Module 1 Assignment

MSc Trauma Sciences ICM 7050Module 1 AssignmentBy Luca Casingena (ID: 443394M)Word Count: 2154 wordscenter744220Title:Critically discuss the following:Which components of an inclusive trauma system exist in your region and which do not?Within your system, what parts are strong and function well and what parts are limited and don’t function well?What would be priorities to strengthen or institute to for an optimal inclusive trauma system?020000Title:Critically discuss the following:Which components of an inclusive trauma system exist in your region and which do not?Within your system, what parts are strong and function well and what parts are limited and don’t function well?What would be priorities to strengthen or institute to for an optimal inclusive trauma system?Table of ContentsIntroduction3Inclusive Trauma System and its Major Components3The Trauma System in the Maltese Islands5Strengths of the Maltese Trauma System8Limitations of the Maltese Trauma System…………………………………………………………………………..8Conclusion………………………………………………………………………9References……………………………………………………..………………10Introduction A trauma system is an implemented organized structure of care of trauma victims within a given geographic region. The ultimate aim of trauma systems is to ensure the best possible care for the severely injured (1).A trauma system will inevitably define the emergency medical service system (“EMS”). The EMS aims to tackle and improve all aspects of the trauma care continuum: starting from the pre-hospital phase of trauma up until and including the rehabilitation process of the patient. The implemented system must strive to continuously evaluate and improve itself (1). The literature highlights various means of achieving this, and categorises it into three main steps. Firstly, there should be identification of risk factors for trauma and ways of prevention and risk reduction. Secondly, a focus on the acute response itself; this will include all stages of trauma care. Finally, the last step is to decrease the overall morbidity and mortality associated with trauma (2). This final step is crucial, as it highlights the importance that a trauma system should not only aim to increase the survival rate but also the overall outcome of the patient, i.e. morbidity post rehabilitation. The injured should be rendered with the same quality of life as that prior to the trauma event (3). Inclusive Trauma System and its Major ComponentsThere are two main types of trauma systems mentioned in the literature: inclusive and exclusive. An exclusive trauma system is one in which a designated major trauma centre acts as a single unit rather than as part of a chain of acute care facilities. The injured is transferred directly to a fully equipped ‘tertiary’ trauma centre by exclusive means (4). On the other hand, an inclusive trauma system entails a group of acute care hospitals spread throughout a geographical region, which are linked together with a major trauma centre in the EMS provided. This network within the system facilitates patient care and stabilisation and inter-facility transfer (4) (5).In order to make an inclusive system possible, there is the necessity to stratify hospitals within the network according to their capabilities. The Trauma Committee of the American College of Surgeons recognizes three levels of capabilities. Level 1 hospitals have the greatest number of in-house trained staff, facilities and resources whilst handling the largest load of major trauma cases per year. These centres are also licensed for education, training and research. Level 2 centres, whilst having comparable resources and in-house staff, deal with a smaller work load of major trauma cases. These centres however do not participate in training, research and education. Level 3 centres are mainly responsible for stabilising the severely injured and preparing them for transfer to higher level centres for more definite management (3). The World Health Organisation (“WHO”), stratifies trauma centres according to maturity. Level I being least mature, and level IV being most mature (6).According to Kristiansen et al (5) (10), an inclusive trauma system is made up of the following network of components:Pre – hospital careAcute care hospital Inter-facility transfer Major Trauma centreRehabilitationEducation, Prevention and evaluation The Trauma System in the Maltese Islands18111188391800The Maltese archipelago consists of an area of 316km2 and holds a population of 420,000 (7) (8). This consist of two mainly inhabited islands, Malta and Gozo together with smaller uninhabited islands. The whole of this area is covered by two main emergency departments, one on each island. These emergency departments, albeit being fully equipped with resources and trained personnel, do not form part of an official designated trauma centre, but rather are an extension of two general government hospitals forming part of the national health service: Mater Dei Hospital (‘MDH’) in Malta and Gozo General Hospital in Gozo. Additionally, in Malta there exist two health care centres located in the Northern Region (Mosta) and another in the Southern Region (Paola) (9). These centres however are only equipped and used for minor emergencies and cannot receive any limb or life threatening cases. All the severely injured are taken directly to MDH. The central location of the A&E department within MDH in Malta makes it no more than a thirty-minute drive from all four corners of the island. The Gozo General Hospital in our sister island is even more accessible as the island itself is thirds the size of Malta. The AE department at Mater Dei hospital is made up of a pre-hospital / Ambulance service, emergency department and a short stay observation unit (9).Pre–Hospital Care Malta, as a small island covering only 216km2, differs from other countries