UNCORRECTED PROOF. The evolution of an integrated State Trauma System in Victoria, Australia

Injury, Int. J. Care Injured (2005) xxx, xxx xxx 1 www.elsevier.com/locate/injury 2 3 The evolution of an integrated State Trauma System in Victoria, Australia 4 5 6 7 8 9 10 11 12 13 Chris Atkin a, Ilan Freedman a, Jeffrey V. Rosenfeld b,c, Mark Fitzgerald c,d, Thomas Kossmann a,c, * a Department of Trauma Surgery, The Alfred and Monash University, Commercial Road, Melbourne, Vic. 3004, Australia b Department of Neurosurgery, The Alfred and Monash University, Commercial Road, Melbourne, Vic. 3004, Australia c National Trauma Research Institute, The Alfred, Vic., Australia d Emergency and Trauma Centre, The Alfred, Vic., Australia Accepted 11 May 2005 KEYWORDS Trauma system; Major trauma; Polytrauma; Trauma database; Trauma center * Corresponding author. Tel.: +61 3 9276 3386; fax: +61 3 9276 3804. E-mail address: t.kossmann@alfred.org.au (T. Kossmann). 0020 1383/$ see front matter # 2005 Published by Elsevier Ltd. doi:10.1016/j.injury.2005.05.011 Summary The incidence of major trauma and associated fatalities in the State of Victoria, Australia, have declined over 20 years following the successful implementation of strategies to modify environmental and behavioural factors that contribute to motor vehicle injuries. However, several system deficiencies in the management of major trauma patients had remained unresolved. To investigate these shortfalls, the State Government of Victoria established a taskforce in 1997 to review trauma and emergency services. The taskforce adopted the principle of the right patient to the right hospital in the shortest time and in 2000 began to deploy an integrated State Trauma System. Implementation of such a system required the designation of specific hospitals of various levels to care for trauma patients; the concentration of trauma expertise at these centres; integration and coordination between the service providers; development of agreed triage and transfer protocols and improved education, training and research programs. A statewide major trauma database was established to enable system monitoring and facilitate further enhancements. The Victorian experience with the development of an integrated trauma system should aid in the development of similar systems nationally and internationally and is described in this paper. # 2005 Published by Elsevier Ltd. Introduction Optimal care of trauma patients requires an organised approach that recognises the complexity, 14 15 16

2 C. Atkin et al. 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 range and time-critical nature of major injuries. The concept of modern trauma systems originated from experiences with the management of soldiers injured in the Korean and Vietnam Wars where evacuation by helicopter and refined pre-hospital care enabled rapid transport of patients to definitive surgical care centres and greatly reduced military casualty deaths. 20 This encouraged the development of a landmark statewide system for treatment of civilian motor vehicle accident victims in Illinois in the early 1970s. 4,21 There is substantial evidence to support the concept that the timely delivery of seriously injured patients to centres experienced in the management of major trauma facilitates optimal outcome. 22 Implementation of a trauma system in Orange County, California, improved the quality of trauma care delivered and the proportion of deaths judged to be potentially preventable decreased. 31 In Oregon, trauma system development led to an increased proportion of trauma patients treated at Level I trauma centres and substantially improved the survival rate. 23 In San Diego a preventable death rate of 22% in 1984 fell to 2% after trauma system implementation 11 and studies from New York State demonstrated a significant decrease in region-wide trauma mortality after system development. 3 Improved outcomes in seriously injured children treated in areas with a statewide trauma system were also demonstrated. 12 By March 2003, 35 US states had implemented a trauma system. However, the quality, level of sophistication and integration of these systems varies considerably. 20 The State of Victoria in Australia has a successful history in reduction of deaths and disability from trauma over the last 35 years. Primary prevention including world-first mandatory seat-belt legislation in 1970, 19,29 compulsory bicycle helmets, random alcohol breath testing, speed cameras and mandatory blood tests for hospitalised trauma patients substantially reduced the road toll. 14 Between 1970 and 1994, the fatality rate decreased from 8.1 to 1.4 per 10,000 registered vehicles and from 30.8 to 8.4 per 100,000 population. 15 The State, however, continued to operate an ad-hoc trauma management approach in which trauma patients were generally delivered to the nearest emergency department and only 40% of major trauma patients admitted to a major trauma centre. 