Injury (1991) 22, (S), 369-371
Printed in Greut Britain
369
Introduction of a trauma team to a district general hospital. The Brighton Experience F. L. P. Heyes and C. A. Perez-Avila Accident
and Emergency
Department,
Royal Sussex County
The response fo major trauma in Britain has been demonstrated to be inadequate. One of the suggested approaches to tackling fhe problem has been the setting up of rapid response trauma teams at disfrict general hospitals. We set up such a team in Brighton and report on itsfirst year of operafion. Numbers of patients were not sufficient to draw any firm conclusions, though no dramatic improvement in oufcome was evident. Problems in setting up such a team are discus&.
Hospital, Brighton, UK
or
Introduction Trauma has become the principal cause of death in the United Kingdom in the under-35 years age group, exceeding the combined total for heart disease and cancer (DHSS, 1987). In the United States, injuries cause the loss of more working years of life than all forms of cancer and heart disease combined. It is likely that a similar, but lesser, situation exists in the United Kingdom. A recent retrospective study of 1000 deaths from trauma in this country has indicated that the management of major trauma is suboptimal (Anderson et al., 1988). This study suggested that one-third of deaths from trauma were preventable. In the United States, Trunkey and others have shown that mortality from major trauma in a region can be improved by improving the quality of prehospital care and by introducing Trauma Centres (West et al., 1979; West et al., 1983; Cales, 1984; Boyd et al., 1987). There is a debate in this country as to whether trauma centres should be introduced into the United Kingdom. A multicentre prospective study, the Major Trauma Outcome Study is being carried out in order to furnish data which will help this decision-making process. In addition, the Department of Health is setting up an experimental Trauma Centre at Stoke-on-Trent which will be evaluated over a s-year period. The establishment of trauma centres in the UK will inevitably involve high expenditure in manpower and resources. In the meantime it is possible that some benefit might be achieved by other means of ‘raising the profile’ of trauma, more quickly and at less expense. In this context, the introduction of a rapid response ‘Trauma Team’ on similar lines to a ‘Cardiac Arrest Team’ has been suggested. The Accident Unit at Brighton currently sees 50000 patients/annum. In June 1988 a Trauma Steering Group was i, 1991 Butterworth-Heinemann 0020-1383/91/050369-03
Ltd
q cm 0
10
Ehx@lotlI% 20
30 Injury
I
I
!
I
I
40
50
60
70
80
severity
scow
Figure 1. Plot used to calculate revised trauma score. 0, Survived. 0, Died.
formed in line with the initial report on the retrospective analysis of 1000 trauma deaths. This group consisted of an accident and emergency consultant, an anaesthetic consultant with interest in intensive care, an orthopaedic surgeon and a general surgeon, both with an interest in trauma. This group set the ground rules for the introduction on 1 July 1988 of a rapid response Trauma Team’. This is a report of its first year of operation.
Method The members of the team consist of an anaesthetic registrar, a general surgical registrar, an orthopaedic registrar and an accident and emergency senior registrar or consultant. A ‘fast bleep’ system contacts members of the team and a response is expected in the Accident and Emergency Department within 10 min. Revised Trauma Scores (RTS) and Injury Severity Scores (ISS) were recorded for each patient; this was later correlated with the outcome (alive or dead). Boyd et al. (1987) have constructed a graph using statistics from the American Major Trauma Outcome Study (MTOS). This is shown in Figure I. The RTS is calculated as follows. Coded values are apportioned to patients for each of three variables; Glasgow Coma Scale, systolic blood
Injury: the
370
3. Shock Case F
Table I. Revised Trauma Score Glasgow Coma Scale
Systolic BP fmmHg)
13-I 5 9-12 6-8 4-5 3
89 76-89 50-75 1-49 0
British Journal of Accident Surgery (1991) Vol. 22/No. 5
Respiratory rate (per min) 1 o-29 29 6-9 1-5 0
Coded
value 4 3 2
(Age 26) 80 per cent burns and severe inhalation injuries. Blind and severely mentally disturbed. Active treatment was considered inappropriate. ps = 0.82
4. Non-kzimatic Case G (Age 50) Recurrent ventricular fibrillation, Fracture of elbow, as a result of fall following an episode of VP. Referred for cardiac surgery. Died postoperaps = 0.99 tively. Late death, not due to injury.
