Amid all the understandable political debate about the independent expert trauma review which proposes the development of two high-quality trauma centres in Ireland, we need to bear in mind one simple fact. If we do it, fewer people will die as a result of major trauma.
This is because they will receive appropriate care, more quickly, than under the current arrangements.
Following major trauma, a patient is seriously injured and in need of complex and immediate expert medical intervention. Almost one in 10 people will die as a result of major trauma. The proposed reconfiguration of trauma services will bring that number down.
The National Office of Clinical Audit (NOCA) 2016 Major Trauma Audit report published last week charts the clinical journey of more than 4,000 patients who sustained life-changing or life-threatening trauma in 2016. Its results starkly highlight the urgent need to rationalise the care of major trauma if we are to save lives.
There is understandably a job of work to be done to persuade the public and politicians based some distance from the two proposed centres that this strategy is in their best interests of their communities. But it is.
More than one in every four patients admitted to hospital after major trauma are later transferred elsewhere because the necessary services are not available on site
Currently, according to the NOCA audit, more than one in every four (28 per cent) patients admitted to hospital following major trauma are later transferred elsewhere for their ongoing trauma care because the necessary trauma services are not available on site. This delay, in a time-critical situation, may be the difference between life and death.
Head injury
The audit also showed that only 8 per cent of patients were received by a specialised trauma team on arrival to hospital and a significant number of patients (45 per cent) with severe head injury did not receive care at a neurosurgical centre. Patients with major trauma are arriving at hospitals that do not have senior clinicians for whom the management of major trauma is routine. Diagnostic procedures such as CT and MRI scans are being delayed.
Direct transfer of major trauma patients to a national trauma centre with experienced trauma specialist teams immediately available will save lives, or mitigate potential long-term disability.
This is not to be critical of the many hospitals around the country where many patients have good and life-saving experiences. Complex time-critical care simply cannot, however, be provided in small, isolated units. Heroic work is done by dedicated staff, but the reality is, the direct transfer of patients with major trauma will ensure better care for the small number of severely injured patients.
The medical, nursing and allied health staff who work in smaller hospitals have a different skillset appropriate to the patient care they routinely provide. Would you be happy to get on a plane if you knew that the pilot only flew it once a year but was making a special effort even though she didn’t have an experienced flight crew with them? The same applies to emergency surgery: experience and volume improves patient outcomes, just as it improves flight safety.
In London, survival rates increased by 50 per cent over five years following centralisation, saving an estimated 610 lives
It is also important to understand that most patients will continue to be treated in trauma units in each region which would deal with less serious cases. In the west, for example, the Galway trauma unit would still deal with the vast majority of trauma cases. Only rare and complex cases will require transfer from trauma units to one of the major trauma centres.
UK example
A similar crisis in trauma care was addressed in the UK in 2010 through the centralisation of the delivery of trauma care. In London, regional trauma care for a population of 10 million was reorganised, resulting in a dramatic improvement in quality and outcomes for the majority of severely injured patients. Survival rates increased by 50 per cent over the five years following the centralisation, saving an estimated 610 lives.
This kind of transformation can happen here too. Of course there are discussions to be had about transport. The development of Ireland’s national road network has shortened journey times from many parts of the country to Cork and Dublin. We need to review the ambulance service, including the air ambulance service. But improvements in these services are a lot cheaper than seeking to maintain underused sub-optimal trauma centres around the country.
We welcome the Minister’s intention to publish the report. Let’s have the debate. It involves issues of balanced regional development and quality of rural and urban life. But above all, it involves a reality that when you get beyond the instant response based perhaps on your affinity for the region in which you live, this plan will save lives everywhere. It’s that simple.
Prof John Hyland is president of the Royal College of Surgeons in Ireland