8 It was increasingly recognised that a high percentage of deaths were preventable in patients who were still alive at the arrival of medical care. In 1992, a Consultative Council on Road Traffic Fatalities (CCRTF) was established by the Victorian Road Trauma Committee of the Royal Australasian College of Surgeons and the Victorian Institute of Forensic Pathology, under the chairmanship of Professor Frank McDermott and Professor Stephen Cordner. 17,18 The CCRTF s 1992 report identified system-wide deficiencies and treatment errors in metropolitan and rural areas and concluded that potentially preventable problems contributed to death in 38% of road fatalities. 16 A further major trauma management study (MTMS) identified similar rates of preventable mortality and complications in survivors. 9 The CCRTF s annual reports between 1992 and 1997 demonstrated no improvement in these figures. During this time, there was also no change in the proportion of major trauma patients admitted to the trauma centres. The CCRTF reports suggested that system improvements were necessary to further reduce trauma mortality and morbidity. 18 It had been recognised that time is critical for major trauma patients and that prompt, appropriate care improves mortality and morbidity. The concept of a comprehensive, integrated trauma system to deliver timely, expert and efficient care to severely injured patients gained support. 27 In 1997, at the instigation of the Victorian Trauma Committee and CCRTF, the Joint Colleges involved in trauma management approached the State Government. The Victorian Health Minister subsequently established a Ministerial Taskforce on Trauma and Emergency Services, which adopted the principle of the right patient to the right hospital in the shortest time and in 1999 developed a framework for the development of an integrated State Trauma System. 27 The recommendations were accepted as State Government policy and implementation of an integrated trauma system commenced in 2000. Target population Victoria, Australia Victoria is the second most populous State in Australia. It has an area of approximately 227,590 km 2 and a population of 4.9 million people of whom 3.5 million live in the capital city, Melbourne. The State is relatively sparsely populated outside the capital with the most distant border over 500 km from Melbourne. Most Victorian trauma occurs in metropolitan Melbourne but there is a higher per capita incidence of trauma in rural areas. This is related to increased travel distances, greater exposure to roads of lower standard and longer journeys at high speed. 27 In 1965, the Royal Australasian College of Surgeons (RACS) first proposed that a trauma committee be established. The Trauma Committee of the RACS was founded in 1970. The causes and types of injuries 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125

The evolution of an integrated State Trauma System in Victoria, Australia 3 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 occurring, preventative measures, the possibility for more effective trauma service organisation, and the standard of surgical training programs were examined. A series of trauma prevention programs was implemented. A comprehensive pattern of injury study subsequently demonstrated a substantial reduction in trauma incidents and a change in injury patterns across Victoria. 25 Separate National and Victorian Road Trauma Committees were formed in 1979 and further improvements in trauma mortality ensued. However, trauma remained the leading cause of death in people aged from 1 to 44 years and remained a source of significant morbidity. 27 A comprehensive Victorian trauma study was undertaken to investigate the frequency, cause, distribution, pattern, and outcome of patients suffering from major trauma in Victoria. 5 By 1999, there were approximately 1800 major trauma cases per year in Victoria. Between 1000 and 1200 were identified as patients with an injury severity score (ISS) >15. An additional 30% of major trauma patients with an ISS <15 were classified using a broader definition. 6,28 This included patients admitted to an intensive care unit for more than 24 h requiring mechanical ventilation, patients who died after injury, patients who received serious injury to two or more body systems and patients who required urgent surgery for intracranial, intrathoracic, or intraabdominal injury or for fixation of pelvic or spinal fractures. 27 In 1992, the CCRTF evaluated the management of all Victorian road traffic fatalities who had been alive when the ambulance services arrived. All hospital data as well as pre-hospital records and autopsy reports (available for 90% of cases) were studied. Several recurring organisational, pre-hospital, and hospital management and system problems were identified. 15,18 These included inadequate pre-hospital and Emergency Department advanced life-support skills, prolonged accident scene times and the triage of patients to hospitals with inadequate resources. In hospital reception of trauma patients by junior staff, delays in investigation and surgical consultation and the inadequate escort of patients requiring inter-hospital transfer were also identified as problems. 