Table II. Weighting coefficietits for RTS Glasgow Coma Scale Systolic blood pressure Respiratory rate
0.9368 0.7326 0.2908
pressure and respiratory rate (Table I). As each of these variables has been found to have a different importance as a predictor of outcome, each coded value is multiplied by a weighted coefficient (TubZeII). The sum of these three products is the Revised Trauma Score (RTS). The Injury Severity Score is calculated from published tables after Baker et al. (1974) based on AIS (‘85) published by the American Association for Automotive Medicine (1985). The oblique line on the graph represents patients with a probability of survival (pS) of 50 per cent, given best available care in the USA. Most patients lying below the line will therefore be expected to live. In calculating the probability of survival a correction is also applied for age and for the presence or absence of penetrating trauma. These corrections are not applied to the graph.
Results Fifty patients were seen by the ‘Trauma Team’ and, of these, 17 died. One patient ‘expected to die survived, whereas seven patients ‘expected to live did not. The causes of these unexpected deaths are as follows: 1. hknmorrhage
Case A
Case B
(Age 24) Hepatic lacerations and multiple fractures. Transfused 1OOml. Whilst in accident and emergency department had cardiac arrest; was resuscitated and transferred to theatre. He died on table (2.5 min after arrival in accident and emergency department). Patient was transfused a total pS= 0.91 of 4.5 litres of blood and other fluids. (Age 73) Multiple fractures. Died soon after ps = 0.58 arrival. Only given I litre of colloid.
2. Major head injures
Case C
Case D Case E
(Age 23) Large laceration, occipital lobe. Large subdural haematoma. Neurosurgeon not conpS = 0.65 sulted at any stage. (Age 23) Intracerebral and extradural haematoma. ps = 0.83 Did not have operation. (Age 83) Severe laceration of cerebral hemipS = 0.65 spheres.
Unexpected survivor The patient who survived unexpectedly, survived with a major disability. He suffered a right frontal subdural haematoma (volume LOO-200ml), an extradural haematoma, a major chest injury with a flail segment, an open, comminuted fracture of the mandible, 21 per cent partial thickness bums and a ruptured spleen. His probability of survival was calculated as 0.27.
Discussion The numbers in this study are too small to draw any significant conclusions. The Trauma Team was felt by the overwhelming majority of staff to have been a great improvement on the previous practice, and its operation will be continued. Awareness of trauma has been raised, the importance of resuscitation stressed, and co-operation among departments improved. However, if, as it appears, 50 per cent of trauma deaths are potentially preventable, then the situation is clearly unsatisfactory. Casual perusal of the deaths in question does suggest that some may not have been avoidable, in spite of the verdict of the TRISS methodology. There are indeed factors which may be contributing falsely to increase a patient’s computed probability of survival (PS’),namely: 1. Incomplete autopsy, underestimating the Injury Severity Score (ISS). 2. Failure to record vital signs until after resuscitation has commenced, thus underestimating the Revised Trauma Score (RTS). 3. Concurrent disease or illness. If the figure of SO per cent is borne out, two conclusions are possible: either trauma teams are not the answer, or we simply have not organized an effective one in our area. Certainly teething problems were experienced in the introduction of the team. Some colleagues in orthopaedics and general surgery feared, with good reason, that it would disrupt established routines and there was some scepticism as to the value of the team. This resolved during the first few months of operation. Failure of the accident and emergency junior staff to use the team when it would be appropriate. More than 50 patients suffering from major trauma passed through the department during the year of study, yet the Trauma Team was not always called. Technical problems with the paging system. Without incurring considerable expense it was not possible to institute a system whereby the switchboard operator could transmit instructions to ail members of the team simultaneously. Consequently each member has to be
371
Heyes and Perez-Avila: Trauma team in a DGH Table III. Trauma Team response
times Team member
Response
A&E
Anaesthetic
General Surgery
Orthopaedic
34 (69%)
41 (84%)
39 (80%)
30 (65%)
10 (20%)
16 (35%)
49
46’
Satisfactory response (i.e. within 10 min of patient’s arrival) Unsatisfactory response (i.e. more than 10 min after patient’s arrival, or no response at all)
15 (31%)
Total
49
‘In three cases orthopaedic
doctor not called.