because only one A&E department caters for all major trauma calls. The EMS are dispatched and transferred to the same hospital, MDH in Malta or GGH in Gozo. All ‘112’ emergency ambulance calls are received by the dispatch unit in MDH and are immediately categorised into three codes. These consist of the following: red, orange or blue code. The red code means severe limb and/or life threatening injuries, orange means that the call is urgent and serious but not limb and/or life threatening, whilst the blue code means stable patients who however still require management in the A&E Department. The dispatch unit of the hospital is made up of emergency department nurses who are specially trained in the field of EMS dispatch and triage. When a code red or orange is declared, the responsible nurse has the task to dispatch an emergency physician response unit (‘EPRU’) according to protocol. There are standard operating procedures which state that the emergency department (‘ED’) nurse must dispatch an EPRU according to what the by-stander information from the 112 call consists of. Such information should concern mode of injury and incident environment, which will guide the ED nurse to decide whether a code red or orange call should be dispatched with or without an EPRU. Should an EPRU be summoned, this is done via an implemented digitalised system called Everbridge which is the fastest way possible to summon this emergency response. Simultaneously, a trauma call-out is sent to trauma pagers of the concerning specialities which make up the trauma team. The latter consists of general surgeons, anaesthetists, orthopaedic surgeons, vascular surgeons and the already alerted A&E senior physician and nurse. If less grievous information about the incident is relayed during the emergency call, the ED nurse is only required to inform the senior physician rather than summoning an EPRU. Abroad, at this phase of pre-hospital care, the EMS must assess the injured party and perform on site triage using pre-set triage protocols. The purpose of triage at this stage is to help the EMS determine to appropriate medical trauma centre which will cater best for the patient’s needs. Furthermore, the EMS must alter the receiving trauma centre so that the concerned teams are assembled and prepared accordingly. This should be done via an effective pre-established communication system (10). In contrast with this, in Malta there is no need for on-site triage as patient is automatically transferred back to MDH. There are no other acute care hospitals spread throughout the island. Furthermore, transport of patient back to hospital is always carried out via road ambulance. It is obviously the most efficient way as compared to air transfer in view of lack of space for helicopter landing and relatively short distances covered. In very rare occasions, air ambulance is only used for transfer of patients between A&E department at GGH to the A&E department in MDH. This is not done routinely, as GGH has a fully equipped A&E department which can deal with most major cases. That being said, despite not having a pre-determined protocol, very few of such cases will occasionally need transfer via helicopter to Malta after stabilisation. Acute care hospital, Inter-facility transfer and Major Trauma CentreAn acute care hospital, is a centre whose main objective is to stabilise the patient prior to transfer to a major trauma centre. This is classified as either level 2 or 3 by the American College of Surgeons or level 1 , 2 or 3 by WHO criteria (3) (6). Should a patient be brought here first and stabilised, he/she needs an efficient, fast and safe way of being transferred to a major trauma centre. This leads to the next component of an inclusive trauma system – the inter-hospital transfer. In Malta however, the last mentioned two components are non-existent. This is because of reasons mentioned above, i.e. the geographical restrictions imposed by our small island. In addition to this, since we have one accident and emergency department, we do not have the WHO or ACS stratification in our trauma care system. This means that we also lack a designated official major trauma centre as defined by the American College of Surgeons or WHO. Rehabilitation Rehabilitation at MDH starts from the ITU care setting, and follows through to in-patient wards. The hospital is equipped with fully qualified teams of physiotherapists, occupational therapists, speech language therapists, social workers, psychologists and psychiatrists. These together with the clinical firm caring for the patient form a multi-disciplinary team for the best rehabilitation the facility can offer to a patient. The bulk of the rehabilitation process takes place during the in-patient stay. This is then followed up upon discharge at the different departments of the concerning specialties. There is one rehabilitation hospital in Malta – Karin Grech Hospital, whose aim is mainly to care for patients who will require a prolonged in-patient stay prior to achieving acceptable levels of functionality in activities of daily living. Education, Prevention and Evaluation Malta’s greatest limitation would be at this level. Firstly, there is no trauma registry implemented within the island’s trauma care system. This has been in the pipeline for the past couple of years, however it has not yet come into action. Trauma registries offer key insight to the evaluation process, improvement and overall growth of a trauma system. Furthermore, the authorities responsible for public transport and road works are not coupled up with public health authorities. Strengths of the Maltese Trauma SystemPre-hospital care: as mentioned above, the pre-hospital care of the local trauma system is efficient and well-tailored to the small geographic area that it cares for. The trauma team in MDH is