16 The error rate was generally lowest in the major trauma centres. 8,27 Ministerial Taskforce and Working Party on Emergency and Trauma Services Due to the complexity of developing a statewide trauma system, a Victorian Ministerial Taskforce and a Departmental Working Party on Emergency and Trauma Services were formed in 1997. 27 These multidisciplinary parties were comprised of medical trauma specialists, representatives of institutions involved in trauma research and education, consumer groups and the Victorian State Government Department of Human Services. The unique challenges in providing care to the State s isolated rural areas were investigated. The requisite components for a cohesive trauma system were identified and an appropriate trauma system structure for Victoria was developed. This structure endeavoured to match the State s resources to patients medical needs to provide optimal and cost-effective trauma care. Subgroups were formed to focus on role delineation, education, medical retrieval, neurosurgery, paediatrics, ambulance communications and system monitoring. 27 International experiences with trauma system development were studied and the key features associated with optimal outcomes and improved trauma mortality were identified. Internationally recognised authorities on trauma system development such as Professor Donald Trunkey (Oregon, USA) were consulted. 30 The guidelines of the American College of Surgeons Trauma Committee, 2 the American College of Emergency Physicians, 1 the Australasian College of Emergency Medicine and the published literature were reviewed and The National Road Trauma Advisory Council (NRTAC) report was studied. 24 The Ministerial Working Party established a close working relationship with the Taskforce through several joint memberships and reported back to the Taskforce with strategies for consideration geared to delivering the right patient to the right hospital by the fastest and safest means. Recommendations for improving pre-hospital care and streamlining pre-hospital triage processes were formulated. Guidelines for transfer of trauma patients to the most appropriate hospital were formulated. Measures to improve inter-hospital transfer of trauma patients were explored and medical retrieval services were revamped. Improved communication systems were designed and updated protocols to allow bypass of some hospitals were developed. Additional recommendations called for improvements to rehabilitation services and integration of trauma care in rural areas under regional trauma committees. System design Ambulance services and pre-hospital care The Victorian ambulance services share common training, dispatch and clinical practice protocols. 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230

4 C. Atkin et al. 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 The services provide a two-tiered clinical response. The first tier is comprised of paramedics with basic life support skills including airway control and laryngeal mask airways (LMA) insertion (but not endotracheal intubation), extrication, splinting, monitoring and defibrillation skills. Mobile intensive care ambulance (MICA) paramedics providing the second tier and have a comprehensive range of skills which include drug facilitated endotracheal intubation, ventilation assisted by concomitant use of paralysing agents when indicated, chest decompression, IV fluid administration and IV narcotics. Dispatch to trauma is computer assisted with a mandatory MICA response for major trauma. In rural Victoria, ground based MICA paramedics provide this response in the major provincial centres, whilst the rotary wing based MICA paramedics provide a secondary response outside the major centres. Patients with short transport times to hospital may forgo MICA intervention. Both rural and metropolitan ambulance services have rigorous audit processes. The CCRTF and the RACS Victorian Road Trauma Committee spurred the rationalisation and integration of the State s ambulance services. In the 1980 s the Metropolitan Ambulance Service Victoria was consolidated to become the sole pre-hospital provider for the 3.5 million people living in and around Melbourne. During the same period rural ambulance services underwent several rationalisations. In 1992, the remaining five rural services were integrated into a single Rural Ambulance Victoria, which now serves the 1.3 million persons living outside the metropolitan area. A third ambulance division Air Ambulance Victoria coordinates a MICA-staffed, rotary wing service that provides three helicopters for primary and secondary trauma response. One operates from Melbourne, a second is based 150 km to the east and a third is based 150 km to the north west of the city. This rotary wing response allows rapid transfer of seriously injured patients from rural areas to metropolitan major trauma services. Air Ambulance Victoria also operates fixed wing aircraft out of the capital city to the more distant rural centres. An integrated pre-hospital system provided the basis for an integrated trauma system. Those involved realised that the benefits achieved from this rationalisation and integration could be extended to the hospital system. Stratification of hospitals to receive major trauma It was neither appropriate nor feasible for every hospital in the State to be resourced to the level of a major trauma centre. 