summoned individually, which clearly takes more time. 4. Slow response or no response at all from the members of the team. Each member of the team failed to see the patient within 10 min of arrival in between 16 per cent and 35 per cent of cases (Table III). Reasons for delay or failure in responding were varied, but were most often in one of the following three categories: i. Team member non-resident, when call comes out of hours (A + E Consultant or Senior Registrar). ii. Team member in operating theatre and/or not carrying bleep. iii. Team member at a different hospital (Brighton DGH is on split sites). 5. Even when the full team arrives promptly, resuscitation and full assessment is still slow because: i. Lack of clearly identified team leader. ii. Failure to perform the necessary tasks simultaneously. ... X-ray gantry. 111. No overhead sited. iv. CT scanner inconveniently Insufficient nursing staff available. V. vi. Time wasted with form filling. We consider
8 (16%) 49
that there should be a minimum number of trauma cases below which the efficiency of a hospital dealing with serious trauma is questionable. One must support Spencer’s comments that Minor Units, where the availability of a team to deal with serious trauma is not implementable, should close to serious trauma. Audit reports such as this one provide us with the evidence to support trauma care in individual hospitals. This type of audit allows us to look at all aspects of trauma care, including prehospital care, the accident and emergency and in-hospital treatment, as well as to observe and assess the documentation and appraise the overall management, leading to correct measures where appropriate. In summary, these deficiencies of the Trauma Team could be remedied provided there is the will and the funds required. An attempt is now being made at this hospital along these lines and we hope in future to be able to repeat
the study in order to determine
whether any improvement in patient outcome has resulted. However, in many cases we feel that the necessary support may not be forthcoming if it is felt that major trauma constitutes an insufficiently high proportion of the district’s case load.
Acknowledgements We would like to thank our colleagues in the Anaesthetic, Orthopaedic and General Surgical Departments, in particular Drs C. Studd and M. Street, and Messrs P. Staniforth and P. Hurst for their helpful comments and continuing cooperation.
References Anderson I. D., Woodford M., de Dombal F. T. et al. (1988) Retrospective study of 1000 death from injury in England and Wales. Br. Med. 1. 296, 1305. Baker S. P., O’Neill B., Haddon W. Jr et al. (1974) The Injury Severity Score: A method for describing patients with multiple injuries and evaluating emergency care. 1. Trauma 14, 187. Boyd C. R., Tolson M. A. and Copes W. S. (1987) Evaluating trauma care: the TRISS method. 1. Truutrua27, 370. Cales R. H. (1984) Trauma mortality in Orange County: The effect of implementation of a regional trauma system. Ann. Emerg. Med. 13, I. Department of Health and Social Security (1987) On the State of Public Health for the Year 1986. London: HMSO. West J. G., Trunkey D. D. and Lim R. C. (1979) Systems of trauma care - a study of two counties. Arch. Surg. 114,455. West J. G., Cales R. M. and Gazzaniga A. B. (1983) Impact of regionalisation - the Orange County experience. Arch. Surg. 118, 740.
Paper accepted 4 February
1991.
Requests for reprints should be aa%-essedto: Mr F. L. P. Hayes, Accident and Emergency Department, Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE.