well-equipped with fully trained professionals and all the necessary specialities which an ideal trauma team should be made up of. The training system at MDH requires that in the concerning specialities, at a senior level, all doctors should have a designated number of years of training abroad in order to widen their exposure and thus improve their experience. They are therefore fully competent and capable of dealing with any trauma scenario. In view of the small surface area covered by the Maltese islands, transport distances are short. Shorter distances are associated with a higher survival rate, (11) (12).Further to the point above, inter-facility transfer is eliminated altogether. Limitations of the Maltese Trauma SystemDespite not being categorised in either the American College of Surgeons or WHO’s criteria, literature shows that for a major trauma centre to function at a high level it needs a certain amount of major trauma case exposure per annum. This will increase the experience of the personnel involved in the trauma team. The American College of Surgeons requires that for level 1 recognition, the trauma centre must be exposed to 400-600 major cases per year. A study performed in Chicago (13) suggested that the baseline requirement exposure of cases for a level 1 recognition should be at least 110 cases per year. In the UK it was estimated that for a major trauma centre to see at least one major trauma case per day, it should be covering a population of about 2 million people (3) (13).Having a population of merely half a million leaves much to be desired in terms of increasing exposure and experience for hospital personnel in trauma scenarios. Another limitation of the system is that there is no trauma registry yet implemented. Monthly morbidity and mortality meetings are being held whereby amongst other unrelated cases, trauma cases are also discussed. Yet no formal database, as suggested by a trauma registry is yet in place. In addition, there are limited studies, if any at all, regarding statistics in trauma cases per annum relevant to the interest of major trauma case workload. ConclusionIn conclusion, there is no formal inclusive trauma system implemented in the national health system. Whilst this is mostly driven by the small geographical region, there is still much to be improved. Firstly, one of the top priorities would be to implement a trauma registry system. Secondly, to have more research and studies conducted to continuously improve the trauma system. Despite Malta’s limitations, one can argue that the system has been organised in such a way so as to make it as efficient as possible to the island that it caters for. References: Hoyt D, Coimbra R. Trauma Systems. Surgical Clinics of North America [Internet]. 2007 [cited 16 October 2019];87(1):21-35. Available from: https://www.surgical.theclinics.com/article/S0039-6109(06)00148-4/pdfMoore E, Feliciano D, Mattox K. Trauma. 7th ed. The McGraw Hill Companies; 2013.Gwinnutt C, Driscoll P, Whittaker J. Trauma systems — state of the art. Resuscitation [Internet]. 2001 [cited 14 October 2019];48(1):17-23. Available from: https://europepmc.org/abstract/med/11162879 Paydar S, Ghahramani Z, Bolandparvaz S, Abdolrahimzadeh H, Keshavarzi A, Moradian M et al. Exclusive versus Inclusive Trauma System Model in High Volume Trauma Regions. Bulletin of Emergency and Trauma [Internet]. 2018 [cited 15 October 2019];6(4):269-270. Available from: http://beat.sums.ac.ir/article_44448_6db555479fa14b478ed5e7b93c23035e.pdf Kristiansen T, Søreide K, Ringdal K, Rehn M, Krüger A, Reite A et al. Trauma systems and early management of severe injuries in Scandinavia: Review of the current state. Injury [Internet]. 2010 [cited 16 October 2019];41(5):444-452. Available from: https://www.sciencedirect.com/science/article/pii/S0020138309002897Dijkink S, Nederpelt C, Krijnen P, Velmahos G, Schipper I. Trauma systems around the world. Journal of Trauma and Acute Care Surgery [Internet]. 2017 [cited 16 October 2019];83(5):917-925. Available from: https://cdn.journals.lww.com/jtrauma/Abstract/2017/11000/Trauma_systems_around_the_world__A_systematic.28.aspxSpiteri A. EMS systems in Malta. Resuscitation [Internet]. 2008 [cited 15 October 2019];76(2):165-167. Available from: https://www.sciencedirect.com/science/article/pii/S0300957207004212 Malta population (2019) live — Countrymeters [Internet]. Countrymeters.info. 2019 [cited 16 October 2019]. Available from: https://countrymeters.info/en/MaltaAzzopardi-Muscat N, Buttigieg S, Calleja N, Merkur S. Malta Health System Review. Health Systems in Transition. 2017;19(1):80-82.Trauma Systems Components/Models [Internet]. American College of Surgeons. 2019 [cited 16 October 2019]. Available from: https://www.facs.org/quality-programs/trauma/tqp/systems-programs/tscp/componentsMcCoy C, Menchine M, Sampson S, Anderson C, Kahn C. Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center. Annals of Emergency Medicine [Internet]. 2013 [cited 17 October 2019];61(2):167-174. Available from: https://www.sciencedirect.com/science/article/pii/S0196064412014254 Crandall M, Sharp D, Unger E, Straus D, Brasel K, Hsia R et al. Trauma Deserts: Distance From a Trauma Center, Transport Times, and Mortality From Gunshot Wounds in Chicago. American Journal of Public Health [Internet]. 2013 [cited 17 October 2019];103(6):1103-1109. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698742/ SMITH R, FRATESCHI L, SLOAN E, CAMPBELL L, KRIEG R, EDWARDS L et al. The Impact of Volume on Outcome in Seriously Injured Trauma Patients. The Journal of Trauma: Injury, Infection, and Critical Care [Internet]. 1990 [cited 17 October 2019];30(9):1066-1076. Available from: https://journals.lww.com/jtrauma/Abstract/1990/09000/The_Impact_of_Volume_on_Outcome_in_Seriously.2.aspx

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