27 The Victorian trauma system design called for stratification of hospitals based upon resource availability and geographic considerations (Fig. 1). Each level of the system provides different complexities of trauma care and patients are managed in a service appropriate for their injuries. The first tier involved designation of one major paediatric (Royal Children s Hospital) and two adult hospitals (The Alfred and the Royal Melbourne Hospital) in the State Capital as Major Trauma Services Figure 1 Structure of the integrated Victorian State Trauma System. 27 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294

The evolution of an integrated State Trauma System in Victoria, Australia 5 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 (MTS) (Fig. 1). These major teaching hospitals would function as services that form the hub of an integrated system. These centres provide 24-h trauma reception teams, on-site neurosurgery, cardiothoracic surgery, intensive care and other specialist resources and deliver definitive care to the majority of the State s major trauma caseload through primary triage from the accident scene or following secondary transfer. Major trauma service classification was restricted to ensure that a high caseload of major trauma patients is consistently treated at the MTS institutions. 8 Caseload concentration also facilitates development of a core group of surgeons who consistently manage large trauma volumes. The MTS centres possess the resources and expertise to deliver leadership and support to the trauma system as a whole. 10 The metropolitan component of the trauma system A second tier of hospitals titled Metropolitan Trauma Services was designated to receive major trauma patients who, for safety or logistic reasons, are unable to be transported directly to a Major Trauma Service (Fig. 1). These metropolitan services provide resuscitation and stabilisation, establish early consultation with the MTS and endeavour to undertake early transfer of severely injured patients to the MTS. The Metropolitan Trauma Services provide 24-h access to surgeons and in some cases provide definitive treatment in consultation with a major trauma service. A third tier of Primary Injury Services consists of hospitals designated as appropriate for treatment of patients with minor injuries (Fig. 1). Ambulance services transporting trauma patients to hospital generally bypass primary injury services in preference for higher level services. The regional component of the trauma system Rural and regional communities face several additional difficulties compared to their metropolitan counterparts. 10 Their geographic location, sparse populations, limited resources and logistical problems were acknowledged. Triage and bypass may be difficult in regions where resources are dispersed. The importance of providing a rapid response retrieval system and efficient inter-hospital transport services was recognised. The regional component of the Victorian trauma system is also led by the Major Trauma Services with Regional Consultative Committees on Emergency and Critical Care Services (RCCECCS) appointed to coordinate the system at a regional level. 27 After consultation with the Taskforce, the RCECCS stratified regional hospitals to particular trauma care roles. Regional Trauma Services (RTS) located in major regional centres serve as a regional focus for trauma management (Fig. 1). These hospitals provide regional communities with service similar to the Metropolitan Trauma Services and receive appropriate trauma referrals from the surrounding catchment area. They provide resuscitation and stabilisation to trauma patients, establish early communication with the MTS and transfer major trauma patients to the MTS. The RTS also provide definitive care to a limited number of trauma patients when injuries are not severe enough to warrant transfer and when the MTS is in agreement with not transferring the patient. Urgent Care Services were formed in smaller rural communities where higher levels of trauma care are not readily accessible (Fig. 1). They provide resuscitation and stabilisation of patients prior to early transfer to a higher level centre. Primary Injury Services were established in isolated areas to provide initial resuscitation and stabilisation prior to early transfer to the MTS (Fig. 1). The primary injury services may be designated for bypass so that major trauma patients may be transported directly to the MTS from the injury scene. The RCCECCS oversee the clinical functioning of the Regional Trauma Services and assist regional hospitals in coordinating system activities such as education, research and quality improvement. The RCCECCS also liaise with interstate bodies to develop referral strategies for border regions. Triage and transfer protocols Concentration of trauma experience in a few specialist institutions requires the majority of major cases to be efficiently delivered to these sites within defined logistic and safety parameters. The efficacy of transfer depends more on the time taken to cover a particular distance and quality of care delivered during inter-hospital transfer than on the actual distance travelled. 