Printed in Greut Britain
369
Introduction of a trauma team to a district general hospital. The Brighton Experience F. L. P. Heyes and C. A. Perez-Avila Accident
and Emergency
Department,
Royal Sussex County
The response fo major trauma in Britain has been demonstrated to be inadequate. One of the suggested approaches to tackling fhe problem has been the setting up of rapid response trauma teams at disfrict general hospitals. We set up such a team in Brighton and report on itsfirst year of operafion. Numbers of patients were not sufficient to draw any firm conclusions, though no dramatic improvement in oufcome was evident. Problems in setting up such a team are discus&.
Hospital, Brighton, UK
or
Introduction Trauma has become the principal cause of death in the United Kingdom in the under-35 years age group, exceeding the combined total for heart disease and cancer (DHSS, 1987). In the United States, injuries cause the loss of more working years of life than all forms of cancer and heart disease combined. It is likely that a similar, but lesser, situation exists in the United Kingdom. A recent retrospective study of 1000 deaths from trauma in this country has indicated that the management of major trauma is suboptimal (Anderson et al., 1988). This study suggested that one-third of deaths from trauma were preventable. In the United States, Trunkey and others have shown that mortality from major trauma in a region can be improved by improving the quality of prehospital care and by introducing Trauma Centres (West et al., 1979; West et al., 1983; Cales, 1984; Boyd et al., 1987). There is a debate in this country as to whether trauma centres should be introduced into the United Kingdom. A multicentre prospective study, the Major Trauma Outcome Study is being carried out in order to furnish data which will help this decision-making process. In addition, the Department of Health is setting up an experimental Trauma Centre at Stoke-on-Trent which will be evaluated over a s-year period. The establishment of trauma centres in the UK will inevitably involve high expenditure in manpower and resources. In the meantime it is possible that some benefit might be achieved by other means of ‘raising the profile’ of trauma, more quickly and at less expense. In this context, the introduction of a rapid response ‘Trauma Team’ on similar lines to a ‘Cardiac Arrest Team’ has been suggested. The Accident Unit at Brighton currently sees 50000 patients/annum. In June 1988 a Trauma Steering Group was i, 1991 Butterworth-Heinemann 0020-1383/91/050369-03
Ltd
q cm 0
10
Ehx@lotlI% 20
30 Injury
I
I
!
I
I
40
50
60
70
80
severity
scow
Figure 1. Plot used to calculate revised trauma score. 0, Survived. 0, Died.
formed in line with the initial report on the retrospective analysis of 1000 trauma deaths. This group consisted of an accident and emergency consultant, an anaesthetic consultant with interest in intensive care, an orthopaedic surgeon and a general surgeon, both with an interest in trauma. This group set the ground rules for the introduction on 1 July 1988 of a rapid response Trauma Team’. This is a report of its first year of operation.
Method The members of the team consist of an anaesthetic registrar, a general surgical registrar, an orthopaedic registrar and an accident and emergency senior registrar or consultant. A ‘fast bleep’ system contacts members of the team and a response is expected in the Accident and Emergency Department within 10 min. Revised Trauma Scores (RTS) and Injury Severity Scores (ISS) were recorded for each patient; this was later correlated with the outcome (alive or dead). Boyd et al. (1987) have constructed a graph using statistics from the American Major Trauma Outcome Study (MTOS). This is shown in Figure I. The RTS is calculated as follows. Coded values are apportioned to patients for each of three variables; Glasgow Coma Scale, systolic blood
Injury: the
370
3. Shock Case F
Table I. Revised Trauma Score Glasgow Coma Scale
Systolic BP fmmHg)
13-I 5 9-12 6-8 4-5 3
89 76-89 50-75 1-49 0
British Journal of Accident Surgery (1991) Vol. 22/No. 5
Respiratory rate (per min) 1 o-29 29 6-9 1-5 0
Coded
value 4 3 2
(Age 26) 80 per cent burns and severe inhalation injuries. Blind and severely mentally disturbed. Active treatment was considered inappropriate. ps = 0.82
4. Non-kzimatic Case G (Age 50) Recurrent ventricular fibrillation, Fracture of elbow, as a result of fall following an episode of VP. Referred for cardiac surgery. Died postoperaps = 0.99 tively. Late death, not due to injury.
