Are Australian and New Zealand trauma service resources reflective of the Australasian Trauma Verification Model Resource Criteria?

Introduction

Trauma remains the leading cause of death in those under the age of 45 years in Australia and New Zealand (NZ).1, 2 Of the many public health challenges facing clinicians on a daily basis, traumatic injury is one of the most significant.

Injury accounted for $A3.4 billion of allocated health expenditure in Australia in 2004–2005, an increase of 22% since 2001, the greatest proportion of which was spent during hospital admission.3 In 2008–2009, Australia-wide, trauma was responsible for 522 330 hospitalizations, the second highest cause of hospital admissions expenditure, following cardiovascular disease.4 In NZ, injury is the second leading cause of hospitalization. Injuries account for more potential years of life lost than cancer and heart disease combined.5 In 2008, the social and economic costs of injury were estimated to be at least $NZ6–7 billion per year.6 For those who survive traumatic injury, recovery periods and long-term disabilities result in a reduced economic contribution and/or long-term economic liability imposed on health and social systems. In view of the magnitude of this problem, the role of trauma clinicians and effective trauma systems with adequate physical and human resources is pivotal.

Trauma systems, which mandate that trauma patients be transported to designated specialist trauma centres, are fundamental to providing a consistent systematic approach to trauma care and improving patient outcomes.7, 8 Within trauma centres, a multidisciplinary trauma service is generally responsible for the oversight and monitoring of trauma care delivery.9 Despite the implementation of regionalized or state trauma systems over the past 30 years,9, 10 their effect has not been formally evaluated in all Australian11 or NZ health systems.12 Errors in trauma management contribute significantly to preventable or potentially preventable morbidity and mortality.2, 13 Most preventable errors occur because the correct therapeutic and diagnostic measures are not performed at the right time, in the right amount or in the right order.13, 14 Implementing and maintaining principles of standardizing trauma care is vital to optimizing patient recovery.

In an effort to improve the quality of care provided at trauma services within Australia and NZ, the Australasian Trauma Verification Program was developed in 2000.15 Trauma verification is an inter-collegiate process to assist hospitals to analyse their systems of care and benchmark them against international standards. The Australasian programme is largely based on the American College of Surgeons Trauma Verification Program which has demonstrated significant improvements in patient care, enhancement of institutional pride and commitment to care of the injured patient in the United States.16, 17 The Australasian trauma verification ‘model resource criteria’ outlines resources that are deemed ‘essential’ or ‘desirable’ for the different levels of trauma services, ranging from Level 1 to Level 5.15 These relate to education and training, treatment capabilities, research output, injury prevention activites and trauma service human resources (Tables 1 and 2). For example, a Level 1 centre should provide 24 h full spectrum of care for the most critically injured patient, from initial reception and resuscitation through to discharge and rehabilitation, and, ideally, a surgical trauma admitting service (bed card). They are also the principal hospital for reception of inter-hospital transfer of major trauma patients in their region. Participation by trauma centres in Australia and NZ remains voluntary and is not linked to trauma centre designation or funding.18

Aim

The purpose of this study was to determine the human resources in Australian and NZ trauma services and make comparison with those recommended by the Australasian Trauma Verification Program.

Methods

In September 2011, all 68 trauma nurse coordinators (TNC) employed in Australia and NZ trauma centres were invited to participate in an electronic survey. Participants were identified by the annually updated trauma network list (last updated 1 month prior to the survey). This survey expands on previous bi-national research.19 Trauma centres were identified and categorized through the trauma network list and cross referenced with The Australian Trauma Quality Improvement Program.20 At the time of the study, there were 27 designated Australian Level 1 trauma centres.

Results

Fifty-three surveys (78%) were completed. All Australian states/territories and the NZ North Island were represented. Twenty-nine (58%) respondents were employed at a Level 1 trauma centre and 19 (39.5%) at a Level 2 or 3 trauma centre.

Discussion

Many trauma services in Australia and NZ do not meet the human resource criteria set out in the Australasian Trauma Verification Program. There is public expectation of an effective trauma system and service; however, the willingness of governments to support a mandatory trauma verification process, such as that conducted by the Royal Australasian College of Surgeons15 is not consistent throughout Australia and NZ. Currently, governments designate trauma centres independently of verification standards18 despite evidence that the verification process improves patient and system outcomes.17

Trauma monitoring and performance improvement programmes are an essential function of trauma services, contributing to improved patient care, decreased mortality22, 23 and reduced treatment costs.24 Without adequate staffing, it is difficult to coordinate such programmes. It is imperative to maintain ongoing evaluation of trauma systems, central to this is quality surveillance data.25

In Queensland, the third most populous state in Australia, the funding for the state-wide trauma registry was rescinded in June 2012,26 and in Tasmania in 2011, with major implications for trauma system surveillance. This is symptomatic of widespread financial strain on the health-care system.27, 28 The current development of a National Trauma Registry29 may assist with lobbying for the maintenance and enhancement of trauma services as government agencies become increasingly aware of the value of trauma registry data.30 Only when this is available can clinicians ensure adequate patient monitoring, benchmarking and comparison of patient outcomes across all trauma centres. Moreover, where deficiencies are detected, it is incumbent on governing authorities to ensure that all trauma centres are adequately resourced, staff are well trained, and compliance with trauma protocols are maintained to ensure that trauma patients receive high quality care.13

A review of the trauma service human resources component of the Australasian Trauma Verification Model Resource Criteria is required. Currently, fundamental roles such as the trauma fellow and trauma coordinator are not indicated as a full time requirement. Further, supportive roles such as that of a trauma bed card,31 the trauma case manager32 and registered nurse to patient ratios which are directly linked to patient outcomes33, 34 are not considered. These roles are essential to the quality of the trauma service. A full-time trauma director is indicated as essential; however, recruiting trainees and surgeons to specialize in trauma has been difficult internationally.35, 36 Alternate models of care should be considered.

Conclusion

Human resources in Australian and NZ trauma services are not reflective of those recommended by the Australasian Trauma Verification Program. A review of the model resource criteria is recommended. Fundamental roles including the trauma fellow, TNC and trauma case manager are essential for the coordination and function of trauma services. Injury surveillance in Australia and NZ is hampered by insufficient trauma registry resources.