10 Streamlined referral processes, agreed triage and transfer protocols and a rapid response retrieval system with enhanced primary response and secondary retrieval capacity were developed (Figs. 2 4). The standard of care during inter-hospital transport aims to be equivalent to or better than at the referring hospital. Closer cooperation with the MTS hospitals was pursued to improve the efficacy of patient reception at the MTS. 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400

6 C. Atkin et al. 401 402 403 404 405 406 407 408 409 410 411 Inadequate identification of major trauma cases and failure to activate a system response has the potential to lead to suboptimal clinical outcomes. Pre-hospital major trauma criteria were formulated using specified physiological, anatomical and mechanistic indicators to identify major trauma patients (Fig. 2). Clinically applicable assessment and inter-hospital transfer guidelines that recognise the evolutionary nature of the diagnostic status in major trauma patients were devised (Fig. 3). Figure 2 Title: pre-hospital major trauma criteria. 27 A 30-min major trauma bypass protocol was developed in which patients who fulfil the triage criteria for major trauma and are within 30 min of an MTS are delivered directly to the MTS, with the ambulance bypassing nearer non-mts hospitals 26 (Fig. 4). This protocol would deliver an additional 145 185 major trauma patients per year to the Major Trauma Services. The infrastructure at the MTS centres was upgraded accordingly. The 30-min transport time was selected so that most patients given average activation and scene times would 412 413 414 415 416 417 418 419 420 421 422

The evolution of an integrated State Trauma System in Victoria, Australia 7 423 424 425 426 427 428 429 430 431 432 433 Figure 3 Major trauma inter-hospital transfer guidelines. 27 reach hospital well within the golden hour of trauma care. 27 When primary triage to the MTS is not possible for safety or logistical reasons or when immediate lifethreatening situations such as failed airway control arise during transport the protocol provides for the patient to be diverted to the nearest designated trauma service for stabilisation. Regular audits of the triage system s efficacy and interpretive consistency are performed to verify that the triage and transfer protocols perform as intended. International studies suggest that with implementation of a trauma system the triage patterns change early and mortality improvements follow. 7,13 Prior to announcement of the new Victorian trauma system the proportion of major trauma treated at the three hospitals designated as Major Trauma Services was 37%. Soon after the announcement this rose to 49%. In the 12 months to June 30th, 2001, the State s busiest Major Trauma Service, The Alfred, treated 484 patients with an ISS >15. This is above the threshold considered to be associated 434 435 436 437 438 439 440 441 442 443 444

8 C. Atkin et al. 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 with improved clinical outcomes. 8 At the end of 2002, the percentage of Victorian major trauma treated at a MTS rose to above 80% and in the 12 months to June 30th, 2003, 603 patients with an ISS >15 were treated at The Alfred. This indicates that the trauma system has been successfully implemented in terms of streamlining major trauma patients to MTS hospitals. Retrieval, transfer and communications Rapid and efficient retrieval and transfer of timecritical patients with a high standard of care during transport required that existing retrieval services were integrated and additional measures developed. 10 A centrally based pool of senior medical practitioners trained in transport medicine and equipped to frequently undertake retrievals was formed. They were sourced from a range of Figure 4 The 30-min bypass protocol. 27 specialties to allow selection of appropriate crews for particular missions. 27 Retrieval teams are staffed by an emergency physician, an anaesthetist or intensive care specialist and a MICA paramedic. Dispatch mechanisms exist to include a trauma surgeon but this is rarely required or utilised. Paediatric retrieval services are coordinated through the paediatric MTS (The Royal Children s Hospital). Communication processes were integrated to provide seamless information transfer and wider application of mobile systems for early pre-hospital to hospital communications was instituted. A single call mechanism to activate retrieval processes and dedicated phone lines, so-called 1-800 Trauma Lines, were established at the MTS. These enable direct 24- h access for referrals and advice. Regional retrieval services coordinate retrieval missions that require treatment at a regional hospital level. Timely liaison 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480