Table II. Weighting coefficietits for RTS Glasgow Coma Scale Systolic blood pressure Respiratory rate
0.9368 0.7326 0.2908
pressure and respiratory rate (Table I). As each of these variables has been found to have a different importance as a predictor of outcome, each coded value is multiplied by a weighted coefficient (TubZeII). The sum of these three products is the Revised Trauma Score (RTS). The Injury Severity Score is calculated from published tables after Baker et al. (1974) based on AIS (‘85) published by the American Association for Automotive Medicine (1985). The oblique line on the graph represents patients with a probability of survival (pS) of 50 per cent, given best available care in the USA. Most patients lying below the line will therefore be expected to live. In calculating the probability of survival a correction is also applied for age and for the presence or absence of penetrating trauma. These corrections are not applied to the graph.
Results Fifty patients were seen by the ‘Trauma Team’ and, of these, 17 died. One patient ‘expected to die survived, whereas seven patients ‘expected to live did not. The causes of these unexpected deaths are as follows: 1. hknmorrhage
Case A
Case B
(Age 24) Hepatic lacerations and multiple fractures. Transfused 1OOml. Whilst in accident and emergency department had cardiac arrest; was resuscitated and transferred to theatre. He died on table (2.5 min after arrival in accident and emergency department). Patient was transfused a total pS= 0.91 of 4.5 litres of blood and other fluids. (Age 73) Multiple fractures. Died soon after ps = 0.58 arrival. Only given I litre of colloid.
2. Major head injures
Case C
Case D Case E
(Age 23) Large laceration, occipital lobe. Large subdural haematoma. Neurosurgeon not conpS = 0.65 sulted at any stage. (Age 23) Intracerebral and extradural haematoma. ps = 0.83 Did not have operation. (Age 83) Severe laceration of cerebral hemipS = 0.65 spheres.
Unexpected survivor The patient who survived unexpectedly, survived with a major disability. He suffered a right frontal subdural haematoma (volume LOO-200ml), an extradural haematoma, a major chest injury with a flail segment, an open, comminuted fracture of the mandible, 21 per cent partial thickness bums and a ruptured spleen. His probability of survival was calculated as 0.27.
Discussion The numbers in this study are too small to draw any significant conclusions. The Trauma Team was felt by the overwhelming majority of staff to have been a great improvement on the previous practice, and its operation will be continued. Awareness of trauma has been raised, the importance of resuscitation stressed, and co-operation among departments improved. However, if, as it appears, 50 per cent of trauma deaths are potentially preventable, then the situation is clearly unsatisfactory. Casual perusal of the deaths in question does suggest that some may not have been avoidable, in spite of the verdict of the TRISS methodology. There are indeed factors which may be contributing falsely to increase a patient’s computed probability of survival (PS’),namely: 1. Incomplete autopsy, underestimating the Injury Severity Score (ISS). 2. Failure to record vital signs until after resuscitation has commenced, thus underestimating the Revised Trauma Score (RTS). 3. Concurrent disease or illness. If the figure of SO per cent is borne out, two conclusions are possible: either trauma teams are not the answer, or we simply have not organized an effective one in our area. Certainly teething problems were experienced in the introduction of the team. Some colleagues in orthopaedics and general surgery feared, with good reason, that it would disrupt established routines and there was some scepticism as to the value of the team. This resolved during the first few months of operation. Failure of the accident and emergency junior staff to use the team when it would be appropriate. More than 50 patients suffering from major trauma passed through the department during the year of study, yet the Trauma Team was not always called. Technical problems with the paging system. Without incurring considerable expense it was not possible to institute a system whereby the switchboard operator could transmit instructions to ail members of the team simultaneously. Consequently each member has to be
371
Heyes and Perez-Avila: Trauma team in a DGH Table III. Trauma Team response
times Team member
Response
A&E
Anaesthetic
General Surgery
Orthopaedic
34 (69%)
41 (84%)
39 (80%)
30 (65%)
10 (20%)
16 (35%)
49
46’
Satisfactory response (i.e. within 10 min of patient’s arrival) Unsatisfactory response (i.e. more than 10 min after patient’s arrival, or no response at all)
15 (31%)
Total
49
‘In three cases orthopaedic
doctor not called.
