and Disability: The Neglected Disease of Modern Society”. It was from this paper that new systems of trauma care were established. Public awareness was increased in the area of trauma and this led to the federal government to become involved in trauma care. There were two trauma centers formed shortly thereafter, in Chicago and San Francisco.
The Maryland Institute of Emergency Medicine became the first organized institute for the care of traumatized patients in 1973. A similar initiative was developed in Illinois in 1971. State laws were enacted to identify trauma centers and, in Virginia in 1981, a statewide trauma system was developed, based on volunteer participation and compliance with national standards set up by the American College of Surgeons Committee or ASCOT.
In 1973, the Emergency Medical Services Systems Act was passed so that certain guidelines and funding could be given to help regional Emergency Medical Systems programs. In addition to this, state and local initiatives were undertaken to help bring people in from the field to regional trauma centers for treatment. These were more geared toward preventable causes of death. Designated local trauma centers could be established for the management of severely traumatized patients. The trauma registry was established, which were important to quality control programs.
Around that time, major teaching hospitals were, by default, recognized as regional trauma centers. They were able to regionalize trauma care systems.
ASCOT developed the “Optimal Hospital Resources for the Care of the Seriously Injured” in 1976, which helped develop standards for the evaluation of trauma care. This document still exists and is periodically revised, the last time is 2006. The first ATLS (Advanced Trauma Life Support) course was established in 1980 which has helped many providers care for trauma patients in a uniform way.
In 1985, the National Research Council and the Institute of Medicine published the document, “Injury in America: A continuing Healthcare Problem” that indicated that, despite a lot of money being put toward trauma research, little progress had been made so far in reducing the injury burden on society, Prevention was stressed in this document as was the necessity of putting more money into epidemiological research.
After the document was created, the CDC was established as the place for injury research, injury prevention, and all other parts of trauma care. In 1988, the National Highway Safety Administration or NTHSA established the EMS Technical Assessment Program and the Development of Trauma Systems Course, which assess the effectiveness of trauma system aspects and system development.
Components of a Trauma System
The parts of the statewide EMS system and trauma systems have been determined. The first part is the development of a legal authority for the development of any system. This is usually state or local level legislation that provides public agency authority. The next part is determining the need for such a system. Most reviews have been targeted toward preventable death. The designated agency along with local surgeons and other health personnel develop the criteria for trauma care in the area. It also determines which places are to be designated trauma centers and establishes the trauma registry which helps the public agencies know what kinds of traumas are present.
Only about 60 percent of states in the US have designated trauma systems and about 20 percent of states have no trauma system whatsoever. A good trauma system has the following:
• Access to care
• Prehospital care
• Hospital care
• Disaster planning
• Patient education
• Financial planning
Using external sources for peer review is essential in having a good program. It helps identify the specific hospital’s capabilities and its ability to deliver the proper level of trauma care. It helps provide direction for constant improvement of care of the trauma patient.
About 15 percent of all trauma patients will have benefit in receiving care from a level I or level II trauma center. Along with this is the inclusion of smaller hospitals, which have a lesser capability of handling severe trauma. The number of people who have trauma is in reverse proportion to the severity of injury. This means that most patients have minor trauma and the least number of patients have severe trauma.
Trauma care is felt by the public to be right up there with police and fire services. Trauma systems must focus on injury prevention based on data produced by current injuries and on what interventions will likely reduce the occurrence of these types of injuries.
The system cannot function without qualified personnel, so that a quality system needs to educate the workers involved in trauma care. This includes emergency personnel, nurses, doctors and others who have an impact on the patient.
The trauma care before the person arrives at the hospital has a direct impact on a person’s survival after an injury. There needs to be prompt access to services and appropriate care at the scene with safe and rapid transport of the patient to the closest and most appropriate facility.
The focus is on education of prehospital personnel when it comes to trauma care. Initial resuscitation and triage are important aspects of this education. Treatment of trauma patients is another important aspect of good trauma care. There needs to be good communication between the EMS services and the hospital or hospitals receiving the patient. The care must be given at a reasonable cost and there shouldn’t be any duplication of services.
You need to have a reliable communication system between EMS professionals and the hospital. This is found to be present more in urban systems and less than in rural systems. A communication system must include access to 911, trained dispatch personnel who can match the EMS services to the patient’s needs, and on the abilities of the EMS staff to communicate with prehospital dispatch, trauma hospitals, and other units involved in the transport of patients. Everyone must know how to access the system as identified by public safety programs and school education programs.
I’m Ed Smith, a Sacramento auto accident lawyer who has been handling serious trauma cases since 1982. Call me anytime for free, friendly advice at 916-921-6400 in Sacramento or 800-404-5400 Elsewhere in California.