The evolution of an integrated State Trauma System in Victoria, Australia 9 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 with the statewide retrieval system occurs for situations possibly requiring tertiary level care. In some cases simultaneous dispatch of regional and statewide retrieval services may be activated to minimise time to definitive care or to provide support to the regional ambulance services or local hospitals. Educational strategies were developed to emphasise the importance of early hospital notification regarding a patient s pre-hospital physiological condition. Standardised comprehensive transfer documentation forms were developed in consultation with the ambulance services. An upgraded aircraft capacity to enhance rural retrieval services is planned. 26 A director of retrieval services maintains overarching responsibility for maintenance and development of the retrieval services. System administration, integration and organisation Successful operation of an advanced trauma system requires smooth integration of its complex components. This extends from the time of notification of ambulance services through every phase of care and includes integration of pre-hospital care providers and within and between city, rural and metropolitan hospitals. An organisational structure with a central non-institutional focus to coordinate the efforts of all agencies involved in trauma care and to implement strategies for improving trauma services was required. Inclusive representation from rural providers in both system planning and maintenance was sought. The Victorian State Trauma System was initially coordinated by an overarching Ministerial Emergency and Critical Care Committee (MECCC), a State Trauma Committee (STC), a Major Trauma Service Coordination Unit (MSCU), and the RCCECCS. The MECCC advised the Health Minister on the coordination, audit and ongoing development of the statewide emergency services. The STC served as a subcommittee of the MECCC, incorporated rural representation and addressed trauma system issues in detail. It oversaw the function of the Major Trauma Services, coordinated between the directors of Trauma Services, consulted with the RCCECCS and was responsible for establishment of education subcommittees, refinement of triage protocols and monitoring system performance. The collaborative MSCU functioned as the implementation arm for trauma system development. The RCCECCS played an essential role in promotion, coordination, monitoring and implementation of the trauma system in a regional context. Coordination of the system has since been integrated into Acute Care (Department of Human Services). Audit, quality control and research A comprehensive statewide trauma registry coordinated by the Victorian State Trauma Outcome Registry and Monitoring Group (VSTORM) and maintained by the MSCU was developed to facilitate collection of system performance data. Hospitals designated to treat trauma patients are required to collect specified Epidemiological Dataset items, those that receive major trauma patients collect additional Trauma Dataset items and the Major Trauma Services collect System Performance Dataset items. 27 Information regarding response to initial calls to ambulance, actions taken at the injury scene and the efficiency of inter-hospital transfers are also analysed. A software developer was employed to design a MS ACCESS database to accommodate the Victorian Major Trauma Dataset. Data collection is undertaken by trauma nurses or allied health professionals. Where possible trauma data is collected concurrent with the inpatient episode. Otherwise, data collection is retrospective. Trauma data is benchmarked for case volume, severity and outcomes across all levels of hospitals and designated key indicators are reported quarterly to the State Trauma Committee. The registry will enable development of systemwide quality improvement programs and injury prevention and health promotion campaigns. These programs will evaluate trauma care through clinical studies, statistical analyses and expert peer review. The economic impact of the trauma system on patients, hospitals and the broader region will also be studied. The STC and MECCC oversee the audit and quality improvement programs. The RCCECCS supervise audits of regional trauma management activities. The Victorian Trauma Foundation (VTF) was formed by the Transport Accident Commission (TAC), a third party insurer of public and private transport, to fund trauma research projects. Road trauma and workplace injuries account for much of Victoria s major trauma. Since February 2000 the VTF has allocated more than $12 million (Australian Dollars) towards a range of projects. For example, in an investigation of functional outcomes following major trauma psychological sequelae, occupational outcome and quality of life were examined and factors that may predict post-traumatic psychological and functional disability were identified. VTFfunded neurotrauma projects include an evaluation of trauma care delivery in brain-injured patients, which identified potentially preventable factors that contribute to neurological disability. Pre-hospital hypertonic saline resuscitation in hypotensive patients with traumatic brain injury is being stu- 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589

