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

2. 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

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

4. 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

5. 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 ?

6. 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

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

8. 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

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

10. 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

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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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 ?

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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