Issues within the Trauma System Emergency Medicine Dr Chris May Dr Colin Myers

The Role of Emergency Medicine within the Trauma System Reception Resuscitation Diagnostics Initial prioritisation & management Referral Transport EM has been very successful at improving the provision of these services over the past 10 – 15 years

The ED has become the hub of current trauma services throughout the trauma network

Pressures within the Health System Increasing demands Increasing workloads Increasing costs Focus on routine services Surgical waiting lists Poor funding for emergency services Lack of understanding of EHS

Pressures within the Health System Falling access to general practice Falling skills engagement in general practice Poor access to in-hospital services Longer waits Fewer clinics Poorly responsive inpatient services Where do these people go ?

The Emergency Department is now: -the only access many patients feel they have to the health system -the only access many GP’s feel they have to the hospital system

Pressures within Emergency Medicine Overcrowding Increasing presentations (10% / yr) Increasing access block (25 – 50%) Dramatically increasing inefficiencies Corridor medicine Workloads Staffing Training Morale Indifference

Pressures within Emergency Medicine Overcrowding Workloads Chaotic work environment Increased total patient contact hours (40 – 50%) Simultaneous management of multiple patients Unpredictable senior staffing levels (retrievals) Staffing Training Morale Indifference

Pressures within Emergency Medicine Overcrowding Workloads Staffing Numbers static or falling Falling skills mix Increasing junior or agency staff Training Morale Indifference

Pressures within Emergency Medicine Overcrowding Workloads Staffing Training Falling numbers of trainees Inadequate time and resources for training Effects worst in regional centres Morale Indifference

Pressures within Emergency Medicine Overcrowding Workloads Staffing Training Morale increasing chaos and inefficiency increasing staff distress & resignations Falling recruitment Sense of hopelessness Indifference

Pressures within Emergency Medicine Overcrowding Workloads Staffing Training Morale Indifference Indifference of inpatient colleagues Indifference of administration Lack of understanding by politicians and the public

The Effects of ED workloads on Trauma Patients Apparently minor trauma waits for hours Major trauma is seen as a burden Trauma teams are poorly constituted Resources are diverted to continue routine management Mistakes and system errors increase rapidly Retrievals are the last straw Retrieval staff fatigued and often on overtime Remaining staff inadequate for workloads Zero surge capacity within the system Mounting a disaster response can still occur

The Role of Emergency Medicine within the Trauma System Reception Resuscitation Diagnosis Initial Management Referral Transport There has been a serious decline in the standards of care provided to trauma patients from within EM in the past 3 years due primarily to overcrowding

Queensland Outcome Data 50% of major trauma is retrieved 90% of patients retrieved take > 6 hours Trauma care in Queensland meets national and international benchmarks Site of injury has no effect on outcome Therefore: Trauma is not time critical Trauma can be managed anywhere Trauma systems are unnecessary

Development of the Trauma System The Trauma Centre Tertiary surgical & ICU centres Not trauma receiving centres Bypass only possible over small areas 150 km max (Sampalis 1999) US Trauma Centre model not cost effective in Australia Must have trauma service

Development of the Trauma System The Trauma Surgeon A dying breed Need availability in trauma centres 24/7 Combine rosters Add other surgeons Not the PHO ! What role should they play Surgery Overall management & decision making Could it be the trauma specialist ?

Development of the Trauma System The Trauma Network Bypass Can’t bypass 1200 km Need hub and spoke model Could consider bypass to level 3’s Resuscitation skills Need to teach ATLS skills to many Retrieval services Acknowledge importance of retrieval services Resource retrieval services

Development of the Trauma System Definitive Care Where to receive these patients Where to resuscitate these patients Where to investigate these patients Where to perform the surgery Where to provide the ICU Regionalisation vs centralisation

Development of the Trauma System Emergency Departments Reduce overcrowding Allow for surge capacity Make ED a viable workplace Acknowledge pivotal role of ED Increase training of ED practitioners Extend ED skills to regional centres

Development of the Trauma System Retrieval Services Acknowledge pivotal role of retrieval services Appropriately resource aircraft Apply dedicated staffing model Improve training of retrieval staff

Development of the Trauma System Philosophy In times of healthcare rationing patients and the public expect that emergency healthcare will always be provided. Therefore priority must be given within the public health system for patients with acute injury or illness rather than routine or booked services. Healthcare resource allocation should reflect these societal expectations

Summary Pathways to Improved Trauma Care “The best bang for the buck” EM currently forms the hub of the trauma system Overcrowding & access block need to be resolved Emergency networks need to be developed Retrieval services need to be funded Regional centres need EM staffing Trauma services must be developed at the TC’s Research, audit & systems development need to be supported Prioritisation of emergency health care must change