10 C. Atkin et al. 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 died. Intensive monitoring of brain injured patients with intracranial pressure (ICP) recorders, transcranial doppler ultrasound, jugular venous oximetry and focal brain oxygen tension monitors is under investigation. A TAC-funded randomised controlled multicenter study of decompressive craniectomy in patients with diffuse brain swelling and severe traumatic brain injury is also underway. Education and training The State Trauma Education Subcommittee and MSCU developed frameworks to assist cooperative efforts between universities, specialist colleges and hospitals in implementing new trauma and injury education strategies. The directors of the respective trauma services are responsible for devising and providing strategies to meet the educational needs of staff involved in trauma care at their centres. Innovative education processes, such as simulators, were developed to maintain skills for personnel with infrequent trauma exposure. Principles of trauma management are to be emphasised in undergraduate medical and nursing education. Further education initiatives were formulated to increase public adoption of safety legislation and policies. The particular educational needs experienced by rural clinicians due to their infrequent exposure to major trauma patients, geographical isolation and difficulty in accessing continuing education and advanced training courses were recognised. The RCCECCS develop and implement trauma education initiatives in their local areas in consultation with the STC. New mobile simulators and video-conferencing technologies will help circumvent geographic access difficulties. A trauma education framework for Victoria has been developed and gazetted in March 2002. The frameworks outlines education requirements for all levels of trauma care provider from first responder to trauma surgeon. As a result, trauma training programs are available for all levels of trauma care provider. Conclusion Despite significant public prevention measures some people will inevitably continue to suffer severe injuries from road trauma and other accidents. Optimal outcome is most likely when such patients are treated at centres experienced and proficient in the management of major trauma. Drawing upon experience elsewhere, the Victorian trauma system structure has established treatment protocols, designated responsibilities and allocated appropriate resources to provide optimal care to injured patients from the time of the accident through the rehabilitation process. Implementation of the Victorian State Trauma System has seen an increase in the proportion of major trauma patients delivered rapidly and safely to designated major trauma services. The coordinated approach and streamlined transfer of major trauma patients in a formalised and structured manner is a major strength of the Victorian Trauma System. At designated hospitals expert multidisciplinary trauma teams and experienced trauma surgeons are able to rapidly institute the most appropriate and definitive treatment. The reporting structure in the Victorian Trauma System ensures that collection of important data for the state is centralised. No other trauma system in the world has such a comprehensive system of data collection. Comparative studies using data from the Victorian State Trauma Outcome Registry and Monitoring Group (VSTORM) will quantify the anticipated improvements in overall survival from major trauma in Victoria. Definitive assessments of the impact on patient outcome and of financial viability of the system are yet to be completed due to the sheer volume of data to be processed. The development of the trauma system in Victoria is unique for Australia. Other states are now reviewing their trauma systems based on the Victorian experience. We believe that the State of Victoria s experience in the development of an integrated State Trauma System supports the pursuit of further integrated trauma systems throughout Australasia and internationally. References 1. American College of Emergency Physicians. Guidelines for trauma care systems. Ann Emerg Med 1987;16:459 63. 2. American College of Surgeons Committee on Trauma. Resources for optimal care of the injured patient. Chicago, IL: American College of Surgeons; 1990. 3. Barquist E, Pizzutiello M, Tian L, et al. Effect of trauma system maturation on mortality rates in patients with blunt injuries in the Finger Lakes Region of New York State. J Trauma 2000;49(1):63 9 [discussion 69 70]. 