summoned individually, which clearly takes more time. 4. Slow response or no response at all from the members of the team. Each member of the team failed to see the patient within 10 min of arrival in between 16 per cent and 35 per cent of cases (Table III). Reasons for delay or failure in responding were varied, but were most often in one of the following three categories: i. Team member non-resident, when call comes out of hours (A + E Consultant or Senior Registrar). ii. Team member in operating theatre and/or not carrying bleep. iii. Team member at a different hospital (Brighton DGH is on split sites). 5. Even when the full team arrives promptly, resuscitation and full assessment is still slow because: i. Lack of clearly identified team leader. ii. Failure to perform the necessary tasks simultaneously. ... X-ray gantry. 111. No overhead sited. iv. CT scanner inconveniently Insufficient nursing staff available. V. vi. Time wasted with form filling. We consider
8 (16%) 49
that there should be a minimum number of trauma cases below which the efficiency of a hospital dealing with serious trauma is questionable. One must support Spencer’s comments that Minor Units, where the availability of a team to deal with serious trauma is not implementable, should close to serious trauma. Audit reports such as this one provide us with the evidence to support trauma care in individual hospitals. This type of audit allows us to look at all aspects of trauma care, including prehospital care, the accident and emergency and in-hospital treatment, as well as to observe and assess the documentation and appraise the overall management, leading to correct measures where appropriate. In summary, these deficiencies of the Trauma Team could be remedied provided there is the will and the funds required. An attempt is now being made at this hospital along these lines and we hope in future to be able to repeat
the study in order to determine
whether any improvement in patient outcome has resulted. However, in many cases we feel that the necessary support may not be forthcoming if it is felt that major trauma constitutes an insufficiently high proportion of the district’s case load.
Acknowledgements We would like to thank our colleagues in the Anaesthetic, Orthopaedic and General Surgical Departments, in particular Drs C. Studd and M. Street, and Messrs P. Staniforth and P. Hurst for their helpful comments and continuing cooperation.
References Anderson I. D., Woodford M., de Dombal F. T. et al. (1988) Retrospective study of 1000 death from injury in England and Wales. Br. Med. 1. 296, 1305. Baker S. P., O’Neill B., Haddon W. Jr et al. (1974) The Injury Severity Score: A method for describing patients with multiple injuries and evaluating emergency care. 1. Trauma 14, 187. Boyd C. R., Tolson M. A. and Copes W. S. (1987) Evaluating trauma care: the TRISS method. 1. Truutrua27, 370. Cales R. H. (1984) Trauma mortality in Orange County: The effect of implementation of a regional trauma system. Ann. Emerg. Med. 13, I. Department of Health and Social Security (1987) On the State of Public Health for the Year 1986. London: HMSO. West J. G., Trunkey D. D. and Lim R. C. (1979) Systems of trauma care - a study of two counties. Arch. Surg. 114,455. West J. G., Cales R. M. and Gazzaniga A. B. (1983) Impact of regionalisation - the Orange County experience. Arch. Surg. 118, 740.
Paper accepted 4 February
1991.
Requests for reprints should be aa%-essedto: Mr F. L. P. Hayes, Accident and Emergency Department, Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE.