4. Bazzoli GJ, Madura KJ, Cooper GF, et al. Progress in the development of trauma systems in the United States. Results of a national survey. JAMA 1995;273(5):395 401. 5. Cameron P, Dziukas L, Hadj A, et al. Major trauma in Australia: a regional analysis. J Trauma 1995;39(3):545 52. 6. Cameron P, Dziukas L, Hadj A, et al. Patterns of injury from major trauma in Victoria. Aust N Z J Surg 1995;65(12): 848 52. 7. Champion HR, Sacco WJ, Copes WS. Improvement in outcome from trauma center care. Arch Surg 1992;127(3):333 8. 8. Cooper DJ, McDermott FT, Cordner SM, Tremayne AB. Quality assessment of the management of road traffic fatalities at a level I trauma center compared with other hospitals in 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696

The evolution of an integrated State Trauma System in Victoria, Australia 11 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 731 732 733 734 735 Victoria. Australia. Consultative Committee on Road Traffic Fatalities in Victoria. J Trauma 1998;45(4):772 9. 9. Danne P, Brazenor G, Cade R, et al. The major trauma management study: an analysis of the efficacy of current trauma care. Aust N Z J Surg 1998;68(1):50 7. 10. Danne PD. Trauma management in Australia and the tyranny of distance. World J Surg 2003;27(4):385 9. 11. Eastman AB. Blood in our streets. The status and evolution of trauma care systems. Arch Surg 1992;127(6):677 81. 12. Hulka F, Mullins RJ, Mann NC, et al. Influence of a statewide trauma system on pediatric hospitalization and outcome. J Trauma 1997;42(3):514 9. 13. Mann NC, Mullins RJ, MacKenzie EJ, et al. Systematic review of published evidence regarding trauma system effectiveness. J Trauma 1999;47(3 Suppl.):S25 33. 14. McDermott FT. Alcohol on wheels. Aust N Z J Surg 1986;56(1):19 24. 15. McDermott FT, Cordner SM, Tremayne AB. Evaluation of the medical management and preventability of death in 137 road traffic fatalities in Victoria. Australia: an overview. Consultative Committee on Road Traffic Fatalities in Victoria. J Trauma 1996;40(4):520 33. discussion 533-35. 16. McDermott FT, Cordner SM, Tremayne AB. Management deficiencies and death preventability in 120 Victorian road fatalities (1993-1994). The Consultative Committee on Road Traffic Fatalities in Victoria. Aust N Z J Surg 1997;67(9): 611 8. 17. McDermott FT, Cordner SM, Tremayne AB. Reproducibility of preventable death judgments and problem identification in 60 consecutive road trauma fatalities in Victoria. Australia. Consultative Committee on Road Traffic Fatalities in Victoria. J Trauma 1997;43(5):831 9. 18. McDermott FT, Cordner SM, Tremayne AB. Consultative Committee on Road Traffic Fatalities: trauma audit methodology. Aust N Z J Surg 2000;70(10):710 21. 19. McDermott FT, Hough DE. Reduction in road fatalities and injuries after legislation for compulsory wearing of seat belts: experience in Victoria and the rest of Australia. Br J Surg 1979;66(7):518 21. 20. Mullins RJ. A historical perspective of trauma system development in the United States. J Trauma 1999;47(3 Suppl.):S8 S14. 21. Mullins RJ, Mann NC. Introduction to the academic symposium to evaluate evidence regarding the efficacy of trauma systems. J Trauma 1999;47(3 Suppl.):S3 7. 22. Mullins RJ, Mann NC, Hedges JR, et al. Preferential benefit of implementation of a statewide trauma system in one of two adjacent states. J Trauma 1998;44(4):609 16 [discussion 617]. 23. Mullins RJ, Veum-Stone J, Hedges JR, et al. Influence of a statewide trauma system on location of hospitalization and outcome of injured patients. J Trauma 1996;40(4):536 45 [discussion 545 6]. 24. National Road Trauma Advisory Council (NRTAC). Report of the working party on trauma systems. Commonwealth Department of Health, Housing, Local Government and Community Services. Canberra: AGPS; 1993. 25. Nelson PG. Aspects of injury patterns in automobile accidents. Aust N Z J Surg 1977;47(2):162 5. 26. Peeters A, Smith K, Cameron P, McNeil J. Predicted impact on Victoria s ambulance services of a new major trauma system. ANZ J Surg 2001;71(12):747 52. 27. Review of Trauma and Emergency Services Victoria 1999. Final report of the Ministerial Taskforce on Trauma and Emergency Services and the Department Working Party on Emergency and Trauma Services. Melbourne, Victoria: Department of Human Services; 1999. 28. Rosenfeld JV, McDermott FT, Laidlaw JD, et al. The preventability of death in road traffic fatalities with head injury in Victoria, Australia. The Consultative Committee on Road Traffic Fatalities. J Clin Neurosci 2000;7(6):507 14. 29. Trinca GW, Dooley BJ. The effects of seat belt legislation on road traffic injuries. Aust N Z J Surg 1977;47(2):150 5. 30. Trunkey DD. Trauma centers and trauma systems. JAMA 2003;289(12):1566 7. 31. West JG, Cales RH, Gazzaniga AB. Impact of regionalization. The Orange County experience. Arch Surg 1983;118(6): 740 4. 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754 755 756 757 758 759 760 761 762 763 764 765 766 767 768 769 770 771 772 773 774 775